Re-engineering practice is tweaking, not starting over

If you feel like achieving any sort of operational efficiency in your office is a complicated, gargantuan task, you have the sympathies of Purdue University management professors Suresh Chand, PhD, and Herbert Moskowitz, PhD. It was their job to improve patient flow at an Indianapolis clinic, and it took them about two years of study to determine how.

Their conclusion, after developing numerous advanced statistics-level formulas and computer simulations of practice life: As it turns out, re-engineering your practice can be less complicated than you'd think.

In a report they are currently submitting for journal review, Drs. Chand and Moskowitz determined that some minor tweaks in how a practice handles registration, phone calls and appointment scheduling can create huge time savings for physicians and staff, letting a practice deliver better care to more patients in a day -- thus leaving their patients happier, and their bottom lines richer.

In fact, they believe their research shows that encouraging such efficiency -- not outright cuts in physician pay and practice revenue -- is key to improving outcomes and keeping a lid on health care system spending.

"What we've come to understand is that increased revenue and improved quality go hand in hand," said Dr. Chand, a professor of management at Purdue's Krannert School of Management. "The simple fact is that if a patient's clinic experience is fast and pleasant, they will avail themselves of more care earlier -- a prescription for better health."

In fall 2004, Drs. Chand and Moskowitz started working with the nine-physician Grassy Creek Community Health Center on Indianapolis' east side as the first major project for Purdue's Regenstrief Center for Healthcare Engineering, which seeks to apply industrial principles to health care. More hospitals and practices are seeking such guidance. For example, the Virginia Mason Medical Center in Seattle is one of a number of entities to rework its operations using Toyota's pioneering Kaizen production system. Others have used Six Sigma, a technique developed by Motorola. In each system, the goal is the elimination of waste in the process.

In the Grassy Creek project, Dr. Moskowitz brought his expertise in Six Sigma, while Dr. Chand added his expertise in a trademarked system called Factory Physics, developed by professors at Northwestern University and Georgia Tech. The goal of Factory Physics is to find sources of unnecessary variation in a project and eliminate them. Thus, the professors (along with co-credited author John Norris, a doctoral candidate) used those techniques to solve the problems of a clinic whose patient capacity was underutilized, yet still had patient wait times and physicians' finish times that were "long and unreliable," according to their paper.

The researchers concentrated on the moments from patient arrival to registration, and from registration to seeing the doctor. While they ran some models on how to standardize some of the physicians' tasks to reduce the variability in how much time they spent with patients, the researchers and clinic staff "agreed that such changes were not possible in the short run," according to the paper.

Among the researchers' conclusions for Grassy Creek:

• The clinic could cut down its no-show rate considerably by moving to a same-day appointment schedule. The average no-show rate for same-day scheduled patients is 3%. The average for advance appointments is 40%.
• Specific registrars assigned to specific physicians is a recipe for creating backups, because patients can't switch to a shorter registration line. Instead of having one registrar handling three physicians only, all three should handle all nine physicians to speed up the queue.
• Registrars should have the patient's registration completed before the patient sits down in the waiting room -- rather than clearing the line, then batching the registrations all at once.
• All phone calls should be centralized so they can't be taken by the registrars. Often, patient registration was slowed because they had to handle call overflow.
• All patients should be asked to come in early -- five minutes for old patients, 10 minutes for new patients.

What all the recommendations mean is that more patients show up and that they wait about half as much time as before, thus allowing a practice to handle more patients -- ergo, more revenue.

The physicians at Grassy Creek are supplied by the Indiana University Medical Group, but the clinic is funded by Marion County. Its patients are mostly Medicare and Medicaid, and many speak Spanish only. But the researchers said their conclusions could be applied to any practice.

"The result of our work with Grassy Creek was, if you make the patients happy, you make the doctors happy. If you make the doctors happy, you make the clinics happy," said Dr. Moskowitz, the Lewis B. Cullman distinguished professor of manufacturing management at Krannert. "Why? Because that creates more income for the medical group -- more patients are going through there. And the doctors go home on time. These [goals] don't conflict. That's the beauty of this."

But the follow-up question, as always, is: Will doctors and staff buy into these changes? After all, patients are not widgets, easily broken down into abstracts for a management class.

Deanna Willis, MD, a family physician and chief medical officer for quality over all 20 Indiana University Medical Group clinics (including eight county-funded clinics), says, yes, they will. In Grassy Creek's case, it helped that the researchers developed a visual computer simulation model that showed exactly how a few small changes would save a lot of time and money.

"In a high-volume, low-margin business, every tiny thing you can shave off in terms of cost and efficiency, and multiply it by the big volume you have, that's where you get the big benefit," said Dr. Willis, also credited as a co-author on the paper. "If you save two minutes [per visit], that's a lot of minutes we save, and that translates to cost savings for the clinic."

Grassy Creek is making some immediate changes based on the research. It is switching to a 60-40 mix of advance and same-day appointments. It is also investigating whether to set up a centralized call system for the community clinics, rather than having each clinic handle its own appointments. But Dr. Willis said that runs into one reality for many physicians -- limited funding. In her case, Dr. Willis has to get county approval to spend the $30,000 or so the professors estimate a new phone system will cost.

Still, she believes that industrial-style research into health care will continue to catch on. In fact, Drs. Moskowitz and Chand recently heard from a former student who is asking for such research to be done to help an Elkhart, Ind., eye clinic that has grown quickly, but also has grown more disorganized.