Step 5 – Expand the Scope
After running through Steps 1 through 4 you will have learned a lot. At this point if you were to go back and do it again, would you take a different approach? Chances are you would say yes. The good news is, now is your chance. Take your learnings, go back and expand the scope of your improvements with more confidence, innovation and expertise. Before you know it you will have transformed how your facility handles its patients.
Southlake Regional Health Centre in Newmarket implemented a system that is “making it faster for patients to register and check in for appointments, including out-patient tests, clinic visits and surgical procedures”.
Located in a designated high-growth area (York Region and South Simcoe – North of Toronto), Southlake is a 365 bed hospital that has seen a quadrupling in size over the past 10 years and handled approximately 600,000 visits in 2009. They implemented a new system last summer, and according to hospital staff “the system, which includes at-home pre-registration, as well as self-serve electronic kiosks and Welcome Centres on-site, is speeding up wait times by as much as 75 per-cent and saving the hospital as much as $400,000 annually”.
Southlake knew that it needed to embrace technology and a process redesign to keep pace with this explosive growth. Led by Judy Dewsbury, Manager, Patient Access, a project was undertaken to centralize scheduling and registration. Partnered with PatientWay, Southlake rolled out their new program over a six month trial period that began in their Cataract Clinic. The program proved to be such a success that it has now been implemented throughout the hospital. Southlake proudly touts their system with the slogan of “Welcome, we have been expecting you…” at key points in the hospital.
Southlake’s Chief Operating Officer at the time of implementation, Peter Finkle, explained that check-in times on day of procedure had improved to “three minutes from eight minutes” on average and he believed “the new technology would provide Southlake with an effective and creative solution to raise the bar in patient service, while increasing the efficiency of the hospital at the same time”.
The immediate benefits of the new technology included “improving the accuracy of patient registration data, expediting patient processing, and improving patient satisfaction as well as hospital productivity”.
After an extensive review of current industry practice, combined with an internal process review, Southlake concluded that a semi-centralized model with “Welcome Centres” located at key entry points to the hospital and supported by a centralized scheduling and preregistration team would yield efficiencies and patient flow simplification.
Here’s how the process works:
Using a two-step registration process a patient will pre-register on-line prior to their arrival. Upon arrival at the hospital on appointment day the patient can decide to swipe their ID card (health card, drivers license, etc.) at a user-friendly touch–screen “Express Check-in” kiosk or to visit a Welcome Centre for personal service. Regardless of which method the patient chooses, the hospital is notified of their arrival and ready for their appointment.
After a full year of using the new patient self-service system, the project generated several positive outcomes:
- 30% reduction in registration staff (redistributed 12 FTEs from the area of patient registrations to other functions within the hospital)
- 50% reduction in registration data errors
- 60% reduction in time to see a registration clerk
- Substantial reduction in the time to check-in to the hospital
- $400K annual operational savings
Because Southlake is aware that not all patients are technologically savvy, they established three on-sitr Welcome Centre’s to provide more traditional personal service. Peter Finkle assed that the Welcome Centres “are meant to transform the patient registration process upon arrival at the hospital from an administrative to a patient-centred approach of “Welcome, we re expecting you.”.
More and more hospitals and physician practices are adopting new technologies, including check-in kiosks and patient web portals. The majority of physicians polled said they will have electronic health records in place by 2013, which will surely drive the adoption of complementary applications that will streamline several processes including the patient registration and check-in experience. The time is now for Hospitals, Clinics and Physician practices to implement Patient Self Service solutions! The case is too strong not to invest in this technology.
Step 4 – Controlled Go-Live
Changing patient flow and registration process is a major change to how your facility operates. After carefully testing your new process, both manually, and then with the support of technology, you’re ready to put real patients through the paces. A controlled go-live will make everyone’s life easier.
Arrange with volunteer services to have a few more on hand and briefed on the change that is about to happen. When the time arrives start by asking a patient if they would be willing to go through a new registration process. Escort the patient through the process and carefully observe that it flows as expected. Watch how much assistance the patient requires and in general how smoothly it flows.
Once you have walked patients through the new process a few times you will be ready to step back and see the new process work for itself. After a reasonable number of successes you will be able to let the process fall to operate on its own and seek help if there is an issue.
Based on the success of this controlled go-live you will be able to make a decision to either a) keep it in operation or b) return to the original process while you readjust the new process. Ideally you will be in a position to keep the new process but it is important to plan for when things don’t work out as you had expected them.
Step 3 – Plan, Do, Check, and Act
LEAN shares a great concept with Agile software engineering: a series of smaller, easier to plan and implement projects is more effective than a single large, complicated and deeply planned project. LEAN refers to these small iterative improvement projects as “kaizen events”; Agile calls them sprints, cycles or iterations.
Rather than feeling pressured to choose between a large single project or a series of smaller sprints consider the following. Use your business case to create your overall implementation strategy. This is your compass that will keep you on course. Your implementation strategy defines your objectives and describes your strategy for realizing them. Think of your implementation strategy as your master plan with a lot of details “to be determined”.
Now, combining your overall implementation strategy with your learnings from your current and future state development you are in a great position to try your iteration (kaisen event, or small change project). Does this mean you need your technical solution for your future state? No. Although your future state will require new technology, system changes, and installation of new hardware, you do not need it to perform your first tests. To test if your future state/process even makes sense have people stand in for technology and use volunteers for patients.
After manually running through your future state does it make sense? Did you have to make any changes? If you like what you’ve discovered then it is time to move to a true implementation of your new, streamlined process.
Each technical implementation will vary depending on a variety of factors: 1) your existing systems and their openness, 2) the availability of your internal IT departments, and 3) flexibility of the new vendors you are bringing into the process. Your ideal vendors are ones that understand the agile nature of your process and will be able to partner with you in your series of iterative improvements (“kaizen events”).
Through out this process look for performance indicators you can measure. Initially these measurements may be performed manually by members of your team. Over time your technology solution will be capturing these measurements for you. What types of measurements can you identify? Here are a few ideas:
• Time spent waiting for a registrar
• Time spent with a registrar for new registrations
• Time spent with a registrar for repeat visits
• Number of patients on the wrong day
• Number of patients early or late for appointments
• Number of staff interruptions by patients needing directions • Staff and patient satisfaction
• Insurance denials due to data quality
• Payment collection
Step 2 – Develop an Ideal Future State/Process
With a good handle on your existing process to accept patients as well as surrounding factors like satisfaction, you have a great basis to design a new process. Again, this is where LEAN does an excellent job in guiding you through this activity. Your ideal state/ process will see the action items of value for the patient being completed as efficiently as possible.
From a patient’s perspective their ideal flow is they enter your facility, go straight to the clinician, be treated immediately and then leave. Since that will never happen, what are the minimum steps that must occur for the patient to receive their service? How can you accomplish this minimum number of steps with the least amount of effort?
When developing this future state try to adopt an impartial viewpoint. While for the past 25 years your registrars have always performed activity, is it truly necessary for a person to perform some of these actions? Where there is repetition and clearly defined rules there is the opportunity to have technology perform the job.
Revisit your desired outcomes from your business case. Here are some additional outcomes you might consider:
1. Improving the patient experience: By standardizing the patient flow, the level of confusion for patients has significantly decreased as they are pre-registered online prior to their visit and there is now one single point of contact in the main lobby for all scheduled visit check-ins.
2. Managing patient expectations and staff interaction: Patient expectations for service levels are met as they are given more control over their experience. Therefore, many of the routine activities such as visit check-ins and selective demographic field updates have been automated. The staff now has reason to enjoy their work environment with a new outlook on their position.
3. Enhanced staff productivity: As a result of enhanced staff productivity and better streamlining of the patient flow in areas such as outpatient services and the ER, the hospital has improved the quality of registration data and eliminated/redistributed FTEs – making it possible to achieve significant cost savings in the first year.
4. Elimination of many labor-intensive manual steps in the patient-admitting process. Direct entry by the patient helps reduce transcription errors and improves overall data accuracy. The ability to give immediate status on patient identification, communication, outstanding clinic time, as well as the future ability to collect funds via credit card swipe, gives these devices an easily definable financial return on investment. Many patients prefer the experience of check-in via kiosk to traditional nurse check-in, citing lack of queues and increased privacy and ease. The limited requirement for interaction with existing systems, coupled with the fact that kiosks do not change clinical workflow, makes them quick and nonintrusive to implement.
Step 1 – Understand Your Current State
How do you eat an elephant? Easy…one bite at a time!
If you’re responsible for 100 clinical areas and process 50,000 patients a month (or ale at it seems that way) you know there’s a problem but you’re not sure where. First, pick an area that you know has issues and if it gets fixed it will be noticed. High volume repeat visits are a good starting place to look.
Next assemble an ad-hoc team to walk through the process and understand what are the steps new and returning patients follow. Methodologies like LEAN are excellent in understanding how you do business today. Consider seeking out the help of someone who knows LEAN or another process engineering methodology.
Additional factors to consider in your current state
- Patient volumes per staff member
- Non-clinical to clinical real- estate ratio
- Patient flow from being parked to first clinical encounter
- Patient communication prior to arriving
- Wayfinding and signage
- Patient Satisfaction rates
- Frontline staff satisfaction
Muda: The Seven Wastes in LEAN
- Delay: Delay on the part of patients waiting for service
- Duplication: Duplication. Having to re-enter data, repeat details on forms, answer queries from several sources within the same organization, etc.
- Unnecessary Movement: Queuing several times, lack of “one-stop shopping”
- Unclear Communication: Seeking clarification, wasting time finding a location that may result in additional waste to assist.
- Lost Inventory: Inventory…The patient forgets or is unable to arrive for their scheduled appointment, perishable items such as isotopes are lost.
- Opportunity Lost: An opportunity lost to satisfy patients such as a failure to establish rapport, ignoring patients, perceived unfriendliness and rudeness.
- Errors: Errors in the service transaction such as data entry