Re-engineering overhauls systems to make them work
Blending traditional roles into multitask workers
The Denver Health Authority’s department of community health needed to make some changes. They wanted to eliminate interminable patient waits, low productivity, inefficient processes, and poor accountability. What was the best way for them to make all of their changes at once?
The answer: Re-engineering. Major improvement sometimes requires radical changes in administration and care delivery, says Richard A. Wright, MD, MPH, director of community health services.
"You’ve got to have a vision, a mission, and a plan to change," Wright says. "You’ve got to have a person who is going to champion the change from the top."
Re-engineering has fundamentally altered the way patients flow through the community health centers and how staff interact with them.
Gone are the parallel chains of command in which nurses answered to nurse managers, physicians to medical directors, and clerks to a business supervisor. Today, the community health centers use self-directed work teams, led by either a business services team leader or a clinical team leader.
Gone is the common refrain, "That’s not my job." Thanks to cross-training, both clinical and clerical staff can take care of multiple tasks. Even physicians are expected to answer the phones if one is ringing nearby and no one else is available.
Gone, too, are traditional roles. There are no more middle managers. About 80% of clerical workers attended retraining sessions and became health care partners or medical office assistants who are paired with physicians or nurse practitioners.
With these changes, the total cycle time for patients, from registration to leaving the clinic, dropped from 71 minutes to 58 minutes. Wright is looking for even more dramatic improvement, including a rise in patient satisfaction although he cannot remove some inherent barriers among his largely indigent population such as language differences and low education. The need to identify possible payment sources for non-insured patients also greatly lengthens the registration process.
"Our goal was to try to get the patient in and out in 45 minutes," says Wright. "We think the more realistic goal is 55 minutes."
The re-engineering began in 1995 as a pilot project at one of the authority’s 11 community health centers and 10 school-based clinics. A re-engineering expert and an internal committee guided the process, while management consultants helped the authority rewrite job descriptions and personnel requirements.
To set customer service goals, such as wait time, the team gathered benchmarks from outside colleagues and medical literature. "We looked externally at what our competitors were doing," says Wright, noting that he had to make allowances for the special population served by community health centers.
For example, physicians were assigned productivity targets a certain number of expected patient visits per day or half-day, based on relative value units that assign greater weight to patients with higher care needs. Wright then used those productivity levels to set staffing patterns. He found that some centers were actually overstaffed while others were understaffed.
Two years later, Wright is still analyzing progress through a patient satisfaction survey and participation in the University HealthSystem Consortium ambulatory clinics benchmarking project.
Success has been hard to measure because in the midst of the restructuring, the community health centers also installed new computer technology. Glitches led to patient delays during registration.
A multitask philosophy formed the centerpiece of the restructuring. "It creates more flexibility in how you use your resources," says Wright. "Multitasking absolutely works."
Previously, patients dealt with three different clerks during the registration process which meant delays before they could make their copayment, update their paperwork, and enter an exam room. Now, the clerks are cross-trained to do all duties.
In fact, with the change to health care partners, only a fraction of the registration clerks remain in that position. The health care partners, meanwhile, perform a hybrid of clinical and clerical duties. They guide patients into exam rooms, take a brief history and blood pressure, and even check charge slips and make future appointments. (Nurses handle higher-level tasks, such as case management with high-risk patients and triage of urgent-care cases.)
Physicians have welcomed the change, which gives them the continuity of an assistant who is paired with them, says Thomas MacKenzie, MD, MSPH, general internal medicine team leader at the Westside center. "Patients know they can go to my health care partner with questions and he has access to me," says MacKenzie.
With fewer hand-offs among different staff, patients feel more comfortable and move more smoothly through the clinic, he says.
The clerks who are now health care partners have higher pay, more job responsibilities, and more marketable skills. But that came at a price; they continued to work full time while often taking retraining classes at night or on weekends. And while some clerks were in training sessions during working hours, others scrambled to fill in their duties.
Staff also felt turmoil and anxiety over the restructuring. "Change has been difficult. I have to be honest about it," says Luz Collins, business service manager at the Westside Family Health Center in Denver, which served as the pilot location.
Still, no one wants to go back to the way things were before, says Collins. In fact, as the staff grew accustomed to the new responsibilities, they felt empowered, she says.
For example, the medical records staff created their own improvement project and eliminated backlogs in pulling charts. "They find themselves more efficient and happier in their new responsibilities," she says.
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