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WordDrive Writing Sample: Medical Staff News

Orthopedic Practice Uses Unique Approach to Improve Delivery of Care

Dr. Chiodo
Chris Chiodo, MD, chief of the Brigham and Women’s / Faulkner Hospital Foot and Ankle Service.

With patient satisfaction and quality assurance at the top of many hospital agendas, it’s not surprising that Brigham and Women’s/ Faulkner orthopedic practices are taking a close look at their care delivery systems. “We are definitely efficient in delivering high quality care on a routine basis,” says Dr. Chris Chiodo, M.D., chief of the Foot and Ankle Service. But, he says, there is ongoing need for improvement in the logistics of patient care, and his Faulkner based team has found a surprising source of help in an approach called “lean manufacturing”. “At first,” says Dr. Chiodo, “we weren’t sure what to think, and wondered whether this might be just another bureaucratic exercise.” But he quickly realized the value of the approach, and says that his team is 100 percent behind it. “It’s tough not to support it once you understand the principles.”

Dr. Chiodo says that “lean” is a process which allows you to “observe, assess, and implement small but discrete changes that can be measured. We designate certain days for observation. We spend a couple of hours observing ourselves and the patient experience, and then we sit and review and discuss what we’ve learned, but without stopping the patient flow.” Lean manufacturing was originally developed by highly successful companies like Toyota and Alcoa, which discovered that the more closely they observed their systems, and the smaller the steps they took to improve them, the greater the quality of their product and the efficiency of production. Steven Spear, a senior fellow at the Institute for Healthcare Improvement and a specialist in lean manufacturing for healthcare, serves as Faulkner’s coach. Funding comes from a grant arranged, in part, by a patient who wanted to encourage improvement in patient wait times.

Kristen Maynard is the lean project facilitator at Faulkner and a senior consultant at the Brigham and Women’s Center for Clinical Excellence. She works closely with Dr. Chiodo and Practice Manager Susan Crozier. The project was launched in May, 2006, and site-specific work at Faulkner Hospital started in the late summer, with a training program by Spear to which all staff were invited.

With a variety of inexpensive improvements, the team reduced patient wait time from an average of 40 minutes to 29 minutes.

One exercise was the “paper airplane assembly line” during which participants learned how to look closely at individual responsibilities and reallocate tasks as needed. “What made this exercise hard in the beginning was ambiguity,” says Maynard. “None of us knew how to make this particular paper airplane, nor which part of the airplane we should each be trying to make.”

So the team learned to observe themselves in operation and how to balance the work load at each station. By establishing an efficient process, they were able to achieve quality, use time well, and reduce noise level and stress—all worthy ambitions for orthopedic teams as well as paper airplane makers.

Now, says Ms. Maynard, “People are learning how to stop and analyze a problem, rather than working around it. They ask questions, talk to each other, and look for root causes.” By November, the orthopedic team had begun to see a difference in the patient experience, and in their own experience as well.

One goal was to reduce the wait time between patient arrival and the actual clinic appointment to less than 30 minutes, allowing time for an x-ray. Patients had been requested to arrive 60 minutes before the appointment, but observation revealed an average wait time of only 40 minutes. With a variety of inexpensive improvements to procedure and equipment, the team was able to reduce the wait time to 29 minutes. As a result, it took only an 11 minute reduction to reach the 30 minute pre-clinic arrival time.

Another difficulty concerned patients bunching up at different points during their visit. The team took a look at the check-in and check-out procedures and saw that at a single desk one person was checking patients in and out, answering the phone, and arranging future appointments.

The team came up with small changes that could be made one at a time to smooth patient flow. They set up separate desks for checking in and out, removed the telephone from the checkin desk, and assigned check-out to a second person. They flagged a passing maintenance man and asked him to remove an unneeded door that was blocking the check-out desk. They interviewed the check-out staff to find out what took them the most time. The response: making MRI and CAT scan appointments, some of them not needed for months. The solution: bundle these appointment requests and complete them during quiet times of day.

Dr. Chiodo is one of the physician leaders on Brigham and Women’s Orthopedic Inpatient Care Improvement Committee, and is preparing to publish an article on the incremental improvement of patient satisfaction. He says that outpatients are, in many ways, more at risk for dissatisfaction. The visit is shorter, for example, and there is less opportunity to sit with the patient and provide comfort and connection.

Dr. Chiodo points out that the close observation of lean techniques can involve large changes as well as small. The orthopedic clinic has, for example, ordered computer tablets that will reduce the use of paper records and give physicians more time to be with their patients. Both Dr. Chiodo and Ms. Maynard recognize that it can be a challenge to change ways of thinking about process, especially when medical care itself is working well. They emphasize, though, that care itself is not at issue. Their goal is, rather, to improve the experience for patients and staff alike. The lean approach is helping them move toward a quieter, more comfortable clinic environment with smoother operations and staff free to concentrate on patients. In the long run, they believe that a comfortable patient with less stress is going to be a healthier one.

If you’d like to learn more about the application of lean techniques at this Faulkner orthopedic clinic, contact Dr. Chris Chiodo at 617 983-7363 or cchiodo@partners.org. For further reading, see the Institute for Healthcare Improvement and search for “lean” or“patient flow.


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