Innovating Practice Management through Lean Application in PACE Cardiology: Dr. Yaariv Khaykin

PACE Cardiology is a large cardiology practice with several locations and close to 30 cardiologists. They have been around for about 5 years and over time they’ve had growing pains. They realized that they’re spending a lot of time doing redundant work. There was some unhappiness among both cardiologists and staff related to communication and making sure that everybody is on the same page. Cardiologists felt that a lot of the times they were either busy and behind the schedule or were sitting and waiting for the patients to come and the patients just weren’t ready on time.

“From a patient’s perspective we have long wait lists to get patients into the clinic when in the clinic patients had to wait in excess of an hour or two to see their cardiologist even if they came on time and we really felt that we had to correct these issues,” said Dr. Yaariv Khaykin, Director and Physician Leader at PACE Cardiology Clinic. “So we embarked on the LEAN process about a year ago and we took a multi-pronged approach which included getting everybody together both the staff and the cardiologists to come up with a mission statement for PACE and what we stand for that brought the group together. We ensured that communication was improved and that everybody was more or less on the same page. But more importantly we’ve had a number of meetings addressing each and every area of work in PACE and walking through the workflow of the different professionals at PACE. We have administrative staff, we have technologists who do anything from ECGs, holters, loop event recorders, stress test, stress echoes, echocardiograms etc. and obviously we have physicians. And while we are largely cardiology practice we have cardiologists, we have internists, we have pediatric cardiologists etc.”

Dr. Khaykin said that they had found that there had been a lot of unnecessary work being done. For instance, patients who were scheduled to have certain investigations did not have them done before their next scheduled visit. They didn’t realize that those patients didn’t have it done until very close to that visit and in some cases had to cancel the visit in order to get those investigations done resulting in significant problems for the patients and in some cases for cardiologists to make sure that their clinics were full and fully booked.

“We also found that during the flow of patients through the office we had patients coming in waves. In essence at the beginning of the day and at the beginning of the afternoon we had about 25-30 patients show up all at once and not enough capacity to see these patients in that hour and in fact this wave then distorted the rest of the day.”

“So we identified these problems and used Lean methodology to work on these problems as kind of root issues behind our waitlists, behind the flow problems in the clinic etc.,” said Dr. Yaariv Khaykin. “The way we addressed these problems was to eliminate certain bottlenecks that we found in the clinic combining certain stations patient had to go through, stations where patients had their history taken, ECG were combined into one step instead of two separate steps which previously were bottlenecking each other.”

“We also changed the way we book and currently use the wheel booking model where slots are inserted into the schedule and patients are spread out. At the end of the day we see the same number of patients per clinic per day but those patients are spread out and so we don’t have to see them all at once. We’ve eliminated these huge waves kind of ups and downs of the patients flow in the clinic and with that we have also incorporated KPI’s (Key Performance Indicators) in evaluating our progress and found that the patient time in clinic waiting for the physician has plummeted dramatically from over 2 hours to under an hour over the last three to four months.”

Dr. Yaariv Khaykin said that they had also been able to largely eliminate their waitlists for patients coming in for general cardiology appointments and for testing. At this point a patient could see a cardiologist within 2 or 3 weeks for a non-urgent referral and patient referred from the emergency room was seen within 72 hours.

“We are able to offer a cardiac testing such as echocardiography stress testing. Stress echocardiography was in a few days to a week to most of our patients at least at our Newmarket location.”

“We looked at key performance indicators relating to how long patients had to wait for their return visit,” says PACE Director. “Historically we found that before undergoing Lean patients who were supposed to be seen at 3 months were not seen until 6 or 9 months later and we have been able to correct it. Looking at the last 6 months we find that patients were generally seen within the period of time + 10 to 12 days beyond their period of time. So if somebody supposed to be seen in 3 months 90% of these patients are seen within 3 months + 12 days which is also significant improvement on the way things used to be before Lean was implemented.”

Dr. Khaykin mentioned that at the end of the day physicians had been a lot happier. They no longer had to either wait for the patients to arrive. They were no longer behind by an hour or two. They were right on time.

As an example, he explained, when he finished a clinic now all of his work was done, the tests were all reported, the letters were all sent to the referring physicians and effectively he walked out of the clinic the same time as his last patient was walking out of the clinic, without having any work left over after that patient was seen and that patient was typically walking out of the clinic within about a half an hour to 45 minutes of when their appointment has been scheduled for.

“We are getting very positive feedback both from our patients and increasingly from our referring physicians as well related to decreased wait times for appointments and decreased time patients have to wait to see a cardiologist when in clinic. Initially we had our growing pains and when PACE started we certainly had significant waitlist and significant flow issues within the clinic which following implementation of the Lean recommendations have them largely eliminated.”

“It’s very important to consider that Lean is a group effort. It’s very important to involve cardiologists and staff, make sure that everybody is on the same page. It’s very important to make sure that you have the electronic back up and an electronic medical record system in place that allows you to implement Lean recommendations and offload the redundant work as well as be able to keep track of your key performance indicators,” Dr. Yaariv Khaykin says.

“To be able to work with one of the Lean consultants and to properly go through the process first of all you have to be ready to implement the recommendations,” Dr. Khaykin explains. “You have to be ready to be fully transparent about practices with your staff, your cardiologists, other physicians, your referring physicians, your patients etc. In fact, one of the very important things that we’ve done is we’ve involved some of our patients in the working groups that got together as part of the Lean process and got a patient feedback incorporated into the Lean recommendations as well as into the mission statement developing for PACE. I think mission statement is very important. Again it brings everybody together and everybody can measure up what they do in the day-to-day basis against the mission statement for the company which needs to be developed and then looked at periodically by all the staff working at the clinic.”

“Lean process did bring all of our staff together,” he concludes. “There were significant issues related to lack of proper communication between physicians and staff, between the company and staff. There was no clear understanding as to where the company is going by all the staff. Among other things we have started to do huddle sessions which happen every day at the huddle board. Any of the new initiatives and processes as well as key performance indicators are tracked on the huddle board. We’ve found that this made a significant difference to making sure that everybody is on the same page and everybody understands where the company is going on a day-to-day basis, what the company is working on as well as where we see us in the future. Our staff had excellent exceptional work ethic and have been working very hard from the beginning and throughout PACE history. We just found that they became more efficient, not necessarily that they became any more productive in a sense that they were already very productive in the first place but it certainly became much more efficient with elimination of a lot of extra work and redundant work.”