Applying Lean Design Principles to a Gastrointestinal Endoscopy Program for Uninsured Patients Improves Health Care Utilization
Authors: Kalpesh K. Patel, Shanna Cummings, Joseph Sellin, Larry Scott, Hashem B. El-Serag
Journal: Clinical Gastroenterology and Hepatology (2015)

There is an emerging national consensus to increase colon and rectal cancer (CRC) screening rates to 80% by 2018. For us, as a nation (and GI specialty) to move from our current 60% to 80% we have to enhance screening among patient populations that are challenged to access our medical system. Those who are underinsured or uninsured pose a special challenge. In this month's Practice Management column, gastroenterologists in Houston, Texas describe the impact of lean management strategies to enhance colon and rectal cancer screening among low-income patients in the Harris Health System. Readers are encouraged to refer to a previous article, which focused on similar patients in Connecticut (Lagarde SP. No one left behind: the road to 80% by 2018. Clin Gastroenterol Hepatol 2014;12:1212–1215).John I. Allen, MD, MBA, AGAFSpecial Section Editor Efficient health care delivery, particularly to uninsured and underinsured patients, is challenging. Limitations include financial constraints, poor communication within complex health care systems, and lack of patient empowerment.1Key facts about the uninsured population. 2013. Available from: http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/. Accessed: January 28, 2014.Google Scholar Overcoming these obstacles requires considerable multidisciplinary effort. Frequently, poorly integrated decisions are made in ways that lead to a low-functioning system. To create a more efficient health care system, principles of lean management have been applied to the process of redesigning health care delivery.2Ahmed S. Manaf N.H. Islam R. Effects of Lean Six Sigma application in healthcare services: a literature review.Rev Environ Health. 2013; 28: 189-194Google Scholar Lean principles originated in the automobile industry and encourage a design of systems with increased value and reduced waste.3A brief history of Lean. 2009. Available from: http://www.lean.org/whatslean/history.cfm. Accessed: January 28, 2014.Google Scholar The application of lean principles involves reiterative analysis of current practices, providing innovations to increase value, remove waste, and implement new processes. Lean management has been used successfully at a few US health care centers—most notably Virginia Mason Institute in Seattle, Washington (http://www.virginiamasoninstitute.org/about). Lean management strategies have been applied to emergency room management,4Naik T. Duroseau Y. Zehtabchi S. et al.A structured approach to transforming a large public hospital emergency department via lean methodologies.J Healthc Qual. 2012; 34: 86-97Google Scholar direct open-access upper-endoscopy clinics,5Hydes T. Hansi N. Trebble T.M. Lean thinking transformation of the unsedated upper gastrointestinal endoscopy pathway improves efficiency and is associated with high levels of patient satisfaction.BMJ Qual Saf. 2012; 21: 63-69Google Scholar and global health system redesigns.6Burgess N. Radnor Z. Evaluating Lean in healthcare.Int J Health Care Qual Assur. 2013; 26: 220-235Google Scholar Little is known about the use of lean principles to improve colorectal cancer (CRC) screening for underserved populations. We describe the process of a lean management–based group and antecedent changes in the system that relate to CRC screening. The Harris Health System provides care to the 1.2 million uninsured and underinsured residents of Harris County, Texas.7Harris Health System. 2013. Available from: https://www.harrishealth.org/en/pages/home.aspx. Accessed: January 28, 2014.Google Scholar The annual incidence of CRC in this population does not differ from national levels. However, CRC-related mortality is significantly higher than the national average because CRCs are diagnosed at later stages.8Healthy People 2020 Goals. Available from: http://www.healthypeople.gov/2020/topicsobjectives2020/pdfs/EducationalPrograms.pdf. Accessed: December 2, 2010.Google Scholar This can be attributed to CRC screening of less than 33% of at-risk individuals. Of patients with positive results from fecal immunochemical tests, 25% to 30% do not complete the screening process or undergo the recommended colonoscopy. There are several reasons that patients do not undergo recommended colonoscopies, including long wait times for appointments, poor communication with their physicians, and lack of education or health literacy.9SerperM Garon AJ. Smith S.G. et al.Patient factors that affect quality of colonoscopy preparation.Clin Gastroenterol Hepatol. 2014; 12: 451-457Google Scholar Most facilities perform large volumes of procedures, but have inefficiencies such as underscheduling of available procedure slots, understaffing of key positions, and miscommunication of appointment schedules to patients. To identify and overcome some of these system limitations, we undertook an endoscopy program redesign project, led by personnel with specific training in lean management. A certified professional in health care quality (CPHQ) with substantial background in lean-process design (Lean Six Sigma Black Belt) directed the group. She, along with the gastroenterologists within the system, first identified representatives from services involved in any aspect of the endoscopy process. These services included physicians (gastroenterologists, anesthesiologists, primary care physicians, oncologists), nurses, hospital administrators, financial staff, and information technologists. As the process progressed, additional members were added by the CPHQ as needs were identified. Once the group was assembled, a charter was drafted by the assembled group that outlined current limitations, the purpose of the project, team members, and proposed methods and outcomes. The charter was approved by the hospital administrative board and a 2-hour meeting was scheduled for each week. The fundamental first step in applying lean principles to process redesign is identifying current limitations in outcomes. In our system, these included long wait times for procedures, patient drop out, underuse of endoscopy time and space, high no-show rates, and low satisfaction scores from patients. These features all contributed to subpar clinical productivity. We captured baseline measures of wait times, no-show and cancellation rates, endoscopy unit utilization, daily procedural volume, and patient satisfaction scores. We then created a map of our current process, and modified it to overcome current limitations. This exercise is known as value stream analysis, whereby any wasteful step is eliminated and replaced with a value-added step. We created a process map of the current state of delivering endoscopic care, beginning at the point of initial patient referral and ending when the procedure was complete. This map was created with attention to every possible step, to provide multiple targets for improvement (eg, preprocedure planning, endoscopic performance, and follow-up care). Each step in the process map then was evaluated to identify waste—inefficiencies of time or resources, bottlenecks, and sources of patient dissatisfaction. Wasteful steps were flagged, and suggestions for improvement were noted. Over the course of several weeks, the entire process was evaluated in this manner and a new, ideal, future-state map was created (Supplementary Figure 1). This new map included new or redefined processes and personnel, and incorporated consolidated processes and information technologies. Once the future-state map was created, the group estimated the impact on outcome measures. These included reductions in wait times, increased volumes of procedures, reductions in no-shows, and improved patient satisfaction scores. We created a list of interventions, in priority of importance, and presented it to the senior administrative board for approval (Supplementary Table 1). Some of the key interventions are as follows. We identified the process of determining whether an individual patient qualified for care in the Harris Health System as a limitation. Often, patients were attending primary care visits, and receiving subsequent referrals for endoscopy, without confirmation of their eligibility for care. The proposed improvements to this process included expansion of eligibility office staff and creation of a telephone hotline to guide patients through the process. Although the Harris Health System has adopted an electronic medical record, there was no uniform detailed referral request form to be used by referring providers. As a result, referral nurses spent variable and often considerable amounts of time determining whether patients required endoscopies, office visits, or both. To overcome this obstacle, a new referral order form or template was developed, to allow providers the option of ordering open-access colonoscopies for patients who met certain prespecified criteria. These referrals are forwarded directly to an endoscopy scheduler, and a procedure appointment is made. This bypassed several time-consuming steps. The flow of patients through the endoscopy process was divided among various providers in multiple geographic locations. Furthermore, the distinct locations of the gastroenterology clinic and laboratory made integration difficult. To overcome these limitations, we created a new position for an endoscopy nurse practitioner (NP). The role of this specialized NP is to oversee the multiple steps of the endoscopy process and to facilitate patient movement. The NP’s specific tasks include reviewing records of patients with complicated medical history to determine sedation needs, adjusting medication, and providing medical clearance for procedures. Other tasks include communication with the endoscopy scheduler to ensure high utilization rates and flexible management of the schedule (ie, filling cancelled slots, rescheduling, and so forth). The NP also has a closing-the-loop function, in which she or he documents pathology results and makes recommendations for follow-up procedures in an easily identifiable consistent position in the electronic medical record. Finally, the NP serves as the point person for patients and providers, troubleshooting any problems in the process. The central role of the NP is indicated by his or her position squarely in the middle of the map. We presented the proposal to the administrative board, which approved several proposed interventions and designated a 12-month implementation period. Target implementation dates for each intervention were determined by the complexity and priority of each process (Supplementary Table 2). After 6 months, an analysis was performed by the CPHQ to measure changes in several desired outcomes (Supplementary Table 3). An increase in daily and monthly procedure volumes was observed to a level that met the predetermined maximum capacity of the endoscopy unit. Patient satisfaction scores, although limited by a small sample size, increased, whereas no-show rates decreased by approximately 15%. Furthermore, the endoscopy NP calculated important quality measures of colonoscopy,10Fayad N.F. Kahi C.J. Quality measures for colonoscopy: a critical evaluation.Clin Gastroenterol Hepatol. 2014; 12: 1973-1980Google Scholar including rates of accurate adenoma detection and proper use of surveillance colonoscopy. However, because of the high and growing demand for services in this system, no significant change in the wait time was observed. The redesign led to several additional unanticipated successes as well as challenges. The breaking down of silos between various entities in a complex system was a crucial step in the process, and the resulting improved intradepartmental communication added significant value. Many misconceptions and misunderstandings of roles and responsibilities were cleared. Finally, a sense of teamwork and a comprehensive endoscopy practice began to develop, as opposed to each member working on only their own individual task. A disheartening challenge emerged: most efficient processes cannot overcome certain fixed obstacles, such as supply vs a large demand for health care and the insurmountable socioeconomic hardships of patients. Although the health care system often is criticized for being inefficient and costly, efforts to redesign delivery processes often are hampered by a lack of training in effective methodology and financial constraints. By applying well-established methods of lean principles, we were able to systematically create a process devoid of wasteful steps; this allowed us to save enough money to increase personnel. Efforts at change within large health care systems often are undertaken in silos, leading to poorly supported changes and delays in implementation. Beginning with a multidisciplinary group and engaging important stakeholders ensured that the final product would be widely supported. The detailed and transparent analysis that went into the design of the final proposal contributed to the executive administration’s approval of resource requests without significant delay. A comprehensive redesign of complex health care delivery processes is possible and greatly aided by application of lean methodology. This approach can be applied to a variety of multistep processes in gastroenterology and hepatology, including management of endoscopy units or treatment of patients with hepatitis C. Further integration of this type of approach into health care systems could increase efficiency and effectiveness of care. Supplementary Figure 1ASA, American Society of Anesthesiologists; CCM, Clinical Case Manager; CHC, Community Health Clinic; CRNA, Certified Registered Nurse Anesthetist; FIT, Fetal Immunoassay Test; GI, gastrointestinal; PACU, Post-anesthesia recovery unit; PCP, primary care physician; RN, registered nurse; pre-op, preoperative.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Supplementary Table 1Intervention Time LineActionMilestoneProgressPerioperative clinical coordinatorComplete: 1 position approvedImplementedPatient navigator roleNo new FTE: external grant was renewedImplementedRNs/gastroenterology techniciansComplete: 2 positions approvedImplementedGastroenterology education case managerComplete: 3 positions approvedImplementedEndoscopy nurse practitionerComplete: 1 position approved per pavilionImplementedCRNA in the Smith ClinicComplete: 1 position approvedImplementedEndoscopy charge nurseComplete: 1 position approvedImplementedMD GI/anesthesia staffingPending approvalPendingCRNA, Certified Registered Nurse Anesthetist; FTE, full time equivalent; GI, gastrointestinal; RN, registered nurse. Open table in a new tab Supplementary Table 2Intervention Time LineActionMilestoneProgressInstall wall workstations in the endoscopy suite at BTGHCompleteImplementedEligibility call centerComplete: no new FTE requiredImplementedMonitor no-show and cancellation screeningPatient education and reminder calls 2 weeks and 2 days before procedureIntegrating the no-show and cancellation tool into the navigator’s roleImplementedMonitor no-show and cancellation screeningPatient education and reminder calls 2 weeks and 2 days before procedureIntegrating the no-show and cancellation tool into the navigator’s roleImplementedPatient commitment letterCompleteImplementedEPIC physician criteria and algorithmCompletePendingScheduled block time for providersBlock time draft developed at LBJ and BTGHPendingAncillary financial planning pilotOn hold: resources not allocatedPendingElectronic consentDesign completePendingBTGH, Ben Taub General Hospital; FTE, full time equivalent; LBJ, Lyndon B. Johnson Hospital. Open table in a new tab Supplementary Table 3Outcomes Before and After InterventionBaselineFuture estimateAfter Lean actualChange, %CRC screenings per month15018018121Time from referral to procedure100 d30 d>60 dN/ARoom use63%85%80%22No-show rates30%5%12%18 Open table in a new tab CRNA, Certified Registered Nurse Anesthetist; FTE, full time equivalent; GI, gastrointestinal; RN, registered nurse. BTGH, Ben Taub General Hospital; FTE, full time equivalent; LBJ, Lyndon B. Johnson Hospital.