Overcoming Barriers…How a National Rehab Facility Rehabs It’s Own Process
In 2006 Rancho Los Amigos National Rehabilitation Facility in Los Angeles applied for a California Health Care Foundation funded, Safety-Net Institute sponsored, Coleman Associates trained and led Patient Visit Redesign (PVR) Collaborative. As the collaborative manager, I studied their application carefully, very, very carefully. They had colossal leadership changes happening; they had some financial difficulties (although they certainly had lots of company in that category!); and for the first time ever, I thought that this clinic may be too different from everyone else to “fit in” with the other clinics in this collaborative. And after multiple conversations with the manager of the Comarr Clinic, I made the uneasy decision not to admit them to the collaborative.
But I never forgot my conversations with Rancho and always wondered how they were doing out there on their own.
Then, in 2007, once again, their application came across the fax for the 2007-08 Coleman Associates Patient Visit Redesign Collaborative. This time, senior leadership had changed, and interim managers who sounded young, bright, eager and ready to go were leading the charge. In my initial conversations, something seemed different…no, really, everything seemed different.
No Barriers to Excel
Rancho was driven to participate in the collaborative and incredibly eager to learn and prove themselves. As before, I could have used the argument that since all of their patients were spinal cord injury patients and in need of specially crafted services, they were “too different” from the other clinics in the collaborative. But I could tell that this new leadership team—Jorge Orozco, then acting CEO (now CEO) and Aries Limbaga, Acting COO and Director of Admissions and Business Development (now Chief Clinical Officer)—were not going to take “no” for an answer a second time. So, with a little trepidation, I said yes and accepted Rancho’s Comarr Clinic into the collaborative.
One of the key barriers to learning that we (Coleman Associates) observe is that adults see themselves as different, unique, and having special circumstances which set them apart and somehow excuse them from expectations of high achievement. It’s a very human desire to forgive yourself in advance for possible failure. For instance, I went to a running race recently and before the race, I overheard people explaining how they had just gotten over a cold, didn’t get enough sleep or were traveling last week…all attempts to explain why they shouldn’t be expected to be wildly successful. But, amazingly, in our initial conversations, Rancho didn’t do this. Instead they minimized their differences and emphasized their determination to succeed. They really wanted to do the best job possible for their patients, and saw that participating in the collaborative would allow them to do so.
Along with the other teams in the collaborative, they collected baseline data which showed that they saw an average of 1.0 patients / provider /hour in the Comarr Clinic and that patients spent an average of 84 minutes under their roof (cycle time) regardless of how much time they actually spent with a clinician. Way, way too much time was spent just waiting.
The Patient Visit Redesign team of front line staff—Claudia, Leilani, Patty, Aries and Tony—left the first Coleman Associates training session with a plan in hand and big hopes in their hearts. They named themselves Team iDesign, and everything about them was sleek, modern and efficient. Apple would have been proud! They did not yet have an electronic medical record, so they created a progress note that could be used in the EMR system that they would eventually get (See Tools You Can Use sidebar). They created patient care teams of cross-functional staff that worked together to make sure all the patients needs were met—not just providing clinical care, but also making sure that future appointments, reminder calls and access and transportation discussions were taken care of.
The New Patient Visit Model
Their patient visit model was fine-tuned in a matter of weeks and bore tremendously better results than the old way of working. A team huddle helps them to start the clinic session off right and plan for their day and their patients. After huddling, the greeter goes out to the waiting area to receive the patients and uses a walkie talkie to call back to the team to let them know that their next patient has arrived. The patient, already pre-registered on the phone the night before (which, by the way, ensures a higher show rate for appointments) gets quickly logged in and then whisked right back to an exam room.
In the back, things are different too. The assistant does vitals and stays in the exam room with the provider for the entire visit to help facilitate care. The assistant makes the follow up appointment, orders labs and assists in medication discussions and patient education. This constant second set of hands in the exam room not only makes the patient feel like the center of attention, but it also allows the provider to really focus on the patient during the exam. After the exam is over, the provider uses a checklist to quickly chart on the visit and then moves to the next patient. Patients love the new process, too.
By November of 2007, just two months after they started, the Team iDesign had already reduced its cycle time (the time the patient spends in the clinic) from 84 minutes to 31 minutes—a stunning 63% decrease. They also increased productivity by 150%—from a miserable 1.0 patients/provider/hour up to 2.5 patients/provider/hour. Wow! No wonder patients gave them 9.5 out of 10 in a patient satisfaction survey, and were making comments like these:
One patient said, “This is the best visit ever and I have been coming here for years!”
And another said, “Everything was fast and excellent.” “You should keep it this way.” Once clinic staff saw the data, they all agreed—they had to find a way to “keep it this way.”
Results—One Year Later
One year after the Comarr Clinic was redesigned, cycle times continue to run in the 30-40 minute range and productivity is still around 2.5 patients/hour per provider. And because they so loved their new patient visit model in one clinic, they decided to spread the model to other clinics in the Rancho Los Amigos system. In 2008 they participated in the Coleman Associates Spread Collaborative and helped staff in two additional outpatient clinics adopt the new model of care.
With their successes in Patient Visit Redesign and their dedication to improved patient care, Rancho Los Amigos National Rehabilitation Hospital was able to win a very substantial grant from Los Angeles County to implement greater technology into their entire facility. (This year Rancho was also named in the top 5 LA County service departments out of over 100 applicants by the Los Angeles County Quality and Productivity Commission. They were the only hospital in the LA system to gain top 10 honors and it was a direct result of their redesign work.)
And because of the success of the iDesign team and the redesigned clinics, Patty Williams, RN, continues as the torch carrier of redesign and change within Rancho. Patty feels that watching the weekly cycle time and productivity data has been key to Rancho’s success in maintaining PVR. “No way I would really stop collecting data,” says Patty. She adds that data is what forces managers and teams to be very transparent and hold themselves accountable for results and to track their progress.
In life and in work, we often have significant hurdles to overcome. Rancho didn’t let the fact that their patients were more challenging excuse them from trying to make their clinic experience fast and efficient. With its fabulous pilot PVR team and forward-thinking executive leadership, Rancho Los Amigos National Rehabilitation Hospital epitomizes the very message they give to their patients—Yes You Can!
By Melissa Stratman