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by Diana Smith and Molly Weisse-Bernstein, Coleman Associates

When Mike Roybal, Medical Director of the Roybal Comprehensive Health Center in East Los Angeles, undertook Patient Visit Redesign™ with his team last year, he was an admitted skeptic. Yet today, the Roybal center is an undisputed success story and is even showcased to visiting federal and state legislative dignitaries as a stellar model of efficient, quality health care.

Patient Visit Redesign™ teams routinely design elegant, efficient, patient-friendly models that become the way they work every day. But, how do you translate that redesign success and make it work at other sites? Roybal Comprehensive Health Center has the answer!

Clinic Cynic

“When we started the Patient Visit Redesign process, I thought it would be impossible to get cycle times (total time a patient is in the clinic from time of entry to exit) under one hour,” said Mike Roybal, MD (no relation to the late Congressman Edward R. Roybal for whom the center is named). A safety net facility, the health center cares for mostly Hispanic patients, 95 percent of whom do not have insurance. “Patients were often late for appointments, and it took a long time to gather information,” Roybal said. With more than 92,000 patient visits each year, that very quickly added up to a serious problem. Cycle times were consistently more than 100 minutes.

The Biggest Surprise

Like all health organizations which are involved in Patient Visit Redesign™, Roybal Comprehensive Health Center started by tracking individual patients. Staff members followed patients from the moment they walked in the door until they left. Down to the minute, they timed a visit from a patient’s perspective—wait time during registration, in the lobby and exam room, and actual care time provided by medical assistants, nurses and clinicians. “The majority of what we learned was not that surprising,” reported Roybal. “We knew we were taking a long time in certain steps, particularly registration.”

He added, “What really surprised us was the amount of time patients spent with their physicians. It averaged only four to nine minutes. That was a real eye-opener,” said Roybal.

Rolling Up the Sleeves

“We obviously had some work to do,” Roybal said. Family Medicine was the first clinic to undergo the redesign training and the team set the goal to reduce cycle times to less than an hour. They developed a new patient visit model and redesigned the patient visit process.

Key components of the new model included:

• Advance preparation. Pre-registration and patient chart updating is completed a day ahead.
• Broadened work roles. Nursing assistants expanded care from just taking vitals to pulling charts and getting procedure results placed in the charts.
• Improved communication. Staff members were issued walkie talkies and use them to stay in touch at all times.
• Patient Teams. Care of the patient was designed around the patient, not clinic processes, and staff was formed into teams to take care of all the patients’ needs.

Sharing Success

The results for the Family Medicine clinic were impressive. Upon completion of the five-month collaborative in October 2005, cycle times dropped to a mere 38 minutes (down from the previous 103 minutes). Productivity increased to 2.8 patients per provider per hour compared to the productivity level of 2 patients per provider per hour prior to redesign.

Based on this success, and the accompanying increased level of patient satisfaction, staff and managers at Roybal CHC were eager to expand the changes to other clinic areas.

To date, Roybal CHC has implemented redesign in three of its targeted areas, and is swiftly moving to redesign the remaining three. And they’re maintaining the original gains that Family Medicine achieved in the collaborative for reduced cycle times and increased productivity.

Taking Progress to Other Clinics

How is the Roybal team taking their success to other clinics? First of all, they know the concept is not a futuristic fantasy. It works! They have a proven redesign model, and they have developed a great training method. But their success started long before this, and relied on being well organized, ensuring that everyone was well-informed about the goals of redesign, and that they were well-supported during the training.

When they got ready to implement the model in their second clinic, Adult Medicine, they relied on these keys to success:

• Knowledge is Power. From the very beginning of the collaborative, the redesign team explained the goals and strategies for redesign to clinic staff in all areas—Adult Medicine, Senior Clinic, Pediatrics and so on. When it was time for the other clinical areas to be trained in redesign, they already had some basic knowledge.
• The Domino Theory. We all know that people change at different rates. But once a certain percentage of people have made the change (the tipping point), it’s easier to get others to change. “We picked Family Medicine to get redesign training first because they had the largest proportion of providers who would be amenable to moving forward,” said Roybal. “That’s why they were so successful.” Then Roybal and his key managers determined which clinic would be next to implement patient visit redesign and which staff in that clinic “was the most open to change.” Adult Medicine was the first clinic trained after the collaborative, followed by the Senior Clinic. Up next: Pediatrics, the Diabetes Specialty Clinic, and Women’s Health.
• On the Job Training. To start implementation, staff from the clinic ready for training jumped in with both feet and came to work in the already-successful Family Medicine clinic. “For example, nursing staff from the Adult Medicine clinic worked in the Family Medicine clinic for a week,” said Roybal. With this first-hand experience, “they knew exactly what the process was before we moved to Adult Medicine.” This week-long “redesign preview” allowed staff to gather real information about the model before having to make any changes in their own work habits.
• Mentors All the Way. To implement redesign, staff members at each clinic underwent a training session in the morning and by afternoon were seeing patients,” said Roybal. Nursing and clerical staff worked in a team with a provider experienced in redesign (usually the provider from the original redesign team) and “they would work with him as he saw patients,” said Roybal. He explained aspects of the redesign model all day long. They also had an on-site coach, someone who knew the job as it had been redesigned. “If it was a clerk that was being trained,” said Roybal, “there was an experienced clerk working with her side-by-side.
  
  Providers received similar training. “The new provider would work with experienced staff,” said Roybal, “and the coach would be an experienced provider guiding the new provider through the model.” In this way, each new team had support until they were well trained.
• Transparency (or Sharing the Bad with the Good). “Not everything worked,” Roybal explained. “We had some setbacks and some resistance from key providers. Yet Roybal didn’t keep the disappointing news under wraps. He disclosed the data to his staff even when the results weren’t what he hoped. That accomplished two goals. First, it established trust with his staff. Second, it eliminated the need for the damage control that is necessary when the bad news does come out—and you’d better believe that it will. “Everybody needs to know what you’re doing,” emphasized Roybal. “And how well you’re doing—or if you’re not doing well, how well you’re not doing.”

(Not So Secret) Secrets of Success

Mike Roybal said that starting with a strong foundation was a big plus. The redesign training team was well-organized—they had to be. For staff to work in different clinics, training dates had to be set far in advance.

Most importantly, they were dedicated to making redesign a reality. Things weren’t perfect, though. “If you’ve got some dysfunction present, either with individuals or your organization as a whole, it’s going to become apparent very quickly, and it will most likely prevent you from being successful,” said Roybal. “So you need to make sure you address these dysfunctional issues either right when they pop up, or if you know they already exist, try to address them proactively.”

“It’s really important for people to understand that redesigning work processes will bring out your dirty, stinky laundry,” said Mike Roybal. At Roybal CHC, they discovered many unpleasant issues that needed to be addressed, from provider competence to employee lateness and staff resistance. But they’re dealing with them the way they deal with everything—head on.

Luckily for their patients, a little dirty laundry didn’t scare them.