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Best in Healthcare Getting Better with Lean

Mayo clinic division of cardiovascular diseases improving patient-flow processes

By George Taninecz

The Mayo Clinic in Rochester, MN., is one of America’s elite organizations and world famous for the quality of healthcare that it provides. Fortune magazine named Mayo Clinic as one of the “100 Best Companies to Work For®” in America, the third year in a row that the organization was tabbed for this annual compilation of companies that “rate high with employees.” For 16 years in a row, U.S. News & World Report named Mayo Clinic one of “America’s Best Hospitals.” Even though Mayo Clinic is at the pinnacle of patient care, leadership keeps looking for ways to improve — and now they’re looking to lean.

Mayo Clinic comprises more than 2,400 physicians and scientists and 30,200 allied staff working at the original clinic in Rochester and clinics in Jacksonville, FL., and Scottsdale, Ariz. Mayo treats more than 500,000 people each year. Multiple medical disciplines at Mayo set the healthcare standard around the globe, and few specialties have more prestige than Mayo’s Division of Cardiovascular Diseases.

“This organization has a very strong culture, has a very rich history, and always has provided the very best patient care. We’ve done that with the great people that we have. We have probably the best nursing staff, physician staff, and allied health staff that I’ve ever encountered in my over 20 years of medicine. It’s phenomenal,” says Dr. Henry Ting, Practice Chair, Division of Cardiovascular Diseases. “Having said that, I do think we have opportunities to improve our processes to provide better quality, safety, and service, as well as to delight our customers.”

Many organizations are drawn to lean thinking in a time of great need, desperately seeking to operationally improve and reverse their fading fortunes. With the Mayo Clinic’s cardiovascular division that was not the case: “We certainly did not come to this because there was a ‘burning platform’ where we had to change,” says Dr. Ting. “Our change has really been because of enlightened leadership. Dr. David Hayes, [Chair of the Division of Cardiovascular Diseases], had the leadership and foresight to say, ‘We can do better. We’re doing good right now, but we can do better.”

The lack of a burning platform, though, can present challenges, notes Dr. Ting, especially among physicians who see world-class care all around them. He tells them, “I’m not trying to change the moment of care, the touch moment between you and your patient. What I’m trying to change is the 95% of the time when the patient is not in your office and you’re not seeing them or providing care to them. And that’s the 95% where we have opportunity for improvement.”

“The point when doctors are willing to accept [lean] is when they grasp the concept that you’re eliminating the waste that gets in the way of them doing what they’re there to do— the care moment,” says Doug Parks, administrator for the cardiovascular division. “And we made it clear in all of our projects related to patient flow that the moment of care, when a physician was with a patient, was off limits. What we’re trying to do is expand that time, give them all the time needed to provide the best care they could.”

Dr. Hayes became aware of lean through initiatives within Mayo’s radiology and pathology departments, where movement of materials and inventory (e.g., film and samples, respectively) is core. The Division of Cardiovascular Diseases was faced with the added complexity of processes tangled with people, information, and material. Priority projects included:

Cardiovascular Health Clinic (CVHC),
ST Elevation Myocardial Infarction (STEMI), Inpatient Admission and Triage,
Cardiac Catheterization Laboratory,
Echocardiography Laboratory,
Complex Ablation Access,
Warfarin Safety, and

Outpatient Appointment Redesign.


“The unified focus has been ‘process improvement’ or how we do our work’” says Dr. Ting. Initiatives for CVHC and STEMI have been in place the longest and each, in different ways, has helped to advance Mayo’s mission to “ ... provide the best care to every patient every day through integrated clinical practice, education and research.” Flow Through CVHC The CVHC is Mayo’s preventive cardiology clinic focused on the needs of people of all ages at risk for heart disease or those already afflicted with heart disease. Services include risk assessment (based on multiple diagnostic modalities) and risk-reduction services (developing action plans for patients that include physical counseling, weight loss, nutrition counseling, smoking cessation, etc.). CVHC was the rollout target for lean because of problems with no- shows, cancellations, perceived lack of demand, and dissatisfaction among both allied staff and physicians with the efficiency of the entire patient journey, especially scheduling appointments — too many handoffs, loopbacks, and wasted time. For example, appointment coordinators were responsible for managing patients up to the time they physically entered the CVHC, then a clinical assistant took on that role until 30 days after the patient left CVHC, and then the patient reverted back to an appointment coordinator; a patient might be asked three times for the same information by three different people. Additionally, appointment coordinators rarely saw the patient or even the physician, making communication and problem resolution difficult. Angie Wills, operations manager for the cardiovascular division’s outpatient practice, says that the many opportunities to improve the CVHC practice combined with a new director, Dr. Randal Thomas, who was willing to lead changes, made the center a logical first initiative. Jonathan Curtright, administrator for the cardiovascular division, adds, “It’s also a snapshot of the division: It’s got a huge outpatient practice, an in-patient practice, a laboratory with exercise testing, and rehabilitation services, so if we can get [lean] to work in that setting it will probably work in other disparate settings within the division.”

Success for CVHC depends largely on providing diverse, high-quality cardiovascular care in a brief period during which physician time is sandwiched by various testing and counseling procedures. “Cycle time, or completing the patient itinerary, is important,” says Dr. Ting. “When you come here for a comprehensive evaluation, we strive to complete it within two to three days.” Many of Mayo’s cardiovascular patients come from around the world. For them to come back for tests in a week or so isn’t practical. Coordinating a patient’s visit requires aligning various disciplines for the patient’s trip to Rochester — capture of personal data, request for outside materials, securing physician time, ensuring lab time, etc. — which often meant multiple tries before an appointment satisfied patient, physician, and other CVHC schedules.

In March 2005, staff studied the patient process in a traditional lean manner, first by attending a three-day workshop where they mapped CVHC current state. They reviewed the entire process as a patient initially contacted and then moved through the CVHC system, from scheduling an appointment to post-treatment followup, and they tracked process time, wait time, and first-time quality. Based on those findings they envisioned a future state and established 30-, 60- and 90-day goals to help them achieve it.

The CVHC lean team implemented:

• Patient risk-assessment intake-triage process using existing registered-nurse (RN) staff. (This process previously required input from RNs and CVHC providers.)

• Standardized protocol for diagnostic testing, evaluation, and treatment based on clear guidelines of cardiovascular risk levels (low, moderate, high, early arthrosclerosis, and metabolic syndrome).

• Standardized care models for each risk level (defined roles and procedures for doctors, RNs, dieticians, exercise technicians, etc.).

• Standardized procedures for preparing previsit information (eliminate duplication and rework).

• Standardized process for patient education, clinical consultation, and how patient hand-offs are communicated.

• Pull scheduling for tests on demand (open slots were incorporated so that CVHC patients could get same day echocardiograms and stress tests).

•Shared job functions for appointment coordinators and clinical assistants, which reduced rework, improved staff communication, and enhanced job satisfaction.
Following the initial lean work, cancellations and no-shows dropped from 30% to 10%. The number of high-yield patients rose from 150 per month to 200 per month. An appointment could be given 90% of the time on first contact with CVHC. “You want to anchor that first phone call,” says Dr. Ting. “We talked about it at our lean workshop: when you make a reservation at a restaurant, you book the time, you don’t book your appetizer, entrée, drinks, and dessert. So we wanted to book the time, because this was the most difficult issue — the appointment slot with the doctor. Everything else we could pull — your echo, your stress test, your lab — based on need.” As a result of the new approach centered on physician availability, physician fill rates went from 70% to 92%, meaning Mayo is optimizing its prized resource.

Across the entire patient process, results were equally impressive: • Process steps went from 16 to six.

• Clinical care time (face time with the doctor) rose from 240 minutes to 285 minutes.

• Wait time (from request for an appointment to finishing the precare consultation) fell from 33 days to three days, a reduction of 91%.

• First-time quality (not quality of care given, but the percentage of time that all material is available to anyone, allied staff or physician, to proceed with their role) rose from 5% to 65%.

“This project has had a lot of really strong outcomes that we’ve been able to take and replicate across the division as identified best practices and better ways to work,” says Wills. The practices are being applied to 18 other subspecial clinics under a program called “Clean” (continuous lean — a continuous process or improving).

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