By LEIGH HOPPER
Houston Chronicle, November 16, 2002

Bogged down in a pinball-like system typical of public clinics, patients at Pasadena's Strawberry Community Health Center bounced from clerk, to nurse, to doctor and back again. Handed off at least nine times—with long waits in between—patients spent nearly three hours at the clinic, but just 13 minutes with a doctor.

This summer, a small teams of staff, equipped with two-way radios and a conviction that the clinic could improve, tweaked every detail of the patient visit. Ultimately, they slashed total waiting times to 14 minutes—down from 130—and increased the physician time to 17 minutes.

The "reengineering" of the clinic, one of the busiest in the Harris County Hospital District, was deemed so successful that the district is taking the process to the LBJ General Hospital obstetrics department. The redesign of Strawberry was paid for with a federal grant.

The hospital district is paying $20,000 more in consulting fees to redesign Northwest Community Health Center and Martin Luther King Health Center, and will use staffers trained in the redesign process to teach others.

"There's a theory in management and performance improvement that talks about incremental improvements. There's another that says, Don't limit yourself. Go for a big, hairy, audacious goal," said John Guest, chief executive officer of HCHD. "This is a good example of that. People were able to achieve a big, hairy, audacious goal."

Harris County's waiting times were some of the worst in the nation, said Roger Coleman, a Santa Fe, N.M., health care consultant who guided Strawberry's transformation and redesigns public clinics all over the country. He said the average wait in the Southeast is 95 minutes; in the Northeast, 80 minutes; in the West, 75 minutes; in the Midwest, 70 minutes. "I don't know what the deal is, but we definitely see higher times in Houston and Austin," he said.

But clinics everywhere, he said, suffer similar problems: Lack of teamwork, entrenched bad habits, failure to use new technology, and outmoded procedures for moving patients through the system. "The people are good, but the systems are bad," Coleman said. "The patient visit is engineered to be a series of stops. What we saw at Strawberry was stop and go, lots of people involved, the patient having to tell his story over and over. It's totally wasted time." To design a new system at Strawberry, Coleman asked for five of the clinic's "best and brightest" employees—no upper-level administrators allowed. He didn't want lower-level workers to feel intimidated.

Over seven months, he taught the team what other clinics had done and helped them brainstorm to reach their own solutions. He told them, "You shouldn't make any change unless it directly benefits patients."

Strawberry patients now get a phone call reminding them of their upcoming appointments. Rather than send patients to different parts of the clinic for procedures and consultations, all services come to the patient who waits in one exam room, eliminating all but 14 minutes of waiting time. Workers in various "pods" communicate rapidly via radios to fetch charts and fill exam rooms.

Pressured to change, Strawberry's onsite medical laboratory reduced its turnaround time to 10 minutes, from one hour. Pharmacy orders are now filled within 20 minutes, instead of 60.

"Our front-line people knew how to make the system work—we just never bothered to ask them," said clinic director Paul Shank. "When we gave them a chance, they said, ‘Oh that's easy, we can do that.'"

The difference was so dramatic that one returning patient became frightened when he was whisked into an exam room, thinking faster service must mean he was gravely ill.

"It made a great difference. I think it's better," said Alton Horn, a 59-year-old former tugboat captain who has used Strawberry since he became disabled from heart disease. Horn visited the clinic Friday and saw his doctor within 15 minutes.

Suzie Diaz, a senior clerk, emerged as a leader in the transformation. It fell to her to persuade co-workers to embrace the new approach—a job that made her so anxious, the mother of four began sewing nursing scrubs at night to relax.

"How am I going to get these girls to think like I do?" she wondered.

Today, when Diaz walks through the clinic, her co-workers give her high-fives. Many have been trained as nursing assistants to take blood, give injections, make follow-up appointments in the computer and read patient charts.

Diaz, who used to spend most of her time at the front desk, not in the room with patients, said the renewed focus on patient care has been an inspiration, making patients seem like people again, not numbers.

She likes hearing clients' stories and has memorized much of the doctors' lectures to patients about diabetes side effects, since she hears them several times a day.

"You get closer to the patient and you have more empathy toward them," Diaz said. "And you learn so much more."