Improving timeliness and efficiency in the referral process for safety ...

J Ambulatory Care ManageVol. 33, No. 2, pp. 124–130Copyright c○ 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsImproving Timelinessand Efficiency in theReferral Process for SafetyNet ProvidersApplication of the Lean Six SigmaMethodologyGloria J. Deckard, PhD; Nancy Borkowski, DBA;Deisell Diaz, PhD; Carlos Sanchez, MBA;Serge A. Boisette, MHSAAbstract: Designated primary care clinics largely serve low-income and uninsured patients whopresent a disproportionate number of chronic illnesses and face great difficulty in obtaining themedical care they need, particularly the access to specialty physicians. With limited capacity forproviding specialty care, these primary care clinics generally refer patients to safety net hospitals’specialty ambulatory care clinics. A large public safety net health system successfully improved theeffectiveness and efficiency of the specialty clinic referral process through application of Lean SixSigma, an advanced process-improvement methodology and set of tools driven by statistics andengineering concepts.Key words: access, ambulatory care, process improvement, Six Sigma,specialty referralAuthor Affiliations: Decision Sciences andInformation Systems, College of BusinessAdministration, Florida International University,Miami (Dr Deckard); Health Care ManagementPrograms, College of Business Administration,Florida International University (Dr Borkowski); SixSigma Master Black Belt, Devin Consulting Group,Miami, Florida (Dr Diaz) and Six Sigma Black Belt,Deivin Consulting Group, Miami, Florida (MrSanchez); and Six Sigma Green Belt, AmbulatoryManaged Care & Quality, Jackson Health System,Miami,Florida (Mr Boisette).The authors thank the members of the Six Sigmateam from Jackson Health System, Miami, Florida:Dr Yolangel Hernandez-Suarez, Associate Chief MedicalOfficer; Dr Angela Burrafato, Medical Director,Ambulatory Care Center; Dr Thresia Gambon, MedicalDirector, Primary Care Centers; Dr Lenworth Anglin,Medical Director, Quality and Managed Care; Mary-Keen Robinson, ARNP, Quality Manager, AmbulatoryServices Division; Ester Eisler, Director, Ambulatory Services;Elaine Perdue, RN, Associate Director of PatientCare Services; Kevin Lynch, Director of Applications andInformation Technology; Dr Suzanne Minor, PrimaryCare Physician; Marta Garcia, RN, Clinical Care Coordinator,Referral Services; Conchita Freitag, RN, ClinicalEducator; and Debbie Turbert, RN, Director of PatientCare Services, Ambulatory Care Center.124ESTIMATES SUGGEST that communityhealth centers (CHCs) and designatedlow income primary care clinics (PCCs) servemore than 18 million individuals annually(National Association of Community HealthCenters [NACHC], 2009a). These safety netproviders largely serve low-income membersof racial and ethnic minorities, who are uninsuredor publicly insured; present a disproportionatenumber of chronic illnesses (NACHC,2009a,b; Robert Wood Johnson Foundation,2005); and face great difficulty in obtainingthe medical care they need, particularly accessto specialty physicians. Although PCCsand CHCs serve as the medical home, thesecenters have limited capacity for providingCorresponding Author: Gloria J. Deckard, PhD, DecisionSciences and Information Systems, College of Business,Florida International University, 11200 SW 8th St,Miami, FL 33199 (deckardg@fiu.edu).

Improving Timeliness and Efficiency in the Referral Process for Safety Net Providers 125specialty care and face difficulties in referralsas fewer private physicians, academic medicalcenters, and community hospitals are willingto provide specialty care to the uninsured(Felt-Lisk et al., 2002). Safety net hospitalsthrough specialty ambulatory care clinicshave become the providers of last resort forspecialty care services for the increasing numberof uninsured and other vulnerable populations.Evidence suggests ever-lengtheningwait times for the uninsured, especially adultswith chronic illnesses, to obtain specialty careappointments, with the first available appointmentbeing in 6 months to a year (Felt-Lisket al., 2002). In addition, healthcare processes(eg, referral systems) created and/or changedon an ad hoc basis over time may becomeunnecessarily complex (Kaplan et al., 2009).Referral processes that are unstructured andcomplex create inefficiencies in the systemand delay the provision of specialty care.Unnecessary complexities in the referralprocess exacerbate delays in the receipt of servicesand impact patient quality of care. TheInstitute of Medicine (IOM, 2001) suggeststhat overly complex delivery processes thatrequire numerous steps and patient “handoffs”slow down care, decrease safety, andwaste resources. Crossing the Quality Chasm(IOM, 2001) identified timeliness—reducingwaits and sometimes harmful delays—forboth those who receive and those who givecare and efficiency—avoiding waste, includingwaste of equipment, supplies, ideas, andenergy—as aims or goals for improvement ofthe US healthcare system. Providing timelyand appropriate care to the uninsured andother vulnerable populations is a national concernthat can be addressed, at least in part, byimproving the PCC/CHC to specialty referralprocess through performance-improvementstrategies such as Lean Six Sigma.PROCESS IMPROVEMENT BY USINGLEAN SIX SIGMAProcess improvement is the act of analyzinga process (macro or micro) to determine howit can be done better and proceed to makethe necessary changes to improve outcomes(Diaz, 2008). There are 2 paths to processimprovement: unstructured and structured.Unstructured process improvement does notprovide an organized method and, thus, canresult in ad hoc changes. Lacking a standardmethodology, improvement relies on individualexpertise rather than on measures ormetrics to guide the process and set goals.Structured process improvement, on theother hand, provides a standard, organizedmethod to guide improvements for changethat is based on measures and responsibilities.Kaplan et al. (2009) note that intentionallydesigned (structured) process-improvementstrategies are more likely to yield efficient andeffective processes.Six Sigma is a tested and commonly knownstructured method that utilizes comprehensivedata-driven tools supported by statisticalanalysis to improve process performance(Diaz, 2008). The Six Sigma methodincludes 5 phases: define-measure-analyzeimprove-control,commonly referred to as theDMAIC technique. These phases are used toimprove existing processes to improve overallperformance. The DMAIC methodology has aproven data drill-down capability that is basedon statistical analysis. This helps achieve thegoal within Six Sigma: reduce variation.Lean provides a set of transitional tools thatidentify valuable and invaluable activities withevents or activities (steps). The Lean analysispinpoints specific improvements by eliminatingsteps that incur costs but are not valuableto the desired end result. Lean and SixSigma combined dramatically reduce variation,unpredictability, and potential negativeoutcomes while minimizing costs.Six Sigma was originally developed byMotorola as a quality improvement methodology,and its use was expanded by othercompanies such as General Electric and AlliedSignal/Honeywell (Black & Revere, 2006).A review of Six Sigma applications acrossa variety of healthcare processes (Vest &Gamm, 2009) demonstrates the effectivenessof Six Sigma methodology for healthcare organizations.The array of processes examinedby Vest and Gamm (2009) includedsurgery turnaround time, clinic appointment

126 JOURNAL OF AMBULATORY CARE MANAGEMENT/APRIL–JUNE 2010access, hand hygiene, antibiotic prophylaxisin surgery, scheduling radiology procedures,and meeting Centers for Medicare and MedicaidServices cardiac indicators. Earlier workby Gamm et al., (2007) suggested the usefulnessof Six Sigma in addressing the IOM“quality chasm.” Lean Six Sigma provides astructured, systematic approach to improvinghealthcare processes and meeting the challengesof quality improvement.APPLICATION OF LEAN SIX SIGMA ANDDMAIC TO A SPECIALTY REFERRALPROCESSRecognizing the value of both Lean and SixSigma approaches, the Jackson Health System(JHS) in Miami-Dade County, Florida, soughtto improve the effectiveness and efficiency ofreferrals for specialty care through applicationof Lean Six Sigma methodology. Two specialtyclinics were identified to participate in theproject: (1) genitourinary (GU) and (2) gynecology(GYN). A multidisciplinary team wasidentified and, with the assistance of 2 SigmaBlack Belt mentors, the project followed theDMAIC approach (Diaz, 2008):DEFINE the project’s purpose and scopeand obtain background on the current processand the customers’ perspectives;MEASURE data that pinpoint problem locationor occurrence; focus the improvement effortby gathering baseline information on thecurrent situation;ANALYZE data to identify and confirm rootcauses; set goals for performance;IMPROVE process by implementingplanned solutions; eliminate or reduce theimpact of the identified root causes; andCONTROL the gains by standardizing processes;use data to evaluate the solutions; anticipatenext steps.DefineOver time, the process of specialty referralfrom primary care physicians (PCPs) at PCCsand CHCs to the JHS ambulatory care specialtyclinics (ACSC) had grown cumbersomeand fragmented impacting the efficiency ofthe process. In addition, the effectiveness ofthe system varied. A Pareto chart (ie, a type ofbar chart that aligns categorical data) was constructedto graph the problems across referringentities. This analysis demonstrated thatPCCs’ consult requests took twice as long asother services and that PCCs were less successfulat converting consult requests to specialtyappointments than were other services.Thus, the PCCs were identified as the focusfor the initial project.A fishbone diagram (Fig 1) was developedto obtain background and understand thecurrent referral process for PCCs. Reviewingthis diagram, the team discovered inefficienciesand developed the following problem description:“The referral process from PCP tothe Patient Clinical Care Coordinator (PCCC)for review is not efficient and the time lagbetween Appointment Made to Day of Appointmentis excessive.” The objective of theproject then became restructuring the systemfor consults to improve quality and timelinessof communication between primary carephysicians, primary care coordinating center,and specialty physicians. Specifically, the aimfor improvement was to reduce turnaroundtime.The next step in the process was to diagrama process map detailing the steps in theprocess from the PCP determining the needfor a referral/consultation through the consultprocess (review, approval, and service)and the returned referral/consult to the PCP.This process map followed a standard SIPOC(supplier, inputs, process, outputs, and customers)analysis and provided the tools toidentify appropriate measures and steps ofvalue/nonvalue activities.MeasuresData were collected to pinpoint the problemsand focus the improvement effort. At thisphase, the Critical to Quality (CTQ) was identifiedas “turnaround time for consult” (referral).CTQs are core customer-focused requirementsthat provide a measure to determinewhether the objectives are being met, thatis, the referrals are processed and appointmentsare made in a timely fashion. Timelyfashion was then quantified; specifically, if the

Improving Timeliness and Efficiency in the Referral Process for Safety Net Providers 127Figure 1. Fishbone diagram outlining background of specialty referral process. PCP indicates primarycare physician.process takes more than 30 days (4 weeks), itdoes not meet the criteria.AnalyzeThe analysis phase utilized several stepsto identify and confirm root causes of inefficiency(ie, delays in making appointments) toaddress process improvement. All paper referralsfor GU and GYN were collected andreviewed; all approved appointments for GUand GYN were collected and reviewed; andpathways were identified and analyzed. Theoutcomes for all referrals (ie, incomplete, inappropriate,approved) were documented ina database.Drill-down analysis revealed delays in thereferral process due to the following:1. Incompleteness of referrals,2. Inadequate staffing in making appointments,3. Lack of staff access to available specialtycare appointment slots, and4. Inadequate number of specialty care appointmentslots (eg, insufficient clinicalcapacity).These delays resulted in extra steps in theprocess, which could be removed throughprocess improvement and standardization.ImproveTo improve the specialty referral process,all PCP/PCCs referrals/consults were:1. Sent to a central area,2. Entered into a database, and3. Reviewed for completeness, appropriateness(based on InterQual evidencebasedclinical decision support criteria)and timeliness.Referrals that were• incomplete were logged and returned tothe originator for proper completion withneeded actions noted;• determined to possibly be inappropriatewere reviewed by the medical directorusing InterQual criteria, and who, ifneeded, performed a literature review forcurrent best practices (ie, evidence-basedmedicine);• determined not to be appropriate werereturned to the originator with an explanationof the reason for the determination;• appropriate and complete requests,specialty appointments were generated;and• outcomes of all referrals were enteredinto the database.

128 JOURNAL OF AMBULATORY CARE MANAGEMENT/APRIL–JUNE 2010Table 1. Pre- and Postmetrics for specialty referral process measures aBaseline,Actual,Metric d (Pre---12/2007) d (Post---8/2008)GenitourinaryTotal process 60.5 (27) 37.5 (12)Consult request to appointment made 21 (17) 9.2 (4.6)Appointment made to day of appointment 36 (22.7) 27.9 (10.1)GynecologyTotal process 135.8 (67.2) 34.9 (9.3)Consult request to appointment made 102 (62.9) 9.9 (3.5)Appointment made to day of appointment 33.1 (14.9) 26.4 (4.7)a Values are presented as mean (SD).The statistical data analysis demonstratedimprovements in the referral process for the3 metrics: total process (number of days thatelapsed between initiation of the referral andthe date of the appointment), consult requestto appointment made (number of days thatelapsed between initiation of the referral andthe date the appointment is made), and appointmentmade to day of appointment (numberof days that elapsed between the datethe appointment is made and the date ofthe appointment). Table 1 provides the preandpostmeasures for both GU and GYN onthe 3 metrics. Linear graphing of the valuesand ranges for the total specialty referral processbefore, during, and after the Six Sigmaimprove phase/process (implementation ofchange) are displayed in Figure 2 for GU andFigure 3 for GYN.The overall process time was substantiallyreduced as were the intervening steps of theprocess. The referral process was reduced inGU from 60.5 to 37.5 days and in GYN from135 to 34.9 days.ControlStandardizing improved processes incorporatesthe Deming Plan-Do-Check-Act Cycle(Deming, 2000). The monitoring, data analysis,and actions are performed by the ACSCadministrative department. The database isupdated each time there is a new referral/consult. In the Plan-Do cycles, the followingmetrics are captured: appointment requestdate, appointment made date, andappointment day date. A report is generatedfrom this database monthly. The Check cycleutilizes control charts from quarterly data toidentify any undesirable patterns or trends. Ifan undesirable pattern or trend is identified,the ACSC administration does the following(Act cycle): establish data collection plan tozoom (drill down) on the problem area, improvebreakdown in process and communication,and continue monitoring to ensure sustainability.CONCLUSIONSData reported here demonstrate the successof the Lean Six Sigma application to a specialtyreferral process in ambulatory care. Asnoted earlier, the total referral process was reduced,as well as the days elapsed, in both thecomponents of the process—initiation of requestto appointment made and appointmentmade to day of appointment. Application ofLean Six Sigma structured methodology to thereferral process improved both efficiency andtimeliness, reducing the total process time by23 days (38%) in GU and by 100 days (74%)in GYN. The aim defined by the team—toreduce the turnaround time—was met; however,the quantitative measure of 30 days (4weeks) was not met. Given the substantial reductionsin days from pre- to post processmeasures, the interventions set a direction fora continuing improvement process. The reductionin times in the total process and wait

Improving Timeliness and Efficiency in the Referral Process for Safety Net Providers 129Figure 2. Variability and range values for GU: Before, during, and after improvement process implementation.GU indicates genital urinary.times for appointment dates improved serviceto the patients, PCPs, PCCs, and, potentially,the quality of care. Undoubtedly, LeanSix Sigma provided a successful means to addressthe IOM aims of efficiency and timelinessin this study.NEXT STEPSFurther improvements in the referral processare planned. Currently, the system continuesto rely on paper referrals and approvals.To achieve increased efficiency andFigure 3. Variability and range values for GYN: Before, during, and after improvement process implementation.GYN indicates gynecology.

130 JOURNAL OF AMBULATORY CARE MANAGEMENT/APRIL–JUNE 2010reach the 30-day target, the safety net systemfor Miami-Dade County is joining togetherto implement a Web-based referral system.Partners in this endeavor include the Miami-Dade County Health Department, the HealthCouncil of South Florida, PCCs, CHCs, JHS,and researchers from Florida InternationalUniversity.Vest and Gamm (2009) suggest the needfor more stringent attention to research measuresas well as sustainability in documentingthe effectiveness of Six Sigma. Future analysiswill study specialty clinics referrals not includedin this study, to compare changes orimprovements in the referral process withoutstructured intervention, and will review theeffectiveness of specialty consults/referralsfrom CHCs that were not part of this study.Both groups will provide “control” data toempirically test and eliminate alternative hypothesesthat may explain the improvementgained through Six Sigma. Although the pre-/posttest findings of this Six Sigma applicationdemonstrated effectiveness and providedsubstantial support for the expansion of thisprocess-improvement methodology in healthcare,the controlled studies will answer anyquestions on the limitations of this design.REFERENCESBlack, K., & Revere, L. (2006). Six Sigma arises from theashes of TQM with a twist. International Journal ofHealth Care Quality Assurance Incorporating Leadershipin Health Services, 19(2/3), 259–266.Deming, W. E. (2000). Out of Crisis. Cambridge, MA: MITPress.Diaz, D. M. (2008). Simple Lean Six Sigma: Global organizationalLean Six Sigma training for systematicimprovement: Driving organizational excellence usingLean and Six Sigma. Miami, FL: Deivin.Felt-Lisk, McHugh, M., & Howell, E. (2002). Monitoringlocal safety-net providers: Do they have adequate capacity?Health Affairs, 21(5), 277–283.Gamm, L., Kash, B., & Bolin, J. (2007). Organizationaltechnologies for transforming care: Measuresand strategies for pursuit of IOM quality aims. Journalof Ambulatory Care Management, 30(4), 291–301.Gilmer, T., & Kronick, R. (2005). It’s the premiums,stupid: Projections of the uninsured through 2013[Web exclusive]. Health Affairs. doi: 10.1377/hlthaff.W5.143. Retrieved July 31, 2009, from http://content.healthaffairs.org/cgi/reprint/hlthaff.w5.143v1Institute of Medicine. (2001). Crossing the qualitychasm: A new health system for the 21st century.Washington, DC: National Academies Press.Kaplan, S., Bisgaard, S., Truesdell, D., & Zetterholm, S.(2009). Design for Six Sigma in healthcare: Developingan employee influenza vaccination process. Journal ofHealthcare Quality, 31(3), 36–43.National Association of Community Health Centers.(2009a). America’s health centers. Retrieved July31, 2009, from http://www.nachc.com/client/documents/America’s Health Centers updated 3.09.pdfNational Association of Community Health Centers.(2009b). Primary care access: An essential buildingblock of health care reform. Retrieved July31, 2009, from http://www.nachc.com/client/documents/pressreleases/PrimaryCareAccessRPT.pdfRobert Wood Johnson Foundation. (2005). UninsuredAmericans with chronic health conditions: Key findingsfrom the National Health Interview Survey. RetrievedJuly 31, 2009, from http://www.rwjf.org/files/research/Urban2005.pdfVest, J. R., & Gamm, L. D. (2009). A critical review of researchliterature on Six Sigma, Lean and StuderGroup’sHardwiring Excellence in the United States: Theneed to demonstrate and communicate the effectivenessof transformation strategies in healthcare. ImplementationScience, 4 ,35. doi:10.1186/1748-5908-4-35.