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*160. Toyota "Lean Thinking" Combined with IHI "Reducing Waits and Delays" used to Re-engineer Primary Care

ML Allen, MD, Chief Primary Care, N FL/S Georgia Veterans Health System; L Boyer, ARNP, Administrative Officer, N FL/S Georgia Veterans Health System; M Wilkes, MSN, Clinical PI Specialist, N FL/S Georgia Veterans Health System

Objectives: To achieve radically increased capacity, remove waste, and reduce clinic waits and delays by 20-30% in Primary Care, Outpatient Pharmacy and Lab, these areas needed "blown-up". Toyota Production System of "Lean Thinking" and the Institute for Healthcare Improvement's (IHI) model for "Open Access" did the job.

Methods: July 1999-IHI Waits and Delays Collaborative initiatives to workdown backlog started.

Elimination of unnecessary provider appointments.

a. Medically stable patients return appointments 6 months or one year and walk-in when ill.

b. Utilize Nursing Clinics for medical monitoring (HTN/Diabetic)

c. Institude "Lab only appointments"

d. Increase use of telephone call backs for review of medication and test results. Nurse callbacks when possible.

January, 2000 Pilot "Open Access Scheduling"

Schedule new/annual and return appointments in the morning. The afternoon is reserved for walk-ins.

May-June, 2000 introduction of Toyota "Lean Thinking" concepts to staff. A "Strike Team" did a complete re-engineering of the Lab, and then another "Strike Team" did the same in Primary Care and Pharmacy.

a. Throughput analysis, stop watch measurements and process analysis completed. Each strike team examined sequencing and pathways for both areas.

b. Physical changes included orientation of lab processing instruments, conversion of offices to exam rooms, removal of walls and unused equipment.

c. Standard works removed redundancy of functions i.e. standard processing, education, and scheduling eliminated waste and confusion.

d Change in healthcare infrastructure with shift of non-provider functions to support staff.

Results: Changes in Lab turn-around times have affected the whole hospital. CBC cycle times were 73 minutes six months ago, currently average 27 minutes. Chemistries were 125 minutes are now 49 minutes. Urinalysis took 140 minutes now take 34 minutes. These are the times from obtaining the specimen until complete and in the computer.

Primary Care re-engineering has made room for 5,700 veterans with not additional MD FTEE. Exam room to provider ratio has doubled. Veteran trips in and out of exam room recreased for 8 to 2. This combined with standard works has cut cycle times by 24% to 50%. Outpatient Pharmary time was reduced by 20%.

Conclusions: Infrastructure changes have increased capacity, access and timeliness of care in Primary Care Clinics at the Gainesville Division. The additional 5,700 new users would generally require hiring 3-4 MDs and 2-4 ARNPs and support staff. We did it with 3 healthtechs and 3.5 LPNs. This is a cost avoidance of more than a million in salary dollars. Only by building a better "mouse trap" can we keep pace with future demands.

Impact: Toyota Production System of "Lean Thinking" combined with the IHI's Open Access Scheduling are two powerful tools that make higher patient volumes in less time possible.