Coordinated Care for the Generations
Denver’s Oldest Community Health Center Took a Lean Approach to Filling the Gaps in Patient-Centered Care
Denver Health’s Eastside Clinic is the oldest U.S. community health center west of the Mississippi, but its long history didn't deter managers from seeking innovative patient-centered approaches to improve the frequency of mothers’ postpartum visits and to remove other barriers to patients’ access.
Eastside Clinic is certified as a Patient-Centered Medical Home, which requires a high level of coordination among services, including: family planning; gynecology and obstetrics; prenatal and postpartum care; adult, pediatric and teen primary care; mental health; social services; dental health; and, laboratory tests.
Providers observed that new mothers were missing postpartum visits checking on their own health and well-being. Yet, they were much more likely to bring their babies in for their 2-month checkups and vaccination series.
Barriers to these routine but important checkups included transportation issues, but also strong aversion to long waiting times once mothers got to the clinic. Any concerted effort to cut new wasted time for patients and double the appeal of checkups with dyad visits by moms and babies would require a big buy-in from everyone on the team. Communication and collaboration would have to be optimized.
How Denver Lean Academy Helped
Key stakeholders, including providers in all departments and medical assistants worked with Lean Academy principles to identify which improvements in the process would result in taking care of the whole family in a way that encouraged mothers’ engagement in routine and preventative care.
The initiative, which began two years ago in 2015, included a series of Rapid Improvement Events, in which participants keyed in on the fact that mothers’ were far more motivated to come receive care for their babies. They decided to tie the infants’ checkups with the postpartum screenings for moms.
The challenge was to coordinate the efforts and schedules of the Primary, Women’s and Pediatric clinics. In addition to achieving the dyad visits, stakeholders wanted mothers’ time to be well spent with various providers while at Eastside. Medical assistants were checking in two people, not one.
One facet of this coordination was to ensure that the various providers were aware of schedule delays or bottlenecks. It was literally about getting providers and support staff on the same page.
Staff had to be engaged in tracking multiple service lines, so if the pediatric provider was running behind, for example, another provider could perform another portion of the dyad checklist, such as behavioral health care for the mother.
A lean-guided focus led to a time study tracking patients’ path from check-in to the end of their time with a provider. A long wait (longer than 15 minutes to see a provider) greatly diminished a patient’s overall satisfaction, even if the quality of care had been excellent. A color-coded system flagging on-time or various delays or bottlenecks was used to quickly identify any place the chain might be faltering.
If a provider was running late, staff explained to the patient and could, in many cases, offer a patient a choice of waiting or seeing another provider. The effective line communication enabled the staff to collaborate and function as a team.
The lean process proved valuable to managers who knew they had to be patient in eliciting and listening to staff issues and concerns during analysis of the process. Without engagement of all stakeholders, the gears could never mesh smoothly. It was important for team members to understand why things worked as they did.
Logistics were developed so that the same patients wasn’t moving in and out of different rooms. Exam rooms had to be fitted and supplied to avoid unnecessary herding of patients from room to room or floor to floor.
The lean process clearly guided the process by ensuring the most meaningful problems or concerns were examined from all perspectives, particularly that of the patients. A patient’s perception often was that they would have to spend half their day for what was only a 20-minute visit with a provider.
Patients were informed of how their visit was unfolding and why, and their increased awareness led to less frustration.
It is very satisfying for new mothers to have to make one trip to the clinic, not two. Less time “waiting for no reason” once they were at the clinic, and a greater understanding of the process, also increased overall satisfaction with the clinic.
- Dyad visits eliminated an extra visit by mothers who often faced transportation and child care barriers
- Waiting times were tracked to reduce unnecessary delays between providers
- More services could be delivered during visits
Eastside Clinic (Ambulatory Care Services) saw marked improvement in Patient Experience scores because of steps taken using lean principles over several Plan-Do-Study-Act (PDSA) cycles. The combination of systems worked together to set aims, accelerate quality improvement and increase patient satisfaction.
- Fewer than 50 percent of women showed up for their postpartum visit before it was made a dyad visit with their babies. The show-up rate is now 85 percent.
- Eighty percent of provider ratings are at 9 or 10 on a scale of 10.
- Recent monthly metrics demonstrate between 80 percent and 94 percent of the pediatric patients were seen within 15 minutes of check-in, compared with 35 percent two years ago.
- Specific comments on patient surveys indicate that mothers find making one trip instead of two extremely helpful and fewer feel they are “waiting for no reason.”
About Denver Health Lean Academy
Unlike many other hospitals in the nation that only implement select Lean tools, Denver Health has installed a unique strategy-based approach to Lean systems deployment.
In 2005, Denver Health began to embrace the Toyota Production System and its Lean principles. The goal was to identify waste and to improve efficiency. Denver’s safety-net hospital, with 525 licensed beds, was ready to undergo a cultural change that would allow it to remain financially stable and continue providing high-quality patient care in an environment of uncompensated care and declining reimbursements. Since then, Denver Health has experienced unparalleled success integrating the Lean philosophy into its culture.
- Denver Health is the first healthcare organization in the world to be awarded The Shingo Bronze Medallion for Operational Excellenceand, in 2016, received the Peak Performance Award.
- Denver Health has involved more than 2,000 of its employees in Lean improvements.
Denver Health Lean Academy participants say it best:
“The Lean Academy principle of staff engagement and collaboration has led to a collective awareness of how well the patient is being served. With our staff, it’s really changed the culture, creating a collaborative approach — with us owning patient care as a team. We share challenges.”