Due to the Health Care Reform Act, health care professionals all over the country have been taking a second look at the procedures and techniques used in health care settings. Virginia Mason Medical Center’s adaptation of these techniques has been highlighted, focusing on ways to reduce wastefulness and increase safety throughout health care. Through this, the flow-station was born, serving as a way to connect physicians with flow-masters and promote teamwork and efficiency. This paper details how a primary care practice in Allentown, Pennsylvania introduced flow-stations in their workplace through a pilot study, and how this implementation can be used to better implement flow-stations in other practices. The data showed differences in use and understanding of the flow-stations between employees, some significant start-up work arounds, an increase in teamwork and communication, and an overall need for more coaching and direction in the implementation to standardize flow-station work throughout the practice.
As change rocketed through Virginia Mason Medical Center with the knowledge learned from visiting Toyota Production Systems in Japan, health care processes were updated to bring the hospital out of the funk it had previously been in. A new way of thinking emerged as a result of visiting the successful manufacturing system, and its values were translated into a healthcare model, reducing wastefulness within Virginia Mason, promoting new values in the workplace and ultimately increasing patient safety. Although change proved difficult at times, most acknowledged that these processes would evolve as the hospital figured out what worked for them.
Patient centered practices, teamwork, equality, and efficiency all became important new focal points of Virginia Mason’s work. Out of these values, the flow-station was born, a way for medical assistants and clinicians to work side-by-side throughout the day, with the medical assistant or “flow-master” conducting work flow for the clinician. The medical assistant “feeds the physician between-visit work” and “completes non-clinical tasks” while leaving the rest for the clinician (Kenney, 206). The medical assistant also directs clinician’s attention to important emails or phone notes, so that they can be addressed in a timely manner (Kenney, 206). Physicians who initially tried flow-stations at Virginia Mason expressed the efficiency and difference it made “eliminating the chaos of non-clinical work that physicians found so annoying” (Kenney, 206) and some even realized they had no need for an office any longer. Other physicians in the practice became eager to try flow-stations once they realized how much earlier physicians using one were leaving for the day, especially with all their non-visit work completed (Kenney, 206).
Also evolving under flow-stations was the usage of employees to the maximum of their licensure. Nurses who had previously been doing only clerical work “became care managers of patients with chronic diseases,” and began educating patients on medicines and addressing a variety of other concerns (Kenney, 207). The idea behind this change was to “cover a fair amount of ground so that key clinical elements can be thoroughly explored” (Kenney, 207).
In choosing Virginia Mason as a model for flow-stations, two practice coaches, the lead physician, and the clinical coordinator at a primary care facility located in Allentown, Pennsylvania, entitled Lehigh Family Medicine Associates (LFMA), a part of Lehigh Valley Health Network, went to observe and learn from Virginia Mason’s work. The present study aims to evaluate the implementation of a flow-station in LFMA in hopes that the pilot study in the practice can serve as a means of learning what barriers may exist in implementation and how these can be overcome and used to teach other locations within the network how to use the flow-stations successfully.
Participants comprised five clinicians, three of which being doctors of allopathy, one doctor of osteopathy, and one certified registered nurse practitioner. These clinicians consisted of one male and four females. At their respective flow-stations, each of these clinicians partner with medical assistants, registered nurses, or licensed practical nurses, all of whom are female, and are referred to as flow-masters. Also observed were two practice coaches, both with outpatient experience, one a registered nurse and the other a practice coordinator, who assisted the practice in flow-station implementation. The clinicians, flow-masters, and practice coaches are employed by Lehigh Valley Health Network, a large and prestigious hospital located in Allentown, Pennsylvania. The practice was chosen for the pilot study due to their high quality scores, participation in patient centered medical home learning initiatives, and readiness and capability for implementation of flow-stations.
To keep track of flow-station usage and comments regarding it, a notebook was used to record data by hand. Access to the practice’s electronic appointment book and clinician’s inboxes was also granted to look at daily schedules and how work was being managed in between patients.
Observations of clinicians and flow-masters working together at their flow-stations took place from a seated position behind their area in places that were unobtrusive to daily work in the practice, but provided a position so that flow-stations and patient rooms were clearly visible. Notes were taken on how flow-stations were set up and used throughout the day and any comments regarding flow-stations or new procedures were recorded in efforts to find common themes occurring throughout the practice. Clinicians observed rotated each time to ensure equal data for each clinician. A time study was also conducted, documenting when the patient was roomed by the flow-master, when the flow-master left the room, when the clinician entered the patient’s room, and when they left. This gave insight into what factors contribute to running behind schedule and how this impacts flow-station work. The time study also determined on average how long clinicians and flow-masters spend in the room with patients, how long patients wait for the clinician to enter the room after the flow-master leaves, and how long the flow-masters and clinicians have to potentially do flow-station work in-between patients.
To determine which themes were prevalent throughout the practice regarding flow-station work, all qualitative notes were coded by four Department of Family Medicine employees using the categories; pros of flow-stations, cons of flow-stations, comments made on flow-stations, coaching and support seen, barriers to flow-station implementation (flowbusters), variations in flow-station use between clinicians, communication about flow-stations, questions regarding flow-station work, and additional opportunities for flow-station coaching. After coding all notes, four overarching themes were prominent, those being; every clinician went through their own phases of implementation, flow-stations provide an environment that facilitates teamwork and communication, internal and external flowbusters occur frequently, and there are many additional opportunities for coaching about flow-stations. When looking at phases of implementation, it was clear that after being taught flow-station procedures, clinicians and their flow-masters would struggle at first to grasp each and every concept, and may even modify flow-station work at first. Then as the weeks went by, and a stronger relationship was built, a more solidified team emerged, work was more efficient, and communication was stronger. Flow-stations were observed to be an excellent way of creating a physical space to put clinician and flow-master together, and this showed lots of communication about patients, paper work, and inboxes. Giving the teams their own spaces kept them organized and consistent throughout their work day. That being said, barriers to flow-station work happened internally when flow-masters were switching clinicians, and therefore some relationships weren’t strong enough or assertive enough to direct work flow or communicate effectively. In regards to pre-visit planning, it was difficult to do this when a flow-master was unsure which clinician she would be working with from day to day. Flow-stations seemed to be more successful when teams were consistent or known ahead of time. External barriers to flow-station work occurred lots of times when patients would arrive significantly late or computer systems would malfunction. Most flow-masters actively try to room patients early or on time to keep the clinician at a steady flow and on schedule, but this effort can be complicated when patients do not arrive on time. Computer systems are also vital to knowing when a patient arrives and to gaining patient information, so when these systems fail, flow-station work is compromised. Since these flow-busters occur often it would be beneficial to have practice coaches more involved in teaching how to problem solve when these situations occur. Also beneficial would be to have more coaching on weeks where clinicians are rolling out flow-stations to serve as a guide for new teams. Seen often were clinicians and flow-masters looking for help or advice on flow-stations and there was no one to give this. Having this extra help from coaches, especially when first rolling out a flow-station, would give a better start to the process and its usage.
Looking at time study data, it became clear that clinicians were sometimes put behind schedule due to prolonged encounter time with patients, although not every clinician had this issue. On average the entire practice spent a total of seventeen minutes (SD = 8.59) with a patient, with a minimum time of two minutes and maximum of forty-five. Average times each clinician spent in the room with patients were calculated, showing differences between each clinician. Clinician 1 had the highest average of minutes spent in the room with patients at twenty minutes (SD = 9.78). Clinician 2 and 4 had similar average times spent with patients (clinician 2 (M = 14, SD = 7.99), clinician 4 (M = 13, SD = 6.49), as did clinician 3 and 5 (clinician 3 (M = 18, SD = 7.17) clinician 5 (M = 19, SD = 8.38).
Also calculated was average time flow-masters and clinicians had between patients to potentially complete flow-station work. In the entire practice, flow-masters had an average of 20.69 minutes (SD = 14.15) between patients and clinicians had an average of 12.99 minutes (SD = 12.46).
A great deal of information was gained as a result of the flow-station pilot study conducted at LFMA. The study hoped to gain insight into how the flow-stations were working within the practice, but also how their experiences learning it can help to teach others. From the qualitative data it was learned that clinicians in the practice went through definitive stages learning how to use the flow-station, the stations promoted communication and teamwork, there were often occurring flowbusters, which could be helped by additional coaching. This data suggests that stages of learning are expected, even if some pick it up right away and that a consistent team is invaluable, as it builds a relationship that is strong and comfortable. Also important is that help is needed when major flowbusters happen, and they will invariably happen.
Quantitative data in the form of the time study showed how much time clinicians spend with patients and how this tends to impact the flow of the day. When running behind, patient flow is slow and flow-station work is hard to complete. However, the data showed that flow-masters have an average of about twenty minutes between patients and clinicians have around thirteen. This signifies that there does exist a good amount of time to potentially do flow-station work, and getting one or two things done is a reasonable expectation.
In assessing the quantitative data, it is apparent that some clinicians have longer encounter times with patients than others, sometimes putting them behind schedule and causing a larger patient wait time. Appointments are mostly twenty minutes, therefore spending seventeen minutes on average is using up most of the allotted time a patient should be in a room, and the maximum visit measure of forty-five minutes goes over even forty minute appointments. While the practice has faced changes from forty to twenty minute appointments, this change will most likely take some getting used to for the clinicians and the patients.
Limitations to the study include this appointment time change and the time studies may have been affected since clinicians and flow-masters are still getting used to a shorter appointment time. Also limiting is not having pre-flow station data to work with, for this would be a good indicator as to how implementation of flow-stations impacted work flow and patient flow.
For future work it would be helpful to standardize work for flow-stations, so that even if flow-masters are switched around with clinicians, they still have protocol to follow and aren’t preoccupied with what their regular partner needs. Standardizing part of patient visits and prioritizing patient issues could serve as a way to get clinicians who are struggling to remain on time, due to spending too much time in rooms, back on track. While this is easy to suggest, clinicians still want to retain their bedside manner and show commitment to their patients and their needs. For some clinicians, this means spending lots of time in the room with them, addressing all their problems in one day. Also helpful for flow-station roll out would be if newly introduced clinicians and flow-masters had the opportunity to shadow others who are successfully doing flow-stations. This modeling could help give them real world applications of flow-stations while also giving them a person to talk to who went through the process of adapting to it, furthering the value of teamwork and communication among health care employees.
The pilot study at LFMA was not without it bumps in the road, but the growth that was observed between teams throughout the weeks shows that more growth is most likely to come. The communication and efficiency skills being learned from flow-stations helped the practice as a whole to move in a better direction. In future roll outs of flow-stations, practice coaches should be actively involved in flow-station teaching, helping to decrease flowbusters and better address flow-station questions.
Kenney, C. (2011). Transforming Health Care: Virginia Mason Medical Center’s Pursuit of the
Perfect Patient Experience. New York, NY. Productivity Press.
Bast, M., Biery, N., (2014, July, 25) Evaluation of Flow-Station Implementation within a Primary Care Facility. Poster presented at LVHN Research Scholar Program Poster Session, Lehigh Valley Health Network, Allentown, PA.