Analysis and Improvement of Processes

A general internal medicine practice analyzed current processes and identified improvements that could lead to better efficiencies and reductions in waste. Every member of the practice—including physicians, nurse practitioners, nurses, and secretaries—completed the Practice Core and Supporting Processes Assessment (Table 6.3). This revealed that the diagnostic test reporting process needed to be improved by shortening the time taken to report results to providers and patients. After flowcharting the process—which revealed rework, waste, delay, and long cycle times— the group brainstormed and then rank-ordered improvement ideas. It decided to test the idea of holding a huddle at the beginning of each day to review diagnostic test results and to specify actions to take. The aim was to eliminate extra phone calls from the patients and delays in taking action due to waiting for the provider to respond. All the group members would know the action plan after huddling with the provider.

Using the plan-do-study-act (PDSA) method the team conducted its small test of change. Within two weeks patient phone calls for laboratory results had decreased, reflecting the fact that staff were now calling patients in a timely manner about their results. (For more information about analysis and improvement see Nelson, Splaine, et al., 1998; Langley, Nolan, Norman, Provost, & Nolan, 1996.)

Know Your Patterns. Each microsystem's particular combination of patients, professionals, and processes creates patterns that reflect routine ways of thinking, feeling, and behaving on the part of both patients and staff in that system. The patterns are also related to the typical results and outcomes—and variations thereof—associated with the microsystem's mission. Some patterns will be well known and talked about (for example, hours of service, busy times of the day or week, common hassles, and bottlenecks). Some patterns may be well known and never discussed (sacred cows). And some may be unrecognized by staff and patients but nevertheless have powerful effects (for example, mistrust stemming



Works Small Well Problem

We're Source of Real Totally Cannot Working Patient

Problem Broken Rate on It Complaint

Appointment system Answering phones Messaging

Scheduling procedures Reporting diagnostic test results Prescription renewals Making referrals Preauthorization for services Billing and coding Phone advice

Assignment of patients to our practice Orientation of patients to our practice New patient workups Education for patients and families Prevention assessment and activities Chronic disease management

Note: Each of the processes is rated by each staff member using the categories shown. If the process is a source of patient complaint, that is also noted.

from a local culture dominated by historical divides that separate staff with different educational backgrounds, such as nurses, receptionists, physicians, and technicians). Answering the following questions will reveal important underlying patterns in the microsystem:

• What is the leadership style?

• How do we act out the mission of our clinical microsystem every day?

• What are the cultural patterns (the norms, sentiments, and beliefs) in our practice setting?

• What barriers tend to separate health professionals and administrative support staff?

• How easy is it to ask a question about patient care?

• How often does the entire staff meet for the purpose of planning services that are patient centered?

• How satisfied are patients with their access to services?

• How do patients feel about the goodness of their outcomes and the costs of receiving care?

• How do we respond to disruptions of our routines?

• How do we notice the failure of our systems that we depend on to prevent accidents and harm to our patients?

Putting It All Together: Planning Services

Based on its assessment, or diagnosis, a microsystem can now help itself improve the things that need to be done better. Once we have knowledge of the purpose, patients, professionals, processes, and patterns, what can we proactively plan for in our daily work to enhance the functioning of our microsystem? Planning services is designed to do the following:

• Decrease unnecessary variation.

• Build feed-forward and feedback mechanisms for informed decision making.

• Promote efficiency by continuously removing waste and rework.

• Create processes and systems that support staff to be the best they can be.

• Design smooth, effective, and safe patient care services that lead to measurably improved patient outcomes.

• Flowchart or specify core processes, supporting processes, and playbooks.

Figure 6.1 offers a panoramic view of a primary care clinical microsystem. It suggests the interplay of patients with practice staff and with processes, which in


Microsystem Name Purpose Core Processes


People with health care needs

Healthy Chronic

High risk

High risk



(Prevention)( Acute )Çchronic )( Palliativ"^( Educate )

People with health care needs met

Functional - Biological fe-HM Expectations


(Prevention)( Acute )Çchronic )( Palliativ"^( Educate )

People with health care needs met

Functional - Biological fe-HM Expectations




Skill Mix: MDs_RNs_NP/PAs_MA_LPN_SECs_

Measuring Team Performance & Patient Outcomes and Costs







Chronic turn produces patterns that characterize the microsystem's performance. Managing these patterns can result in the best health care for patients and for microsystem staff. Typical supporting processes in a primary care practice include such activities as renewing prescriptions, reporting diagnostic test results to patients, and making referrals.

Flowcharts can be used to diagram and diagnose each process to learn how to redesign it to maximize efficiency. This tool is particularly valuable with core or supporting processes whose patterns are characterized by hassles, bottlenecks, and mistakes. Many clinical microsystems have used the methods in Part Two of this book for guided discovery and for taking actions to redesign their services; some examples of their work are provided in Table 6.4.

A review of some of the microsystem improvement efforts to which we have contributed has uncovered many common sources of waste. Table 6.5 summarizes some of these sources and recommends ways to reduce waste and improve efficiency.

A clinical microsystem might ultimately build its own playbook—an organized collection of flowcharted processes that can be used for training, performance management, and improvement. The playbook can be used for educating new staff, cross-training staff, managing performance, and troubleshooting because it describes how processes should work.


To be able to intentionally plan services and care for populations of patients and individual patients, high-performing clinical microsystems meet regularly to review current process and outcomes to match with patient needs.

Intentional Planning of Services and the Value of Meeting for Service Planning. Our study of microsystems in health care revealed that high-performing units intentionally designed patient-centered services to support patients and families and the staff providing care. As shown in the Evergreen Woods case study, planning services can be intentional and well orchestrated. Moreover, it should be supported by a continuous flow of data (for example, data can be produced throughout the day to identify unfilled appointment slots) to inform every member of the microsystem, to drive corrective actions (any staff person can schedule patients into unfilled slots anytime during the day), and to spawn improvements (at monthly all-staff meetings and annual retreats).

The service sector has many examples of people coming together to plan the services they deliver. In good restaurants, waiters, cooks, and hostesses preview the menus for the day and cover strategies to ensure that the meal service is


Know Your Patients


Actions Taken

1. Age distribution

2. Disease identification

3. Health outcomes

Most frequent diagnosis

5. Patient satisfaction

Know Your Professionals

30% of our patients are > 66 years old

We do not know what percentage of our patients have diabetes.

Do not know what the range of HbAlc is for our patients with diabetes, or if they are receiving appropriate ADA-recommended care in a timely fashion.

We learned we had a large number of patients with stable hypertension and diabetes seeing the physician frequently. We also learned that during certain seasons we had huge volumes of pharyngitis and poison ivy.

We don't know what patients think unless they complain to us.


Designed special group visits to review specific needs of this age group, including physical limitations, dietary considerations.

Team reviewed coding and billing data to determine approximate numbers of patients with diabetes.

Team conducted a chart audit with 50 charts during a lunch hour. Using a tool designed to track outcomes, each member of the team reviewed 5 charts and noted the findings on the audit tool.

Designed and tested a new model of care delivery for stable hypertension and diabetes, optimizing the RN role in the practice using agreed-upon guidelines, protocols, and tools.

Implemented the point of service patient survey, patients completed and left in a box before leaving the practice.

Actions Taken

1. Provider FTE

2. Schedules

3. Regular meetings

4. Hours of operation

5. Activity surveys

We were making assumptions about provider time in the clinic without really understanding how much time providers are out of the clinic with hospital rounds, nursing home rounds, and so on.

Several providers are gone at the same time every week, so one provider is often left and the entire staff work overtime that day.

The doctors meet together every other week. The secretaries meet once a month.

The beginning and the end of the day are always chaotic. We realized we are on the route for patients between home and work and they want to be seen when we are not open.

All roles are not being used to their maximum. RNs only room patients and take vital signs, medical assistants doing a great deal of secretarial paperwork, and some secretaries are giving out medical advice.

Changed our scheduling process; utilized RNs to provide care for certain subpopulations.

Evaluated the scheduling template to even out each provider's time to provide consistent coverage of the clinic.

Began holding an entire practice meeting every other week on Wednesdays to help the practice become a team.

Opened one hour earlier and stayed open one hour later each day. The heavy demand was managed better and overtime dropped.

Roles have been redesigned and matched to individual education, training, and licensure.

Know Your Processes


Actions Taken

1. Cycle time

Patient lengths of visits vary a great deal. There are many delays.

2. Key supporting None of us could agree on how things get done in processes our practice.

3. Indirect patient pulls The providers are interrupted in their patient care process frequently. The number one reason is to retrieve missing equipment and supplies from the exam room.

Know your Patterns


The team identified actions to eliminate and steps to combine and learned to prepare the charts for the patient visit before the patient arrives. The team also holds daily huddles to inform everyone on the plan of the day and any issues to consider throughout the day.

Detailed flowcharting of our practice to determine how to streamline and do in a consistent manner.

The team agreed on standardization of exam rooms and minimum inventory lists that were posted on the inside cabinet doors. A process was also determined for who would stock exam rooms regularly and how the rooms would be stocked, and through the use of an assignment sheet, people for this task were identified and held accountable.

Actions Taken

1. Demand on the practice

2. Communication

3. Cultural

4. Outcomes

5. Finances

There are peaks and lows for the practice, depending on day of the week, session of the day, or season of the year.

We do not communicate in a timely way, nor do we have a standard forum in which to communicate.

The doctors don't really spend time with nondoctors.

We really have not paid attention to our practice outcomes.

Only the doctors and the practice manager know about the practice money.

The team identified actions to eliminate and steps to combine, and learned to prepare the charts for the patient visit before the patient arrives. The team also holds daily huddles to inform everyone on the plan of the day and any issues to consider throughout the day.

Every other week practice meetings are held to help communication and e-mail use by all staff and to promote timely communication.

The team meetings and heightened awareness of behaviors have helped improve this.

Began tracking and awareness and posting results on a data wall to keep us alert to outcomes.

Finances are discussed at the team meetings and everyone is learning how all of us make a difference in practice financial performance.

Note: HbAlc = glycosylated hemoglobin; ADA = American Diabetes Association; URI = upper respiratory infection.



Common High-Yield Wastes

Recommended Methods to Reduce Waste

Traps to Avoid

1. Exam rooms not stocked or standardized: missing equipment or supplies.

2. Too many appointment types, which creates chaos in scheduling.

3. Poor communication among the providers and support staff about clinical sessions and patient needs.

4. Missing information or chart for patient visits.

5. Confusing messaging system.

5. High number of prescription renewal requests via phones.

Create standard inventory of supplies for all exam rooms. Design process for regular stocking of exam rooms, with accountable person. Standardize and utilize all exam rooms.

Reduce appointment types to 2 to 4.

Use standard building blocks to create flexibility in schedule.

Conduct daily morning huddles to provide a forum to review the schedule, anticipate the needs of patients, and plan supplies and information needed for a highly productive interaction between patient and provider.

Review patient charts before the patient arrives—it is recommended this be done the day before to ensure information and test results are available to support the patient visit.

Standardize messaging process for all providers. Educate and train on messaging content. Use a process with a prioritization method, such as a bin system in each provider office

Anticipate needs of the patients.

Create reminder systems in the office, such as posters, screen savers.

Standardize the information support staff obtain from patients before the provider visit—include prescription information and needs.

Don't assume rooms are being stocked regularly—track and measure. Providers will use only "their own" rooms. Providers cannot agree upon standard supplies— suggest "testing."

People are not showing up for the scheduled huddle—gain the support of providers who are interested; test the idea and measure the results. Huddle lasts longer than 15 minutes—use a worksheet to guide the huddle. Avoid doing chart review when patient is present.

If you have computerized access to test results, don't print the results.

Providers may want their own way—this adds confusion for supply staff and decreases cross-coverage capacity.

Content of message can't be agreed upon—test something!

It doesn't need to be the RN who takes the call— medical assistants can obtain this information.

7. Staff frustrated in roles and unable to see new ways to function.

8. Appointment schedules have limited same-day appointment slots.

9. Missed disease-specific or preventive interventions and tracking.

10. Poor communication and interactions between members.

11. High no-show rate among patients.

12. Patient expectations for visit not met, resulting in phone calls and repeat visits.

Review current roles and functions, using activity survey sheets.

Match education, training, licensure to function. Optimize every role. Eliminate functions.

Evaluate follow-up appointment and return visit necessity. Extend the intervals of standard follow-up visits. Consider RN visits.

Evaluate the use of protocols and guidelines to provide advice for home care— Use flowcharts to track preventive activities and disease-specific interventions.

Use "stickers" on charts to alert staff to preventive or disease-specific needs.

Review charts before patient visit.

Hold weekly team meetings to review practice outcomes, staff concerns, improvement opportunities.

Consider improving same-day access.

Use CARE vital sign sheet.

Evaluate patient at time of visit to determine whether their needs were met.

Be sure to focus on talent, training, and scope of practice, not on individual people.

Do not set a certain number of same-day appointments without allowing for variations throughout the year.

Be alert to creating a system for multiple diseases, and do not use many stickers and many registries.

Hold weekly meetings on a regular day and at a regular time and place.

Do not cancel—make the meeting a new habit.

Automated reminder telephone calls are not always well received by patients.

Use reminders to question patients about needs being met.

New habits not easily made.

flawless. Plans are made to cover breaks, and what-if scenarios are rehearsed. Flight crews routinely preview the flight plan, use checklists to prepare for takeoff, and review flights after their completion, because they know all of this contributes to a culture of trust, reliability, and safety.

Similarly, high-performing clinical microsystems have learned to reap the benefits of daily meetings, or huddles, to plan the day and weekly or monthly meetings to strategize and manage improvement, as described by the plastic surgery team in the boxed example that follows. Holding regular sessions to advance patient-centered care and services has several benefits. It can

• Promote collegiality and create an environment of equality.

• Improve communications.

• Make visible the team of interdisciplinary professionals engaged in planning and providing care for patients and families.

• Keep staff members patient focused.

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