Prior to 2001, patients averaged 104 minutes for a visit at Lincoln Hospital's Women's Health Clinic in New York City. That is from the time the patient appears at the clinic's front desk until the time she exits. After the clinic participated in a Patient Visit Redesign™ Collaborative in 2001, the patient visit cycle time dropped to a respectable 55 minutes.

But the 55 minute average didn't reflect all visits at Lincoln Women's Health. There were "carve outs" like the new prenatal patient visit that took hours to complete. In 2001, this visit process looked like a nut "too hard to crack". So, new prenatal visits were simply not incorporated into the cycle time statistics. And, as a testament to the truism "That which is not measured is not improved", the visit was never redesigned. Nevertheless, management and staff were justifiably proud of what they had achieved. They had reduced cycle times for most visits, and patients were very appreciative.

But over time the average patient visit time began climbing. Staff drifted away from teamwork, charts and written orders piled up on counters and in baskets, and the sense of urgency that keeps a redesigned clinic running smoothly slowly evaporated.

The Associate Executive Director of Ambulatory Care, Marcy Pressman, asked Coleman Associates to conduct RealTime Redesign™ at the Women's Health clinic. This technique translates into a team of Coleman Associate RealTime Specialists (or, trainers) working with staff and managers in real time over four rigorous days.

The philosophy of this technique is as follows:

• RealTime Specialists work with available levels of staffing (rather than relying on solutions that increase staffing levels), so it's important for Specialists to install simple and streamlined processes, and introduce readily available tools.
• Specialists must engage the hearts and minds of staff and managers. Dramatic change is not possible without this emotional element.
• To sustain redesign results, clinic managers must learn how to do redesign. This requires that managers be immersed in the execution, troubleshooting, and success of redesign. Managers are the active, continual partners of the RealTime Specialists.
• In RealTime Redesign™, Specialists swiftly tailor and install engineered modular work processes to redesign the patient visit and allow managers to sustain results over time.

The week that the Specialists spend onsite is called "Conversion Week", the week the clinic converts from the old way of doing things to the new way of doing things. For the Specialists, the week begins with an afternoon clinic session. During this session, trainers observe processes and people in the clinic, and build rapport with staff. By late afternoon, the trainers begin working closely with clinic managers to vet staff and patient schedules, organize staff into Patient Care Teams (PCTs), and prepare the managers to coach the PCTs over the next few days.

At Lincoln Women's Health, it was readily apparent (though by no means unusual in a health care setting) that the three key managers (administrative, nursing, and medical) worked within their own functional silos rather than together as a unified team. There were three different staff schedules that sometimes dovetailed and sometimes did not. Managers tackled problems individually rather than orchestrating their efforts to overwhelm a system hurdle or dysfunction. But the managers were clearly capable, bright, and open minded. Obviously there was great potential, though the potential had yet to be realized.

Marcy Pressman recognized that:

In 2001, we all had the warm, fuzzy idea that we should have the line staff drive the changes. But, we excluded the clinic managers. For sustainable gains, both levels of staff must be engaged. Why? Staff and leaders come and go. There needs to be enough people in place with the memory, commitment and energy to sustain the process of change. It doesn't happen just because we have these egalitarian visions of how change should occur in a perfect world.

Coleman Associates trainers oriented the clinic managers to the principles of redesign and good coaching techniques. Then the clinic managers organized all staff into Patient Care Teams (PCTs). A PCT is a home to a panel of patients. The team typically consists of a clinician, a medical assistant, and a front desk person. Together these folks work together like a mini medical practice to take care of the patient's needs.

The very next morning, the managers began coaching the PCTs. These coach-managers focused the Patient Care Teams on getting the clinic session off to an on-time, fast, and orderly start. The objective was to get the first wave of patients registered and into exam rooms in record time to eliminate the typical clinician downtime that occurs at the start of the day. Starting on time is the prerequisite for finishing on time. The coach-managers worked to get every PCT member playing her or his role optimally and to get every PCT to seize control of the patient flow.

The Coleman Associates huddled every few hours with the coach-managers to troubleshoot emerging issues and problems. Unstated objectives of these huddles included forging the managers into a tight team and conditioning everyone to think like a work process expert.

By the end of the first morning clinic session, many more staff were going to lunch on time and going home on time. Then the trainers and coaches focused on an on-time start for the afternoon session. After an orderly clinic start was secured in the afternoon session, a trainer and nurse manager worked to install an Express Line by the front desk (actually, in front of the front desk) to quickly sort all patients entering the clinic to prevent backlogs in the front and handle problems expeditiously when possible. This avoided having patients wait to have forms completed or that should have been in a different clinic altogether.

In redesign, there is the mantra: "Data is meaningless, but information is critical to success." In other words, collecting and reporting data has little impact on anything. And that includes patient visit cycle times. But make the "data" public and highly visible and it becomes "information" that results in different behavior and different results. So, cycle times are tracked and posted publicly on a flip chart sheet. At any time, for any clinic, it is clear how many patients have been seen, how long each visit took (cycle time), and the average cycle time for all patients seen so far. Also, another flip chart sheet posted in the clinic hallway is used by patients to record their comments about their visits. When it's public, it's like a scoreboard at a sports event. Staff can change tactics and thereby mold their results as the clinic session proceeds.

During the afternoon of the first full day of "conversion", patient cycle times were in the 50s. A trainer and a manager carefully reviewed the patient schedule for the next few weeks to eliminate "nasty surprises". Managers were solved problems in real time as they emerged. As the clinic wound down to a successful conclusion, the trainers and managers huddled to prepare for the next day, Day Three of the conversion.

By the end of the next day, the waiting room was empty. The flow was so smooth that patients, including walk-ins were seen after only a minimal wait time in the main waiting room. The management team had begun the hard work of consolidating three disparate staff schedules. They also took control of overbooked provider templates. And, substantial work had begun on redesigning the new patient prenatal visit.

Being on a real tem has changed Marcy Pressman as a leader. She said:

We all think we're the only ones who care about the patients. When someone 'opposes' our viewpoint, we think they don't have the same commitment to our mission. It isn't true. They just believe passionately that their way will deliver the best outcome. Have faith in your colleagues; embrace their passion, if not their ideas.

When conversion week was over, the clinic had achieved dramatically improved results. But success was still fragile. The new habits were not entrenched. The teamwork was too tenuous. But the manager-coaches knew now what to do. The future was now their responsibility. Over the next six weeks, this group of managers, with support and scrutiny from a trainer, improved upon the cycle times achieved during conversion week. And, they created the necessary conditions for redesign to stick.

The clinic cycle times have been consistently less than 60 minutes. Staff members go to lunch and home on time, even clinicians. At the end of each session the waiting room is empty. Patients are happier. Staff members are happier. Teamwork is apparent at all levels.

Are things perfect at Lincoln's Women's Health Clinic? No. But staff and managers now realize they have more control over the quality of their work day than they had thought possible. And, they report that patients are happier and truly appreciate the care they receive from the staff. Monthly cycle time averages dipped as low as 45 minutes in March 2005.