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By Jeff Olivet, Coleman Associates

Before the Blitz

It was ugly. The elevator doors would open at 8 a.m. and a mob of people would emerge and descend upon the front desk of the Medicine clinic at Cumberland Diagnostic and Treatment Center in Brooklyn, NY. There they would wait to be registered. This log-jam up front would last most of the day, with very few moments of reprieve for staff or patients. By 10 a.m. the waiting room was full and poor Carmen—the first line of defense at the front desk—looked as though she would fall out of her chair at any second.

With only one point of registration for the entire clinic, it was not unusual that a patient would wait 20-30 minutes or more just to be signed in. The cycle time—or the total amount of time the patient is in the clinic—was 75 minutes…on a good day. On a bad day a patient might be in the clinic for more than an hour and a half.

So that was the front end of the clinic. The back could be ugly too. Providers were territorial about their exam rooms, and some refused to use more than one exam room. Instead, patients were moved from place to place through the course of the visit.

The nursing staff was fragmented, bombarded with one crisis after another—when they were with a patient they were constantly distracted by questions from staff or other patients, phone calls, or patients walking in and needing forms filled out or PPDs read.

No one went to lunch on time, and at the end of the day, it still felt as though the waiting room would never empty out.

The Blitz

Although the clinic had made some efforts at redesign, clinic leadership felt they had not achieved everything they had wanted. So, during one week in June of last year, Coleman Associates brought in its “Blitz Team” to work with staff and managers to redesign the patient visit process.

A strong management team quickly emerged—Cynthia Boakye, MD; Ed Adkins, RN; Wanda Harris, Clinic Manager; Carmen Cruz, Clerical Supervisor; Shirley Holliday, Finance Supervisor, Norma Wright, On-Site Administrator; Jacqueline Brown, RN, Sr. Associate Director, Nursing; Lynette Livingston, RN, Assistant Director, Nursing and Christie Davis, Deputy On-Site Administrator. These people quickly proved that once they decided to come together to solve problems, they were thoughtful, creative, and effective. They also realized that their main problem in the past had been their failure to come together to solve problems.

The first problem to solve was the log-jam up front. Two dramatic innovations were implemented immediately: 1) decentralized registration, and 2) Fast Track Nurse.

Decentralizing registration meant moving Clerical Associates away from the front desk and back into the “pods” where the clerks become integrated into the Patient Care Teams. For the patients, this meant when they came off the elevators, they were first greeted then directed straight back to the pods to the appropriate Patient Care Team.

Patients and staff noticed the difference instantaneously. There was no longer a wait at the elevator. Patients were registered much more quickly, and because the volume was dispersed, staff no longer felt so overwhelmed.

To make this work, though, someone needed to be up front directing traffic: the Fast Track Nurse. (See Patient Visit Redesign™ in New York City in the Success Stories section to read how this concept was used by another clinic.) The nurse in this role “worked the waiting room” to make sure every patient was taken care of. No one was allowed to fall through the cracks. If something could be handled quickly, such as a PPD reading, the Fast Track Nurse would take care of it. If one Patient Care Team was overwhelmed with walk-ins and another had no-shows, the Fast Track Nurse would coordinate with the Patient Care Teams to ensure all patients were seen as quickly as possible while still maintaining continuity of care.

After the Blitz

In the weeks following the week-long Blitz, cycle times, which previously had been 78 minutes and higher, plummeted to less than 60 minutes, where they have stayed. Staff was astounded. Patients were delighted.

It was a transformed place. By the end of the morning, the waiting room was empty, and everyone went to lunch—together and on time. At the end of the day, the waiting room was again empty and everyone went home on time. “It was just a slow day,” they would initially say to each other. But when every day was a “slow” day, and they looked more closely at the data, they saw the clinic’s volume had actually INCREASED at the same time that the cycle time had DECREASED!!

Again, they were astounded.

Greatest Successes

Three months after the Blitz, the Management Team savored their achievements:

A 5-6% increase in the number of patients compared to the same months the previous year. A decrease of 25% in cycle time. Short or non-existent patient registration lines. When a line does begin to form, there is a sense of urgency among the staff to get those patients where they need to be. The Fast Track Nurse has been an enormously important innovation. Patient Care Team schedules were developed. Before, there were separate schedules for clinicians, nurses, and support staff. Now a consolidated one-page, user-friendly document that includes all the schedules is distributed to all staff each day. Patient financial service staff was increased. Now in addition to financial screening, they also register patients. Providers treat exam rooms like resources instead of personal possessions, and now use whichever rooms are available, whether that’s one, two, or three exam rooms per provider. Patients are more satisfied, as exemplified by frequent positive patient comments.

Challenges Ahead

As important as it is to celebrate success, it’s equally—or even more—important to identify and develop strategies to combat problems which can thwart redesign. The Management Team has realized that there’s no room for complacency. Their current challenges include:

• Maintaining staffing levels to make the redesigned patient visit model effective—specifically related to the number of RNs in the clinic.
• Maintaining consistent Patient Care Teams.
• Maintaining consistency in the Fast Track Nurse role.
• Integration of specialty clinics into the redesigned model.
• Continuing to deal with staff who are slow to embrace the new model.

As other clinics commit themselves to great results through redesign, they should certainly look to Cumberland Medicine as a great example and a great inspiration—a place where staff and managers came together in teams, and through teamwork, transformed their clinic into a place where patients not only receive great care, but where the patient’s time is also highly valued and made a priority.

And Now…

The elevator doors open. Rather than seeing a mob of people overrunning an overwhelmed staff, one sees a calm, welcoming environment. Poor Carmen no longer looks as if she will fall out of her chair at any moment. The waiting rooms are quiet because patients are being seen quickly and going home. And most importantly, patients constantly remark how much better this is than the old way.