In a Rural New Mexico Clinic, Leveraging IT to Optimize Patient and Activity Flow

April 26, 2017
Dan Hamilton, COO of the Nor-Lea Hospital District in rural southeastern New Mexico, has been leading an IT-facilitated initiative that is optimizing patient and activity flow in a rural outpatient clinic setting

The leaders of patient care organizations across the U.S. are leveraging healthcare information technology for a very wide variety of use cases, some of them involving long-term organizational strategy, others addressing far more immediate and urgent needs. Falling into the latter category is how the leaders of the Nor-Lea Hospital District in Lovington, New Mexico, five hours southeast of Albuquerque, have been leveraging RTLS (real-time locating system) technology from the Traverse City, Michigan-based Versus Technology. Beginning in 2010, the Nor-Lea Hospital District’s leaders faced unprecedented population growth in the Lovington area, as natural gas and oil production was soaring, and new residents were flooding into the area, taxing the resources of the district’s 25-bed critical access hospital and its clinic, originally designed for only 10 providers, but whose patient population was soaring.

With patient satisfaction plummeting as the district’s outpatient clinic was being overwhelmed, Nor-Lea leaders turned to Versus’ RTLS technology to help map movement and processes, in order to reengineer patient flow and activity flow, and optimize clinical work processes. Dan Hamilton, Nor-Lea Hospital District’s COO, has been leading the ongoing process optimization work for several years now, helping to lead the reengineering of patient flow and of the physical positioning of rooms and other physical resources in the district’s outpatient clinic. Hamilton spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland about the clinic flow reengineering project. Below are excerpts from that interview.

In terms of your organization’s outpatient clinic, it was a very small, cramped facility, correct?

Yes. It was a five-provider rural healthcare clinic. We were seeing the volume in patients growing so fast, it was unreal. So we expanded the clinic to eight providers. And that still wasn’t large enough. We were seeing high volumes of patients, with the doctors being booked far in advance. So we were able to put 10 providers into the clinic; and ultimately, we decided to build a new clinic with 20 providers. We already had 14 providers when we moved into the new clinic.

What was the timeframe for the forward evolution of your RTLS-facilitated work on improving patient flow and activity flow in the clinic?

The biggest boom was in 2010. The price of oil was going up, so we had new people coming in to work. We were one of the biggest oil producers in the area. Eunice, Howell, Jobs, Lovington and Tatum were growing, and we were the only family practice in Lea County. And it was taking anywhere from 60 to 90 days to see you if you were a new patient. So we knew we had a problem; plus, our patient satisfaction was plummeting.

So we got Versus in in 2012, and for the first time, we were able to effectively track patients in real time. We could track where our problems were; we could track patients’ movement from registration to lobby, lobby to patient room, patient room to provider, provider to discharge. As a result, we were able to look at each step of the process and see where we were falling short and where the wastes were. And even the design of the clinic was dysfunctional because of the shape of the building. So we put our lobby in the leg of the clinic rather than in the middle. And that streamlined the time it took patients into the rooms.

So some of this work involved participating in time-motion studies?

Yes, a lot of it did, but also tracking patient wait times. We were having one to two hour wait times to get people into the rooms, and people were getting miffed. It helped us track patients.

What did you find once you had done data-gathering?

We found that our clinic had very poor layout in terms of patient flow. We also thought we had to run three rooms, but we really were running two rooms with patients sitting in the third room. And it was taking 20-30 minutes to get a patient through registration, so they were becoming late to see the provider and the provider was refusing to see them. So [using the RTLS system to gather motion-based data] allowed us to break things down into patient flow, and we were able to adjust our room-turnover rates; and we also looked at staff, what our staffing ratio was like. We were at the high end in terms of using registered nurses. We had a ton of RNs, but were lower on the other staff positions. We were paying for RNs, but they were doing a lot of administrative work, calling patients back on the phone, calling in medication refills, and why? For every two providers, we had one RN and we took the other one and shifted them to the floor, and replaced them with MAs. So today we staff at the level of one RN for four providers, and the rest MAs. That works better for us; I can hire two MAs for one RN. Meanwhile, in the fall of 2014, we moved into the new clinic. So we started Versus in 2012.

So you spent two years optimizing flow and processes?

Well, before that, I was working without Versus. But it was in 2010 that we were seeing a wave of new arrivals in town, and patient satisfaction was going down. So I read books and became a green belt in Lean and Six Sigma. And it was in 2012 that we decided to engage Versus. Our patient satisfaction scores were in the lowest 2 percent in the nation at that time, and physician satisfaction was terrible, too. And the times were all skewed, and it was very hard to figure out what was going on.

So you needed a very systematic approach to this, essentially.

Yes, that’s right.

So, looking at all this work from a Lean/Six Sigma perspective, what have the biggest lessons been learned so far?

The biggest lesson learned is that you have to have accurate data. Before that, without the data, we did everything in a very reactive way. And we ended up making a lot of changes that actually were making things worse. We were making our registration process worse by focusing on the wrong things. We didn’t have the data to show us. We had an EMR. But people tended to want to hide their mistakes, so they would fudge on the times. So I would focus on other things, and I couldn’t see what was going on. The second thing I learned was that I had to have the staff, the providers, buy into this. I thought I could do this on my own—you think you can change the world—but I couldn’t. I had to have the staff engaged in this, and show them that people were regarding us as mediocre to poor. And I asked them, don’t we all want to be the best? And of course they did.

So on the green belt side, it was having the data that I could pull up every morning, to figure out what to focus on. And if I had a room that wasn’t turning over, it meant that I was bottlenecking. And the staff were shocked at how many hours a day they were wasting in running from one place to another. So staff are now located within steps of supplies. It was two to three hours of waste per day just moving patients from the lobby to  the provider rooms. So it helped us to design clinics, and now we have two new more ones opened, based on what we learned. Versus wasn’t easy to roll out, in that the staff were suspicious and resentful of how it might be used. So I let them roll it out; they came up with the slogans and what was important. I signed the commitment with them that nobody would be punished because of data we found in Versus; so I had things like that in place.

We’re going to have to do more and more in healthcare with less and less. This case study really speaks to process optimization while making use of less-than-full resources, correct?

Yes, and we’re seeing that here today. The price of oil has bottomed out, and so we’re now overstaffed. And so we’re having to look at staffing carefully. We thought we were running pretty lean, but we’ve got to run even leaner now.

So everyone’s going to have to do this kind of work, then, correct?

Correct. Everyone’s going to have to look at processes. And in our new clinic, we’re mapping how long it takes to register. And we have two EMRs, and registration has to register twice, once for the hospital and once for the clinic. And how can we save time in such a situation? And Versus helps you analyze and find the waste in your system.

What would you say to CIOs and CMIOs about this kind of work?

I think the thing that I look at most is simplification. If you rely on people to give you your data, meaning that it can be inaccurate, people will fudge on the data they present. That’s why I liked Versus, because it eliminates the human factor.

So by leveraging information technology, you’re limiting the judgment calls and the subjectivity?

Yes, correct. And also, you can segment the data on the visit and drill down in more detail. I can track from when they walk in the door to when they register, when they go with the nurse, go to the physician, etc. It gives you accurate data. EMRs—the data you get depends on the human factor. And if you want to come up with good processes, you need reliable data; otherwise, you’re being reactive.