Webinar | Fundamentals for Improving Flow in the Ambulatory Setting

Virginia Mason Institute

Improving flow in the ambulatory setting can help you tackle backlogs and increase patient access, all while improving the staff and patient experience. Learn the fundamentals of improving flow including foundational principles, methods, and routines that can help you optimize the clinical environment with simple team-led improvements.

Learning objectives:

  • Describe how improving flow can positively impact patient and staff experience
  • Describe principles, methods and routines that help to improve the clinical environment, streamline processes, create efficiency, address backlogs and change culture
  • Understand the necessary elements to sustain flow improvements
  • Understand benefits and pathway for additional learning and coaching

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Listen to the audio-only recording as a podcast:

Q&A Transcript

I would say that’s a journey. In some areas, they kept their private offices as they built their flow stations and then found they weren’t going back to their office anymore except maybe once a day. They had agreements of an acquired environment to do that dictation at the flow station and then other areas they started to team up the offices so it was two physicians or two providers to an office, and some areas it’s three or four that have work stations in an office if they need that private time, if they’re doing um some legal things that they might have to do, or other more private things that they might take them away from their workstation. Video appointments as well. But some clinics have migrated to only having flow stations and then having office space that they can use as a hot desk.

Every time I look at this it’s different. They tell me it was about 1.3 MAs to a provider so they have their main one and then there’s a 0.3 medical assistant that was in a what used to be a phone room but now it’s more of a phone portal room that manages the incoming for the whole practice so they share these MAs throughout the practice and so in that room they’ll manage all the incoming messaging and then they’ll send them out to the respective areas if they haven’t already routed to those areas. And then that medical assistant who’s forward-facing to patients today will help manage any of that indirect work that needs to be done in flow and submitted to the provider and so she basically manages his inbox. But there is another small portion of an MA that’s shared throughout the practice so it might be that five physicians would have eight medical assistants throughout the practice and three of those would be sort of off-site or off offline in the back.

Value added. We deem value as a task as valuable from the perspective of the customer and so as we’re timing the work that an individual does if it takes 10 minutes to room a patient, what pieces of that are value-added versus non-value-added? And I would say taking my blood pressure, taking my weight, doing my vitals, is going to be value-added but running around looking for a larger blood pressure cuff is probably not value-added, and so as we do our time studies we separate those between value-added non-value-added.

There are a couple of ways you can look at it. One is if you were to just look at the flows throughout your clinic, your clinic is different than someone else’s clinic, so how is it engineered within your clinic and where are you embedding the safety and quality checks throughout? Doing the it takes two, the checking the name and the date of birth for the patient, or doing that Covid check at the door. Those quality and safety checks embedded as well as where is the process improvement or kaizen opportunities, where are the visual controls to help manage the work, where have we redesigned and re-improved the process, and so we call all of that process engineering.

Like I said with the lamination example, helping get things set, you know, whether you’re procuring things or helping organize the space. One way if we’re trying to organize an exam room and we don’t have time to redesign it in a way that’s going to work for everyone and standardize it, what if we took the top drawer and laid everything out the way we are proposing to have it but we needed to get input from everyone so let’s bring that to the break room and have feedback so that people can give feedback and say “yeah that that works for me” or “no I need this other supply in there,” so there’s lots of offline ways to sort of engage people in the activities to help to capture feedback. As you’re doing some of the process improvements some of that will rely on engaging individuals who are working and some of it will rely on the leader or the if you have the luxury of a process improvement specialist then someone like that. On the other hand, again, it’s the having the leader help to make time for individuals to help work on things because if you think about all the time that’s wasted doing it the hard way and if you could just take the time to improve it you’re going to save so much time in the long run.

You want to start small and start broad versus dictating every single thing that’s happening. And so how can we document the overall general guidelines around standard work and then get to some of the more tasky things around standard work but then at one point there will likely need to be a little bit of flexibility so every schedule is not the same for every physician. We might agree that we have 15s and 30s in our schedule or we have all 20s, 20 20 20 within an hour in our schedule, but all physicians might not have the same number of 15s and 30s, it just depends based on their demand and so making sure we have guidelines of what needs to be standard, these are the way we build these slot types but then have flexibility to be flexible to each physician and the type of specialty they are and the way that they do their care. There are some things that we want to make sure that we script or that we do exactly the same way every time and so the way we’re washing our hands is exactly the same way every time but when it comes to building that rapport and relationship with the patient, a lot of that is just directed by each physician.

Additional Audience Questions

One of the core tenets of our approach is that those who do the work improve the work, so it’s important for each team to help drive the direction of their improvements. It’s also important to balance this with the organization’s vision and strategy which is why we advocate for a process like Strategic Goal Development and Deployment.

Much of our approach is meant to be applicable regardless of clinic design or specific technology. An important part of this is starting with a clear understanding of the current state of processes and barriers that team members face, and then working to determine and test improvements, regardless of if the “flows” are physical or virtual. An example of this is the migration from a paper process for phone messages, patient test results or forms to a virtual process of managing workfiles in the EHR by making the work visual, agreeing on standard messaging, flow and organizing of the information.

Rhonda Stewart, Senior Partner, Transformation Services

Rhonda Stewart, Senior Partner, Transformation Services

Rhonda Stewart is a Senior Partner of Transformation Services at Virginia Mason Institute with over 25 years experience at Virginia Mason. At organizations worldwide, she leads health care leaders to build a lean culture and coaches them to set up a solid infrastructure to support lean implementation and organizational learning — always with a focus on patients. Rhonda is a seasoned keynote speaker and has been invited to conferences to speak on topics related to leadership and organizational transformation.

Rhonda Stewart is a Senior Partner of Transformation Services at Virginia Mason Institute with over 25 years experience at Virginia Mason. At organizations worldwide, she leads health care leaders to build a lean culture and coaches them to set up a solid infrastructure to support lean implementation and organizational learning — always with a focus on patients. Rhonda is a seasoned keynote speaker and has been invited to conferences to speak on topics related to leadership and organizational transformation.

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