Healthcare systems are facing a rapidly evolving shift in care delivery, moving from the historically acute care–centered model to a model in which many traditionally hospital-based services are provided in community ambulatory care clinics. The volume shift toward ambulatory care is a national trend, making services more accessible and affordable for patients while also improving outcomes and care quality in the most financially sustainable manner.
According to a CBRE analysis of national census data, the number of outpatient centers in the US grew 51% from 26,900 in 2005 to 40,600 in 2016, coinciding with the mind-set shift from volume to value and the challenge to deliver care in the most appropriate, cost-effective setting. The increase in volume and types of care delivered in the ambulatory space is driving the need to increase focus on efficiency and effectiveness to simultaneously show a return on investment and ensure quality excellence. To address this burning platform, many progressive ambulatory care centers are applying Lean management tools and tactics to involve staff in the identification and implementation of process improvement projects meant to bolster clinic throughput, quality excellence, and financial performance.
As clinics optimize their patient flow, space and schedule management become paramount, and constant communication is key to ensure all team members are engaged and integrated into daily decision-making. In a typical ambulatory care setting, the focus is on day-to-day workflow, and clinic teams are often operating under the stress of an ever-changing schedule. Reacting to issues and finding work-arounds becomes the norm as teams try to adjust to changes in real time rather than pausing before each day begins to assess the schedule and plan for any issues that could arise. The absence of team-based planning makes it nearly impossible to bring attention to longer-term improvements or higher-level changes. By using the three methods of instituting lasting change listed below, process improvement becomes an everyday expectation for clinic staff that is integrated into daily workflows.
1. Daily Huddles
Daily team meetings are a critical first element on the path to enhancing clinic performance. Huddles serve as a rapid assessment by all team members to prepare for the day’s workflow. They typically occur 10 to 15 minutes before the arrival of the first patient and foster team collaboration and collective problem solving. With a standard agenda and set leader, the team can quickly focus on any anticipated issues for that day, including provider availability, equipment or lab issues, patients with special needs, staffing levels, and any last-minute changes to the schedule. By including physicians and clinic support staff, the multidisciplinary team can proactively manage the clinic workflow and minimize unanticipated delays.
The degree of difficulty to institute daily huddles is relatively low, and there is potential for a large return on investment. By scheduling this meeting at the same time every day, clinic support staff will begin to consider this part of everyday work and adjust accordingly. Change management may be more difficult for physicians, as huddles are an added responsibility, but highlighting the direct benefits of fewer delays and issues should encourage their participation and engagement in the process. Physicians can also use these daily forums as a platform to surface physician challenges and concerns and enable administration to respond quickly and incorporate their input. In addition, electing a physician champion who can lead by example is a crucial element to ensuring physicians’ engagement in process improvement efforts.
Figure 1: Example of a Daily Huddle Board from Children’s Mercy Hospital
2. Visual Management Board
The next change management technique to institute for performance improvement is a visual management board. These displays are living documents in the clinic that are updated during huddles or throughout the day by team members. The boards highlight key metrics that are tracked in real time each day and allow staff to know at a glance which elements are important and how performance is trending over time. To implement the boards, the huddle team and clinic leadership must determine metrics and goals that align with hospital or health system objectives, such as safety, quality, patient experience, financials, and staff engagement. Once goals are identified, it is critical to note the difference in leading and lagging indicators and ensure the staff understands.
Lagging indicators are outcomes based and the result of actions and things that are done every day in the clinic (patient satisfaction, quality scores, patient no-show rates, patient wait times, etc.). Leading indicators are predictive, behavior-based measures and the daily actions that will positively influence the performance of lagging indicators. For example, if the targeted lagging indicator is the patient no-show rate, then leading indicators would be percentages of patients who received reminder calls, preregistered for their visit, and prepaid for their visit. The visual management board offers the ability for staff to track leading measures daily to promote compliance and subsequently see the downstream impact on the lagging measures once data is available.
The degree of difficulty to implement and maintain visual management boards is moderate due to the time investment required to track leading measures each day. It is key that the staff feels ownership of the reporting process to ensure engagement in both the improvement process and the eventual outcome of the team’s efforts. Once staff sees the impact of the time and work investment, the positive momentum becomes the main driver behind successful change management in the clinic. Additionally, it is important to provide team training on how to correctly use the boards. Some ideas may be quick wins or “just-do-its” and may take relatively little time to address. Other ideas will require a bigger lift. Teams need to learn how to prioritize these suggestions and how to assign the work to different team members to ensure a solution is reached.
Figure 2: Example of a Visual Management Board from University of Kansas Health System
Once the clinic staff has acclimated to daily huddles and visual management boards, the last performance improvement tool is Kaizen. Derived from the Japanese business philosophy of continuous improvement in the workplace, Kaizen is a method gaining widespread notoriety in the healthcare industry. The theory behind Kaizen is that the people performing the work know the most about their jobs and challenges and how to improve them. By providing staff members with the inclusive, open environment to voice their thoughts and suggest solutions, Kaizen helps focus the staff’s attention on small, continuous adjustments in the clinic. Each change will result in a slight enhancement, and as time passes and more changes are instituted, minor improvements accumulate into significant steps toward process improvement and better patient outcomes. Kaizen represents a culture shift in the clinic, away from reactionary measures and limited staff influence to an environment in which everyone’s voice is heard and standards for performance and outcomes are raised on a daily basis. As such, it is the most difficult tool to implement in terms of change management, but it has the biggest potential return on investment over the long term.
Examples of Kaizen range from a suggestion box or idea board to a multihour process mapping meeting with clinic staff, each with the intent to identify a problem or bottleneck and collectively brainstorm for potential solutions. Staff members must feel empowered to voice their thoughts, and clinic management must listen and commit to supporting solutions within reason. Kaizen is truly a staff-led, leader-supported approach. If done well, it can generate sustained performance improvement and quality excellence over time for the clinic.
Performance improvement requires continuous attention and effort to ensure short- and long-term operational refinement in ambulatory clinics. Change management tools like daily huddles, visual management boards, and Kaizen can be used to foster multidisciplinary teamwork and engage clinic staff in the daily management of improvement efforts. Once clinic staff members understand the direct impact of their time and efforts on patient care, the positive momentum can lead to significant gains in operational throughput, patient experience, and medical outcomes. As the number of ambulatory clinics and new types of services continue to grow, it is critical to maintain focus on regular performance improvement to ensure optimal patient care and staff experience.
Applying the Tactics
In response to the growing need for performance improvement within the ambulatory space, your team should consider the change management tactics described above. By streamlining your processes and implementing proven lean methodologies, you will see efficiencies in daily workflows and financial performance.