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Ambulatory Health Care Facility of the Future: Integrating Lean Workflow Redesign and Lean Facility Design Principles
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Ambulatory Health Care Facility of the Future: Integrating Lean Workflow Redesign and Lean Facility Design Principles


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For more information, go to or call 970.493.8747 …

For more information, go to or call 970.493.8747

As presented on March 19, 2010 at the 2010 AMGA Annual Conference

Presented by: Randall Huss, M.D., President, and Gerald Dowdy, VP Operations, St. John’s Clinic – Rolla Division; and Miguel Burbano de Lara, AIA, NCARB, Senior VP Healthcare, The Neenan Company

When faced with the opportunity of designing a new ambulatory facility to house a multi-specialty clinic practice, ASC and other outpatient services to be completed a year after implementation of their EHR, the St. John’s Clinic-Rolla team partnered with a progressive architectural team, The Neenan Company, to design and build a facility around the new electronic workflows. They integrated Lean workflow redesign and Lean facility design elements to achieve a facility capable of supporting the digital, paperless ambulatory practice of the future.

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  • Goal of business: transform healthcare delivery in the outpatient setting
  • This is the charge to the architects
  • Communication by cordless phones, walkie talkies with PTT microphones, and earpieces
  • Managing: quality, safety, light, sound, smells, comfort, privacy
  • Transcript

    • 1. ST. JOHN’S CLINIC
      Rolla, Mo
      Rolla, Mo
    • 2. Ambulatory Health Care Facility of the Future:Integrating Lean Workflow Redesign and Lean Facility Design Principles
      Randall Huss, MD, President
      Gerald Dowdy, VP Operations
      St. John’s Clinic-Rolla Division
      Miguel Burbano, VP for Health Care
      The Neenan Company
    • 3. What if . . . ?
      What If . . .
      Standard exam rooms
      Greeting lobby with kiosk check-In
      Immediateaccess to information
      Servicesbrought to patient
      Patient-centered comfort
      Leverage capabilities of robust EHR
      Fully digitalservices
      Teams of physicians and nurses
      Improved communication
      Sharedphysician lounges
    • 4. At lesscost!
      Morepoints of care
      Morerevenue per square foot per provider
      . . . . In 14 months or less
    • 5. Opportunity
    • 6.
    • 7. What if . . . ?
      The Future
      Do more with same or less
      Baby boomers surge
      Integrated, coordinated care
      Team-based care
      Leverage technology
      Chronic disease management
      Multiple access points
      Transparency and accountability
    • 8. Charge to Architects: Ambulatory Facility of the Future
    • 9. Strong, clear vision
      Embrace economic challenges
      Physician buy-in
      Workflow redesign
    • 10. Lean Principles
      What if . . . ?
      Lean Principles
      Remove waste - eliminate non-value added work
      Pursue perfection - zero defects
      Workplace organizationandstandardization
      “Just in time”inventory
      Single piece flow; eliminatebatching
      “Pull” vs. “push”
      Continued pursuit of improvement
    • 11. US health care costs highest in the world
      It is the access point to health care
      Less technologicallycomplex; more logisticallycomplex
      (compared to inpatient care)
      The Mandate to Transform Ambulatory Care
    • 12. Obsolete Practices
      The Mandate to Transform Ambulatory Care
      Typical office workflow & designhave changed little in the last 50 years
      American Ambulatory Care is still a cottage industry, uncoordinated and unaccountable
    • 13. Why transform Ambulatory Care?
    • 14. Greater opportunity to improve health of population
      Frontline for preventive health care / wellness
      Increase patient safety
      Demand for patient–centered care
      Patient–Centered Medical Home initiative
    • 15. Manage
      Lean Principles
      What if . . . ?
      New Model of Care
      Over 65population will double by 2030
      Health care must support the increased demand
    • 16. Lean Principles
      What if . . . ?
      New Model of Care
      Team-based care
      Multiple points of access
      Chronic caremodel
      Telemedicine and e-visits
      Patient-Centered Medical Home
    • 17. Patient-centriccare
      Leverage capabilities of robust EHR
      Avoid paving the
      “cow paths”
      Why Redesign Workflows?
    • 18. Lean Principles
      What if . . . ?
      “It’s About Time . . .”
      “The Patient-Centered, Physician Efficient Visit”
      To focus on the patient’s experienceand expectations
      To enhance the efficiencyand effectiveness of the physician
    • 19. Site visits
      University of Utah
      Community Clinics
      “Learning Days”
      Frequent provider meetings presenting Lean design opportunities
      Earlyexecutive decision
      for call center
      Getting Started
    • 20. Physician & Co-Worker
      Off-Site Retreat
      Getting Started
      Utah Leadership presented experience
      St. John’s OPI Lean Team led group exercises
      Physicians and co-workers challenged to apply workflow changes priorto Epic implementation
    • 21. Focus on patient experience
      Right person / right job
      Lean facility design
      Leverage and exploit technology
      Effective communication
      Core Principles
    • 22. Lean Clinic Workflow Redesign
    • 23. Manage
      Lean Principles
      What if . . . ?
      The Patient Centered Physician Efficient Visit
      The Goals
      Analysis of Ambulatory office visit process from patient’s perspective
      Optimize physician time and satisfaction
    • 24. Manage
      Lean Principles
      What if . . . ?
      The Patient-Centered Physician Efficient Visit
      Eliminate steps; avoid provider leaving the room
      Eliminate all waste including non-value added work
      Minimize patient movement
      Standard workflows,room layout and supplies
      Lean Process Improvement
    • 25. Manage
      Lean Principles
      What if . . . ?
      The Patient-Centered Physician Efficient Visit
      Implementation Strategies
      Call center: centralized scheduling, registration, nurse triage, medication refills, Epic messaging
      Monitor and manage call center metrics
      Advanced access scheduling, minimal rules
      Ultimately patient self-scheduling (Epic “My Chart”)
    • 26. Manage
      Lean Principles
      What if . . . ?
      The Patient Centered Physician – Efficient Visit
      Implementation Strategies
      In-room scheduling and check-out
      Patient has future appointments before leaving exam room
      The Care Team model
    • 27. Manage
      The Care Team Model
      LPNs/MAs trained to
      advanced competencies
      Participate In Epic documentation
      Off-load physician tasks
      LPNs/MAs work as team;
      not assigned to one provider
    • 28. Manage
      The Care Team Model
      Up-staffLPNs/MAs per provider
      Provider and LPNs/MAs co-located
      Only caregiversin the suite
    • 29. Manage
      The Care Team Model
    • 30. Manage
      Facility Design Considerations
      Lean principles
      Design for EHR workflows
      Reception/check-in “kiosk” design
      Minimize lobby area (“waiting” room)
      Galleria concept for visitor comfort
    • 31. Manage
      Facility Design Considerations
      Care Team core located centrally in suite
      Receptionist, check-out, and chart storage areas eliminated
      Flexible interconnected business unit modules with “swing rooms”
      Significantly reduced storage – Just in Time inventory
    • 32. Manage
      Facility Design Considerations
      Optimized space efficiencies within offices
      Shared physician lounges over physician offices
      Standard rooms; not assigned to only one provider
      Allow minimum 3 rooms/provider in clinic
    • 33. Manage
      Facility Design Considerations
      Telemedicine room on each floor
      Digital radiography with PACS; no wet processing
      Pharmacy with drive-up
      C.O.W. (“Calf”) and printer in each room
      Community room doubles as group visit room
    • 34. Engagement, participation andcollaboration
      Led to acceptanceof Lean principles
      Financial analysis of Lean design alternatives
      Sealing the Deal
    • 35. SPACE – 13% Reduction
      CAPACITY – 16% Increase
      Lean Facility Design Results
    • 36. SPACE – 20% Reduction
      CAPACITY – 16% Increase
      Lean Facility Design Results
    • 37. Financial Savings
      Lean Facility Design Results
      Construction Cost
      Annual Occupancy Cost
      Annual Operation Cost
      $110,000 +/-
    • 38. Occupancy Cost
      Lean Facility Design Results
      Reduction in allocated occupancy cost to physicians
      800-900 vs. 1300-1500
      sq. ft. / physician
    • 39. Model for the Future
      Model For future Ambulatory Care & facility design for
      St. John’s Clinic and
      Mercy Health System
      Regional and national interest
    • 40. Operational Deployment and Challenges
    • 41. Manage
      Operational Challenges
      Epic EHR Go Live October 2008
      Occupy new facility in September 2009
      Fully Functioning EHR thus No Paper Charts
      Implementation of Lean Design and Philosophy
      Care Team Model
      Call Center
      Economic downturn
    • 42. Manage
      Operational Challenges
      Widespread support for the EHR
      General agreement with Lean principles
      Resistance to change focused on the Care Team model and call center
    • 43. Manage
      Project team had multiple visits to University of Utah Community Clinics - “Learning Days” Program
      Embrace skeptic thought and clinic leader
      Attended additional educational seminars for Lean
      Leadership attended Lean training
      Pre Epic “Go Live” retreat
    • 44. Manage
      Preparation / Call Center
      Physician survey regarding expectations
      Physician Champion
      One on One physician meetings
      Physician appointment schedule template
      Protocol development
    • 45. Manage
      Implementation of
      Call Center
      Largest Rolla Family Medicine Business Unit - initial site for call center while implementing Lean workflow redesign focused on:
      Self-identified units added each week
    • 50. Manage
      Critical Success Factors
      Passionately follow the vision
      Make data driven decisions
      Plan and design for the regular 90% and manage to the 10% exceptions
      Significantly reduce or eliminate appointment rules
    • 51. Manage
      Critical Success Factors
      Physician-led protocols for common messages
      • Prescription refills
      • 52. Patient triaging
      • 53. Test reporting / communicating
      When resistance occurs, ask why five times
      Willingness to accept incremental improvement
    • 54. Manage
      Overcoming Resistance
      Lean Implementation
      Improved efficiency
      Lowertotal costs
      Physician champions
    • 55. Manage
      Overcoming Resistance
      The Care Team
      Better overall care
      More patient-centered
      A team of “best” nurses rather “your” nurse
      EHR enables Care Team model
      Physician champion
    • 56. Manage
      Overcoming Resistance
      The Call Center
      Allow clinical area to focus on care of the patient
      Redesign the receptionist position
      Key component of the Care Team concept
      Noise reduction – minimal phone disruption
      Expanded and consistentphone coverage
    • 57. Manage
      Overcoming Resistance
      The Call Center
      Best practices model
      Call center metrics
      Physician champions and executive decision
    • 58. Manage
      Lessons Learned
      EHR is still not a paperless world - scanning challenge
      Care Team challenge to function as a “team” in support of physician
      • Tendency to regress to traditional paper workflow and batching
      Begin EHR workflow redesign early
    • 59. Manage
      Lessons Learned
      Call Center
      Unknown call volume
      Schedulers vs. nursing staff
      Staffing model for demand
      Staff selection and competency
      New digital technology – new processes
      Educating patients
      “Call Center” label
    • 60. Design and FacilityImplementation
    • 61. Manage
      The Magnitude of Change
      is it ?
    • 62. Manage
      Health Care Challenges
      Constant change
      Continuous improvement & flexibility
    • 63. Manage
      Health Care Challenges
      Doing morewith less
    • 64. Disrupt status quo…
      Thinking differently…
    • 65. Reinvent
      your organization, your strategy,
      your marketing, your image
    • 66. Reinvent
      your organization, your strategy,
      your marketing, your image
    • 67. Continuous Improvement
    • 68. These are extraordinary times which require extraordinarysolutions
    • 69. Manage
      “Patient-Centered” Solutions
      Pebble Project
      Plane Tree
      Six Sigma
      Digital Simulations
    • 70. Manage
      Collaboration Trends
      “Design thinking” is more than one discipline...
      It requires interdisciplinary innovation
    • 71. Manage
      Program at a Glance
    • 72. Manage
      Site Plan
    • 73.
    • 74.
    • 75.
    • 76. Manage
      The Care Team Core
    • 77.
    • 78. Manage
      The Galleria Lobby
    • 79. Manage
      The Galleria Lobby
    • 80. Manage
      The Galleria Lobby
    • 81. Manage
      The EHR Enabled Exam
    • 82. Manage
      The Digitally Enabled OR
    • 83. Manage
      Shared Physician Lounge
    • 84. Manage
      The Care Team Core
    • 85.
    • 86. And just in case you think this project consumed the entirety of the past two years…
    • 87.
    • 88. QUESTIONS?
      Dr. Randall Huss: Randall.Huss@Mercy.Net
      Gerald Dowdy: Gerald.Dowdy@Mercy.Net
      Miguel Burbano de Lara: