Spinning straw into gold

How a small Ohio unit-based team used what they had to up-end dismal patient access numbers

FRIDAY, OCTOBER 24, 2008 :: By Cassandra Braun

Nine months ago, the chances were just about nil that a patient needing an appointment would get in right away with the pulmonology department in the Ohio region. But with little more than sheer determination, the team members have not only resuscitated the rate at which patients get seen—they've shot past the organization-wide goal of 80%.

At the start of 2008, only 10% of Kaiser Permanente's Ohio members secured an appointment with the pulmonary specialty department within two weeks from their first request.

By August 2008, the department reported a record high of 89% of members being seen within two weeks.

"Seeing us at rock bottom, we wanted to fight our way out of it," said Evelyn Lumbus, LPN and the unit-based team's labor co-lead. "We were the lowest compared to other regions and other departments within our own region."

Lumbus believes the key to their success was their change in mindset.

"We changed our attitude when we took ownership of the process. We focused not on the challenges but on the goal, the reward," Lumbus says. "We changed from ‘we can't,' to asking the question, ‘Well, what can we do?'"

Hard realities

The pulmonary team knew they faced some very real challenges. As the sole pulmonologist for the region, Andre Smith, MD, splits his time between two medical centers—Cleveland Heights and Parma—to treat the patients with asthma and other lung diseases. He is assisted by two respiratory therapists and two nurses, including Lumbus.

Smith and his modest team were strapped for time. They couldn't pin their hopes on additional resources, such as adding another physician to help with the load.

"Because our financial situation is very dire, we had to do whatever we could without increasing costs to our department or the organization," said Cheryl Young, Ohio's medical specialties manager and the UBT's management co-lead. "We really could be in danger of ceasing to exist, and I think staff knows that. I think that's what makes people more open to change and trying new things."

When the unit-based team started work to tackle the access problem, the team members turned to the Rapid Improvement Model. They focused on what they could accomplish with the tools and resources they had available, Lumbus said.

"We don't have complete control over everything," added Dr. Smith. "But the things we can control, we can change."

Right patient, wrong appointment

The team began by taking a hard look at their schedule template. They quickly noticed that patients were being scheduled in the wrong appointment slots. Consultation visits are allotted twice as much time as the quicker follow-ups—but patients who were there for follow-ups were being scheduled for consult visits, and members needing the time and attention required for a consultation were being crammed into follow-up slots.

The pulmonology UBT also noted that they had high levels of cancellations and no-shows which left vacant appointment slots. The Cleveland Heights clinic has a no-show rate of 14%, according to Lumbus.

The team then got to work testing different solutions. Immediately they saw results – jumping to 45% access after the first month.

"Just that quick change and how they scheduled patients opened everything up," Young said. "Everyone was excited, especially after the first attempt and they got immediate gratification."

The team's motivation gained momentum from there.

Increased workload

While the hard work has paid off, it has meant additional work for everyone. Dr. Smith estimates the phone visits alone have tacked on an additional 1.5 hours to the end of his day. Lumbus and the other nurses look for every spare moment into which they can squeeze a little more work.

The team is now looking toward figuring out how to incorporate the additional work while preventing burnout—and while sustaining their access to members. But they all agree that the improvements and further refinements are all part of an on-going process.

"The way I look at it is I'd rather make that sacrifice now and keep Kaiser whole and intact, rather than Kaiser go under and not have that choice," Lumbus said. "I think Kaiser is great and we want to keep it viable."

How they did it: the nuts and bolts

• Collaborated with member services and primary care departments—both of which can make referral appointments for the specialty care—to ensure that all departments were on the same page about which appointments were appropriate for which type of visit.
• Increased the number of consultation slots by having some routine follow-up appointments handled by primary care physicians.
• Minimized the number of unused appointment times caused by cancellations by keeping a list of patients who could be contacted and potentially moved into a vacated slot.
• Decreased rate of no-shows by calling some members ahead of time to re-confirm appointment time.
• Some in-person visits transferred to phone appointments.