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Practice Management Teams Use Lean to Serve Patients Better

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Practice Management Teams Use Lean to Serve Patients Better

Practice Management Teams Use Lean to Serve Patients Better

Thomas Reifsnyder, chief of the Division of Vascular Surgery at Johns Hopkins Bayview Medical Center, took part in the Ambulatory Management Program's second cohort.

Date: 03/01/2015

Tom Reifsnyder was skeptical. Willing but skeptical.

Asked to participate in the Ambulatory Management Program (AMP), the busy vascular surgeon was at first slightly dismayed by the time commitment—two full days of training in the quality improvement methodology Lean, followed by two hours per week over five months. But those first intensive days won him over.

“Initially, I thought, ‘How will Lean be useful to me?’ But then it hooked me. It allows you to look at problems in a new way and gives you a common vocabulary with which to address them,” he says.

The program is overseen by John Flynn, executive director of the Clinical Practice Association. AMP trains practice management triads composed of physician directors, nurse managers and clinic managers in the basics of Lean, then requires them to use the well-established business methodology to increase their clinics’ efficiency.

Reifsnyder, who is chief of the Division of Vascular Surgery at Johns Hopkins Bayview Medical Center, and the other members of his AMP team—Sally Adams, ambulatory services manager; Holly McDaniel, the charge registered nurse; and Wanda Bennett, practice manager for the medical office coordinators in surgery—were part of the program’s second cohort, which like the one that preceded it, consisted of 10 triads representing a range of specialties and locations, among them Johns Hopkins Community Physicians’ internal medicine practices at Howard County, North Bethesda and Hopkins Bayview, and ophthalmology from the Johns Hopkins Outpatient Center and Green Spring Station. Each cohort attempts to group specialties together so that their practice management teams can share solutions to similar problems.

Wait-Time Studies and Spaghetti Charts

As a vascular surgeon, Reifsnyder treats patients with compromised circulatory systems. But his clinic had a circulation problem of its own, he and his colleagues discovered when they used Lean to track the movement of patients and providers. The analysis they conducted included a “spaghetti chart”—multiple overlapping lines revealed bottlenecks in how providers and patients moved through the clinic. They also performed wait-time studies. As a result of their efforts, they reduced the amount of time patients spent in examination rooms alone by 40 percent and refined work processes to eliminate the bottlenecks their wait-time and spaghetti chart exercises had revealed.

Another AMP team, from the Pediatric Specialty Clinic at The Johns Hopkins Hospital, performed wait-time studies and created spaghetti charts in their efforts to streamline the check-in process for patients of Peter Mogayzel, the clinic’s medical director. They mapped the movement of patients and their parents from the time they walked into the clinic until they were brought back to see Mogayzel and his staff. Patients and their families had to zigzag across a very large waiting room to check in: They pulled tickets at one end, registered using the kiosk at the other end, sat down, got up to talk to the patient services coordinator, sat down again, went to triage and so forth, says Mogayzel.

The goal, therefore, was to minimize the amount of moving around people had to do and create a feeling of order and calm. The team experimented with using only the ticket pulls and eliminating the kiosks. Then they moved the kiosks and ticket pulls closer. They rearranged the furniture several times. Each experiment lasted one to two weeks.

They have shortened the time from pulling tickets to getting through triage from about 15 minutes to under 10. “The wait time was never terrible, but in the process of looking at it, we discovered that no one was really happy with their experience in the waiting room. There was a chaos of movement,” says Mogayzel. They stationed a patient services coordinator out front to guide traffic and answer questions. “In terms of patient and parent satisfaction, that’s been as important as shortening the time people are in the waiting room,” he says.

Small Changes Add Up

Erik Hasenboehler is an assistant professor of orthopaedic surgery who practices at Hopkins Bayview’s Musculoskeletal Clinic, where appointments are typically long—many patients need casts removed and then new casts applied, time-consuming processes both. Along with ambulatory practice manager Carolyn Shiflett and charge nurse Kimberley Kries, Hasenboehler participated in AMP’s first cohort. The triad focused on lead time—the time from patient check-in to checkout—for Hasenboehler’s patients, with the goal of reducing it by 25 percent. Using Lean, the team refined their communication board system and created team pods, even though the physical space made that somewhat challenging. They also standardized equipment in the examination rooms and changed work flows so that patients were not moving as much between rooms.

They compared taking vital signs manually versus using a machine and found that the machine saved three minutes per patient.

“With as many as 120 patients per day, that adds up,” says Kries.

At the end of the project, Hasenboehler and his staff reduced lead time by 61 percent.

Tools to Use and Reuse

One advantage of the program, report several attendees, is that Lean methodology has equipped them to identify, then tackle problems outside and beyond the program. Mogayzel and his group, for instance, discovered that families found the checkout process lengthy and confusing. With the check-in process now streamlined, the team is looking for ways to do the same for checkout.

“When you keep looking at the rip in the wallpaper, you don’t see it anymore,” says Shiflett. “AMP gave us the opportunity to step back and look at things in a new light. And now we have tools to solve the problems we find.”

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