Continuous Improvement of Patient Flow Efficiency Through Lean Implementation: Technology and a Case Study

Lean Six Sigma is an adaptation of Toyota principles applied to healthcare processes and management. The idea is to improve the process of patient flow and patient care. Lean is a process “for identifying and eliminating waste and improving the flow of a process while engaging employees.”(1) Lean management in healthcare puts the customer first by implementing a pull system instead of a push scenario. In this environment, patient demand determines where providers spend their time.(2) In essence, the work today is done today, compared with the “push” environment, where it can be done tomorrow. By following this model, we improve not only the flow of patients through their visit, but satisfaction and outcomes as well.

Among the challenges with typical physician’s offices, the most critical are the wait times in the waiting room and in the exam room waiting to be seen. These result in very long door-to-door or turnaround times, causing decreased patient satisfaction and wasting a patient’s valuable time. By improving patient flow efficiency, the message is confirmed that the practice values and respects each patient and his or her valuable time. This ultimately improves the facility’s bottom line.

Lean Patient Flow and Continuous Improvement

Lean is best defined by Toussaint and Berry: “Lean is not a program; it is not a set of quality improvement tools; it is not a quick fix; it is not a responsibility that can be delegated. Rather, Lean is cultural transformation that changes how an organization works; no one stays on the sidelines in the quest to discover how to improve daily work . . . Lean is a journey, not a destination.”(3) Lean involves participation from all areas of an organization, from CEOs to frontline staff. The Lean culture creates “an insatiable appetite for improvement” by continually defining “what ‘good’ is.”(3)

The essence of Lean principles in healthcare focuses on continuous improvement (CI) (Figure 1). There is a growing demand for CI in today’s challenging healthcare environment. Medical practices have to focus on improving the overall patient experience to protect their financial security. CI permits the identification of opportunities to streamline workflows and reduce waste, and thereby decrease costs. It is “a systematic approach to process improvement by removing waste in order to maximize value for the end-user of the service and a commitment to respect, challenge and develop the people who work within the service to create a culture of continuous improvement.”(4) The system relies on continually asking, “How we are doing?” and “Can we do better?” CI emphasizes that most things can be improved, and with improvement comes better patient care and greater patient satisfaction.

Figure 1. Continuous improvement (Kaizen).

When waste is removed, the patient flow process becomes more streamlined.

Lean patient flow implementation in healthcare has many benefits that ultimately will bring more to the facility’s bottom line. Lean cuts out wasted time and resources and increases efficiency in treating patients, so that more patients can be seen or providers can spend more time with individual patients. This process not only allows for more time with each patient, but improves the overall safety and care of the patient. By improving the clinic’s efficiency, productivity is improved and wait times are reduced.

When waste is removed, the patient flow process becomes more streamlined, subsequently minimizing wait times and improving patient satisfaction. One of the other benefits of Lean is the positive impact on the return on investment (ROI). The more efficient the patient flow, the more time the provider can spend with each patients, the more patients they can see, or a combination of the two. All of this ultimately brings more money to the clinic’s bottom line.

Plan-Do-Check-Act

PDCA (plan-do-check-act) is a four-step method used for CI problem solving and enabling change (Figure 2). This continuous quality improvement cycle allows development strategies to be tested and measured to drive further advancement:

Figure 2. The PDCA model is a repetitive four-stage model for continuous improvement in business process management. The four stages are PLAN, DO, CHECK and ACT.

• The first step—Plan—involves the analysis of the challenge or challenges within the clinic or other healthcare environment. During this phase, the process is analyzed to determine where things are now and where they will go upon implementation. Considering problems uncovered during the analysis, the solutions are developed and then implemented in the next phase.

• The “Do” step is the physical execution of the solution decided upon in the first phase. This step of putting the Lean process into place inevitably reveals other problems along the way. Solving the problems throughout the process is the key to successful implementation of the solution. It is easy to revert to old habits. Standardization of the process helps maintain the change for the long term.(5)

• Checking the process once it is put into place ensures that the solution worked and is maintainable. Assessing the improvement of the key performance indicators (KPIs) and how they continue to improve gives proof that the solution was beneficial.

• The outcome of what was uncovered in the Check process determines what will continue in the Act step. If the goals were achieved, then the process can be standardized and maintained. If the implementation was unsuccessful, then a return to the Plan stage will be required to determine the cause of the failure and the need to find other solutions to the problem.

Continuous Improvement Leads to Lean Patient Flow Efficiency

Our company’s solution, the Expeditor Lean Patient Flow Solution, is composed of three modules that focus on improving the KPIs most critical to the improvement of patient care and patient satisfaction: waiting room wait time; wait time in the exam room; provider–patient encounter time; and overall door-to-door time. The components of this system are the Expeditor Light Signaling System, Real Time Patient Flow Monitor, and Lean Clinical Consulting with predicative analysis (Figure 3).

Figure 3. Continuous improvement: Lean patient flow efficiency process.

The first module, the Expeditor Light Signaling System, tracks one of the most crucial data points in a patient visit that can determine the patient’s ultimate satisfaction with the overall visit. Using a real-time one-way feed from the client’s electronic health record, waiting room wait times can be collected. Improving patient wait time at the beginning of a visit ultimately can improve patient satisfaction throughout the visit. Studies have shown that patients who have waited for extended periods of time before being placed in the exam room report decreased total satisfaction for the visit. Paying attention to this information enables the practice to improve wait times for patients and better set the schedule for the providers each day, ultimately improving patient satisfaction and overall patient care.

Expeditor’s core product is a fully customizable light signaling system that equips a practice with easy-to-use light panels positioned outside each exam room. These lights provide visual cues that are a simple way to manage which patient is to be seen next. This ultimately improves staff communication and decreases patient wait times, allowing a clinic to run at peak efficiency.

KPIs, set from national benchmarks, are gathered by the Expeditor Light System. With the push of specific buttons on the light panel, data are gathered from the moment the patient enters the exam room, including:

• Patient waiting room wait time;

• How long the patient waits in the exam room for the provider;

• How long the provider or any ancillary staff is with the patient;

• How long the assistant spends with the patient;

• How long the provider spends between patients;

• Provider time between patients; and

• Complete door-to-door visit time.

These data points are reflected on the real-time monitor positioned in the clinic and in an online metrics dashboard for each clinic. Immediate access to these times provides the clinic with insight into the level of efficiency in real-time, as well as with daily, weekly, and monthly data.

The Real-Time Patient Flow Monitor, or visual cue, is the second of the Expeditor Lean Patient Flow modules. The real-time monitor pulls data from the light system and allows clinics to see details of each stage of the patient visit. This allows immediate changes to be made and also promotes immediate staff conversations to resolve these challenges.

The real-time monitor clock starts when the patient enters the exam room and remains in the green status until the set KPI is exceeded, at which time it turns red. The staff is alerted that the predetermined ideal time for that portion of the visit has been exceeded, prompting the staff to intervene and move the visit along. All team members can see and manage patient activity from the real-time monitor screen, improving patient flow efficiency and promoting teamwork. Knowing what is currently happening eliminates physician downtime and overall patient wait time in the practice. Being able to see the actual elapsed time of each interaction with the patient in the room improves the flow of the patient through the visit, thus improving the patient’s satisfaction. The real-time monitor displays the key performance indicators at the right time so that they can be managed and monitored during your patient’s complete experience, from check-in to check-out.

The third module of the Expeditor Lean Patient Flow solution involves Lean Clinical Consulting, with predicative analysis provided to every client on a monthly or quarterly basis. From the data points gathered by the light system, formal analysis and consultations are provided by Expeditor’s team of Lean clinical consultants to help improve the patient flow and overall satisfaction within the facility. Each KPI produces the data that are compiled into a Lean patient flow efficiency scorecard each month. These scorecards show an average for the facility from a high level, but also include more specific provider data in the monthly and individual scorecards. Expeditor’s consultants provide scorecards monthly to their clients to highlight the areas of improvement. Each of the KPIs mentioned earlier in the article is collected.

Through monthly consultations and quarterly review, Expeditor’s Lean team provides regular monitoring of your patient’s complete experience from door to door, for the continued improvement of your clinic. A plan is developed to increase the overall patient flow efficiency and implement the necessary changes. The historical data, combined with the real-time monitor, form a yin and yang relationship: each relies on the other so that the efficiency of the clinic can be improved. By looking at all of this together, the Lean process is maximized, and the bottom line ultimately is improved. Our goal is to improve patient flow efficiency continuously each month.

Lean Case Study

With the implementation of Lean and a focus on value-based healthcare to improve the overall patient experience, one large multispecialty medical office clinic saw a throughput revenue increase. This was accomplished with the help of the Expeditor Lean Patient Flow Solution and monthly clinical consults where the data was analyzed.

In January 2016, this clinic installed the Expeditor Light System in six suites to improve clinic efficiency. Use of this system ultimately allowed the providers to see more patients per day and decrease overall visit time for each patient. One suite improved its turnaround time by 20 minutes, yielding even more ROI. The time savings resulted in seeing 36 more patients per day for six providers, thus gaining more than $1 million in additional revenue. Over the course of the year, more than 1600 hours of wasted time was recovered, enabling almost 2000 additional patients to be seen. In addition to revenue increase, patient satisfaction also was shown to increase greatly.

Through monthly consultations with the Expeditor Lean team, this clinic identified potential areas of improvement in each suite. The KPIs from the Light System were analyzed and compared with national benchmarks each month. The average data from each suite, as well as each provider or ancillary staff, are placed into a Balanced Scorecard to show where they fall with regard to each KPI. From these scorecards, improvements or deficiencies can be highlighted for the clinic to focus on and improve.

Conclusion

Improvement in the healthcare process has been greatly needed for some time. Using Lean Six Sigma and the Lean process to place greater focus on patients and their care is an ideal solution for the focus of value-based medicine. Eliminating time spent waiting, increasing the quality time spent with the patient, and improving their satisfaction is the goal in providing exceptional patient care. Application of the Expeditor Lean Patient Flow Measurement process enables a facility, big or small, to assess the patient throughput, including wait times, encounter times with the provider, and overall door-to-door times. The clinical consultants at Expeditor can help improve the process through Lean management and CI with monthly consultations on the data. With improvements made with the Expeditor process, the message is sent to the patients that they are valued and respected by the facility, thereby improving patient care and satisfaction.

References

1. Sperl T, Ptacek R, Trewn J. Practical Lean Six Sigma for Healthcare: Using the A3 and Lean Thinking to Improve Operational Performance in Hospitals, Clinics, and Physician Group Practices. Chelsea, MI: MCS Media; 2013.

2. Van Der Voort MR. how does “pull” work in a hospital? Lean Thinking in Healthcare. October 24, 2009. http://leanthinkinginhealthcare.blogspot.com/2009/10/how-does-pull-work-in-hospital.html .

3. Toussaint JS, Berry LL. The promise of lean in health care. Mayo Clinic Proc. 2013;88:74-82. http://www.mayoclinicproceedings.org/article/S0025-6196(12)00938-X/fulltext . doi: http://dx.doi.org/10.1016/
   j.mayocp.2012.07.025.

4. Clark DM, Silvester K, Knowles S. Lean management systems: creating a culture of continuous quality improvement. J Clin Pathol. 2013;66:638-643.

5. Roser C. (2016, April 29). The key to lean – plan, do, check, act! April 19, 2016. www.allaboutlean.com/pdca/ .