Excessive wait times in a hospital can be a source of great frustration for patients, which affects their level of satisfaction with the hospital. Since hospitals will be held more accountable for their scores on the Hospital Consumer Assessment of Healthcare Providers and Systems survey, they will need to improve things like wait times to ensure patients are satisfied.
Cleveland Clinic reduced the wait time for chemotherapy patients in the Taussig Cancer Institute from approximately two hours to less than 20 minutes over three years — a decrease of more than 80 percent. Darryl Greene, executive director of continuous improvement at Cleveland Clinic, explains how the health system used Lean principles to achieve this significant reduction in wait time.
Excessive wait times
In 2006, outpatient chemotherapy patients at Cleveland Clinic's Taussig Cancer Institute had to wait from one to two hours to receive treatment after checking in. This long wait time influenced not only patient satisfaction, but also employee satisfaction, as employees' goal is to deliver care to patients when needed. In addition, the extensive waiting period often caused patients to become vocal and animated about their frustration with the providers, according to Mr. Greene.
1. Multidisciplinary team. To solve this problem, Cleveland Clinic's continuous improvement team developed a multidisciplinary team including Taussig's administrator, the chemotherapy unit leader, physicians, nurses, laboratory technicians and pharmacists. This chemotherapy wait team analyzed the current process of treating patients to identify areas of inefficiency.
One of the keys to the success of the intervention was the team members' collaboration. Mr. Greene says clinicians and staff working together to provide care is a different dynamic than working together to solve process problems. "Just because people are a team in care delivery doesn't mean they are a cohesive team when solving problems using Lean or other problem-solving techniques," he says. The leaders, staff and clinicians in the chemotherapy unit needed to understand each other's roles and work together to effectively identify areas of non-value added activity and develop solutions.
2. Registration. One area of inefficiency the team identified was how patients were checked in and taken to rooms for treatment. Initially, the first available nurse would take the first patient who signs in to his or her room. The process was not formal or organized, and it created delays.
The improvement team changed this process by developing schedule templates that assign nurse navigators to specific patients on the schedule. The nurses guide patients through their treatment, improving both efficiency and patients' experience. In addition, the team established team leaders in the unit to address any bottlenecks in patient flow.
3. Scheduling. Another area Taussig's chemotherapy wait team addressed was scheduling. Originally, the chemotherapy schedules did not account for the length of treatment for each patient. Depending on the patient's condition, treatment may last anywhere from one to four hours, according to Mr. Greene. The team created new schedules that enabled staff to optimize scheduling for long and short treatments
4. Lab. To speed treatment, Taussig moved the lab equipment from outside the building to the floor above the chemotherapy unit. The physical proximity of these departments speeds turnaround time for lab results, preventing delays and backups.
5. Pharmacy and physician orders. The chemotherapy team shared the unit's schedule with the pharmacists to ensure they would have the correct medication for patients on time. The team also paired nurses with physicians to ensure each patient receives the correct medication and dosage.
In addition, the unit worked to improve the completeness of physicians' pharmacy orders. Sometimes orders for patients' medication would be absent, missing a signature or have the incorrect medication. Initially, roughly 15 percent of physicians' orders had at least one problem, according to Mr. Greene. By tracking each physician's rate of incomplete orders and posting these rates visibly, unit nurse managers motivated physicians to improve. The nurse managers also reviewed the rates regularly with physicians to help them reduce the rate of problem orders.
6. Leadership. Reports on patients' wait times in the chemotherapy unit are reviewed at several levels of the organization, from the frontline workers to the heads of the department all the way to the CEO, according to Mr. Greene. "Having key measures at every level of the organization and having a focus on it consistently has allowed [the short wait time] to sustain itself," he says.
Outcomes for patients and providers
Through these efforts, the chemotherapy wait team at Taussig reduced the wait time for chemotherapy patients from two hours to 35 minutes to 20 minutes and eventually less than 20 minutes. Ongoing changes and process evaluation caused these incremental reductions, enabling the unit to continue making progress.
The Lean improvement project also benefited the providers' relationships. "They start to understand the demands and expectations of each other and the creation of commitments upstream and downstream," Mr. Greene says. "There's a strengthened comprehension of what each [person] does and respect for what each [person] does."
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Cleveland Clinic reduced the wait time for chemotherapy patients in the Taussig Cancer Institute from approximately two hours to less than 20 minutes over three years — a decrease of more than 80 percent. Darryl Greene, executive director of continuous improvement at Cleveland Clinic, explains how the health system used Lean principles to achieve this significant reduction in wait time.
Excessive wait times
In 2006, outpatient chemotherapy patients at Cleveland Clinic's Taussig Cancer Institute had to wait from one to two hours to receive treatment after checking in. This long wait time influenced not only patient satisfaction, but also employee satisfaction, as employees' goal is to deliver care to patients when needed. In addition, the extensive waiting period often caused patients to become vocal and animated about their frustration with the providers, according to Mr. Greene.
1. Multidisciplinary team. To solve this problem, Cleveland Clinic's continuous improvement team developed a multidisciplinary team including Taussig's administrator, the chemotherapy unit leader, physicians, nurses, laboratory technicians and pharmacists. This chemotherapy wait team analyzed the current process of treating patients to identify areas of inefficiency.
One of the keys to the success of the intervention was the team members' collaboration. Mr. Greene says clinicians and staff working together to provide care is a different dynamic than working together to solve process problems. "Just because people are a team in care delivery doesn't mean they are a cohesive team when solving problems using Lean or other problem-solving techniques," he says. The leaders, staff and clinicians in the chemotherapy unit needed to understand each other's roles and work together to effectively identify areas of non-value added activity and develop solutions.
2. Registration. One area of inefficiency the team identified was how patients were checked in and taken to rooms for treatment. Initially, the first available nurse would take the first patient who signs in to his or her room. The process was not formal or organized, and it created delays.
The improvement team changed this process by developing schedule templates that assign nurse navigators to specific patients on the schedule. The nurses guide patients through their treatment, improving both efficiency and patients' experience. In addition, the team established team leaders in the unit to address any bottlenecks in patient flow.
3. Scheduling. Another area Taussig's chemotherapy wait team addressed was scheduling. Originally, the chemotherapy schedules did not account for the length of treatment for each patient. Depending on the patient's condition, treatment may last anywhere from one to four hours, according to Mr. Greene. The team created new schedules that enabled staff to optimize scheduling for long and short treatments
4. Lab. To speed treatment, Taussig moved the lab equipment from outside the building to the floor above the chemotherapy unit. The physical proximity of these departments speeds turnaround time for lab results, preventing delays and backups.
5. Pharmacy and physician orders. The chemotherapy team shared the unit's schedule with the pharmacists to ensure they would have the correct medication for patients on time. The team also paired nurses with physicians to ensure each patient receives the correct medication and dosage.
In addition, the unit worked to improve the completeness of physicians' pharmacy orders. Sometimes orders for patients' medication would be absent, missing a signature or have the incorrect medication. Initially, roughly 15 percent of physicians' orders had at least one problem, according to Mr. Greene. By tracking each physician's rate of incomplete orders and posting these rates visibly, unit nurse managers motivated physicians to improve. The nurse managers also reviewed the rates regularly with physicians to help them reduce the rate of problem orders.
6. Leadership. Reports on patients' wait times in the chemotherapy unit are reviewed at several levels of the organization, from the frontline workers to the heads of the department all the way to the CEO, according to Mr. Greene. "Having key measures at every level of the organization and having a focus on it consistently has allowed [the short wait time] to sustain itself," he says.
Outcomes for patients and providers
Through these efforts, the chemotherapy wait team at Taussig reduced the wait time for chemotherapy patients from two hours to 35 minutes to 20 minutes and eventually less than 20 minutes. Ongoing changes and process evaluation caused these incremental reductions, enabling the unit to continue making progress.
The Lean improvement project also benefited the providers' relationships. "They start to understand the demands and expectations of each other and the creation of commitments upstream and downstream," Mr. Greene says. "There's a strengthened comprehension of what each [person] does and respect for what each [person] does."
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