Winning the war on waits, delays requires ‘continuous flow’ systems
Winning the war on waits, delays requires continuous flow’ systems
It’s something like just-in-time’ medicine
The campaign to reduce waits and delays in the health care system is far from over. Practitioners and administrators are constantly fighting the battles in facilities throughout the nation — and a number of them are winning.
Some of the warriors in this fight are completely redesigning their service delivery systems to do more things at the same time. Others are making less comprehensive changes instead, implementing relatively small procedural adjustments in order to bring system capacity more in line with demand. But no matter what actual course of action they — and you — take, the winners in these battles will be the clinicians that survive and thrive in an increasingly competitive health care services marketplace because those clinicians will be providing customers with quality care, delivered on a timely basis.
Queuing up vs. continuous flow
These winners will have to overcome a health care system where waits and delays affect all parties involved, says Donald M. Berwick, MD, president and CEO of the Boston-based Institute for Healthcare Improvement (IHI). "Everybody waits, not only the patients but also the doctors and staff," he says.
And they all suffer. "Waiting hurts everybody," says Berwick. "It hurts the doctors, nurses, and staff who have their work flow disrupted by delays." At the same time, "Just as the doctors wind up not knowing when they can get to patients, the patients themselves have no idea when they are going to be seen."
The origin of the problem lies within the design of the current health care system. Take the average clinical scheduling system, for example. "The system in use now is typically a batch’ system," he says. "It works by creating inventories of stacks, waiting lists, and queues," he explains, "which turns health care into a type of warehousing, which we know now is not an efficient way to operate."
Modern management techniques focus on a "continuous flow," explains Berwick. "This is a little bit like the just-in-time’ delivery systems you hear about in manufacturing." In the health care arena, "these systems are essentially same-day access systems with no-waiting, open-access designs," he says. The emphasis is on "doing today’s work today, instead of stacking up today’s work for tomorrow — which is why people wind up having to wait."
Do today’s work today
When a health care organization "does today’s work today," it establishes a scheduling process that basically asks the patient "when do you want to be seen." And that, says Berwick, "is when they get seen."
A simple enough concept, but the benefit is clear. "Not only do patients waitless, but staff feel less burdened," he points out. "The staff are not busy spending all their energy building and managing the long waiting lists and the enormous queues; they are using that energy to see patients."
The path from queue building to continuous flow/today’s work today operations isn’t particularly tortuous, but it does require a few changes in the way business is normally conducted in the health care business. Those that have successfully reduced waits and delays in their systems "have applied some simple rules and methods for profiling demand, scheduling services, and streamlining procedures — rules and methods that have been standard in many service industries other than health care for decades," says Berwick.
One of the key attributes of systems that have successfully attacked waits and delays is a high degree of internal communication and cooperation, he adds. "Practitioners cannot view themselves as islands.’ They have to be good citizens’ of their systems." Practitioners don’t have to work harder, "but they have to be willing to cooperate in new ways with each other, their support staffs, nurses, and others." Most of all, Berwick adds, "They have to be willing to make changes because if they don’t, they will always feel the effects of the waits and delays the same way they do today."
"You have to be willing to make changes," agrees Mark Murray, MD, MPA. Murray and his nurse Catherine Tantau are cited by Berwick as having "produced same-day access and nearly wait-free patient flow for ill patients at Kaiser Permanente’s Roseville Medical Center" in Sacramento, CA. They also reduced delays for routine appointments from 55 days to one day — all with no expansion in staff.
Delays are built into the fabric of today’s health care business, according to Murray. "While delays are considered bad in most industries, in health care they are part of the way we think. If I send a patient to a dermatologist, for example, there is immediately a distinction made between whether this is a skin rash that is urgent or is it one that can wait," he says.
Multiply that one patient by thousands, and you’ve got a system where no one is happy. "The problem [at Roseville] manifested itself in the early 1990s," says Murray, "in the form of long waits for appointments, disgruntled physicians, dissatisfied patients, and a flat growth rate." Customer surveys taken at the time indicated that the ability to see their own doctor and have access to him/her when they chose were two factors of primary importance to patients, he says. "So we built our system around them."
The first step was to get rid of the facility’s urgent care clinic. "People think they can solve any access problems they have with urgent care clinics," says Murray. But in reality, "the urgent care clinic makes things worse. Patients have to wait, and they don’t get to see their own doctors."
Next on the agenda was reducing the waiting time for routine appointments. An analysis of demand at Roseville showed that the backlog, which generated the 55-day average wait, had held steady over time. "The backlog was always the same, which told us that supply and demand were in equilibrium, and that we were in a steady state,’" says Murray.
With a longstanding balance between supply and demand at the 55-day-wait level, all Roseville had to do to eliminate delays was get rid of its backlog. "We increased our capacity for the short period of time it took to get the backlog reduced," he says. Once the backlog was absorbed, the average waiting time for routine appointments dropped to one day. "Patient and physician satisfaction increased," adds Murray, "as well as our growth, as measured by numbers of new patients."
The Roseville experience has been replicated by Murray and Tantau at a number of other organizations and has proven especially successful in fee-for-service environments, he says. In all types of health care service environments, the keys to success in efforts to reduce waits and delays include overcoming the resistance of the doctors who feel demand is insatiable (it is not, says Murray) and building systems around what patients want. Also, "You’ve got to have the right ideas," says Murray, "and talk with someone who has experience."
There were problems with delays in the operating room until about three years ago at Sewickley (PA) Valley Hospital. The median delay was measured at around 80 minutes, a situation creating a variety of problems for expensive surgical personnel, anxious patients, and worried families. Working in collaboration with IHI, the hospital was able to bring that delay down to less than 10 minutes in the space of three months.
It didn’t take that much time, but it took a lot of work to reduce waits and delays at Sewickley Valley. "One thing we really had to crack down on was the preoperative process," says Marcia Cifrulak, perioperative manager of surgical services. "It doesn’t matter what you do in the OR to trim time. You can cut turnover times and do all sorts of process improvements," she notes. "But all of that accomplishes nothing if your patients are not ready for surgery when you call them."
One key to attacking the delay problem at Sewickley was making sure all hospital staff involved used the same point of reference in coordinating their actions. Differing perspectives among nurses, anesthesiologists, and surgeons about what exactly constitutes the "start time" for surgery required the creation of a formal, universal definition, says Cifrulak. "We defined incision time as the start time for surgery, educated everybody involved on this point, and made sure they knew that the patient had to be ready to leave for the OR a minimum of half an hour before that time."
Another key action, "so simple and costing nothing," was using Sewickley’s computer-based, actual-surgery-times reporting system, a common feature in most ORs, according to Cifrulak. "Most people choose to ignore these reports," which provide information on individual practitioner times for procedures, "and wind up suffering delays because they set up schedules that are impossible for anyone to follow," she says.
And finally, "We had to get our people to view surgical services as one department, not a bunch of little kingdoms," says Cifrulak. "If you are used to having a lot of strict departmental definitions where everyone is territorial and doesn’t cross lines, you’ll never get anywhere."
Even limited cross-training of staff to improve communication and understanding between departments involved in the delay-reducing effort pays dividends, says Cifrulak. "One thing we have told our people is that we never want to hear the term that’s not my job,’" she says. "Instead, we encourage a spirit of cooperation, where any problem that comes up is of mutual concern and we all work together to fix it."
[For further information, contact:
• Institute for Healthcare Improvement, 135 Francis St., Boston, MA 02215. Telephone: (617) 754-4852. Fax: (617) 754-4865. Web site: www.ihi.org.
• Mark Murray, MD, MPA, Catherine Tantau, Murray, Tantau & Associates, 2209 Capital Ave., Sacramento, CA 95816. Telephone: (530) 273-6550. E-mail: [email protected] or [email protected].
• Sewickley Valley Hospital, 720 Blackburn Road, Sewickley, PA 15143. Telephone: (412) 741-6600.]
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