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Adoption of Rapid Cycle Improvement Process From Toyota Increases Efficiency and Productivity at Community Health Clinics
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Related QualityTool: Lean Hospitals: Six Sigma and Lean Healthcare Forms Jump to: What They Did | Did It Work? | How They Did It | Adoption Considerations
Snapshot
Summary
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Adoption of Rapid Cycle Improvement Process From Toyota Increases Efficiency and Pr...
http://www.innovations.ahrq.gov/content.aspx?id=1807
Denver Community Health Services, the primary care clinic component of Denver Health (Colorado's primary safety net institution), uses the Toyota "Lean" rapid cycle process improvement system to enhance efficiency in eight Federally Qualified Health Centers. As a result of these improvements, the clinic has cut patient registration time in half, increased provider productivity by 25 percent, reduced patient cycle time and the patient no-show rate, and increased revenues by approximately $3.5 million.
Developing Organizations
Denver Health
Patient Population
Race and Ethnicity > Hispanic/Latino-Latina; Vulnerable Populations > Immigrants; Impoverished; Medically uninsured; Racial minorities; Urban populations
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Many medical practices are characterized by inefficient, unproductive processes that can lead to extended wait times for patients and inefficient use of clinician and staff time. In today's environment of declining reimbursement and rising costs, these inefficiencies can undermine the financial viability of a practice. Extended patient wait times: Surveys by the American Medical Association suggest that the average patient waits 19 minutes before seeing the physician.1 Highly variable, often long patient cycle times: Patient cycle time (the time between patient arrival and departure) varies widely across practices, from 30 minutes in highly efficient practices to 90 minutes in highly inefficient ones.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. Time-and-motion studies conducted in physician practices typically show many gaps in workflow, adding to inefficiency.2 Common bottlenecks include inflexible or poor scheduling, late patient arrivals, the need to look for information, and poor office setup (e.g., drug-dispensing units located far from examination rooms).2 Negative impact on finances: Because the vast majority of practice revenue is a function of the physicians time, inefficient use of clinician time can have a negative financial impact. Maximizing the productivity of all providers allows a practice to serve more patients without hiring additional clinicians, which is critical to the long-term financial viability of the practice.1
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Adoption of Rapid Cycle Improvement Process From Toyota Increases Efficiency and Pr...
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Adoption of Rapid Cycle Improvement Process From Toyota Increases Efficiency and Pr...
http://www.innovations.ahrq.gov/content.aspx?id=1807
roles of the doctor, medical assistant, and nurses in the practice. Designated teams: Initially, the provider dyads were variable according to staffingthat is, any physician could be paired with any medical assistant. However, even with standardized roles, the clinic found that small differences in physician work processes still existed. To address potential inefficiencies, the clinic now defines the provider dyad so that the same pair of providers works together each day, allowing the two to develop a familiarity with each other and a standard process to enhance efficiency. Redesigning "desktop management" tasks: Denver Health has redesigned several desktop management tasks (patient carerelated activities completed without the patient present), such as filling out patient forms, refilling medications, and obtaining and communicating laboratory test results. The goal isto the extent possibleto take work that does not require a face-to-face visit away from providers, giving it instead to support staff. Key changes include the following: 72-hour turnaround policy for forms: Previously, patients who dropped off forms (e.g., sports physical forms, back-to-work forms, durable medical equipment authorizations, prior authorizations) received little instruction as to when they would be completed. As a result, patients often called repeatedly to check on the status of a form. In response, Denver Health established a 72-hour turnaround policy, with all patients being clearly informed that they can either pick up the form or have it mailed to them after 72 hours. As a result, staff no longer spend time handling inquiries as to the status of a form. Denver Health has also relieved physicians of many of the duties related to filling out such forms, having nurses and support staff do them instead. Centralized medication refills, Pap smear followup: Denver Health has switched from having each clinic handle medication refills to using a central distribution site for all refills. 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, handling refill requests across all clinics. This approach frees up significant time for clinic-based nurses. The same concept is being implemented for followup to Pap smear testing.
Innovator Disclosures
Dr. Melinkovich has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
Did It Work?
Results
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The process improvements resulted in significant improvements in provider productivity, patient registration time, patient cycle time, and
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Adoption of Rapid Cycle Improvement Process From Toyota Increases Efficiency and Pr...
http://www.innovations.ahrq.gov/content.aspx?id=1807
no-show rates, leading to a significant increase in clinic revenues. Specific improvements include: Enhanced productivity: The number of patient visits per provider 4-hour session increased by roughly 25 percent, from 8 to 9.9. The annual number of "users" (i.e., unique patients cared for by the clinics) increased by roughly 4 percent in 2008, with no increase in staffing and no negative impact on patient satisfaction or clinical outcomes. Reduced registration time: The average registration time per patient was cut in half, from 4 to 2 minutes; this is a meaningful time savings considering that the clinics register thousands of patients each week. Reduced patient cycle time: The provider dyad system reduced patient cycle time by 34 percent, from 88 to 58.4 minutes. Fewer no shows: The patient no-show rate declined from 21 percent to 15 percent. 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).
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Denver Community Health Services, a division of Denver Health (Colorados primary safety net provider), provides primary care services through 8 family health centers, 12 school-based clinics, and 2 urgent care centers employing 61 physicians, 80 registered nurses, and 47 allied health providers. The Federally Qualified Health Center has 320,000 patient contacts annually, serving a population that is largely Hispanic (80 percent) and either covered by Medicaid (representing 55 percent of patients) or uninsured (40 percent). Roughly 90 percent of patients have incomes below 200 percent of the Federal poverty line. The clinic became involved in organizational process improvement as a result of Denver Health's focus on efficiency improvement as an organizational goal. In pursuing this goal, Denver Health's CEO and executive staff assessed several different process improvement methods, including Lean, Six Sigma, and the Institute for Healthcare Improvement's Breakthrough Series Collaborative Approach. The executive team selected Lean because they believed it offered the most efficient and rapid improvement system.
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Adoption of Rapid Cycle Improvement Process From Toyota Increases Efficiency and Pr...
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and collecting metrics; these facilitators have been trained along with clinic managers on the Lean technique. Rapid improvement events: Process improvements are developed and implemented during 4-day "rapid improvement events." This Lean-adopted event is a method by which improvements can be designed and tested, with the goal of eliminating process steps that do not have any value. Participants work as cross-functional teams of managers and staff routinely involved in the process in question, with a trained on-staff clinic facilitator assisting them in their work. In some cases patients and/or community members participate as well. The 4-day event includes the following: Day 1: Determining which process to improve, defining which elements of that process are value-added and which are wasteful, and creating a roadmap of the subcomponents of the process. Day 2: Creating a roadmap of an ideal process, discussing barriers, reviewing potential metrics, and brainstorming suggested process changes. Day 3: Defining metrics and testing suggested changes. Day 4: Implementing one of the changes. Ongoing: Measuring improvements on a weekly basis using a "production board" that lists metrics and ongoing performance on each metric. Strategic planning: Executive leadership meets annually to map a plan for the projects to be undertaken that year; leadership also meets several times a year to review overall activities and assess progress.
Funding Sources
Agency for Healthcare Research and Quality; Denver Health The program was funded internally by Denver Health, with a grant from the Agency for Healthcare Research and Quality covering the initial evaluation.
Adoption Considerations
Getting Started with This Innovation
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Adoption of Rapid Cycle Improvement Process From Toyota Increases Efficiency and Pr...
http://www.innovations.ahrq.gov/content.aspx?id=1807
Limit focus of improvement: Do not attempt to improve too many processes at once. A narrower focus will be more likely to be successful. Pursue changes that are meaningful for the system, fairly straightforward, easily measurable, and able to be accomplished within the scope of a defined improvement project. Obtain training: Because Lean is a systematized methodology of pursuing process improvement, formal training and education is required. Ensure support at the top levels of organization: Process improvement will not be successful if only middle management is supportive. 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, thus building staff loyalty.
1 2
Woodcock, E. Mastering patient flow: more ideas to increase efficiency and earnings. Englewood, CO: Medical Group Management Association; 2003.
Martin E. Running behind? Try re-engineering. ACP/ASIM Observer. July/August 2000. Available at: http://www.acponline.org/clinical_information /journals_publications/acp_internist/jul-aug00/reengineering.htm
Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.
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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, 2008. Original publication indicates the date the profile was first posted to the Innovations Exchange. Last updated: October 03, 2012. Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange. Date verified by innovator: April 23, 2009. Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.
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