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Principles of Redesign™—Part Two

There are twelve principles in total, developed in 1998 by Coleman Associates to help teams construct powerful redesign models. The first six, the “blockbuster principles,” are presented in an article previously published on this website. These are the remaining six. Once you read through them, however, you might be tempted to call them the “other blockbuster principles,” because when teams apply these six principles diligently, they create very robust models of delivering patient care.

Principle 7

Exploit Technology. We don’t use much technology, and what we have we don’t use well. Our favorite quote from a physician: “My local pizza parlor uses more information technology than the health clinic I work in.”

technologyiPads, scanners, online appointment systems, telemedicine, electronic medical records, automated lab results messaging, hand-held lab testers, body fat content scales—are all examples of technologies that can be used to create a much more satisfying and efficient visit experience. Redesign is about designing work to be done differently from the way we do it now. Technology offers tools for working differently. Technology and redesign make a good marriage. And the great advantage of computer technology over paper is that terminals can be placed throughout the clinic—everywhere. A computerized patient scheduling system allows us to make follow up appointments in exam rooms by anyone who knows the software and has access to a terminal, however, habit keeps us sending patients back up to the front desk to make follow up appointment rather than leveraging our technology.

Principle 8

Match Capacity and Demand. The scheduling system is a very crude device for approximating capacity. It tells you little about your capacity to see patients. Capacity is often greater than the scheduling template indicates.

Balancing real-time capacity and demand leads to much higher productivity without compromising visit cycle times or quality care.

In looking at thousands of patient visit trackings, we’ve seen no correlation between patient appointment times and when patients are actually taken from the waiting room to the clinical area. We also see no correlation between the length of appointment slots and the time clinicians spend with patients. Capacity has to be assessed in real-time by the Patient Care Team. It is the combining of the information from different functions—mainly the clinical staff along with triage and the front desk—that allows real-time ad-hoc decision making around “Can we squeeze in another patient now?” This capacity and demand balancing act is what leads to much higher productivity without compromising visit cycle times or quality care.

Principle 9

Prepare for the Expected.What are the three most important words in redesign? Anticipate, anticipate, and anticipate. So prepare for the expected and just about everything is expected—i.e., can be anticipated. For example, we know the days of the week that the clinic will be busiest. We know the days of the week we will have the most absenteeism.

If we used our information systems to our advantage, we could predict the volume of prescription refills that would come in per day, on average, and even predict the patients who would be calling. This principle has huge implications. For our clinics to work well for our patients and ourselves, they must become “thinking” versus “rote” clinics. Every person in the clinic must be working at her full power of anticipation. This is how we get ahead of the day so we don’t feel besieged eight hours a day, five days a week.

Principle 10

Get the All Tools You Need. We often are penny wise and pound foolish. We limit the availability of tools to “save” money (one large blood pressure cuff, one Doppler, one electronic thermometer, one scale) though we pay staff well to conduct frequent searches for these tools.

Only one cent of every dollar your organization spends goes to equipment.

Most of us think of our organizations as “poor” organizations. Think poor, be poor. Seventy-five cents of every dollar your organization spends goes to payroll and fringe benefits. Less than 4 cents of every dollar goes to supplies. One cent of every dollar goes to equipment. It is this 1% that allows us to efficiently leverage the 75%. You should want to spend it! Give each person all the tools they need to become more effective: wireless phone headsets so they can be mobile, walkie-talkies so they can communicate, printers in exam rooms to print out information for patients, PDAs so staff are armed with vital reference data that helps avoid errors, voice recognition software to make dictation easy, and anything else that makes sense.

Principle 11

paperDo Today’s Work Today. Never, ever allow backlogs to occur whether it is in the form of a stack of lab slips that need to be entered into paper records, or encounters that have yet to be logged into your computer system, or staff you need to confront over poor performance, or medical charts that require visit notes.The best time to tackle any of these pesky tasks is as soon as they present themselves. In the case of visit notes—they should be dictated or entered into the EMR at the time of the visit. There is nothing more demoralizing to staff than to start the day staring at yesterday’s work—and in many cases it is a stack of work left over from last week or even last month. And if patients call in to get an appointment ASAP for a visit, see them today if at all possible. It will keep a clinician’s future schedule from being “stressfully” clogged.

Principle 12

Ruthlessly Eliminate All Unnecessary Work. A lot of the work we do is simply unnecessary. A lot. And most of our work is comprised of tiny steps, like the taking of a patient temperature. No step is too small, or takes too little time to eliminate. You have to think like a cab driver: it all adds up. A lot of the work we do is unnecessary and makes us lose focus on the true priority: patient care. Once you get into the rhythm, there is so much that can be eliminated: wasteful steps, useless meetings, redundant forms, non-performing staff, and many rules and procedures.

A lot of the work we do is unnecessary and makes us lose focus on the true priority: patient care.

The more this clutter is removed from the clinic environment, the better we can focus on the true priority: effective patient care.

By Roger Coleman

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