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Lean workflow training points the way to reducing staff stress and providing more timely care

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This article was originally published in July 2009.

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Qualis Health led a cross-functional team from the University of Washington (UW) Neighborhood Clinics through a three-day course on Lean methodology and helped the team understand, identify, and prevent “waste” of all kinds—especially wasted time in the form of phone tag between medical assistants, physicians, and patients.

With a new workflow in place, patients are now able to get immediate answers to their clinical questions, instead of waiting days for a response. According to one patient, “We have been patients here for over seven years. Having a triage nurse take my call and expedite communications with the doctor has to be the best addition to the clinic yet.”

So, how did the wait times grow so long, and how did the team prune them back again so effectively?

Unintended consequences of a “virtual front desk”

After opening in the late 1990s, the UW Neighborhood Clinics established a “virtual front desk” call center, staffed by non-clinical phone operators, to handle incoming patient telephone calls for all its clinics. The goal was to achieve economies of scale for incoming appointment calls and free up the clinics’ actual front desks to concentrate on checking in patients.

However, one unintended consequence of this otherwise efficient system was that patients calling for clinical advice often had to wait several days for someone to call them back. (Messages regarding their calls were entered into a standardized form and sent electronically to the clinics, where medical assistants were responsible for processing the calls along with their myriad other duties.)

Qualis Health provides training and guidance

In 2007, Qualis Health was invited to evaluate the Network’s processes and help them figure out how to redesign the call-handling processes in order to provide better and more efficient patient care.

Jeff Hummel, MD MPH, who led the effort for Qualis Health, said, “Although it was unintentional, the system had been designed so that there was literally zero chance of a patient getting an answer to their clinical question on their first call to the clinic. We approached the workshop design with the concept that the goal should be to get the question to a person who could answer it as quickly and efficiently as possible.”

The workshop, which included Network administrative staff, healthcare providers, representatives from every clinic in the Network, and several people whose jobs included answering phones, was broken down into three phases:

  • The first phase was designed to establish goals for the project and make sure that all of the participants understood all the different kinds of waste that can be found in dysfunctional workflows. Succinctly stated, the arrived-at goal was to design an advice call process that worked as well when the clinics were open as it did when they were closed. (During off hours, calls were routed directly to a nurse at nearby Harborview Hospital, who had the ability to answer clinical questions immediately.)
     
  • The second phase had participants map out, in very specific detail, all of the steps that occurred each time a patient-advice call came into the virtual front desk. This process identified a long and convoluted string of callbacks, phone tag, checks, and rechecks passing between medical assistants, physicians, and patients.
     
  • In the third phase of the workshop, the participants combined their goals and what they had learned about waste with all of the ideas for improvement that came up during the mapping of the current workflow, whereupon they designed a “future state” that they thought would accomplish their goal. They then designed a small-scale test of their future state to make sure it actually worked before rolling it out to the organization as a whole.
     

Pilot project shows immediate promise

The pilot project was carried out for one week at a single clinic. A physician assistant wore a phone headset throughout the day to answer patient calls directly (with no call center as the intermediary). This new structure dramatically lowered stress levels at the pilot clinic—since medical assistants (who had neither the time nor the training to handle the calls effectively) were no longer responsible for the calls, and since physicians were no longer interrupted by the advice calls.

On top of the impact at the pilot site itself, the other Network clinics noticed a reduction in the amount of spillover work and were able to operate more effectively as well.

The pilot was so successful that the leadership realized they could not go back to the old workflow. It became clear to all that the cost of not answering clinical advice calls directly, in terms of wasted staff time and patient frustration, was far greater than the cost of hiring a nurse to answer the calls as they came in the first time.

New workflow spreads throughout the Network

Over the course of the following six months, each clinic hired a triage nurse to fill the role the physician’s assistant had played in the pilot. This freed up physician time to focus on patients who really needed their attention, while the nurses were able to handle less urgent phone questions on their own. “The work Qualis Health did is probably responsible for having nurses in our clinics at all,” said Jan Schurman, Director for Clinical Systems at UW Neighborhood Clinics.