The Apollo 11 Case Study

Introduction

This is a case study of the redesign effort undertaken by HealthNet Community Health Centers in Indianapolis, Indiana. This account illustrates the lessons we learned from that experience and how they apply to organizational transformation. What began at HealthNet as a typical reengineering effort became a poignant discovery of organizational potential and the rekindling of a passionate commitment to patients. We sincerely hope that by sharing this experience with you, your own journey towards a dramatically improved patient experience and organization will be rewarding.

HealthNet is a primary care organization with five clinical sites accommodating a total of 100,000 visits annually. It is affiliated with the highly regarded Methodist Hospital system in Indianapolis. HeathNet's CEO invited Coleman Associates, the ambulatory care reengineering specialists, to train a redesign team comprised of seven staff largely from one clinical site: The Southeast Health Center (SEHC). This site had 16 staff and 3 full-time-equivalent providers. The site was chosen as the pilot project because of long patient waiting times, poor patient flow, and the staff's own diminishing satisfaction with the quality of work and work life.

Redesign, or reengineering, is an approach to the reorganization of work methods and staff for dramatic improvements in productivity and quality. The idea is to start with a clean slate and design new processes as if not encumbered by the current ones. Coleman Associates directs teams to focus on radically redesigning the patient visit, since that is the core business process of ambulatory care organizations—even in managed care environments.

SEHC team members adopted "Apollo 11" as the team name in reference to the first Apollo mission to land on the moon. Just as the Apollo mission changed the world's perception of what was possible, so the team sought to change HealthNet's perception of what was possible with respect to the patient experience. The redesign journey led not only to a radically different patient visit model, but—unexpectedly—to an utterly transformed Southeast Health Center (SEHC).

The Patient Visit Model

A 51-year-old woman, Emily Stamper, arrives at SEHC for her 2:00 p.m. appointment with Dr. Warner for an episodic illness. It is 1:48 p.m. as she walks into the building and almost runs into a staff member stationed just inside the clinic entrance who welcomes her to SEHC and asks if she has an appointment. There is no counter or desk between the greeter and Ms. Stamper. She is a little startled by the expectant face and the immediate attention that stops her well short of the front desk to which she usually "reports" upon arrival. The greeter invites Emily to help herself to refreshments and have a seat in the waiting room, assuring her that a medical assistant will be calling her shortly.

The waiting room, Emily notes, withstands her fastidious cleanliness standards. This certainly was not true in the past, she says to herself. While the facility is nothing to write home about, it's obvious that the waiting area has been recently painted and decorated. She notes the new toys and videos for kids.

Meanwhile, the greeter has informed the medical assistant via walkie-talkie that Emily has arrived for her two o'clock appointment. [This eliminates two typical delays in patient visits: an unresponsive front desk and paper-based communications that depend on staff checking for processed paperwork before a patient can proceed to the next step.]

After waiting for about 10 minutes, a medical assistant (MA), Patricia, comes to the waiting room, greets Emily, and leads her directly to an exam room. [This scenario is realistic because each provider typically has two medical assistants and three exam rooms.] It is in the exam room that Patricia takes Emily's weight—in privacy—and her vital signs. She also asks Emily if her address, phone number, or insurance coverage has changed. Emily's phone number has changed, so Patricia writes the new number on the encounter form. She will key it into the computer after the visit concludes.

[If Emily's insurance had changed, the MA would summon the cashier to the exam room to do the necessary paperwork. The cashier would work to complete this change before the provider arrived, but would complete the paperwork at the conclusion of the visit should the provider interrupt the process. The principle: Nothing interferes with the encounter between patient and provider.]

When Dr. Maria Warner enters the exam room, Patricia—the MA—remains to serve as vital support to Dr. Warner. Patricia focuses on the paperwork and logistics, while Dr. Warner focuses exclusively on the patient. So Dr. Warner, Patricia the MA, and Emily the patient are in the exam room together. Emily appreciates the extra attention. While Dr. Warner examines and treats Emily, Patricia is making entries—at Dr. Warner's direction—on a specially engineered SOAP notes form. Towards the end of the encounter, Patricia drafts a prescription as requested by the provider and hands it to the provider for review before she, in turn, gives it to Emily.

[During this encounter, medical record entries were completed at the time of visit—so records will not accumulate into a depressing stack on the provider's desk to be updated at the end of day. Also, please note that medical record entries reflect what was communicated to the patient. Typically the provider reviews entries at the close of the visit.]

Dr. Warner asks Patricia to set up a follow-up appointment for Emily in two weeks and makes sure she understands her medication schedule. Dr. Warner moves on to see another patient while Patricia carries out Warner's instructions without Emily having to leave the exam room. Patricia has noted that Emily's new insurance status necessitates a co-payment so she informs the cashier that the encounter has concluded. The cashier then enters the exam room to tell Emily she will not need to go to the cashier's window because all collections now take place in the privacy of the exam room. Though at first startled, Emily appreciates the privacy.

As Emily is leaving, several staff ask if she has everything she needs, and once assured that she does, say goodbye. As she passes a clock, she realizes it is 2:30 p.m. Only 40 minutes have elapsed since she arrived at SEHC. She realizes this has been a very efficient visit: Almost no waiting time, no shuffling from stop to stop, her needs were well attended to, and her clinician didn't seem rushed. She's always appreciated the care received from SEHC staff, but—truth be told—she's hated the hurdles and waits that she assumed were necessary evils. Now, she notes, she's getting the care without the hoopla. What's the catch?

The Principles of the Apollo 11 Model

• Focus on the Patient! Work is organized around the patient's needs. Policies not patient-focused are discarded (e.g., a policy stipulating that a patient will not be seen if more than 15 minutes late for an appointment), patients are weighed and money collected in exam-room privacy, and the team does whatever it takes.
• Patient Waiting Time Is Minimal and Delightful. Front desk is eliminated, waiting time minimized, refreshments made available, as are toys and videos for children, and waiting patients are kept informed.
• Clinicians Are Well Supported. Each clinician works with two medical assistants and three exam rooms. The MAs and provider form a Core Care Team. When ratios are changed, productivity increases dramatically and unit (visit) costs drop.
• Teamwork Abounds. Care Teams huddle every morning to review the patient schedule and strategize around patient care. Team members anticipate each other's needs in the context of delivering care. All work is intensely patient-focused.
• The Clinician is Freed from Paperwork. The medical assistant records SOAP notes, drafts prescriptions, helps complete pre-encounter paperwork.
• Clinical Charting is Completed During the Visit. No piling up the charts for those end-of-day updates. Everyone goes home on time.
• Clinical Support Staff Are Cross-Trained in All Functions. This eliminates handoffs. Medical assistants are cross-trained in all support functions. A medical assistant can follow a patient from the beginning to the end of a visit.
• The Environment Is Attentive, Professional, Warm, and Friendly. Facility is clean and orderly, staff professionally attired, and a patient-first attitude prevalent.
• Patient Care Teams Are Self-Managing. All team players adopt the philosophy "It is my job." Shared ownership fosters shared responsibility and accountability. Site-based team (all Care Teams combined) sets goals and monitors its performance.
• Results Are Measured Continually. Charts are audited for quality of care. Outcomes are measured as are patient satisfaction, patient visit cycle times, staff satisfaction, and productivity.

Patient Reaction

• "Less waiting time! Convenience of everything in room was great. It was also easier to get in. Dr. Johnston seemed less rushed."
• "I did not have an appointment, but was worked in within minutes. I was very pleased."
• "Upon entering the clinic, we were greeted by the staff right away! The clinic was very cheerful and clean. We were helped right away. Way to go! Thanks."
• "My entire visit went faster than my time I usually wait [under the old system]. Keep this up...it is a miracle!"
• "All doctors' offices should run this efficiently. I feel comfortable and relaxed which makes a much better relationship between patient and doctor."

Staff Reaction

• "I do not want to ever go back to the old way of doing things."
• "I was a skeptic in the beginning, but ..."
• "I think the medical assistants have a much better feel for what happens during an encounter now. Before, I think they'd just think we'd disappear into an exam room for too long, but now they know what's involved and can help prepare for the visits better."
• "This system lets me have much more of an effect on patients. I'm more involved with patients and can do a lot of patient education."
• Medical assistant: "I'm learning so much because I'm in the exam room with the provider and patient."
• Medical assistant: "I feel as valued as a nurse."
• "I was not happy about all these changes when the Apollo visit started, but I've grown into it and if I had to go back to the way things were, I think I'd quit first."
• "Sometimes I get so involved with the patient encounter that I will [unconsciously] stop recording notes...then the provider will remind me."

Intimacy, learning, and giving are the key elements here. Teamwork demands collegial intimacy, which in turn—given competent staff—translates into respect and trust among staff as well as a continual journey of self-discovery. This intimacy and self-discovery fuel a learning environment where people grow and further reveal their potential. "Giving unto others" is important to community health center staff. It is a simple, but powerful truth: When staff members create satisfying experiences for patients, they themselves derive satisfaction.

The combination of the three elements—intimacy, learning, and giving—create a workplace where satisfaction is not merely occupational, but almost spiritual. Is this consistent with the basic mission of community health centers?

Results

Since the focus of reengineering is to dramatically improve productivity while maintaining or improving quality, the question must be asked: "What are the measurable results of this radical redesign?" The following table shows the post redesign measurement of key indicators:

The Transformed Organization

What's most remarkable about the impact of the Apollo Visit Model is not its key undeniable benefit—the elimination of the traditional long wait that accompanies a visit to the provider. More remarkable is the transformation of a group of people into a truly patient-focused team. The following excerpts from an article in the Methodist Hospital system newsletter demonstrate this change:

"I love my job now." That's the positive feeling that's spreading through HealthNet's Southeast Health Center, according to Carla Vaughn, an LPN at the center. "Two years ago we were dead in the water," she said. "Paint was peeling, our staff was angry and our patients were often lined up out the door just to get waited on. Last summer, the average patient visit lasted 83 minutes from entrance to exit. By February of this year, we had cut that time to 43 minutes [after redesigning the patient visit]."

"All it took was a little coaching to bring us closer together" said Norma Hughes, an appointment coordinator and telephone operator at the center. "Now everybody steps up the plate to help the patient."

Roger Coleman, the General Manager of Coleman Associates, describes the spirit of this remarkable journey this way:

Two factors determine our ability to dramatically increase our organizational effectiveness. First is our ability to envision new possibilities. Second is our willingness to change. The first leads to innovation, the second to experimentation. These are the keys to transforming the patient experience and they are not dependent upon financial resources, but—rather—imagination and willpower.

Though our patients have serious needs and our resources are constrained, our organizations must change if they are to thrive as first-rate providers of health care. The Apollo Team experience taught us a powerful lesson: Organizational transformation is largely a matter of the heart—of values we care most about. Apollo taught us that we can create a health center where we inspire ourselves daily; where team intimacy discovers and fosters individual potential; where one's idealism is rekindled into youthful passion; where people can come for the best care delivered by anyone anywhere.

And the Apollo Team experience leaves us with one last lesson as well: Living our ideals can be a very powerful business strategy."