Journal of Pediatric Urology (2015) 11, 228.e1e228.e6
Optimizing value utilizing Toyota Kata methodology in a multidisciplinary clinic Paul A. Merguerian a, Richard Grady a, John Waldhausen b, Arlene Libby a, Whitney Murphy a, Lilah Melzer a, Jeffrey Avansino b a
Division of Urology, Seattle Children’s Hospital, Seattle, WA, USA
b
Division of General Surgery, Seattle Children’s Hospital, Seattle, WA, USA Correspondence to: P. A. Merguerian, Seattle Children’s Hospital, 4800 Sandpoint Way NE, Division of Urology, Seattle, WA 98105, USA [email protected] (P.A. Merguerian) Keywords Toyota Production Systems; Quality improvement; Value; Cost Received 2 March 2015 Accepted 20 May 2015 Available online 19 June 2015
Summary Introduction Value in healthcare is measured in terms of patient outcomes achieved per dollar expended. Outcomes and cost must be measured at the patient level to optimize value. Multidisciplinary clinics have been shown to be effective in providing coordinated and comprehensive care with improved outcomes, yet tend to have higher cost than typical clinics. We sought to lower individual patient cost and optimize value in a pediatric multidisciplinary reconstructive pelvic medicine (RPM) clinic. Materials and methods The RPM clinic is a multidisciplinary clinic that takes care of patients with anomalies of the pelvic organs. The specialties involved include Urology, General Surgery, Gynecology, and Gastroenterology/Motility. From May 2012 to November 2014 we performed time-driven activity-based costing (TDABC) analysis by measuring provider time for each step in the patient flow. Using observed time and the estimated hourly cost of each of the providers we calculated the final cost at the individual patient level, targeting clinic preparation. We utilized Toyota Kata methodology to enhance operational efficiency in an effort to optimize value. Variables measured included cost, time to perform a task, number of patients seen in clinic, percent value-added time
(VAT) to patients (face to face time) and family experience scores (FES). Results At the beginning of the study period, clinic costs were $619 per patient. We reduced conference time from 6 min/patient to 1 min per patient, physician preparation time from 8 min to 6 min and increased Medical Assistant (MA) preparation time from 9.5 min to 20 min, achieving a cost reduction of 41% to $366 per patient. Continued improvements further reduced the MA preparation time to 14 min and the MD preparation time to 5 min with a further cost reduction to $194 (69%) (Figure). During this study period, we increased the number of appointments per clinic. We demonstrated sustained improvement in FES with regards to the families overall experience with their providers. Value added time was increased from 60% to 78% but this was not significant. Conclusion Time-based cost analysis effectively measures individualized patient cost. We achieved a 69% reduction in clinic preparation costs. Despite this reduction in costs, we were able to maintain VAT and sustain improvements in family experience. In caring for complex patients, lean management methodology enables optimization of value in a multidisciplinary clinic.
Figure Improvement made in patient preparation that allowed for cost reduction. Noon conference refer to our pre clinic huddle that occurs 1 hour before clinic start. http://dx.doi.org/10.1016/j.jpurol.2015.05.010 1477-5131/ª 2015 Published by Elsevier Ltd on behalf of Journal of Pediatric Urology Company.
Toyota Kata methodology in a multidisciplinary clinic
Introduction It is estimated that 20% of the gross domestic product in the United States will be spent on healthcare by the year 2018 [1]. Increasing costs negatively impact value in healthcare. Value is measured in terms of patient outcomes, achieved per dollar expended. The central focus of the healthcare industry must be to increase value for patients by measuring outcomes and cost at the patient level [2]. One of the challenges is the acquisition of accurate cost information on which to base strategic, pricing, and management decisions [3]. Recently Kaplan and Anderson [4] developed an approach, called the time-driven activitybased costing (TDABC), that is based on the unit cost of supplying capacity and the time required to perform an activity. The practice of Kata is the act of practicing a pattern so it becomes second nature. It is a day-to-day management system practiced at Toyota. It teaches a way of working (a Kata) that is a step-by-step discovery process through experimentation at the front lines and using the PDCA cycle (Plan Do Check Act) to get from a current condition to a desired or ideal condition [5]. In an effort to provide value for patients, a multidisciplinary pediatric specialty clinic was created to treat children with anomalies of the pelvic floor organs. Multidisciplinary clinics have been shown to be effective in providing coordinated and comprehensive care with improved outcomes, yet tend to have higher cost than typical clinics [6e9]. This paper describes the use of TDABC as a cost accounting method to direct our continuous improvement efforts based on the Toyota Production Systems philosophy. We sought to lower cost per patient and optimize value in a multidisciplinary outpatient clinic.
Methods The study From May of 2012 to November of 2014, the clinic has utilized Toyota Kata Methods to enhance operational efficiency and improve value for our patients. Value was derived using cost and quality outcomes. We measured cost at the individual patient level using a TDABC analysis by measuring provider time for each step in the patient flow and estimating the hourly cost of the providers (MD, Registered Nurse [RN], MA, Advanced Registered Nurse Practitioner [ARNP]) at the individual patient level. For this study we only targeted clinic preparation. Quality variables included time to perform a task, number of patients seen in clinic, percentage value-added time (VAT) (face-to-face time with patients), and Family Experience Survey scores (FES). A research assistant or an administrator acquired times for TDABC and VAT manually. VAT was calculated by manually acquiring the time the patient was seen by a provider(s) and dividing that over the entire time the patient was in an examination room. As an example, if a patient was in an examination room for 2 h and was seen by
228.e2 three providers for a total of 1 h face-to-face time, VAT was calculated at 50%. Family Experience Surveys (National Research Corporation) were administered at the end of clinic using an iPad (Apple, Cupertino, CA, USA) with data collection software (Tonic, Menlo park, CA, USA). Data were compiled in Excel (Microsoft, Redmond, WA, USA). Data were reviewed and a proposed change was discussed and implemented.
The clinic The Reconstructive Pelvic Medicine Clinic is a multidisciplinary clinic based in a stand-alone tertiary pediatric children’s hospital. The clinic focuses on the care of children with anomalies of the organs of the pelvic floor such as anorectal malformations, Hirschsprung’s disease, cloacal exstrophy, bladder exstrophy, Mullerian anomalies, and idiopathic constipation. The clinic consists of pediatric specialists in the following disciplines: urology, general surgery, gynecology, and gastrointestinal motility. The clinic is supported by two MAs, three nurses, and a nurse practitioner. The clinic occurs twice a month. Clinic is preceded by a multidisciplinary conference/huddle to discuss the patients. During clinic, one to five providers may see an individual patient.
Change methodology The clinic’s initial value improvement initiative was supported by the hospitals Quality Improvement Department. A consultant was assigned to our team to facilitate the initial implementation of TDABC and improvement methodology. First, all members of the clinic team were convened to define and obtain data on the current condition and create a process map to identify the tasks that each member of the team performed before, during, and after clinic. Second, the work was divided into the following three buckets: (1) clinic preparation, (2) clinic flow, (3) coordination of care. Third, a challenge state map was created (Fig. 1). The total cost of the clinic based on the baseline data collected was $1449 per patient, which included the cost of preparation, patient flow, and care coordination. The focus of this study was the clinic preparation component. Fourth, the team was committed to measuring outcome and cost variables and making one small change per clinic. A huddle is conducted at the end of each clinic where data for that clinic is shared with all staff, deficiencies in care are discussed, and changes for next clinic (Kata) are discussed and implemented. Table 1 lists notable changes and the dates implemented.
Statistics Shewhart Control Charts (ImR [individuals and moving range chart]) were used for the study. The central line in these charts depicts the sample mean. Upper and lower control limits are calculated at three standard deviations from the mean. If the process is in control (common cause variation) all the data points fall between the control limits. When
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P.A. Merguerian et al.
Figure 1 Toyota Kata challenge state map. Note. Cost is total cost (clinic preparation, patient flow and care coordination). Q Z quality; C Z cost; D Z delivery.
new improvement causing significant change is introduced, special cause variation will occur and is depicted on the charts when one data point is above or below the upper and lower control limits, or if more than eight data points are above the mean, or if six data points in a row are increasing or decreasing.
Institutional Review Board As this was a quality improvement initiative it was exempt from Institutional Review Board approval.
Results At the beginning of the study period, clinic preparation cost were calculated to be $619 per patient. Table 1 Incremental 2013e2014.
improvements
(Kata)
made
Date
Improvement
6/18/2013 6/18/2013
Schedule MA visits Clinic prep report completed by MA instead of surgeon Start conference at 12:15 and finish at 12:55 Start new white board Automated report in EPIC for MA Clock to alert >20-min wait Team Room Quarterback MA pages provider if family waits >20 min Standard work for sending conference list week ahead of clinic Reduce MA visits to 15 min Noon conference improvements; increased number of patients discussed Visual cue for last appointment MA reduced cycle time prep from 7 min per patient to 5 min per patient
7/2/2013 8/6/2013 9/3/2013 4/15/2014 6/3/2014 8/5/2014 9/2/2014 9/2/2014 10/21/2014 11/4/2014 11/7/2014
The first part of the study was to evaluate the work that each provider performed and reorganize that work without affecting quality of care. We documented the time spent by each of the providers preparing for clinic: time spent reviewing the chart, reviewing studies, ordering tests, and time spent in pre-clinic conference. We were able to reduce average conference time from 6 min/patient to 1 min/patient. This was achieved by spending the majority of conference time discussing the more complex patients and minimal time for the least complex patients. By doing so, MD preparation time was reduced from 8 min/patient to 6 min/patient. We also increased MA preparation time from 9.5 min/patient to 20 min/patient, achieving a cost reduction of 41%, to $366 per patient (Fig. 2). Prior to implementing the change, most of the patient preparation work was performed by the physician, RN, and ARNP. Some of this work was transferred to the MA. This was mostly achieved by having the MA review the patient chart, making certain that all the studies, and laboratories are available, making certain that orders are in for laboratories and radiographic studies, maximizing clinic utilization by reviewing and recommending changes in patient flow, and providers seeing the patient. Continued improvements further reduced the MA preparation time to 14 min and the MD preparation time to 5 min with a further cost reduction to $194/patient (69%) (Fig. 2). During this study period we reorganized the patient flow in order to allow for improved utilization of provider time. For example, we were able to place a patient with Hirschsprung’s disease who needed to be seen by Gastroenterology alone in the same time slot as a patient with bladder exstrophy who needed to see a urologist only, or a patient who needed to be seen by Gynecology alone with one who needed to be seen by Urology and Surgery. By doing so, we increased the number of appointments per clinic from 14 to 43 (Fig. 3) without affecting quality as the time spent with the patient was not reduced. As seen in Fig. 3, these improvements resulted in a special cause
Toyota Kata methodology in a multidisciplinary clinic
Figure 2
228.e4
Cost of reconstructive pelvic medicine clinic preparation.
variation with eight consecutive data points above the mean. By staggering appointment times and creating slots for MA visits we were able to increase value added time from 60% to 78% (Fig. 4). This change was not significant as the control chart shows common cause variation. We demonstrated sustained improvement in FES with regards to the families overall experience with their providers (Fig. 5).
Discussion Our study shows that Toyota production system methodology can be utilized to improve efficiency and reduce waste in a multidisciplinary clinic. By using one of Toyota’s improvement tools, Toyota Kata [5], we achieved a 69% reduction in clinic preparation costs and improvements in outcome metrics such as clinical volume, family experience and to a lesser extent value-added time. We are currently evaluating methods to further improve the value added time from the current 78% to our goal of over 90% including the use of visual aids and communication tools. We made sure that these improvements in patient volumes and cost did not affect cost. Patient volumes were
Number of appointments in a 4 hour clinic
50 45 40 35 30 25 20 15 10 5 0
Nov-12
increased merely by improving use and reducing physician time waiting to see a specific patient. The use of control chart for this type of continuous improvement is controversial. Control charts were created to monitor processes in order to determine if they were stable and therefore prevent tampering with the system if the process is in common cause variation. We chose to use control charts to show change and determine if the changes we implemented cause the process to move to a new and improved state. Control charts are used to identify variation. When a process is stable and in control, it displays common cause variation, variation that is inherent to the process. If the process becomes unstable such as during an improvement project, it displays special cause variation as the process moves from one stable process to the improved stable process. Control charts are robust tools for understanding process variability. Control chart rules take advantage of the normal curve distribution in which 68.26% of all data are within plus or minus 1 standard deviation from the average, 95.44% within plus or minus 2 standard deviations, and 99.73% of data is within plus or minus 3 standard deviations from the average. The ImR chart is one of the most commonly used charts for continuous data and is applicable when one data point is
Mar-13
Jul-13
Figure 3
Sep-13
Jan-14
Jun-14
Aug-14
Oct-14
Number of appointments per 4-h clinic.
Percent Value Added Time for Families
100 80 60 40 20 0
Dec-12
May-13
Jul-13
Figure 4
Sep-13
Nov-13
Apr-14
Value-added time for families.
Aug-14
Nov-14
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P.A. Merguerian et al.
Figure 5
Family experience survey.
collected at each point in time. Our decision to utilize control charts for this improvement project was to analyze and determine if changes in a process have moved our quality metrics from a current state to a new and improved state. Moreover, it helped provide us with a tool to determine if the new process is sustained with it new and improved common cause variability. Healthcare in the United States is undergoing a dramatic period of change, with new legislation driving health systems to standards of higher quality and efficiency [6]. This new era of healthcare aims to enhance consumerism by providing patients with improved access to quality, outcome, and cost data to better inform their decisions. These market adjustments bring to light the concept of value to healthcare, with value defined as the patient outcomes divided by the cost of providing those outcomes [10]. Value should be centered around the patient and should determine the rewards for the patient, providers, payers, and suppliers. Currently, the volume of services delivered drives revenue in healthcare. This shift from volume to value is the central challenge [10]. Organization of complex multidisciplinary care exemplifies this challenge. Many conditions seen in pediatric specialty care are rare and heterogeneous and require multiple specialists to care for the patient. Currently, our health system cares for these patient with uncoordinated, sequential visits to multiple providers, physicians, departments, and specialties. This results in increased costs and poor patient satisfaction, working against the value proposition [2]. It is for this reason we created the Reconstructive Pelvic Medicine Program. We have reorganized our care delivery around a specific group of related medical conditions that require the skills and services required over the full cycle of care for these conditions. Porter [2] argues that such a structure organized around a patient’s needs will result in care with much higher value and far better experience for patients. However, before improving value, one must first understand how to measure it.
Healthcare costs have always been very difficult to measure, as they are typically estimates based on charges. Time-driven activity-based cost accounting is an analytical costing system that takes a comprehensive look at the true cost of providing healthcare services to a patient [4.] TDABC uses process maps to disaggregate a patient’s care processes into a series of clinical activities. These process maps allow for micro-costing, which enables the true cost to be ascribed to a particular part of the process map. In this study, we used TDABC to track personnel costs, as these account for 70% of operational costs in a hospital. In addition, we were in immediate control of these costs, allowing for rapid improvement. The transparency of cost enabled us to best direct where to make our changes. This provides opportunities to redesign processes so that providers perform work that only they are qualified to perform, referred to as working at the “top of their license” [11]. In this study, providers (MD, RN, ARNP) were performing the majority of the pre-clinic preparation and this was transitioned to the MA. The MA’s level of work was elevated as this individual was now reviewing charts, extracting technical details, and generating a review for the team. As an example, the MA would evaluate each patient chart and make sure that the necessary studies and laboratory results including outside studies are available in the chart for review. The MA would make sure that orders were in for studies needed prior to the visit such as KUB, uroflowmetry, and ultrasound, and if not recommend an order to be placed in the chart. By doing so, we reduced waste and improved patient flow during the clinic visit; we reduced wait time for studies, and reduced delays in seeing patients. All these factors together helped reduce clinic preparation costs. It has also been shown that when staff work at the top of their license, performing work that best leverages their education, training, and experience, overall costs decrease and staff satisfaction increases [11]. TDABC allows determination of the actual costs of the resources being used. One can also calculate the capacity cost rate by multiplying the total minutes the resource is available by the cost of the resource. By measuring the actual cost and calculating the capacity cost, one can identify the cost of unused capacity [12]. The transparency of cost helped us to identify unused capacity, which allowed us increase the number of encounters per clinic block. The chart review by the MA and the pre-clinic huddle enabled the team to identify patients who were scheduled to be seen unnecessarily by a provider, or patients who should be seen by a provider but not scheduled, further reducing cost and increasing capacity by allowing that provider to see another patient. Despite the ability to measure cost and outcomes, a quality improvement methodology must be in place to make the necessary iterative changes to enable a successful improvement effort. Approximately 12 years ago, our institution embarked on a lean journey using the Toyota Production Systems (TPS) methodology. The practice of Kata involves the act of practicing a pattern so it becomes routine behavior [5]. The routine behavior of making small iterative changes by frontline workers results in large improvements over time and enhances employee engagement.
Toyota Kata methodology in a multidisciplinary clinic Improvement Kata is a four-part routine that includes the following steps: (1) understand the direction/challenge, (2) grasp the current condition, (3) establish the next target condition, (4) PDCA (plan, do, check, act) toward the target condition. An example of this in our study involved adding an MA visit prior to the providers visit. During the MA visit, patients would get X-rays, vital signs, and other studies such as urinalysis and post-void urine residuals. This portion of the visit was typically occurring during the provider’s visit, as patients would arrive at the time of the provider’s visit despite instructions to arrive early. This resulted in clinic delays. MA visits improved ontime starts for the providers but resulted in an unintended decrease in value-added time as these patients were waiting after their MA visit for the provider. As a result, iterative changes were implemented such as shortening the MA visit and tailoring of the MA visit based on the needs of the patient. The nature of the MA visit was determined during pre-clinic preparation. Persistent measuring of cost and outcomes, coupled with a change in management philosophy and culture, enabled successful improvements in cost, outcomes, and family experience overtime.
228.e6 and outcome metrics that are meaningful to the clinic and the patient’s condition. Using Toyota Kata methodology achieved a 69% reduction in clinic preparation costs as well as improvements in clinical volume, Family Experience. Value added time was improved but further improvement is required to make this significant and sustained. We demonstrated that a time-based cost analysis effectively measures individualized patient cost and that Toyota Kata methods enable optimization of value in a multidisciplinary clinic. We are currently also identifying new ways to improve data collection and extend this work to other areas of the hospital.
Conflict of interest None.
Funding None.
Ethical approval Limitations First, this study is a value improvement study. As a result a single intervention was not compared pre- and post implementation. A series of small iterative interventions were implemented. Individual employees were encouraged to make small changes to their workflow to improve efficiency. Many of these small changes were not captured. As a result it is difficult to attribute any single intervention to the overall improvements in cost. Second, measuring cost is a labor-intensive process. It requires an individual to manually collect data. Third, the individual providers collected clinic preparation data. The quality of the data was dependent on the provider but was expected to be consistent over time. Fourth, cost data were not collected on facilities or other personnel involved in the patient’s care such as security, greeters, schedulers and family service coordinators. Inclusion of these individuals would have enhanced opportunity for cost savings.
Future direction We plan to extend our improvement efforts to clinic flow and ultimately coordination of care. Currently, manual effort to measure cost accurately is difficult. We are looking at ways to automate the data collection process to eliminate the resource required to acquire data. With continued practice and enhanced tools for measuring cost, we will be able to determine value for our patients other areas of the hospital such as the inpatient units and operating rooms.
Conclusion Value-based care can be established for a multidisciplinary clinic that manages rare complex anomalies of the pelvic floor. Measures of value can be accomplished using TDABC
This is a quality improvement article and therefore does not require ethical approval.
References [1] Sisko A, Truffer C, Smith S, Keehan S, Cylus J. Health spending projections through 2018: recession effects add uncertainty to the outlook. Health Aff (Millwood) 2009;28: w346e57. [2] Porter ME. A strategy for health care reformdToward a valuebased system. N Engl J Med 2009;361:109e12. [3] Demeere N, Stouthuysen K, Roodhooft F. Time-driven activitybased costing in a outpatient clinic environment: development, relevance and managerial impact. Health Policy 2009; 92:296e304. [4] Kaplan RS, Anderson SR. Time-driven activity-based costing. Harv Bus Rev 2004;82:131e8. [5] Rother M. Toyota Kata. New York: McGraw Hill; 2010. [6] Thanamayooran S, Rose C, Hirsch J. Effectiveness of a multidisciplinary kidney disease clinic in achieving treatment guideline targets. Nephrol Dial Transpl 2005;20: 2385e93. [7] Goldstein M, Yassa T, Dacouris N, McFarlane P. Multidisciplinary predialysis care and morbidity and mortality of patients on dialysis. Am J Kid Dis 2004;44:706e14. [8] Rasmussen C, Nielsen GL, Hansen VK, Jensen OK, SchioettzChristensen B. Rates of lumbar disc surgery before and after implementation of multidisciplinary nonsurgical spine clinics. Spine 2005;30:2469e73. [9] Kaufman BA, Terbrock A, Winters N, Ito J, Klosterman A, Park TS. Disbanding a multidisciplinary clinic: effects on the health care of myelomeningocele patients. Ped Neurosurg 1994;21:36e44. [10] Porter ME. What is value in health care? N Engl J Med 2010; 363:2477e81. [11] Kaplan RS. Improving value with TDABC. Health Care Financ Manage 2014;68:76e83. [12] Donovan CJ, Hopkins M, Kimmel BM, Koberna S, Montie CA. How Cleveland clinic used TDABC to improve value. Healthc Financ Manage 2014;68:84e8.
Optimizing value utilizing Toyota Kata methodology in a multidisciplinary clinic Paul A. Merguerian a, Richard Grady a, John Waldhausen b, Arlene Libby a, Whitney Murphy a, Lilah Melzer a, Jeffrey Avansino b a
Division of Urology, Seattle Children’s Hospital, Seattle, WA, USA
b
Division of General Surgery, Seattle Children’s Hospital, Seattle, WA, USA Correspondence to: P. A. Merguerian, Seattle Children’s Hospital, 4800 Sandpoint Way NE, Division of Urology, Seattle, WA 98105, USA [email protected] (P.A. Merguerian) Keywords Toyota Production Systems; Quality improvement; Value; Cost Received 2 March 2015 Accepted 20 May 2015 Available online 19 June 2015
Summary Introduction Value in healthcare is measured in terms of patient outcomes achieved per dollar expended. Outcomes and cost must be measured at the patient level to optimize value. Multidisciplinary clinics have been shown to be effective in providing coordinated and comprehensive care with improved outcomes, yet tend to have higher cost than typical clinics. We sought to lower individual patient cost and optimize value in a pediatric multidisciplinary reconstructive pelvic medicine (RPM) clinic. Materials and methods The RPM clinic is a multidisciplinary clinic that takes care of patients with anomalies of the pelvic organs. The specialties involved include Urology, General Surgery, Gynecology, and Gastroenterology/Motility. From May 2012 to November 2014 we performed time-driven activity-based costing (TDABC) analysis by measuring provider time for each step in the patient flow. Using observed time and the estimated hourly cost of each of the providers we calculated the final cost at the individual patient level, targeting clinic preparation. We utilized Toyota Kata methodology to enhance operational efficiency in an effort to optimize value. Variables measured included cost, time to perform a task, number of patients seen in clinic, percent value-added time
(VAT) to patients (face to face time) and family experience scores (FES). Results At the beginning of the study period, clinic costs were $619 per patient. We reduced conference time from 6 min/patient to 1 min per patient, physician preparation time from 8 min to 6 min and increased Medical Assistant (MA) preparation time from 9.5 min to 20 min, achieving a cost reduction of 41% to $366 per patient. Continued improvements further reduced the MA preparation time to 14 min and the MD preparation time to 5 min with a further cost reduction to $194 (69%) (Figure). During this study period, we increased the number of appointments per clinic. We demonstrated sustained improvement in FES with regards to the families overall experience with their providers. Value added time was increased from 60% to 78% but this was not significant. Conclusion Time-based cost analysis effectively measures individualized patient cost. We achieved a 69% reduction in clinic preparation costs. Despite this reduction in costs, we were able to maintain VAT and sustain improvements in family experience. In caring for complex patients, lean management methodology enables optimization of value in a multidisciplinary clinic.
Figure Improvement made in patient preparation that allowed for cost reduction. Noon conference refer to our pre clinic huddle that occurs 1 hour before clinic start. http://dx.doi.org/10.1016/j.jpurol.2015.05.010 1477-5131/ª 2015 Published by Elsevier Ltd on behalf of Journal of Pediatric Urology Company.
Toyota Kata methodology in a multidisciplinary clinic
Introduction It is estimated that 20% of the gross domestic product in the United States will be spent on healthcare by the year 2018 [1]. Increasing costs negatively impact value in healthcare. Value is measured in terms of patient outcomes, achieved per dollar expended. The central focus of the healthcare industry must be to increase value for patients by measuring outcomes and cost at the patient level [2]. One of the challenges is the acquisition of accurate cost information on which to base strategic, pricing, and management decisions [3]. Recently Kaplan and Anderson [4] developed an approach, called the time-driven activitybased costing (TDABC), that is based on the unit cost of supplying capacity and the time required to perform an activity. The practice of Kata is the act of practicing a pattern so it becomes second nature. It is a day-to-day management system practiced at Toyota. It teaches a way of working (a Kata) that is a step-by-step discovery process through experimentation at the front lines and using the PDCA cycle (Plan Do Check Act) to get from a current condition to a desired or ideal condition [5]. In an effort to provide value for patients, a multidisciplinary pediatric specialty clinic was created to treat children with anomalies of the pelvic floor organs. Multidisciplinary clinics have been shown to be effective in providing coordinated and comprehensive care with improved outcomes, yet tend to have higher cost than typical clinics [6e9]. This paper describes the use of TDABC as a cost accounting method to direct our continuous improvement efforts based on the Toyota Production Systems philosophy. We sought to lower cost per patient and optimize value in a multidisciplinary outpatient clinic.
Methods The study From May of 2012 to November of 2014, the clinic has utilized Toyota Kata Methods to enhance operational efficiency and improve value for our patients. Value was derived using cost and quality outcomes. We measured cost at the individual patient level using a TDABC analysis by measuring provider time for each step in the patient flow and estimating the hourly cost of the providers (MD, Registered Nurse [RN], MA, Advanced Registered Nurse Practitioner [ARNP]) at the individual patient level. For this study we only targeted clinic preparation. Quality variables included time to perform a task, number of patients seen in clinic, percentage value-added time (VAT) (face-to-face time with patients), and Family Experience Survey scores (FES). A research assistant or an administrator acquired times for TDABC and VAT manually. VAT was calculated by manually acquiring the time the patient was seen by a provider(s) and dividing that over the entire time the patient was in an examination room. As an example, if a patient was in an examination room for 2 h and was seen by
228.e2 three providers for a total of 1 h face-to-face time, VAT was calculated at 50%. Family Experience Surveys (National Research Corporation) were administered at the end of clinic using an iPad (Apple, Cupertino, CA, USA) with data collection software (Tonic, Menlo park, CA, USA). Data were compiled in Excel (Microsoft, Redmond, WA, USA). Data were reviewed and a proposed change was discussed and implemented.
The clinic The Reconstructive Pelvic Medicine Clinic is a multidisciplinary clinic based in a stand-alone tertiary pediatric children’s hospital. The clinic focuses on the care of children with anomalies of the organs of the pelvic floor such as anorectal malformations, Hirschsprung’s disease, cloacal exstrophy, bladder exstrophy, Mullerian anomalies, and idiopathic constipation. The clinic consists of pediatric specialists in the following disciplines: urology, general surgery, gynecology, and gastrointestinal motility. The clinic is supported by two MAs, three nurses, and a nurse practitioner. The clinic occurs twice a month. Clinic is preceded by a multidisciplinary conference/huddle to discuss the patients. During clinic, one to five providers may see an individual patient.
Change methodology The clinic’s initial value improvement initiative was supported by the hospitals Quality Improvement Department. A consultant was assigned to our team to facilitate the initial implementation of TDABC and improvement methodology. First, all members of the clinic team were convened to define and obtain data on the current condition and create a process map to identify the tasks that each member of the team performed before, during, and after clinic. Second, the work was divided into the following three buckets: (1) clinic preparation, (2) clinic flow, (3) coordination of care. Third, a challenge state map was created (Fig. 1). The total cost of the clinic based on the baseline data collected was $1449 per patient, which included the cost of preparation, patient flow, and care coordination. The focus of this study was the clinic preparation component. Fourth, the team was committed to measuring outcome and cost variables and making one small change per clinic. A huddle is conducted at the end of each clinic where data for that clinic is shared with all staff, deficiencies in care are discussed, and changes for next clinic (Kata) are discussed and implemented. Table 1 lists notable changes and the dates implemented.
Statistics Shewhart Control Charts (ImR [individuals and moving range chart]) were used for the study. The central line in these charts depicts the sample mean. Upper and lower control limits are calculated at three standard deviations from the mean. If the process is in control (common cause variation) all the data points fall between the control limits. When
228.e3
P.A. Merguerian et al.
Figure 1 Toyota Kata challenge state map. Note. Cost is total cost (clinic preparation, patient flow and care coordination). Q Z quality; C Z cost; D Z delivery.
new improvement causing significant change is introduced, special cause variation will occur and is depicted on the charts when one data point is above or below the upper and lower control limits, or if more than eight data points are above the mean, or if six data points in a row are increasing or decreasing.
Institutional Review Board As this was a quality improvement initiative it was exempt from Institutional Review Board approval.
Results At the beginning of the study period, clinic preparation cost were calculated to be $619 per patient. Table 1 Incremental 2013e2014.
improvements
(Kata)
made
Date
Improvement
6/18/2013 6/18/2013
Schedule MA visits Clinic prep report completed by MA instead of surgeon Start conference at 12:15 and finish at 12:55 Start new white board Automated report in EPIC for MA Clock to alert >20-min wait Team Room Quarterback MA pages provider if family waits >20 min Standard work for sending conference list week ahead of clinic Reduce MA visits to 15 min Noon conference improvements; increased number of patients discussed Visual cue for last appointment MA reduced cycle time prep from 7 min per patient to 5 min per patient
7/2/2013 8/6/2013 9/3/2013 4/15/2014 6/3/2014 8/5/2014 9/2/2014 9/2/2014 10/21/2014 11/4/2014 11/7/2014
The first part of the study was to evaluate the work that each provider performed and reorganize that work without affecting quality of care. We documented the time spent by each of the providers preparing for clinic: time spent reviewing the chart, reviewing studies, ordering tests, and time spent in pre-clinic conference. We were able to reduce average conference time from 6 min/patient to 1 min/patient. This was achieved by spending the majority of conference time discussing the more complex patients and minimal time for the least complex patients. By doing so, MD preparation time was reduced from 8 min/patient to 6 min/patient. We also increased MA preparation time from 9.5 min/patient to 20 min/patient, achieving a cost reduction of 41%, to $366 per patient (Fig. 2). Prior to implementing the change, most of the patient preparation work was performed by the physician, RN, and ARNP. Some of this work was transferred to the MA. This was mostly achieved by having the MA review the patient chart, making certain that all the studies, and laboratories are available, making certain that orders are in for laboratories and radiographic studies, maximizing clinic utilization by reviewing and recommending changes in patient flow, and providers seeing the patient. Continued improvements further reduced the MA preparation time to 14 min and the MD preparation time to 5 min with a further cost reduction to $194/patient (69%) (Fig. 2). During this study period we reorganized the patient flow in order to allow for improved utilization of provider time. For example, we were able to place a patient with Hirschsprung’s disease who needed to be seen by Gastroenterology alone in the same time slot as a patient with bladder exstrophy who needed to see a urologist only, or a patient who needed to be seen by Gynecology alone with one who needed to be seen by Urology and Surgery. By doing so, we increased the number of appointments per clinic from 14 to 43 (Fig. 3) without affecting quality as the time spent with the patient was not reduced. As seen in Fig. 3, these improvements resulted in a special cause
Toyota Kata methodology in a multidisciplinary clinic
Figure 2
228.e4
Cost of reconstructive pelvic medicine clinic preparation.
variation with eight consecutive data points above the mean. By staggering appointment times and creating slots for MA visits we were able to increase value added time from 60% to 78% (Fig. 4). This change was not significant as the control chart shows common cause variation. We demonstrated sustained improvement in FES with regards to the families overall experience with their providers (Fig. 5).
Discussion Our study shows that Toyota production system methodology can be utilized to improve efficiency and reduce waste in a multidisciplinary clinic. By using one of Toyota’s improvement tools, Toyota Kata [5], we achieved a 69% reduction in clinic preparation costs and improvements in outcome metrics such as clinical volume, family experience and to a lesser extent value-added time. We are currently evaluating methods to further improve the value added time from the current 78% to our goal of over 90% including the use of visual aids and communication tools. We made sure that these improvements in patient volumes and cost did not affect cost. Patient volumes were
Number of appointments in a 4 hour clinic
50 45 40 35 30 25 20 15 10 5 0
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increased merely by improving use and reducing physician time waiting to see a specific patient. The use of control chart for this type of continuous improvement is controversial. Control charts were created to monitor processes in order to determine if they were stable and therefore prevent tampering with the system if the process is in common cause variation. We chose to use control charts to show change and determine if the changes we implemented cause the process to move to a new and improved state. Control charts are used to identify variation. When a process is stable and in control, it displays common cause variation, variation that is inherent to the process. If the process becomes unstable such as during an improvement project, it displays special cause variation as the process moves from one stable process to the improved stable process. Control charts are robust tools for understanding process variability. Control chart rules take advantage of the normal curve distribution in which 68.26% of all data are within plus or minus 1 standard deviation from the average, 95.44% within plus or minus 2 standard deviations, and 99.73% of data is within plus or minus 3 standard deviations from the average. The ImR chart is one of the most commonly used charts for continuous data and is applicable when one data point is
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Figure 3
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Jan-14
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Number of appointments per 4-h clinic.
Percent Value Added Time for Families
100 80 60 40 20 0
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Figure 4
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Value-added time for families.
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228.e5
P.A. Merguerian et al.
Figure 5
Family experience survey.
collected at each point in time. Our decision to utilize control charts for this improvement project was to analyze and determine if changes in a process have moved our quality metrics from a current state to a new and improved state. Moreover, it helped provide us with a tool to determine if the new process is sustained with it new and improved common cause variability. Healthcare in the United States is undergoing a dramatic period of change, with new legislation driving health systems to standards of higher quality and efficiency [6]. This new era of healthcare aims to enhance consumerism by providing patients with improved access to quality, outcome, and cost data to better inform their decisions. These market adjustments bring to light the concept of value to healthcare, with value defined as the patient outcomes divided by the cost of providing those outcomes [10]. Value should be centered around the patient and should determine the rewards for the patient, providers, payers, and suppliers. Currently, the volume of services delivered drives revenue in healthcare. This shift from volume to value is the central challenge [10]. Organization of complex multidisciplinary care exemplifies this challenge. Many conditions seen in pediatric specialty care are rare and heterogeneous and require multiple specialists to care for the patient. Currently, our health system cares for these patient with uncoordinated, sequential visits to multiple providers, physicians, departments, and specialties. This results in increased costs and poor patient satisfaction, working against the value proposition [2]. It is for this reason we created the Reconstructive Pelvic Medicine Program. We have reorganized our care delivery around a specific group of related medical conditions that require the skills and services required over the full cycle of care for these conditions. Porter [2] argues that such a structure organized around a patient’s needs will result in care with much higher value and far better experience for patients. However, before improving value, one must first understand how to measure it.
Healthcare costs have always been very difficult to measure, as they are typically estimates based on charges. Time-driven activity-based cost accounting is an analytical costing system that takes a comprehensive look at the true cost of providing healthcare services to a patient [4.] TDABC uses process maps to disaggregate a patient’s care processes into a series of clinical activities. These process maps allow for micro-costing, which enables the true cost to be ascribed to a particular part of the process map. In this study, we used TDABC to track personnel costs, as these account for 70% of operational costs in a hospital. In addition, we were in immediate control of these costs, allowing for rapid improvement. The transparency of cost enabled us to best direct where to make our changes. This provides opportunities to redesign processes so that providers perform work that only they are qualified to perform, referred to as working at the “top of their license” [11]. In this study, providers (MD, RN, ARNP) were performing the majority of the pre-clinic preparation and this was transitioned to the MA. The MA’s level of work was elevated as this individual was now reviewing charts, extracting technical details, and generating a review for the team. As an example, the MA would evaluate each patient chart and make sure that the necessary studies and laboratory results including outside studies are available in the chart for review. The MA would make sure that orders were in for studies needed prior to the visit such as KUB, uroflowmetry, and ultrasound, and if not recommend an order to be placed in the chart. By doing so, we reduced waste and improved patient flow during the clinic visit; we reduced wait time for studies, and reduced delays in seeing patients. All these factors together helped reduce clinic preparation costs. It has also been shown that when staff work at the top of their license, performing work that best leverages their education, training, and experience, overall costs decrease and staff satisfaction increases [11]. TDABC allows determination of the actual costs of the resources being used. One can also calculate the capacity cost rate by multiplying the total minutes the resource is available by the cost of the resource. By measuring the actual cost and calculating the capacity cost, one can identify the cost of unused capacity [12]. The transparency of cost helped us to identify unused capacity, which allowed us increase the number of encounters per clinic block. The chart review by the MA and the pre-clinic huddle enabled the team to identify patients who were scheduled to be seen unnecessarily by a provider, or patients who should be seen by a provider but not scheduled, further reducing cost and increasing capacity by allowing that provider to see another patient. Despite the ability to measure cost and outcomes, a quality improvement methodology must be in place to make the necessary iterative changes to enable a successful improvement effort. Approximately 12 years ago, our institution embarked on a lean journey using the Toyota Production Systems (TPS) methodology. The practice of Kata involves the act of practicing a pattern so it becomes routine behavior [5]. The routine behavior of making small iterative changes by frontline workers results in large improvements over time and enhances employee engagement.
Toyota Kata methodology in a multidisciplinary clinic Improvement Kata is a four-part routine that includes the following steps: (1) understand the direction/challenge, (2) grasp the current condition, (3) establish the next target condition, (4) PDCA (plan, do, check, act) toward the target condition. An example of this in our study involved adding an MA visit prior to the providers visit. During the MA visit, patients would get X-rays, vital signs, and other studies such as urinalysis and post-void urine residuals. This portion of the visit was typically occurring during the provider’s visit, as patients would arrive at the time of the provider’s visit despite instructions to arrive early. This resulted in clinic delays. MA visits improved ontime starts for the providers but resulted in an unintended decrease in value-added time as these patients were waiting after their MA visit for the provider. As a result, iterative changes were implemented such as shortening the MA visit and tailoring of the MA visit based on the needs of the patient. The nature of the MA visit was determined during pre-clinic preparation. Persistent measuring of cost and outcomes, coupled with a change in management philosophy and culture, enabled successful improvements in cost, outcomes, and family experience overtime.
228.e6 and outcome metrics that are meaningful to the clinic and the patient’s condition. Using Toyota Kata methodology achieved a 69% reduction in clinic preparation costs as well as improvements in clinical volume, Family Experience. Value added time was improved but further improvement is required to make this significant and sustained. We demonstrated that a time-based cost analysis effectively measures individualized patient cost and that Toyota Kata methods enable optimization of value in a multidisciplinary clinic. We are currently also identifying new ways to improve data collection and extend this work to other areas of the hospital.
Conflict of interest None.
Funding None.
Ethical approval Limitations First, this study is a value improvement study. As a result a single intervention was not compared pre- and post implementation. A series of small iterative interventions were implemented. Individual employees were encouraged to make small changes to their workflow to improve efficiency. Many of these small changes were not captured. As a result it is difficult to attribute any single intervention to the overall improvements in cost. Second, measuring cost is a labor-intensive process. It requires an individual to manually collect data. Third, the individual providers collected clinic preparation data. The quality of the data was dependent on the provider but was expected to be consistent over time. Fourth, cost data were not collected on facilities or other personnel involved in the patient’s care such as security, greeters, schedulers and family service coordinators. Inclusion of these individuals would have enhanced opportunity for cost savings.
Future direction We plan to extend our improvement efforts to clinic flow and ultimately coordination of care. Currently, manual effort to measure cost accurately is difficult. We are looking at ways to automate the data collection process to eliminate the resource required to acquire data. With continued practice and enhanced tools for measuring cost, we will be able to determine value for our patients other areas of the hospital such as the inpatient units and operating rooms.
Conclusion Value-based care can be established for a multidisciplinary clinic that manages rare complex anomalies of the pelvic floor. Measures of value can be accomplished using TDABC
This is a quality improvement article and therefore does not require ethical approval.
References [1] Sisko A, Truffer C, Smith S, Keehan S, Cylus J. Health spending projections through 2018: recession effects add uncertainty to the outlook. Health Aff (Millwood) 2009;28: w346e57. [2] Porter ME. A strategy for health care reformdToward a valuebased system. N Engl J Med 2009;361:109e12. [3] Demeere N, Stouthuysen K, Roodhooft F. Time-driven activitybased costing in a outpatient clinic environment: development, relevance and managerial impact. Health Policy 2009; 92:296e304. [4] Kaplan RS, Anderson SR. Time-driven activity-based costing. Harv Bus Rev 2004;82:131e8. [5] Rother M. Toyota Kata. New York: McGraw Hill; 2010. [6] Thanamayooran S, Rose C, Hirsch J. Effectiveness of a multidisciplinary kidney disease clinic in achieving treatment guideline targets. Nephrol Dial Transpl 2005;20: 2385e93. [7] Goldstein M, Yassa T, Dacouris N, McFarlane P. Multidisciplinary predialysis care and morbidity and mortality of patients on dialysis. Am J Kid Dis 2004;44:706e14. [8] Rasmussen C, Nielsen GL, Hansen VK, Jensen OK, SchioettzChristensen B. Rates of lumbar disc surgery before and after implementation of multidisciplinary nonsurgical spine clinics. Spine 2005;30:2469e73. [9] Kaufman BA, Terbrock A, Winters N, Ito J, Klosterman A, Park TS. Disbanding a multidisciplinary clinic: effects on the health care of myelomeningocele patients. Ped Neurosurg 1994;21:36e44. [10] Porter ME. What is value in health care? N Engl J Med 2010; 363:2477e81. [11] Kaplan RS. Improving value with TDABC. Health Care Financ Manage 2014;68:76e83. [12] Donovan CJ, Hopkins M, Kimmel BM, Koberna S, Montie CA. How Cleveland clinic used TDABC to improve value. Healthc Financ Manage 2014;68:84e8.
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