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Adoption of Rapid Cycle Improvement Process From Toyota Increases Efficiency and Pr...

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Service Delivery Innovation Profile

Adoption of Rapid Cycle Improvement Process From Toyota Increases Efficiency and Productivity at Community Health Clinics
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increased provider productivity by 25 percent. drug-dispensing units located far from examination rooms).gov/content. Evidence Rating (What is this?) Moderate: The evidence consists of comparisons of key indicators before and after implementation of the process improvements. the primary care clinic component of Denver Health (Colorado's primary safety net institution). Impoverished. the clinic has cut patient registration time in half. Vulnerable Populations > Immigrants. Extended patient wait times: Surveys by the American Medical Association suggest that the average patient waits 19 minutes before seeing the physician. from 30 minutes in highly efficient practices to 90 minutes in highly inefficient ones.. Developing Organizations Denver Health Date First Implemented 2006 Patient Population Race and Ethnicity > Hispanic/Latino-Latina. which is critical to the long-term financial viability of the practice. Urban populations What They Did Problem Addressed Back to Top Many medical practices are characterized by inefficient.5 million.ahrq. these inefficiencies can undermine the financial viability of a practice.2 Negative impact on finances: Because the vast majority of practice revenue is a function of the physician’s time. Time-and-motion studies conducted in physician practices typically show many gaps in workflow. Racial minorities. and increased revenues by approximately $3. In today's environment of declining reimbursement and rising costs.1 2 of 9 16/01/2013 5:20 PM . unproductive processes that can lead to extended wait times for patients and inefficient use of clinician and staff time. Maximizing the productivity of all providers allows a practice to serve more patients without hiring additional clinicians..1 Highly variable.1 Inefficient use of clinician and staff time: A major cause of long waiting and cycle times are inefficient processes that do not take full advantage of scarce clinician and staff time.. adding to inefficiency.2 Common bottlenecks include inflexible or poor scheduling. often long patient cycle times: Patient cycle time (the time between patient arrival and departure) varies widely across practices. and poor office setup (e. http://www.innovations. late patient arrivals.g. reduced patient cycle time and the patient no-show rate. Medically uninsured. the need to look for information. uses the Toyota "Lean" rapid cycle process improvement system to enhance efficiency in eight Federally Qualified Health Centers.aspx?id=1807 Denver Community Health Services. inefficient use of clinician time can have a negative financial impact. As a result of these improvements.Adoption of Rapid Cycle Improvement Process From Toyota Increases Efficiency and Pr.

Now. this information is verified on a quarterly basis. now. who neglect to make a followup appointment at the appropriate time. symptoms. which reduces time spent on the phone and makes it easier to find an early open slot on the schedule. 1:20 p. with only 30 percent of appointments having been made in advance.aspx?id=1807 Description of the Innovative Activity Using key elements of the Toyota Lean Production System. with no assurance of provider availability. a medical office assistant would meet with the patient first to take vital signs and ask about history. No appointments made too far in advance: To reduce no-shows.g. Patient registries are used to contact patients with chronic diseases. a physician and a medical assistant visit with the patient at the same time so that information is conveyed only once. (For more information on the role of Lean in this program..m. please see the Planning and Development section. physicians varied in how they delegated tasks to the medical assistant. Open-access scheduling system: The schedule leaves some slots open each day so that visits can be scheduled quickly for sick patients. then. such as asthma and diabetes. now. Patients who require followup care beyond the 2-week timeframe are asked to call for an appointment sometime within the 2-week window. scheduling three patients at the top of the hour... Stricter policy for early and late arrivals: Previously. and 1:40 p. early patients must wait until their appointment time to be checked in. http://www. insurance coverage.ahrq.m. rather than sequential. Policy for patient no-shows: It is now clear to patients that they should call the office if they need to cancel an appointment. front desk staff verified address. patients arriving late would be worked into the schedule. now. resulting in some patients having to wait). Simplified registration process: Previously. the clinic now schedules each patient for a specific time. the medical assistant enters all information into the electronic medical record while the physician offers care. appointments are not scheduled more than 2 weeks in advance. and other information with patients at every visit. Rather.g. Now.m. Provider dyads to enhance productivity: The clinic changed the work process of the physicians and medical assistants so that they work in tandem as a team rather than seeing patients sequentially: Tandem. and medications.. a 20-minute visit. the appointment is rescheduled. Previously. and patient registration.Adoption of Rapid Cycle Improvement Process From Toyota Increases Efficiency and Pr. well visit or visit for an acute condition)..gov/content. only one type of appointment is available. Designated appointment time: Rather than operating a block appointment schedule in which multiple patients are scheduled for a single block of time time (e. They also publicize a new policy: Any patient who is a no-show twice without calling to cancel will no longer be able to make an appointment. such as at 1:00 p. Denver Community Health Services pursued process redesign in all eight of its clinics to improve appointment scheduling. a physician would enter the room and ask the same questions. the clinic has standardized the 3 of 9 16/01/2013 5:20 PM . Standardized roles: Previously. Now. new or returning patient. the clinic offered two different appointment types—a 30-minute visit and a 15-minute visit—depending on patient circumstances (e. Centralized scheduling under consideration: Denver Health is currently evaluating the creation of a centralized system with a single call center that would eliminate the need for each clinic to handle its own scheduling. Otherwise. provider coordination.innovations. Approximately 70 percent of visits are for appointments made on that same day.. late patients are only seen if there is room on the schedule. these patients can only be served on a "walk-in" basis. a patient arriving an hour early would be checked in right away. Having two different appointment lengths made it necessary for front desk staff to ask patients about their care needs and then find an appropriate time slot. care: Previously.) Key changes are described below: Streamlined appointment scheduling: The clinic implemented the following changes to facilitate appointment scheduling and reduce no-shows: One appointment type: Previously.

sports physical forms. However. the clinic found that small differences in physician work processes still existed. The goal is—to the extent possible—to take work that does not require a face-to-face visit away from providers..melinkovich@dhha. As a result. with all patients being clearly informed that they can either pick up the form or have it mailed to them after 72 hours. having nurses and support staff do them instead. Designated teams: Initially. Did It Work? Results Back to Top The process improvements resulted in significant improvements in provider productivity. refilling medications. MC 0278 Denver. CO 80204-4507 Phone: (303) 602-4954 E-mail: paul. MD Director. http://www. and obtaining and communicating laboratory test results. Pap smear followup: Denver Health has switched from having each clinic handle medication refills to using a central distribution site for all refills. As a result. patient registration time. even with standardized roles. This approach frees up significant time for clinic-based nurses.. allowing the two to develop a familiarity with each other and a standard process to enhance efficiency.ahrq. Denver Health established a 72-hour turnaround policy. and nurses in the practice. patients often called repeatedly to check on the status of a form. Denver Health has also relieved physicians of many of the duties related to filling out such forms.org Innovator Disclosures Dr. and 4 of 9 16/01/2013 5:20 PM . Community Health Services Denver Health 777 Bannock St.gov/content. handling refill requests across all clinics. medical assistant. patients who dropped off forms (e. Contact the Innovator Paul Melinkovich. giving it instead to support staff. however.innovations. the clinic now defines the provider dyad so that the same pair of providers works together each day. staff no longer spend time handling inquiries as to the status of a form. such as filling out patient forms.aspx?id=1807 roles of the doctor. To address potential inefficiencies.. Melinkovich has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile. Nurses who previously spent significant amounts of time handling refills at a single clinic have been reassigned to the central distribution site where they work directly with a pharmacist. Centralized medication refills. durable medical equipment authorizations.Adoption of Rapid Cycle Improvement Process From Toyota Increases Efficiency and Pr. patient cycle time. The same concept is being implemented for followup to Pap smear testing. prior authorizations) received little instruction as to when they would be completed.g. information on funders is available in the Funding Sources section. the provider dyads were variable according to staffing—that is. Redesigning "desktop management" tasks: Denver Health has redesigned several “desktop management” tasks (patient care–related activities completed without the patient present). In response. back-to-work forms. Key changes include the following: 72-hour turnaround policy for forms: Previously. any physician could be paired with any medical assistant.

Higher revenues: Clinic revenues have increased by roughly $3.5 million as a result of the Lean-inspired improvements in patient flow (as of December 2009). IA) to train staff and facilitate improvement activities. The annual number of "users" (i. unique patients cared for by the clinics) increased by roughly 4 percent in 2008. Planning and Development Process The Lean Production System is a process improvement system developed by Toyota Motor Company that incorporates different tools and techniques that can help businesses reduce waste.gov/content. Reduced registration time: The average registration time per patient was cut in half. Reduced patient cycle time: The provider dyad system reduced patient cycle time by 34 percent. 80 registered nurses. Roughly 90 percent of patients have incomes below 200 percent of the Federal poverty line. The Federally Qualified Health Center has 320. How They Did It Context of the Innovation Back to Top Denver Community Health Services. In pursuing this goal. Specific improvements include: Enhanced productivity: The number of patient visits per provider 4-hour session increased by roughly 25 percent. Ottumwa. and 2 urgent care centers employing 61 physicians. from 8 to 9. and enhance productivity while increasing quality. 12 school-based clinics.. Fewer no shows: The patient no-show rate declined from 21 percent to 15 percent. Denver Health's CEO and executive staff assessed several different process improvement methods. with no increase in staffing and no negative impact on patient satisfaction or clinical outcomes.ahrq. a division of Denver Health (Colorado’s primary safety net provider).aspx?id=1807 no-show rates.9. The clinic became involved in organizational process improvement as a result of Denver Health's focus on efficiency improvement as an organizational goal. The executive team selected Lean because they believed it offered the most efficient and rapid improvement system. http://www. leading to a significant increase in clinic revenues.4 minutes. lower costs. and 47 allied health providers. Evidence Rating (What is this?) Moderate: The evidence consists of comparisons of key indicators before and after implementation of the process improvements.e.innovations. from 88 to 58. from 4 to 2 minutes..000 patient contacts annually. this is a meaningful time savings considering that the clinics register thousands of patients each week. In-house staff: Seven in-house facilitators and one facilitator manager were hired to assist with preparation for the process improvement activities 5 of 9 16/01/2013 5:20 PM . More than 100 clinic managers have undergone the 1-week training sessions to date. Training: Contracted with a consultant (Simpler.Adoption of Rapid Cycle Improvement Process From Toyota Increases Efficiency and Pr. Lean methods are being implemented in a growing number of health care organizations. provides primary care services through 8 family health centers. including Lean. Initially embraced by manufacturing companies.. serving a population that is largely Hispanic (80 percent) and either covered by Medicaid (representing 55 percent of patients) or uninsured (40 percent). Six Sigma. and the Institute for Healthcare Improvement's Breakthrough Series Collaborative Approach. The clinic undertook the following planning and development steps in adopting Lean process improvement methodologies: Executive buy-in: Executive leadership embraced the Lean system as a way to promote change and encouraged mid-level managers to support the system as well.

facilitator and facilitator manager compensation. Costs: The costs of the program include consulting/training costs. Resources Used and Skills Needed Staffing: Most people participate in the program as a part of their regular duties. defining which elements of that process are value-added and which are wasteful.aspx?id=1807 and collecting metrics. with a trained on-staff clinic facilitator assisting them in their work.jcrinc.. these facilitators have been trained along with clinic managers on the Lean technique.org/offerings/conferences/Summit2009/Pages/default.ahrq. The cost of this activity cannot be easily determined because facilitators work across a number of "value streams" in addition to primary care. the Institute for Healthcare Improvement held its 10th Annual International Summit on Redesigning the Clinical Office Practice. reviewing potential metrics. Links to all available presentations from that conference can be found at http://www. Adoption Considerations Getting Started with This Innovation Back to Top 6 of 9 16/01/2013 5:20 PM . with a grant from the Agency for Healthcare Research and Quality covering the initial evaluation. discussing barriers. and staff time in developing and implementing the rapid improvement events. leadership also meets several times a year to review overall activities and assess progress. Rapid improvement events: Process improvements are developed and implemented during 4-day "rapid improvement events.Adoption of Rapid Cycle Improvement Process From Toyota Increases Efficiency and Pr. Ongoing: Measuring improvements on a weekly basis using a "production board" that lists metrics and ongoing performance on each metric.com/Books-and-E-books/ADVANCED-LEAN-THINKING/1278/. with the goal of eliminating process steps that do not have any value.ihi. Day 3: Defining metrics and testing suggested changes. The 4-day event includes the following: Day 1: Determining which process to improve. http://www. Tools and Other Resources The Joint Commission recently released a report on Lean that includes information on Denver Health's activities in the area of primary care. In some cases patients and/or community members participate as well. In March 2009. New "staff" include the seven facilitators and one facilitator manager.innovations. Participants work as cross-functional teams of managers and staff routinely involved in the process in question.aspx. Day 4: Implementing one of the changes. and brainstorming suggested process changes." This Lean-adopted event is a method by which improvements can be designed and tested. and creating a roadmap of the subcomponents of the process.gov/content. A number of presentations from that conference discuss the application of Lean to the office-based setting. Strategic planning: Executive leadership meets annually to map a plan for the projects to be undertaken that year. Funding Sources Agency for Healthcare Research and Quality. Denver Health The program was funded internally by Denver Health. The report is available for purchase at http://www.. Day 2: Creating a roadmap of an ideal process.

Track metrics: Without measurement. including Borgess Ambulatory Care in Kalamazoo. Sustaining This Innovation Hold frequent events: During the first year (2006). Leaders found that this was not adequate to truly promote change. Martin E.. New York City Health and Hospitals Corporation. Denver Health held only one rapid improvement event at each of the eight clinics. CO: Medical Group Management Association. there is no way to know whether the team is making progress. http://www. 1 2 Woodcock. 2003.S. easily measurable. Read more.acponline. and Hennepin County Medical Center in Minneapolis. thus building staff loyalty. Organizations that stick with Lean will continue to see improvements. fairly straightforward. ACP/ASIM Observer. and able to be accomplished within the scope of a defined improvement project. Be persistent: Although Lean can yield quick improvements in the clinic setting. formal training and education is required. July/August 2000. the Agency for Healthcare Research and Quality. holding three events at each. it should generally be considered a long-term process.org/clinical_information /journals_publications/acp_internist/jul-aug00/reengineering.. Let front-line staff drive process: Letting front-line staff (rather than senior management) identify needed changes and drive the improvement process ensures that changes are grounded in the reality of the work and that workers embrace and feel empowered by the new process. In 2007. Ensure support at the top levels of organization: Process improvement will not be successful if only middle management is supportive. Obtain training: Because Lean is a systematized methodology of pursuing process improvement.innovations.Adoption of Rapid Cycle Improvement Process From Toyota Increases Efficiency and Pr. Department of Health and Human Services.htm Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U. A narrower focus will be more likely to be successful. MN. Use By Other Organizations A number of organizations have applied Lean principles to the clinic setting.ahrq. E. Denver Health limited the number of participating clinics to three. Available at: http://www. Mastering patient flow: more ideas to increase efficiency and earnings. Service Delivery Innovation Profile Classification 7 of 9 16/01/2013 5:20 PM . Running behind? Try re-engineering.gov/content. or Westat of the innovation or of the submitter or developer of the innovation. Englewood. Pursue changes that are meaningful for the system.aspx?id=1807 Limit focus of improvement: Do not attempt to improve too many processes at once. MI. even in processes in which substantial waste has already been eliminated.

2009. Date verified by innovator: April 23.gov: The U..innovations. Original publication indicates the date the profile was first posted to the Innovations Exchange. http://www. Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.S.Adoption of Rapid Cycle Improvement Process From Toyota Increases Efficiency and Pr. Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. Government's Official Web Portal 540 Gaither Road Rockville. AHRQ Home U.aspx?id=1807 Patient Population: Hispanic/Latino-Latina Immigrants Impoverished Medically uninsured Racial minorities Urban populations Stage of Care: Chronic care Preventive care Primary care Setting of Care: Federally qualified health center Safety net provider Patient Care Process: Appointment scheduling Disparities reduction Improving access to care Pre-visit history taking Primary care Waiting time management IOM Domains of Quality: Efficiency Timeliness State: Colorado Organizational Processes: Process improvement Workflow redesign Developer: Denver Health Funding Sources: Agency for Healthcare Research and Quality Denver Health Original publication: April 14.ahrq. 2012. This site complies with the HONcode standard for trustworthy health information: verify here. and verify the profile annually. 2008. Department of Health & Human Services | Questions? | Contact AHRQ | Site Map | Freedom of Information Act | Disclaimers | Privacy Policy | Plain Writing Act | The White House | USA.. The innovator is invited to review. MD 20850 Telephone: (301) 427-1364 Agency for Healthcare Research and Quality 8 of 9 16/01/2013 5:20 PM .gov/content. update. Last updated: October 03.S.

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