I am very pleased that Lakesha Cotton has agreed to share her expertise and experiences with our class. She was recently appointed the Director of Operational Effectiveness for UF Shands. Lakesha graduated Magna Cum Laude from Florida A&M University with a degree in Healthcare Administration. And following graduation she joined the US Army where she served in Iraq as the support operations maintenance officer. She was responsible for maintaining $126 million worth of equipment. She subsequently obtained her MBA with as focus on healthcare management from Indiana Wesleyan University. She has formal training in Lean management and Six Sigma. Prior to coming to UF Health, she worked for a Norton Healthcare in Louisville Kentucky as the director of clinical effectiveness. She has worked for over a decade to improve the delivery of healthcare, she is going to discuss how she improved the work flow or leveled the work flow in multiple busy, primary care clinics at Norton Healthcare. I asked her three questions. How do we improve our patient waiting times in our clinics? How do we level our work flow and meet patient demands? How do we keep the team engaged and make changes stick? >> The initial issue that was brought for us to improve was patient scheduling and access. So initially when we dug into what was the real issue, what we saw was that physician schedules were all over the place. There were no controls in place to kind of help maintain the process. If you were going on vacation on January 3 and you changed your schedule on January 3, in some instances it never got changed back to match your non-vacation schedule because there was no controls in place to make sure that the schedules were changing and they were being looked at. And then on the opposite end, if you decided that you wanted to leave every day at three o'clock because that was convenient for your schedule. You as a physician and the scheduler at the front desk could go make these changes. And administration knew nothing about this, people who were trying to make decisions on our volume for the company knew nothing about this. So they were basing volumes of time where doctors weren't in the office. The process improvement was not just about fitting more patients in, it was about looking at what the volume was, what the need was, and how efficient and effective our physicians were. So the way we did this, was to first break down the project into smaller projects. Patient wait times was one pieces of it, access was another piece of it and leveling was a way that we worked on to make sure that the patient wait time and the flow was correct. So how did we do this? How did we improve patient wait times? The first thing that we did was we got a true time study using time stamps, and making sure we understood who came in and how long that they were there. We didn't just take patient complains and use those one or two examples we get statistically good data. And what we saw was that there were wait times, our wait times vary from the time a nurse roomed the patient to the physician getting in. So that was something that we said, okay, well, it looks like our front desk process is working. We're getting the patients back, they're not waiting a long time there. What's happening between a nurse doing her triage and a physician getting into the room? So now if you talk about let's solve the world, we have this larger problem. It's much more easier for a team to dig in and be excited about because we are not just trying to solve everything. We have a key focus area and our focus area is what's going on between the nurse, the patient's room, and the physician coming in. So that's one tactic that we use. We broke it down into smaller projects so that they were attainable. So what you do is that you work that project. You celebrate it. You get a win from it, then you move forward. So breaking that down, and we'll talk about KPIs, how you maintain that process in another video when we talk about KPIs. Another piece that we looked at was the demand. So we have physicians who were slammed on Monday and Tuesday because that's the beginning of the week. People are coming into the office. That's the preferred time for visits. But then by Thursday and Friday it was like okay we can breathe. This is a normal work day. So our goal was to level out their days. So that every day they kind of knew what to expect coming in. And take out some of the blocks in our physician schedule. Where we demanded and told patients when they were coming in. We our a patient-centric organization and we should not be telling patients where they fit in on our schedule, we should be open to seeing a patient that comes through the door. A great analogy that one of my old bosses was told me was that you never go into Nike and they tell you, your shoes look good. We shouldn't sell you any shoes today. That never happens. So if a patient wants to come in and see us, we should be able to accommodate that patient. So another thing that we did to work on that process it that, I thought was that we're going to do a little mind trick on the physicians. And we said if we level out their day we would improve access. How do we do that? Our thought was that if their days were level, they will come to us and say, hey, my days are pretty smooth. Based off the way I used to work, I think I can fit more patients in. So that was kind of the thought process of how do we improve access by not saying work more hours, let's work on Saturdays, let's work later. Our goal was to level their days. Well, how do you level workflow? You level workflow by using a team-based approach. Everybody that works in the office should work as a care team. And so with that being said, you have to prep for patients. You have to make sure that everybody's working at their top of their license. You have to make sure that when a patient comes in, it's not a surprise why the patient comes in. We know why the patient came in. They made an appointment, they told us why they were here, they saw a nurse before the doctor came in. It's getting all of the information, so when the doctor walks in he can come in and do what he needs to do. We wouldn't ask a nurse to block no-show patients because that's not what a nurse should do, somebody at the front desk should be doing that. So, it's just making sure that everybody on the care team looks at that patient and makes sure that patient has a whole experience from the time they walk into the door, from the time that they check out. With everybody working at the top of their licenses to do their level of work for that patient. So really understanding how do you level that work flow and get people to do that you have to get them to buy in you got to make it a team. You got to make sire the physician is telling you in advance that for every diabetic patient this is what I need to happen. For every patient that's missing an immunization this is what should happen. So you have that communication and you do huddles. There's a lot of different techniques and ways that you can do it. But what I want you to walk away with is that you're prepared. You're prepared for a patient that comes in, and we know how to give this patient the best care at this visit. Because who know, we may never see this patient again. This patient may be nine months before they come back to us. So we want to make sure that ever interaction that we have with a patient they're going to remember that we do care about them. And maybe encourage them to come back to come back to us and finally how do you keep the teams engaged? So we've made all these good process improvements. We've looked at patient wait time and we've made sure that from the time that a nurse rooms a patient that the physician gets a tap on the door maybe if he's been in the previous patient too long so he know he's running behind schedule, there's checkered flags that you could put up. There are different things that you could do. So let's say we've done that. We've cleared that hurdle. And we have physicians moving timely. We've leveled out their day. We've done that. We've made sure that the front desk has people humming. We've made sure that at the end of the day a patient is getting an after visit summary and they know what's expected. How do we make sure that we keep this momentum going? We set goals, so if our goal is that every patient that walks out of our visit is 100% immunized and they have their AVS Summary and they don't spend more than 45 minutes to an hour in our clinic, that's our goal. Our goal. And if we're not meeting our goals we talk about it. We don't point fingers, we don't blame people. We say how do we as a team, because we're working together as a team, how as a team do we make sure that we meet our goals. But you have to first start it by setting goals. So, team based approach in changing the culture of your office. Change should not be looked at as something bad. We maintain a high level of excellence if we continue to talk about how do we improve this. So, now how do we change it? Not how do we come in and do a one time project but how do we continually improve and always looking for ways to strive to be better in the clinic? And that's how you maintain change by always trying to change.
