Three Examples of Reducing Patient Wait Times at Health Care Sites
The third habit of Stephen Covey's The Seven Habits for Highly Effective People is Put First Things First.
The basic premise is that for many there are a lot of things competing for our time and attention.
Some are important; some not.
Some are urgent; some not.
Covey emphasizes that we should prioritize our time to concentrate on the important but not urgent.
To achieve this goal requires some reflection and decision-making skills, as well as some trial and error.
In many healthcare settings I think many believe that it would be a luxury to able to actively decide what is important and what is not urgent and focus on these things.
There does not seem to be enough time to get the important things done.
Many if not most tasks seem urgent.
Consider a visit to the primary care physician.
The standard seems to be that a patient will get a 15 minute visit.
Spending more time would not produce enough income.
Even if it is important that a visit be longer, affording the time seems impossible.
This is just one example.
I am sure that each of you can recount many daily situations where finding time to get the important things done is next to impossible.
Fortunately there is an approach to finding more time to get the important things done, so that the urgent become much less so.
The path lies with taking the approach of the Toyota Production System of identifying wasted time and eliminating it.
Wasted time in the TPS is one of the seven types of waste.
Since most in healthcare are not trained to recognize wasted time or effectively change it when we do recognize it, we end up delivering less effective care than we would like at times.
Consider the following examples of wasted time: A.
A surgery scheduled in a hospital is delayed or postponed because a vital piece of information such as a test result does not show up in time.
Delays in scheduled surgeries are all too common in some hospitals because the right information such as test results cannot be found or a member of the surgical team is delayed in arriving.
B.
There are long waits in the emergency department for most patients except the critical ones.
There just does not seem to be adequate staff to meet the volume of service demand.
With the increase of patients due to the increasing number of uninsured, the problem seems only to be worsening.
These delays affect the bottom line of the hospital as patient throughput drops.
C.
Patients at primary care sites have to wait past their scheduled appointments or have to wait for weeks or longer to schedule appointments for noncritical care.
The Institute of Medicine identifies timeliness of delivery of care as an important goal for the primary care site in Crossing the Quality Chasm.
Not doing so can cause serious problems.
For instance, a patient who cannot get an appointment within a day or two of calling may experience a complication of a problem which would otherwise could be treated simply.
Having patients endure long waits for scheduled appointments can lead to stress and ill will towards the health team at the site.
In any other service market, such as financial products markets, such treatment of customers would not be acceptable.
The customer would undoubtedly find a better service provider.
Although healthcare patients seem to accept delays as inevitable, physicians are most likely losing patients, losing income because of lower throughput of patients, and experience more difficulty interacting with patients who feel neglected.
These delays and many like them can be overcome.
More time can be found to get the important things done.
It will take changes in culture and thinking, changes in communication, and learning the use of new tools and approaches to accomplish the changes.
Let me illustrate what can be accomplished and what it takes to achieve them with some examples.
In one emergency department there were often long delays in providing service.
A lean quality expert studied the activities of the triage nurse.
The quality expert in mapping the movements of the nurse with a tool used in Lean production-a spaghetti diagram--found that the nurse was walking approximately 10 miles each shift.
At a normal walking pace that is four hours of walking, time not accomplishing the tasks he or she should be doing.
With a team of representatives from the ED that time was cut down considerably and patient wait times decreased significantly.
Patient throughput increased.
At Virginia Mason Hospital delays in surgery were considerably lessened using the pull system and takt time from the Toyota Production System.
The ideas behind the two concepts is that all the necessary tools, personnel, patient and information arrive at the right time for the surgery to begin on time and proceed without delay.
The timing of the flow of personnel, patient, instruments and information is carefully measured over many occasions, identifying bottlenecks and waste as measurements are taken.
Teams then work to eliminate the waste and unblock the bottlenecks.
By eliminating wasted time, eliminating bottlenecks, and coordinating flows, delays are mostly eliminated.
To accomplish these changes at Virginia Mason it was necessary to change the culture of the hospital.
Leadership had to learn and understand the Toyota Production System and actively support it.
Staff needed to learn new ways of working together in teams to identify and eliminate waste and bottlenecks.
The changes did not come easily or quickly.
Much of the experience of change at Virginia Mason Hospital is described in John Black's book The Toyota Way to Healthcare Excellence.
Primary care facilities can overcome many of the patient delays with open access scheduling.
With open access scheduling, time is left open in patient scheduling so that patients can call in for an appointment and be seen either that same day or the next day.
Using open access scheduling not only decreases delays for the patient it also improves patient throughput.
The number of no-shows for appointments decreases, thus improving throughput.
Implementing open scheduling is not easy.
It requires patience, much effort by the staff working as a team, and often a change in focus to become more patient-centered.
As Stephen Covey points out, it is very necessary to focus on how we spend our time so that we can be highly effective.
Time seems to be a precious commodity at most healthcare sites and always in short supply.
Using approaches and tools to identify and eliminate wasted time-a hallmark of the Toyota Production System-can dramatically improve patient outcomes and financial outcomes.
To achieve these goals requires a new ways of working together and active involvement by leadership in guiding the necessary changes.
The task is not easy.
The basic premise is that for many there are a lot of things competing for our time and attention.
Some are important; some not.
Some are urgent; some not.
Covey emphasizes that we should prioritize our time to concentrate on the important but not urgent.
To achieve this goal requires some reflection and decision-making skills, as well as some trial and error.
In many healthcare settings I think many believe that it would be a luxury to able to actively decide what is important and what is not urgent and focus on these things.
There does not seem to be enough time to get the important things done.
Many if not most tasks seem urgent.
Consider a visit to the primary care physician.
The standard seems to be that a patient will get a 15 minute visit.
Spending more time would not produce enough income.
Even if it is important that a visit be longer, affording the time seems impossible.
This is just one example.
I am sure that each of you can recount many daily situations where finding time to get the important things done is next to impossible.
Fortunately there is an approach to finding more time to get the important things done, so that the urgent become much less so.
The path lies with taking the approach of the Toyota Production System of identifying wasted time and eliminating it.
Wasted time in the TPS is one of the seven types of waste.
Since most in healthcare are not trained to recognize wasted time or effectively change it when we do recognize it, we end up delivering less effective care than we would like at times.
Consider the following examples of wasted time: A.
A surgery scheduled in a hospital is delayed or postponed because a vital piece of information such as a test result does not show up in time.
Delays in scheduled surgeries are all too common in some hospitals because the right information such as test results cannot be found or a member of the surgical team is delayed in arriving.
B.
There are long waits in the emergency department for most patients except the critical ones.
There just does not seem to be adequate staff to meet the volume of service demand.
With the increase of patients due to the increasing number of uninsured, the problem seems only to be worsening.
These delays affect the bottom line of the hospital as patient throughput drops.
C.
Patients at primary care sites have to wait past their scheduled appointments or have to wait for weeks or longer to schedule appointments for noncritical care.
The Institute of Medicine identifies timeliness of delivery of care as an important goal for the primary care site in Crossing the Quality Chasm.
Not doing so can cause serious problems.
For instance, a patient who cannot get an appointment within a day or two of calling may experience a complication of a problem which would otherwise could be treated simply.
Having patients endure long waits for scheduled appointments can lead to stress and ill will towards the health team at the site.
In any other service market, such as financial products markets, such treatment of customers would not be acceptable.
The customer would undoubtedly find a better service provider.
Although healthcare patients seem to accept delays as inevitable, physicians are most likely losing patients, losing income because of lower throughput of patients, and experience more difficulty interacting with patients who feel neglected.
These delays and many like them can be overcome.
More time can be found to get the important things done.
It will take changes in culture and thinking, changes in communication, and learning the use of new tools and approaches to accomplish the changes.
Let me illustrate what can be accomplished and what it takes to achieve them with some examples.
In one emergency department there were often long delays in providing service.
A lean quality expert studied the activities of the triage nurse.
The quality expert in mapping the movements of the nurse with a tool used in Lean production-a spaghetti diagram--found that the nurse was walking approximately 10 miles each shift.
At a normal walking pace that is four hours of walking, time not accomplishing the tasks he or she should be doing.
With a team of representatives from the ED that time was cut down considerably and patient wait times decreased significantly.
Patient throughput increased.
At Virginia Mason Hospital delays in surgery were considerably lessened using the pull system and takt time from the Toyota Production System.
The ideas behind the two concepts is that all the necessary tools, personnel, patient and information arrive at the right time for the surgery to begin on time and proceed without delay.
The timing of the flow of personnel, patient, instruments and information is carefully measured over many occasions, identifying bottlenecks and waste as measurements are taken.
Teams then work to eliminate the waste and unblock the bottlenecks.
By eliminating wasted time, eliminating bottlenecks, and coordinating flows, delays are mostly eliminated.
To accomplish these changes at Virginia Mason it was necessary to change the culture of the hospital.
Leadership had to learn and understand the Toyota Production System and actively support it.
Staff needed to learn new ways of working together in teams to identify and eliminate waste and bottlenecks.
The changes did not come easily or quickly.
Much of the experience of change at Virginia Mason Hospital is described in John Black's book The Toyota Way to Healthcare Excellence.
Primary care facilities can overcome many of the patient delays with open access scheduling.
With open access scheduling, time is left open in patient scheduling so that patients can call in for an appointment and be seen either that same day or the next day.
Using open access scheduling not only decreases delays for the patient it also improves patient throughput.
The number of no-shows for appointments decreases, thus improving throughput.
Implementing open scheduling is not easy.
It requires patience, much effort by the staff working as a team, and often a change in focus to become more patient-centered.
As Stephen Covey points out, it is very necessary to focus on how we spend our time so that we can be highly effective.
Time seems to be a precious commodity at most healthcare sites and always in short supply.
Using approaches and tools to identify and eliminate wasted time-a hallmark of the Toyota Production System-can dramatically improve patient outcomes and financial outcomes.
To achieve these goals requires a new ways of working together and active involvement by leadership in guiding the necessary changes.
The task is not easy.
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