When patient appointments at The Vanderbilt Clinic (TVC) weren’t beginning on time, everyone thought they knew the reason. Either patients weren’t getting checked in on time or physicians were delayed, or maybe both issues were contributing to the problem.
But once a group of leaders at Vanderbilt University Medical Center (VUMC), including clinicians, administrative staff and organizational experts, sat down and applied Lean process improvement methods to dig to the problem’s root, they discovered appointments were veering off schedule largely because patients were indeed not arriving on time. And it wasn’t because they didn’t set their alarm clocks. They were arriving after their scheduled appointment time because they didn’t know where to park and couldn’t find their specific clinic once they did get parked.
“Instead of jumping straight to solutions, Lean asks, ‘Wait, what are the five Whys?’” said Erin Dietrich, MBA, a Health Operation Systems consultant in the VUMC Operations Improvement Department.
“The problem is that appointments don’t begin on time. Why? ‘Because the provider is late.’ Well, we found data that proved that was wrong. Why? ‘The patient service representatives don’t check patients in fast enough.’ We looked at the data, and that was totally wrong. We went through five Whys, and we finally got down to the fact that patients were delayed in arriving to their appointments. And the reason they were delayed was because they didn’t know where to park and couldn’t find the clinic.”
This fact-finding group exercise was part of a year-long initiative called The Vanderbilt Clinic Model (TVCM), during which more than 30 VUMC physicians, nurses, staff and organizational experts met regularly to examine six areas related to clinic flow and the patient experience with the goal of creating “a consistent experience for the patient while facilitating an efficient and meaningful professional experience for clinical teams.”
TVCM was led by Paul Sternberg Jr., M.D., Chief Medical Officer for Vanderbilt Medical Group and Chief Patient Experience Officer for VUMC; Titus Daniels, M.D., MPH, MMHC, Executive Director of the Vanderbilt Medical Group (VMG) and Chief Operating Officer for Adult Clinic Operations at VUMC; Dietrich and Jenny Slaughter, R.N., MMHC, principal relationship manager for Health IT.
“When we were making the conversion from ICD-9 to the ICD-10 medical coding system in 2015, we discovered variations in both the flow of clinics and in the patient experience at our different clinics,” said Sternberg. “We realized we had time to address inconsistencies before the Epic software system comes online in November 2017. Putting Lean methodology to work to do this made sense.”
Lean is a process improvement method first developed by Toyota, and its core concept is maximizing customer value while minimizing waste. As health care facilities in the United States seek ways to increase the quality and efficiency of patient care, many have turned to tools such as Lean to standardize and improve the daily processes of their staff. Many VUMC executives, including Sternberg and Daniels, have participated in executive site visits at Denver Health’s Lean Academy, a leading training center that caters to health care systems.
TVCM is just one initiative Medical Center leaders have used to engage employees in applying Lean concepts to their practices. The VUMC Operations Improvement Department has several Lean facilitators who lead exercises for others on campus. VUMC executives meet weekly to identify Lean initiatives, and already, many groups have applied Lean to their processes.
For example, a multidisciplinary initiative in Neurology this year achieved a 61 percent reduction in the time general Neurology patients remained hospitalized without a medical reason.
Vanderbilt University School of Nursing also offers a Lean Methodology in Health Care course for graduate students, and Lean training will be offered to medical center employees in 2017.
Daniel Biller, M.D., MMHC, associate professor of Clinical Obstetrics and Gynecology, was the clinical leader for the workgroup charged with discovering why patients weren’t “in room and ready” for appointments. He had previously received training in Lean methodology during his Master of Management in Health Care (MMHC) coursework at Vanderbilt Owen Graduate School of Management and was thrilled to hear Lean would be applied in this project.
“We were able to use Lean methodology to identify where the real bottlenecks were,” he said. “Using that methodology gave us a framework to identify, implement and perform a test of change to see if our interventions actually improved throughput as well as patient satisfaction. The Lean process was robust, and that allowed us to prove or disprove our theories in an efficient, effective manner.”
As a result of the TVCM process, clinics are making changes to address the problem of getting patients into rooms by adding phone calls from staff to patients 48 hours before their appointments so they can confirm appointments, ensure they know how to get there and where to park, and communicate that they need to get to the clinic earlier than their actual appointment time to complete the check-in process.
Projects or “work streams” addressed by TVCM included:
• “In Room and Ready,” led by Biller; Cynthia Biggers and Brenda Pesek. This group focused on better ways to get patients into rooms, ready to be seen by providers.
• “Pre-visit Information,” led by Sean Donahue, M.D., Ph.D., Sam and Darthea Coleman Professor of Pediatric Ophthalmology, Seth Smith and Jodi Fawcett. This group defined ways to improve the consistent collection of pre-visit patient information.
• “First Impressions,” led by Rick Abramson, M.D., assistant professor of Radiology and Radiological Sciences, Shellian Elliott and E.B. Jackson. This group examined the check-in process, as well as ways to best support the role of the patient service representative.
• “New Patient Letter/Map,” led by Abramson, Lane Stiles and Carol McCorkle. This group worked to streamline the process for generating new patient letters and created an updated medical campus map.
• “Just Say Yes,” led by Jeffrey Martus, M.D., assistant professor of Pediatric Orthopaedics, and LeaRae Herron-Rice. This group worked toward a patient-centered approach to new patient access to VUMC by reviewing current state, defining the preferred future state, and then implementing a test of change via a best practice model.
• “Post-discharge Follow-up Appointments,” led by Karen Bloch, M.D., associate professor of Infectious Disease, and Sheryl Redlin-Frazier. This group developed a standardized operation procedure to ensure that patients being discharged from VUH get timely follow-up clinic appointments. This included the development of a tracking mechanism for scheduling rates and cancellation/no shows.
“This exercise proved that when we put our minds together, we can make significant, achievable changes in how we work that benefit both our patients and our employees,” said Daniels.
“Teaching and applying Lean principles at Vanderbilt is not a flavor of the moment; this is how we do business. And as we move forward with sharpening our strategic focus for fiscal year 2017, it makes sense to apply Lean thinking to every aspect of our operation.”
