The Principles of Redesign™
The principles were developed in 1998 by Coleman Associates to help teams quickly construct redesign models. The question we asked ourselves in formulating the principles was:
“If we look at the most successful redesign models to date, do they share common characteristics?”
The answer was “Yes.”
There are twelve principles in total. The first six, which we call the “blockbuster principles,” are presented in this article—the remaining six will appear in a future article. The blockbuster principles have always appeared in successful models. Let’s restate it even more emphatically—there has never been a successful model which has NOT contained these six principles. They provide teams with a framework within which they can quickly and creatively construct patient visit redesign models suited to the peculiarities of their clinics without sacrificing cycle time or productivity outcomes. And the more strongly they’re applied to visit model development, the more bold and effective the model will be.
THE SIX “BLOCKBUSTER” PRINCIPLES
1. Don’t Move the Patient.
The old model is “patient flow.” The new model is “staff flow.” Whenever we ask participants in a Patient Visit Redesign™ collaborative to design an ideal visit for themselves, as patients, they always say “I go into an exam room and that’s where I stay until my visit is over. No moving from room to room.”The old model is “patient flow.” The new model is “staff flow.” The old model is comprised of staff stations where patients stop for service: reception, registration, examination, lab, scheduling. The new model is the patient’s office: the exam room. The old model is staff-centric. The new model is patient-centric.When there are objections around this principle, it almost always has to do with “We can see more patients if we don’t tie up our exam rooms. So, we may start with the patient in the exam room, but if they need to have blood drawn or another service, we send them down the hall.” It’s a fallacious argument for two reasons. First, we’ve yet to see a clinic that manages its exam rooms efficiently so there’s a lot that can be done short of moving patients around. Second, the patient takes up space wherever they are in the clinic. There’s no space savings in sending them down the hall. Future clinics will have more and larger exam rooms, with very little space allocated to lab, waiting rooms, and other functions.
2. Increase Clinician Support.
If you are going for the very best that you can achieve in cycle time and productivity (and professional staff retention), your clinicians need to be optimally supported. Over the years, we’ve experimented with ratios, and we’ve seen steady productivity and cycle time improvement up to a ratio of four medical assistants per clinician.The gains come in decreasing proportions as you up the ante—going from three to four medical assistants, for example. We don’t put a lot of stock in ratios, but a ratio of one medical assistant per clinician is the minimum (unless we are talking about residents), and a two to one ratio is common.You must measure clinician support not via the budget, but by measuring direct, real-time support rendered to a clinician throughout the day on the clinic floor. Many healthcare organizations cite ratios of 3:1, but on closer inspection you find most of the “support” is buried in the overhead functions (like billing). That’s no help on the clinic floor. Increasing support does not mean hiring new staff. It requires something more difficult from healthcare managers: a keen eye for seeing marginally useful positions and staff, and then doing something about it. More staff are moved to the back clinical area where they can directly impact patient visits. We call this “shaking the bushes” to create new resources for a more radical redesign.But let us share with you this stunning revelation: there are two ways to dramatically lower your clinic labor expenses. In a clinic where productivity is less than two patients per hour per clinician, eliminate all medical assistants. Yes, all. Providers will gripe, but productivity will not decrease because it’s at rock bottom already. But per visit costs will drop substantially.The second way to get significant cost savings is to pay your support staff much more—say 20%-33% more than you do now. “What?” you’re saying. How can we save money by paying more? You don’t actually pay your current staff more, but you do begin hiring at a much higher rate, with broader job responsibilities, and you demand a much better candidate for your money.Here’s what you’ll find: you’ll need many less support staff. More skilled and talented staff require substantially less supervision, less rules, and less performance monitoring. And they use much more judgment during the course of the day. The quality of work is much higher and the cost is lower.
3. Create Broad Work Roles.
It does no good to increase clinician support if everyone has a narrow job description. Narrowly defined jobs result in handoffs—many handoffs. And handoffs extend patient visit cycle time because the patient must wait for the next person to pick up the baton before the visit commences again.If the average wait between handoffs is five minutes and there are five handoffs per visit, then 25 minutes of wait time is already built into the process. And even more detrimentally, handoffs are where most errors occur. They are the cracks that stuff slips through. When every staff member has a broad job role, everyone can do many things for the patient, and everyone can move the patient through an efficient, patient-centric visit. One source of resistance to this principle comes from the concern that “if I learn to do more things, I will be doing too much work.” Never confuse the breadth of what one can do in a job role with the volume of work. They are two separate factors.The other source of resistance relates our simplistic notion of job roles. “She’s a receptionist…she can’t…”Why can’t a front desk person take a patient to an exam room? Or weigh a patient? Or take a temperature even? (These are almost always digital now, so it takes no training to do accurately.) Why can’t a medical assistant or a nurse ask if the patient has had changes in address, phone number or insurance since the last visit? Why can’t a nurse, physician, or medical assistant make a follow-up appointment for a patient? Why can’t a medical assistant draw blood?
4. Organize Patient Care Teams.
Patient Care Teams (PCTs) are medical homes for patients and they take care of a patient’s needs whatever they are—same-day appointments, prescription refills, post-visit questions, and even explaining a patient bill. Patient care teams result in higher quality care, more efficient service, and more satisfying work. It’s more satisfying work because the same staff work together every day and develop a team intimacy that is critical to high quality work and efficiency. Because the same people work with each other every day with the same panel of patients throughout the year, patients learn the names of all team members and all team members have credibility with patients. This gives the clinician far more support than in non-PCT environments. Here’s a shocking aspect of this principle. A clinician may go on vacation, but Patient Care Teams are in business every clinic day. So it is the wise healthcare organization that hires locum tenens to fill in for vacationing providers and preserve the integrity of the “patient’s medical home.” Patient Care Teams can be small—for example, one clinician along with one to two medical assistants. Or they can be expansive—as in a team comprised of a clinician, a couple of medical assistants, a nurse shared with another PCT, a biller, a medical records person, and a front-desk staffer. There’s really no limit to the range of configurations as long as the team size stays small, usually three to eight staff in total.
5. Communicate Directly.
No notes, flags, charts in racks or other indirect communication methods. Emails and discussion are modes of direct communication. In the clinic, we recommend that each Patient Care Team claims a channel and communicates via walkie-talkie. On average, these units cost about $25 a piece. There’s no cheaper investment you can make with so much bang for the buck.
Direct communication doesn’t just refer to communication devices, but how we communicate with each other.Almost everyone is initially resistant to this idea. A coach must get the redesign team to experiment with walkies, and usually team members become converts in little time. Once they realize that walkies save walking and really aid teamwork, they will find them indispensable.There’s one important caveat regarding this principle: You never use patient names—ever. “I’m putting your 9 o’clock in room 4” is a great way to announce to a clinician that a patient is ready in exam room four.Direct communication, however, does not just refer to communication devices, but how we communicate with each other. There are three principles to effective teamwork communications:
- Clarity. Say what you mean, and mean what you say. State everything so it is easily understood by the person with whom you are talking.
- Brevity. Don’t waste your time or the time of others. The fewer words you use to get your point across clearly, the better you will be understood.
- Directness. Talk directly, don’t beat around the bush.
- When communication devices are combined with a direct communication style, teams become enormously effective.
6. Start All Visits on Time.
It’s like flying. If your flight is late getting out of the airport, then it’s going to be late arriving and late leaving the next airport. So ALL visits must start on time.We’ve looked at a lot of statistics, and none has stunned us more than the prevalence of the first appointment of the day being the very first for which staff are behind schedule. How could that be? We’re not even on time for the first visit!This is often true because providers frequently are late to begin the day! It’s true. But if you ask providers why, they’ll respond (practically in unison): “There’s never a patient in the exam room for me to see until a half-hour after the clinic begins.”That’s also what we see in our observations of clinics: Most clinics take about 90 minutes to fill the exam rooms after the morning session begins. This throws the entire day behind schedule. Starting on time is your best chance of staying on time. The mantra: “The three o’clock appointed patient is in the exam room with a clinician and the medical record at 3:00.” That’s what “on time” means.
The beauty of these six blockbuster principles is that they make so much sense! How could you apply them where you work?
Read the companion article, Principles of Redesign™—Part 2 where we discuss six more principles…
By Roger Coleman