Patient Visit Redesign in New York City
Take a look into Lincoln Women’s Health Clinic in the Bronx at the start of 2005. Long lines of patients. The phone ringing off the hook. Oodles of patients in the waiting room, some waiting for hours. The average total time a patient spent in the clinic? One hundred four minutes. (Initial prenatal visits could extend to three or four hours.) It wasn’t pretty. This is the way it used to be.
But then Lincoln Women’s Health Clinic and Coleman Associates teamed up to implement RealTime Redesign™. In RealTime Redesign™, a team of work process redesigners work shoulder-to-shoulder with staff and managers and together make radical patient-focused changes within a week.
Cycle times have been reduced by over 44% to 58 minutes on average, including those interminable initial pre-natal visits.
Productivity has increased to 3.3 patients per provider per hour, versus the previous 2.9. Despite great results, Marcy Pressman, Associate Executive Director, is quick to state that Patient Visit Redesign is “never a done deal. It’s a continuous effort”. She continues humorously, “We will forever struggle to keep the wait off as we are genetically predisposed to excess wait.”
The ongoing success of Lincoln Women’s Health redesign relies on three key elements:
- Using data to make tactical decisions;
- Redesigning the nursing triage process; and
- Knitting together a tight management team.
Using Data to Make Tactical Decisions
Data—in this case, cycle times and productivity—helps Patient Care Teams evaluate how effectively they are working. A Patient Care Team (PCT) at Lincoln Women’s Health Center is comprised of two clinicians and two medical assistants, with a front desk person and a nurse shared between two PCTs.
The mandate is to see 90% of all patients in 60 minutes or less.
If cycle times increase, the Patient Care Team starts problem-solving to produce better results.
The data needs to be not only timely and easy to collect, but also simple to calculate. Lincoln Women’s Health uses a very uncomplicated process.
A front desk person writes down the patient’s arrival time on a post-it note and sticks the post-it note on the patient’s encounter form.
That encounter form and post-it note accompany the patient to the exam room, where the post-it note is stuck to the exam room door.
When the visit is completed, the last person to see the patient writes down the departure time on the same post-it note.
This person quickly calculates the total cycle time and sticks the post-it note on a flip chart sheet that’s hanging on the wall near the exam rooms.
Each Patient Care Team has its own flip chart sheet where cycle times for each clinician are posted. With this system, cycle times are always visible, so each Patient Care Team knows how well it is meeting its 60-minute goal. At the end of each clinic session, cycle time and productivity averages are quickly calculated by each Patient Care Team.
Because the raw data is so evident, teams are inspired to work more efficiently.
The desire among staff to make sure the patient doesn’t wait and friendly competition between Patient Care Teams keep everyone engaged. Cheryl Abraham, Coordinating Manager, said “Discussing the data with clinicians gets them interested and involved. During the day they become very mindful of what they’re doing.”
Overall trends are scrutinized in monthly meetings with staff. “It has become part of our nature to focus on cycle times in this clinic,” said Suyapa Villalobos, Head Nurse. If cycle times are increasing, the managers troubleshoot with individual Patient Care Teams to get back to their goal of 60 minutes or less.
Fast Track Nursing
Pamela Weisse, RealTime Redesign™ Coach, asked Villalobos, “If you had a magic wand and could use the skills of your nursing staff more fully, what would you change?” Villalobos’s biggest idea, the Fast Track Nurse, has been a huge success. “The objective of the Fast Track Nurse is to identify patients and issues which can be dealt with quickly without making patients wait, sending them elsewhere, or having them return at a later date,” said Weisse.
The Fast Track Nurse (an RN, LPN, or very perceptive Medical Assistant) is stationed with a mobile computer and a telephone right at the entrance to the clinic. Her job is to make a quick assessment of all patients as they approach the registration desk. She first targets those who don’t have an appointment: patients who need a form filled out, a pregnancy test, a RhoGam injection, or simple lab work. Or, patients who may even be in the wrong clinic, and only need to be redirected. Even though the Fast Track Nurse has been in place for the last few months, “a lot of patients go straight to the Fast Track nurse, who they know can help them,” said Eunice Ramirez, Assistant Coordinating Manager.
“The object is to keep patients from waiting unnecessarily,” said Weisse
“… and especially to prevent them from waiting to see a provider when they could easily be taken care of by the nurse.” Villalobos adds “In the past we would put a patient in the back just for the doctor to tell her that everything was fine. That was a wasted visit. Everybody’s time was wasted, and of course the patient’s time, foremost, was compromised.”
The Fast Track Nurse surveys the waiting room at least every hour, surveying patients she hasn’t yet had contact with, and through constant communication with the front desk and the Patient Care Teams, makes sure that each patient is cared for appropriately.
This is not triaging. Instead of spending precious nursing time figuring out who will have to take care of this patient, as in a traditional triage system, the Fast Track Nurse cares for many of the patients directly, and patients don’t fall through the cracks. “We’ve all experienced the patient that gets lost in the mix,” said Villalobos, “the patient that’s been here for many hours that nobody realizes has been overlooked.” Since instituting the Fast Track Nurse, that doesn’t happen any more.
The Management Team
“Lincoln Women’s Health already had a strong core of managers before,” said Weisse, “but since redesign, they have learned how to work even better as a team.” Because they are willing to look at their relationships and put personal differences aside, they work more effectively as a team.
Here’s one example. Suyapa Villalobos and Cheryl Abraham both have strong personalities and a great deal of passion, and they would often clash. Marcy Pressman, Associate Executive Director, came up with an inventive solution: she assigned each of them alternating days of the week “to be passionate.” When it’s Abraham’s day to be passionate, Villalobos demurs. The result: fewer clashes between two very talented people.
The team meets daily to anticipate problems before they arise and to find solutions for ongoing problems. Abraham said that by meeting daily, it’s possible to “get a jumpstart on the day.” They don’t just rely on one plan, though: “We always make a backup plan,” said Abraham, “so in case that one fails we have something else we can resort to.”
Abraham said the team noticed that cycle times increased when there wasn’t a manager on the floor. So, as a team they’ve created a schedule for themselves. “Now someone is always out on the floor,” said Abraham. “Everyone still has enough time to do office work, but there’s always someone on the floor to make sure things are running smoothly.”
Lincoln Women’s Health Clinic will continue to wow patients through redesigning patient-unfriendly processes, self-correcting Patient Care Teams, and an on-the-floor management team.
“Staff members see a change and the patients are really impressed,” said Ramirez. “If everybody works together it can be done.”
Written by Molly Weisse-Bernstein