Moving a Women’s Health Center from ‘Good’ to ‘Great’ in Florida
To preserve the anonymity of this health center and the names of those involved in their transformation, all real names and places have been replaced with pseudonyms.
Why Rapid Dramatic Performance Improvement in Florida?
This Women’s Health Center in Florida was similar to many other health centers in the United States: it was good, but it wasn’t great. You may have heard of Jim Collins, who coined this phrase. He’s a popular business writer who finds that mediocrity persists in too many U.S. companies. He says, “Good is the enemy of great. And that is why we have so little that become great.[1]”
I understood this concept all too well, and not just because I’m a Collins fan. I understood the problem as a consumer. I have walked into too many shops, restaurants, airports, airplanes, banks, hospitals, you name it – where nothing was ‘awful’ but nothing was ‘great’ either. There wasn’t grime on the walls or toilet paper strewn in the bathrooms, but I wasn’t over the moon about my experience either. I’ve witnessed the conundrum and seen its effects in the form of complacency and, ultimately, subpar customer service. When there isn’t anything bad enough to motivate a company to change, it usually doesn’t.
The Women’s Health Center was the equivalent of a person who needed to lose 15 pounds because he saw the long game. Nothing was dire, no bad report from the doctor… but he knew that if he didn’t lose the 15 now, he’d suffer the consequences to his skeletal and cardiovascular system later. He had the foresight to do what many companies lack the prudence to do. This health center called Coleman Associates because it wanted to be great.
This article is a ‘Good to Great’ client experience making transformational changes at the women’s health center using the Rapid Dramatic Performance Improvement (DPI™) method. The article details four key areas that transformed this organization from Good to Great:
- Early Operational and Quantifiable Victories
- On-Site Coaching
- Daily Review of Operational Metrics aka The Performance Dashboard
- The Infrastructure Team
What Did the Data Tell Us?
Prior to walking into any health center for a Rapid DPI, we review baseline data and other documents, such as floor plans, to familiarize ourselves with the site and its starting point. This intel tells a story in and of itself. Our job is to investigate the root cause of these numbers and understand the real impact on the patient experience. The numbers are an excellent starting point and help give the health center a baseline. It’s like getting on the scale before a weight loss program. It helps to know where you are starting to motivate you as you set the goal for losing 15 pounds.
Their Baseline Data
What Does “Good” Look Like?
When the clinic doors opened that Monday morning, we saw a significant lag time between the first appointment time and the time the first patient was seen by the clinician. The doors opened at 10:00 and after patients checked in they were back in the waiting room at 10:05 ready for their visit. Or so we thought. After the patient checked in, the front desk staff spent about 10 minutes verifying insurance eligibility and entering the patient’s demographic information. Then, they’d put a chart up in a bin towards the back of the front desk area. Ultimately, our team saw that the first patient was brought back at 10:17….10:23 rolls around, and the clinician is still not in the room. Whoa! That’s 23 minutes between when the doors open and the first patient is seen by the clinician. Already, we’re thinking that if we were that patient, we would be wondering, ‘why did I arrive at my appointment time only to wait 23 minutes to see my provider?’
From the clinic administrative point of view, 23 minutes is already one and a half visits behind. That’s one and a half patients you couldn’t see because of a late start. While one could argue ‘23 minutes isn’t bad… heck, at ER’s we wait an hour before being brought back. Isn’t 23 minutes good enough?’ Yes, 23 minutes is okay. But it’s not great! Our team could already see some room for improvement.
Next, we observed a disjointed workflow between the Nurse Practitioner (NP) and the Medical Assistants (MAs). The NP, Kathy, was working out of an unused counseling room down a long hall while the MAs were stationed in the back of the front desk area. We observed little to no communication between the MAs and the clinician, which would ultimately leave Kathy without direction before going into the exam room. She’d read through the Electronic Medical Record (EMR), adding more precious minutes to the visit and then ultimately started the visit from scratch again, “why are you here today?” Well, didn’t the patient just tell the MA that? This would leave the patient thinking, “don’t you two talk to one another?”
Later that morning we observed a few other low-hanging fruit issues that would eliminate inconveniencies for patients: for example, having them schedule a future appointment for a service like an IUD (intrauterine device) insertion that can be addressed at the current appointment. If the patient knows she wants the IUD, why does she need two visits to get it? Further, the implications of this delay could be significant for the patient to prevent unwanted pregnancy.
Getting to Great
Throughout the next three plus days, our team would recommend and help implement 15 different recommendations that were all specifically tied to improving the patient experience and patient-related operational measures.
On day one, we moved the MA workstation closer to the clinician. Next, we coached a new workflow between the Provider and MA called the “Team Dance” and taught the front desk how to prep for patient arrival by moving the work that ordinarily happened after the patient arrived to before the patient even entered the building. That recommendation alone, to move verifying eligibility and patient demographics to prior to the patients’ visit, reduced every cycle time by 10-15 minutes. Now patients didn’t have to wait as long in the waiting room before their actual visit.
Early Victories
By day two, results radically improved. With hands-on coaching, this Florida location saw a 42% decrease in Cycle Time. Their 102-minute average baseline cycle time when down to 59 minutes on average!
Getting a victory within 24 hours is key to getting staff aboard the ‘change train’ at a “Good to Great” health center. Once staff can see the effects of their change efforts and more importantly feel the effects of their changes, it will help ensure the change is replicated and sustained. It’s also psychologically important to show staff that good is not great. Once you’ve felt the jeans slide on, you know how it feels to be five pounds lighter… Once you’ve felt the endorphin rush of a good run, you start to crave it. Day two’s results were the equivalent of a five-mile run that left the staff feeling tired, endorphin-filled and proud. It also helped get leadership on board to sustain change from their ‘seats on the bus.’
Brian, Project Lead for the Rapid DPI in Florida said, “I am usually a naysayer. I wasn’t expecting to see the dramatic results that were in the title of the actual thing {DPI}…. And being able to see it on day one was huge. It was huge for the buy-in for the staff and buy-in to the process and speaks volumes to the impact of your process the minute you walk in the door.”
So it was now day two and big strides had been made. The question now became, how do we help instill the motivation to keep these changes up? What will the staff do once we leave on day four? Will they carry on without us?
Follow-up Coaching
The remainder of the Rapid DPI Week focused on training Internal Coaches to sustain the changes from within. What’s an Internal Coach? It’s someone who works for the health center who is trained by Coleman Associates to coach and sustain new habits the staff just learned and correct old habits when and if they return.
We worked with two Internal Coaches, Brian, the project leader, and, Annabelle, a staff trainer. Members of our Coleman Team worked with Brian and Annabelle to train them to coach on the floor. We trained them to coach like we do. We taught them to observe the staff carefully and then offer praise when a new habit or workflow was performed without prompting. Then we’d make sure they nudged and reminded staff about the new processes they hadn’t yet internalized. This kind of coaching is time-consuming and often annoying for staff; however, it’s effective and that’s why we use it. It’s like having a coach on the basketball court or a personal trainer watching your sit-ups. The trainer makes sure you are following the correct form and do the correct number before moving on to the push-ups.
A really great sign of coaching is when you can back off the subject, keep your eyes on them, and he or she does the new habit anyway! If staff can perform the new habit without thinking about it, or perform it automatically, new habits are forming. We’d coach the Internal Coach to step back sometimes, but always with a keen eye observing the person being coached.
Once Brian and Annabelle were trained, we knew their site had strong support in place to keep an eye on the team over the next 60 days. Later, in the next two weeks, Brian and Annabelle would train other executives and key leadership to coach as they did. What did the staff do the other days of the week when no one was there, you ask? The staff recorded their results and leadership checked on them…every day. They knew what great looked like now and they couldn’t let the results slip back to ‘good enough,’ i.e. over 60-minute cycle times.
The Infrastructure-Team
A key component of this Women’s Health Center’s success was the involvement of their Leadership Team. I can say quite honestly that this Women’s Health Center would not have sustained their initial one-week gains without the oversight, encouragement, praise, critique and involvement of their leadership. We called this group of leaders the “Infrastructure Team” or I-Team, for short.
The I-Team consisted of eight members from their top leadership, including the CEO and COO. This group had a major undertaking ahead of them and they did it while also running eleven other health centers in their organization. But this group was committed. They had already invested significant time and money into this project and we told them that to support this transformation, their job was just starting.
We recommended that the I-Team go to the health center at least once per week. They were also asked to get on weekly coaching calls every Friday to review data. Every week, I’d join the I-Team over the phone to analyze their week-end results. Often companies that think they’re ‘good enough’ review quarterly reports or month-end reports. By contrast, great companies have their fingers on the pulse at all times. They review data in real time. And, they review it with a specific focus and goal–to put the brakes on or to give instant and specific praise for a job well done.
Every week, we’d review what had happened to evaluate whether or not results were slipping. This would tell us whether the center was upholding the model we had helped them put in place that first Rapid DPI week. Conference calls started with someone volunteering to take notes and volunteering to read the data aloud. In the beginning we were going off of a Google drive excel file to report each session’s numbers. Then, about 6 weeks in, we asked the organization’s data guru and excel extraordinaire to build something that would tell a visual story—something we call, a Performance Dashboard. Whether it was raw numbers or a trending line, someone would read the data and then I’d instruct the team to react: “what are your impressions, what’s working, what’s not working?” From there a rich dialogue would ensue with occasional chime-ins by me as their coach. The team would then decide who was going to bring the health center team coffee the next day or lead the charge on writing the appreciation card. Whether it was giving praise or figuring out what exactly was happening with a specific clinic session, this team jumped in and figured out an action plan.
Brian from this health center described being on the I-Team like being ‘all-in.’ He said, “You need buy in from everyone. From Finance to IT. Fundraising, public affairs, we all speak about it. Everyone needs to see the value in DPI. In the beginning you need the entire executive team’s buy in. If you don’t involve everyone, (it feels like overkill at first), you won’t be as successful.”
And buy-in is what they had. The weekly phone calls, the constant on-site support, and the off-site coaching from Coleman Associates sustained their results and kept the focus there. Patrick Lencioni, a popular business writer and author of Five Dysfunctions of a Team, says that the most important focus companies and teams alike can have is a focus on results: “A functional team must make the collective results of the group more important to each individual than the individual members’ goals.[2]”
At their final site visit, what we call their “Capstone Visit,” this Women’s Health Center in in Florida celebrated achieving significant results. After 73 business days their final data was impressive:
Rapid DPI™ Capstone Date (73 Business Days after They Began)
That last day that I was at their health center, their core Pilot Team of Kathy, Annie and Luz achieved incredible results. In one shift they had a 35.22 minute cycle time, an 8% No-Show Rate, and saw 2.45 patients per hour. Now that’s what I call great! They even got a positive Yelp review in the middle of their DPI. And so they achieved their ultimate goal: a thank you from patients at the end of their day. The Yelp review said, “I made my appointment over the phone, super easy. I went to the wrong location, and notified them ahead of time that I’d be late. My wait wasn’t too long. The medical assistant took care of me, I was doing an STD screening. She was so nice and attentive, I felt like I was sincerely being taken care of.”
Present Day: 3 Months Later
So now it’s June, 2016…. three months after their final Capstone visit in March 2016. We called Brian back to see how things were going and to check in on what had ‘stuck’ and to ask about the health center’s results.
Brian said that the team still meets regularly to review data, both teams. The DPI Team at the health center meets and so does the Infrastructure Team. Brian told us, “Now we look at our data on one sheet, on a Performance Dashboard. It gives us the whole picture. If we have really good RVUs or the No-Show rate is low, it allows us now to see everything from a larger perspective and in real time. The Dashboard was a product of the DPI. We had the data but we didn’t pull it as frequently, and weren’t looking at it in the same way. We weren’t looking at the cycle times in a timely way or trending way before. We do now.”
And so, a good health center learned how to become a great one. A great company, says Collins, can have occasionally bad days. A great company “is not a function of circumstance. Greatness as it turns out, is largely a matter of conscious choice, and discipline[3].”
This Women’s Health Center occasionally hits some bumps in the road. Sometimes they go back in to coach or step in when results have slipped too far. But, they know what great is and everyday, they continue to work to get there using the processes and infrastructure they established their first week.
Author’s Note: One month later I received an updated Performance Dashboard from Brian. Here are their most recent results:
Most Updated Results: 4 Months After the Capstone
[1] Collins, James. “Good to Great: Why Some Companies Make the Leap and Others Don’t.” New York, NY. Harper Collins, 2001.
[2] Lencioni, Patrick. Five Dysfunctions of a Team: A Leadership Fable. San Francisco, CA. Jossey-Bass, 2002.
[3] Collins, James. Good to Great: Why Some Companies Make the Leap and Others Don’t. New York, NY. Harper Collins, 2001.