How Lean Can Help Patients Adopt Technology

By Dane Falkner and Darv Andersen

Background

Before the South Jordan Health Center’s (SJHC) January 2012 opening, the health system’s patient check-in process had remained relatively unchanged. SJHC installed self-service kiosks in centralized patient check-in areas that serve multiple clinics. The kiosks improve labor efficiency by accommodating volume fluctuations throughout the day. Customer service staff members are on-hand to guide with the technology and to help patients who choose not to use the kiosks. 

SJHC leadership was surprised to find only ~20% of check-ins were completed with the kiosks. Darv Andersen, Director of Patient Experience, wondered why the kiosks weren’t being used and how his team might improve the kiosk experience.

What is Utah’s Value Improvement Methodology?

Following a structured improvement methodology helps a team act its way into thinking about a problem. U of U Health’s value improvement methodology is based on lean, six sigma, and PDSA. Its six phases are:

1. Project Definition
2. Baseline Analysis
3. Investigation
4. Improvement Design
5. Implementation
6. Monitoring

Project Definition

The value improvement methodology relies on the expertise of those who do the actual work. In service of this principle, Darv involved coworkers Kari Smith, then-Supervisor of Patient Relations (PRS), and PRS staff members, including Kelli Norby and others. This team crystallized their vision of a patient’s experience when interacting with the kiosk: Efficient, private, intuitive, complete, and no waiting.

Darv also addressed the team’s intrinsic motivation, which is to avoid patient frustration. A patient who was just failed by our attempt at automation approaches the Patient Services desk with heightened frustration compared to someone who begins with the desk. On the other hand, patient frustration grows with wait time standing in a queue. Darv reflected, “The PRS team was getting extremely busy, and they envisioned the kiosk as a way to process more patients quickly without waiting or slowing down clinic flow.”

Baseline Analysis 

The team examined recent data and found that 19-24% of 2nd-floor check-ins were accomplished with a kiosk compared to a national benchmark estimate from Vanderbilt University of 60%. Darv felt 60% was overly ambitious. To keep the goal attainable, the team somewhat arbitrarily set their goal to double the baseline utilization. The team was concerned about too much focus on utilization to the detriment of the patient experience. The goal-setting work resulted in two SMART goals:

1.    Increase kiosk utilization from 22.4% to 44.8% by June 2016. 

2.    Maintain EPE by not falling below 90th%ile ranking for the Press Ganey question, “courtesy of registration staff.”

Darv remembers, “Initially, the scope of the project was to improve kiosk usage for multiple community clinic locations. After examining my sphere of influence, I reduced the scope to SJHC, then subsequently reduced the scope to the 2nd-floor check-in area, where PRS staff were highly motivated and engaged to improve. I felt that if we could make it work on the 2nd floor, other areas would adapt quickly.”

Investigation

The PRS staff shared stories of barriers to success they had personally witnessed as well as patient feedback. In a facilitated session, the team created a cause and effect diagram categorically summarizing this information and identifying additional potential causes of low utilization.

The cause and effect session immediately transitioned to a gemba walk when the physical layout was identified as a major barrier. The team moved from the conference room to the reception area. The facilitator pointed out excessive motion witnessed between PRS staff and patients. This pattern of motion (one of the seven wastes) was captured in a spaghetti diagram.

The following images capture the current state.

As shown in Figures 5 and 6, some kiosks allow the user a direct line-of-sight to the PRS staff, while decorative glass panels block others. These panels are designed to provide privacy. The team observed patients favoring kiosks with line-of-sight to a PRS staff member, as though patients were more comfortable with help nearby should they need it. Meanwhile, kiosks with no line-of-sight were mostly ignored.

When a kiosk experience ends unsuccessfully, requiring PRS staff to complete the check-in, it’s known as a “divert.” Diverts are obviously frustrating to patients and staff. The team investigated the causes of diverts and summarized the data with a Pareto analysis (Figure 7). The analysis revealed that ~ 75% of diverts were due to a variety of missing information. Theoretically, this information could have been gathered when the appointment was scheduled. However, the long-standing problem of missing information is ultimately about patient behavior. It involves a different setting that was out of this team’s scope. Further analysis showed only 1 of 6 kiosk experiences diverted. The team made an informed decision not to address the problem of missing information; the layout issue would have a greater impact on usage and was within their control.

Improvement Design

Darv’s team suggested removing the privacy barriers, which spurred a debate over the impact of patient privacy and PRS personal space. The PRS staff had expressed concerns that patients would approach from behind and see HIPAA-protected information on their computer screens; previously, their backs were protected by the frosted glass panels. 

Implementation

It was thought that removing the privacy screens would be a complicated and time-consuming task, estimated to take weeks. Darv recalls, “a member of the team just started unscrewing the privacy screens to demonstrate how simple the screens could be removed.” A work order was submitted, and the screens were removed the next day, creating a more engaging atmosphere with line-of-sight to assistance for all kiosks.

To further improve patient engagement, the team standardized credit card readers' placement on kiosk monitors and brought in taller chairs so seated staff would be eye-to-eye with patients. The staff’s computers were also integrated with the kiosks to provide support to patients without leaving their work station. 

Monitoring

The immediate results of these changes exceeded expectations. Kiosk usage increased well beyond the 44% goal while still maintaining 90th%ile ranking for the Press Ganey question, “courtesy of registration staff.”

Additional unintended benefits of the project include an average monthly collections increase of ~$20,000, better patient privacy to visually vs. verbally verify demographic information, improved staff satisfaction with registering patients (focusing on the patient and not the technical tasks the kiosk performs), minimal waiting at the registration desk, and addressing emergency situations faster, that otherwise could have been missed. For example, almost immediately upon removing the privacy screens, a woman had collapsed in the lobby. With the privacy screens in place, this woman would have been blocked from PRS line-of-sight. The PRS staff has also been able to quickly spot children climbing on railings and noticing patients that may be waiting longer than is necessary.

Spreading the Learning

Building on the momentum of the success, Darv sought input from the Revenue Cycle Team, which educated staff on presenting kiosks' benefits to patients. Darv not only spread the project lessons, now thought of as best practice, to the other check-in areas in SJHC, he, along with the Revenue Cycle Team, also helped other locations improve, such as the Greenwood Health Center.

The kiosks manage volume fluctuations so staff can focus on maintaining an exceptional check-in experience. After implementation, patients began flowing through the check-in process much faster without feeling rushed. Even peak hours flowed with little additional effort, leaving staff to provide extra customer service instead of overcoming technical issues.

As is commonly the case in transformative flow projects, downstream stakeholders had learned to rely on upstream delays. Darv commented, “We now have care providers indicating that we are processing patients too fast at registration.” 

Lessons Learned

1. Make it easy (kiosks were moved to be the first point of contact).
2. Challenge assumptions (fiddling with the privacy screens showed they were easy to remove and didn't require major construction).
3. Go to the gemba (watch how patients and staff interact with the kiosks).