I Went Through a Rapid DPI™
In 1999 I started my first job at Community Health Clinic Ole. It was an exciting time to be there to say the least–I didn’t realize it then but I do now. The reason for the excitement was due to the fact that we were growing quickly. We grew from a small Community Health Center Clinic with only medical services to an organization that added broader care for our underserved patients. This was the time when we were making changes, staff was jazzed up, and management was excited and looking for great opportunities to help our community. To most of us staff, we loved helping our community…our community was our family and friends and where we lived and that was what made us focus on doing the right thing. The paycheck was necessary but we felt it was a plus. In that ten-year period we added a Dental Dept, Behavioral Health Dept, Prenatal Care Dept, Obstetrics and Gynecology Dept, and also implemented an EHR at multiple satellite clinics throughout our county. We managed the rapid growth for many years but like a lot of organizations, medical or not, rapid growth eventually caught up with us.
It was late 2009 to early 2010 when I remember sitting in a room for a weekly supervisors meeting. I remember this meeting because it was here when we finally made a decision as a team to throw up our hands and ask for help. We were in a financial hole that kept getting deeper. Note: this was not an easy decision for us, but we knew it was the right one.
The next question was who or what could help us. We all brought ideas and suggestions as to what could potentially help. Our Medical Director remembered and suggested we call Coleman Associates. This brought up great memories for those of us who were on the Coleman Team five years ago. We were team MASVAT team. (MASVAT’s definition was a combination of MAS –Spanish for MORE and the Coleman Acronym V.A.T., which translated to Value Added Time–or time face-to-face, as opposed to wait time). Team MASVAT had been successful, and we had a positive experience with Coleman and organizational change.
Our main topic of conversation then wasn’t whether it would help, it was whether or not we could have an outsider come in, air our dirty laundry, and help us fix what we haven’t been able to fix in years. We put aside those worries, and we redirected our attention and thoughts to the fact we needed help. We all agreed it was time. Our Medical Director, Dr. Bob Moore, sent an email requesting help from Coleman. “Help” was scheduled quickly for the week of June 21, 2010.
Coleman Associates had received from admin our baseline data which included: 8.9 patients per shift on average, a dropped call rate in the upper 20%’s, cash collection around $6000.00 a week, average cycle time of 52.6 minutes, and a Third Next Available Appointment which was 46 days away. I remember pausing two weeks before the Rapid DPI week. We did not know what to expect, but it was coming and it was coming very fast. We tried to prepare ourselves for the typical consultants, and even I too was confused on what to expect.
The Rapid DPI™ week
Monday, June 21st, management pulled us together as a new combination of team members called the “Ops team” (short for operations team). In this meeting the so called Ops team was told by administration that we had been chosen for this great opportunity to lead these changes at Ole and they gave us their blessing and encouragement and asked us to make all the changes necessary to improve our organization.
Tuesday 7am came, and we were nervous but excited. We started with introductions around the table and Coleman painted us a picture of how our week would go. They asked us what we would like to see come out of this week. They also mentioned to us that we would potentially be followed by their team members –followed everywhere and asked questions about how things are truly done and our thoughts about how it could change. Again our leadership gave us the blessing to make changes. Though scary, we knew we had the power to make positive change. We also knew that anything we did would help. There were possibilities that we could make mistakes, but at this point it did not matter because we were financially sinking and patient satisfaction was down. We didn’t have much to lose, and besides that, we thought we had tried everything we could think of.
After a few hours and many questions that felt sometimes uncomfortable to answer, we managed to get through the first half day. Little did we know it was going to start getting really interesting, really quickly. We sat down at a Tuesday midday lunch huddle and the Coleman Team started giving us their observations.
They told us that they were amazed at the demand we created for ourselves especially in the walk-in clinic (we would get easily 60 – 70 patients a day walking in during winter). They also pointed out how we created work for ourselves by how we handled patients when physically present in the clinic. They shared with us that both how and what we communicated over the phone, how we addressed patients when calling them into their appointment, and what kind of things they saw our front desk collect or not collect regarding key financial information. Then they kept going. They commented on how we used our Medical Assistants and how our providers work extra hard because of our lack of teamwork. Then there was the issue on how to use our RNs and how inefficient our processes were.
The interesting thing that they kept going back to was that we were creating our own artificially high sense of demand and that we needed to put our heads together to figure out, with them, how to drain the pond of pent up demand. We obviously were shocked and in denial because no one wants to believe that they are that bad or that they are creating work for themselves. After all, we were a popular clinic and patients just had to wait awhile to get in to see our doctors.
The next thing coming was the Coleman “Recommendations” for the next session. The first recommendations focused on saying “yes” to our patients and allowing them into our clinic. It was ridiculously simple and yet hard to swallow as you can imagine; however, we agreed. The rest of the recommendations were also insightful, simple and yet it was becoming evident that we needed just this advice and perspective. We agreed to every recommendation made. In looking back, that was absolutely the right choice.
We had our work cut out for us but we were making big strides in the right direction and we were excited. This process of implementation, coaching, and training continued clinic shift after shift all week. It was exhausting but fruitful!
For Every Patient: Care with a Provider and Team They Know
We added a few other smaller recommendations including preparation steps like team huddles and chart preparation but then the big recommendation hit us. Their recommendation: Eliminate the walk-in clinic.
We all got serious and our Medical Director reacted as if a gust of hurricane wind hit him. With wide opened eyes as if someone scared him, he just looked around the table. Finally our Executive Director said, “Wait. That’s where a lot of our revenue comes from. We can’t do that!” We all agreed.
The Coleman Team calmly reflected back to us our data from this week with the impact of their earlier recommendations. They told us objectively how we had accommodated many patients in our schedule and if we wanted to focus on continuity of care and becoming a true medical home for our patients, we needed to get rid of our walk-in schedules, emphasize continuity of care, and get patients in with their PCP (Primary Care Provider).
Minutes passed and after a healthy conversation with healthy conflict we decided to accept. (Note: We were still scared about what we had agreed to do.) We needed more planning and data to make the decision about when we would eliminate our walk-in clinic and be able to train our staff on how to deal with this huge change. We decided we would not do this in the week of our Rapid DPI™, but promised we would make the change soon enough.
With the thought of eliminating our walk-in clinic came the energy to figure out how to sustain the changes made in our patient care model–some would call it fear! The last recommendation was to create a Performance Dashboard, so we could track our progress.
The Follow Up
Coleman associates helped us get out of the hole. They helped us to be patient centered and our staff felt the positive change. This follow up was a 2-month coaching process that had its ups and downs, but we were focused on the data and outcomes we were producing as a team. Though this process was exhausting at times, we managed to get through the initial bumps and it made it easier to succeed. We continued to review our dashboard and act accordingly to make change in the right directions.
A few weeks after our Rapid DPI™ week, with proper notification to our community, we eliminated our walk-in clinic AND we were able to absorb all walk-in patients into the care teams stressing continuity and access. We did it all without losing revenue.
For staff, their job had gotten easier – because patients were prepared and not waiting so long. It was amazing the impact on all staff due to reduced stress from patients waiting. Most importantly, our patients felt the culture shift and they were happy.
Throughout this time period and beyond, we collected data and reviewed our dashboard regularly. We noticed great progress that was sustainable. Our stats continued to steadily improve and eight months later we were at 11 patients per provider per shift, our average cycle time stayed about the same (just under an hour) but quality of visit went up along with staff and patient satisfaction. Our dropped call rate fell to under 8% average, cash collections doubled from $6000 / weekly average to $14,000 /weekly average AND most amazingly our wait for an appointment (Third Next Available Appointment or TNAA) dropped to 3 days on average—this was down from a 46 day average pre-DPI. Not only did we survive the DPI™, we thrived as a result of our combined efforts.
According to the Clinic Ole web site and public disclosure of form 990, Clinic Ole, during the year 2010 when Coleman Associates conducted this DPI™ (June 2010), saw an increase in patient services revenue and the overall income to the clinic was doubled from years 2009 to 2010 (after expenses).