MANAGED CARE July 2002. ©MediMedia USA
"Physicians are always amazed when I tell them that only 50 percent of their work day is productive time," says Sherry Delio, an expert in clinical practice work flow and efficiency.
"They say, 'I can't believe that. I worked all day.' I say, 'Yes, but you had a lot of waits and delays.'"
Delio, director of clinical programs at St. Joseph's Hospital in Phoenix, is responsible for patient satisfaction and work measurement and flow. She has studied time-use patterns of hundreds of physicians, and is the author of Perfect Practice for an Efficient Physician [1].
Unfortunately, inefficient office practice is so common that its symptoms have become a cliché — a chaotic work environment, long waits, backed-up telephone lines, low staff morale, and high employee turnover. Sounds like great material for a new prime time series, except that it also translates into low-quality care, patient dissatisfaction, and lost revenue.
Charles Burger, MD, a family practitioner, thinks one reason for this sorry state of affairs is that most physicians simply aren't very good at thinking about their practices in terms of systems, work flow, and value. Even if they are, they may not have the time. "How do you paint the boat while you're sailing it?" Burger asks.
Burger years ago solved this dilemma by hiring people with the right skills to assist with office redesign. These people — called human relations developers — are trained in systems thinking, use of data for decision making, customer service, and communication skills, and are committed to continual improvement. At Norumbega Medical Group, a 35-provider primary care practice in Bangor, Maine, where Burger is CEO, their charge was to rationalize work flow and train staff members in new programs.
"Physicians need to work closely with people trained in process development and total quality concepts — people who know how to take ideas and operationalize them, transform them into systems," says Burger.
Need more Toyotas
A second reason for inefficiency in physician office practices and other environments of care is that notions of workplace efficiency, value, and quality that have evolved over the last several decades are only recently being applied in health care. Thanks in large part to Japanese innovations in car manufacturing, these ideas have been embraced since at least the 1980s by leading enterprises in all sectors of the global economy.
Books such as The Machine That Changed the World, Lean Thinking, The Goal, and Learning to See build on the Total Quality Management revolution of the 1980s and are profoundly influential in today's health care improvement community. The concepts they espouse (flow, lean thinking, managing constraints, and eliminating waste) are incorporated in the Institute for Healthcare Improvement's Idealized Design initiatives and Impact (for IMProvement ACTion), a new international network of health care organizations committed to improving patient care www.ihi.org [2].
According to these new principles, much of what we used to think of as efficient really isn't. For example, many providers dictate their notes at the end of the day because they think it's more efficient to do all their charting after the office closes. In reality, this practice unnecessarily lengthens the work day and degrades the value of the documentation in those charts. Recall can't possibly be what it was during the actual patient encounter.
This example of "batching and queueing," with its built-in backflow and quality problems, has other counterparts in the typical office practice: keying charge tickets en masse at the end of the day instead of when patients check out, and batching prescription refill requests instead of training staff members to handle most of these requests through simple protocols.
"Real-time work means we don't batch," says Delio. "The first thing I look at is real-time work. I think that's the key to everything we do in health care today."
To generate maximum value, real-time work has to "flow," a central concept of lean thinking. In office practice, for example, value resides in the face time between patient and provider. The flow of this value stream is maximized by eliminating waiting, waste, and re-work.
In "Key Changes for Improving Office Efficiency," a presentation that they give, Charles Kilo, MD, MPH, and Gordon Moore, MD, contrast a typical office visit with one in which unnecessary waiting and wasted steps have been eliminated. Face time (14 minutes in each case) accounted for only 30 percent of total time spent in a standard office practice, but 65 percent where their improvements had been implemented.
Kilo, an internist, is a fellow of the IHI and CEO of GreenField Health System in Portland, Ore. Moore, a family physician in private practice, is an assistant quality officer at Strong Health/University of Rochester Medical Center, helping clinical teams and departments in their transition to lean production. He is also a senior instructor in family medicine and in community and preventive medicine at the University of Rochester, and is on the faculty of IHI's program on access and efficiency.
Flow charts
The first step in increasing practice efficiency is to diagram patient flow ("First, the patient checks in, then she ..."), then paper flow, and then what each provider and staff person does. The second is to measure patients' progress through the system, as well as what providers and staff members do, to find out where the waits, delays, errors, and waste are.
"If you can't explain what you do, you can't improve it," says Delio. "Putting it on paper shows there's a process. Without a process, we have chaos."
Eliminating waste, maximizing productivity, and measuring progress is hard work. It means optimizing the care team, training staff members, and meeting regularly to discuss how processes can be improved — perhaps even reconfiguring the physical layout of the practice. Kilo believes that this analysis and planning is the hardest part of initiating change, and that its value isn't appreciated.
"Focused time to review work processes, at least once a quarter on a Saturday morning or for a structured half day on the slowest day of the week, can be time worth spending," says Kilo. "It's really the only way to get the work done, and everybody can come out much happier," he says.
Physicians who think they're already under too much pressure probably have the most to gain from improving their practice efficiency. According to Delio's findings, a relatively modest investment in efficiency could pay off in higher quality care, greater job satisfaction, and increased revenue. The challenge is to work smarter, not harder.
But it won't happen overnight, cautions Linda Turner, human relations developer at Norumbega Medical Group. She has worked with Burger for over 20 years, helping to build what may be one of the most efficient, innovative, and quality-driven group practices in the country.
Turner has completed courses in advanced TQM that that help her teach providers and staff members — many of whom also have TQM training — to use contemporary information technology, analyzing appropriate data to refine work processes.
But it wasn't always like that. Turner remembers how, years ago, she would send out for pizza to "celebrate" discussions of mistakes at group meetings. She saw those as opportunities to improve the system — "We called it buried treasure," she says. "Once it got rolling, they didn't even ask for the pizza any more. Finding the mistakes was enough in itself."
She tells the story to emphasize the critical role of corporate culture in initiating and sustaining long-term change. Another key ingredient is the participation and leadership of physicians, not only in changing the culture, but in improving and integrating their own work processes with everyone else's in the practice.