Physical therapy plays a vital role in the health-care setting. It has become one of the primary areas in health-care management. Patients who need physical therapy care are generally referred by direct referral or specialist physicians. Patients find difficulty in obtaining appointments in the physical therapy departments due to loads of patients who already receiving the services. Long time waiting often leads to the chronicity of the condition and the patient may extend their sick leave. This not only affects the patient but also affects the physiotherapist who finds it very difficult in managing the patient (The Arthritis Society March 2006 -2007).
The large number of patients (45%–50%) is noted in the waiting list, and the significant numbers of patients feedback were received with waiting time dissatisfaction. The senior management team wants to fix the issue at the earliest by quality expertise in the physiotherapy department. The aim of the study is to reduce patient waiting time and improve patient flow with optimized patient experience to using LSS methodology in an outpatient physical therapy department (OPD).
Patients' waiting time has been defined as “the length of time from when the patient gets the insurance approval to attain the first session of the physical therapy”. Extended delays in accessing health-care services, known as “wait times” or “waitlisting,” may compromise patient health outcomes through delays in diagnosis, treatment, or follow-up. They indicate health system inefficiencies that reduce cost-effectiveness. (British Columbia Medical Association – June 2006, Cancer Quality Council of Ontario- on june 18th 2004 & Kielar AZ, El Maraghi RH, Schweitzer ME - 2010;7:573-81).[2,3,4] Waiting time is a serious problem for the bulk of patients and is recognized as the central element for their satisfaction (Eliers GM. 2004;41-43). Currently, patients experiences are documented as one of the major factors of health-care quality with safety and effectiveness (Sizmur S, Redding D – 2009:1-20).
A source of dissatisfaction with outpatient departments, often noted by patients, is the amount of time they wait during a clinic visit. Several studies have documented the relationship between waiting for service and overall satisfaction, with longer waiting times being associated with decreased patient satisfaction. This relationship between patient waiting time and satisfaction is not only localized to individual organizations or types of care but is well documented in general situations involving waiting customers (Dansky KH, Miles J. 1997;42:165 77 & Katz KL, Larson B, Larson RC- 1991;32:44-53).[7,8]
The literature supports the patient's flow to increase the effectiveness of care in practice, decrease wasted time, and enhance overall system quality, in addition to improve customer and staff experience (Jones J, Pereira P: 2013. p. 1 51.). The importance of making change in patient's journey by time management and utilizing the resources in a better way. The change resulted in eliminating waste, speeding up the movement, attracting more people, enhancing the use of the space, and reducing costs with increasing its recovery (Pons J; 2012;25:31-3).
The team decided to initiate the as strategic plan of an Outpatient Appointment Reminder System (OARS) was initiated to help in rescheduling the appointment which succeeded in decreasing the nonattending rate. An OARS was implemented development in the study based on the recommendations in Kamil and Lyan (2014) Study (Ho ET: 2014;2:u201918.w1006 & Kamil A, Lyan D. April -2014).[11,12]
Lean Six Sigma (LSS) is a fusion of two important and powerful management systems. Lean is both a strategy and a set of techniques. The strategy of lean is simple yet compelling: minimize waste and maximize customer satisfaction. The first, lean thinking, is focused on the creation of value through the elimination of seven codified and well-known wastes (Womack JP, Jones DT. 1996,2003 Free press NY 10020). In LSS or Lean Sigma, there is a particular pattern to follow named define–measure–analyze–improve–control (DMAIC) that leads in a rigorous way toward improvements in general (Bahensky JA, Roe J, Bolton R. 2005;19:39 44 & Harry M, Schroeder R. USA. 2000: ISBN -0-385-49438-6).[14,15]
The main strategy of key elements that were consider in the study is improving patient's flow pathway, mapping process, impact of waiting time on patients' satisfaction, effective scheduling, and improve quality of care.
SUBJECTS AND METHODS
In the define phase, the team mainly focused on the voice of the customer (VOC). Understanding the VOC is one of the most important issues in the define stage (George ML; 2002:0-07-138521-5.). The lead physiotherapist and team developed the flowchart [Picture -1], and process map,(SIPOC Analysis (Marques, Pedro, 2013- VL -4) -[Table -1]) and define the business case. A VOC analysis [Picture -2] was performed by interviewing the team with key questions and analysis the patient feedback form (Beth EM-2009). After extracting the information, a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis (Casebeer A.1993 Mar 17-Apr 6;49(6):430-431,[Table -2]) was developed that provided information that was helpful in matching the organization's resources and capability to the competitive environment in which it operates. The institutional ethical committee approval was obtained from the ethics committee prior to conduct this study.
As a next step, the dashboard was developed by the team and used to identify the critical to quality (CTQ) factors. The following CTQs were identified by the team after the dashboard was created.
- Waiting time
- Patient Experience
- PT workload
- Patient Appointment System.
The primary objective of the team is to reduce the waiting time from 21 (3 weeks) days to 4 days with achieve the optimal patient experience. The patient administrators were instructed to categorize the insurance card and give priority for postoperative patients. All the physiotherapists were instructed to give at least three slots for new patients every day and effectively use the OARS-Tuotempo. The key process output variable was the average days taken for to give a first appointment to the patients for physiotherapy.
In the measure phase, conduct the brainstorming session with the team members to extract the data using the checklist and selecting the quality tools for analyzing the data. The data were collected for 45 days using the purposive sampling method and measured units in days. The team suggested brainstorming ideas to improvement strategy for reduce the waiting time. The patient experience related suitable self-completion questions were selected from NHS physiotherapy service patient satisfaction survey questionnaires. (Chartered Society of physiotherapy -FCP 2019, 18th November - [Table -3]). The team was assigned for 45 days of data collection and documentation with the following checklist templates and patient experience questionnaires'.
Patient experience questionnaires
In the part of the measure phase, the current process and performance were measured by the baseline data collection. The run chart (Anhøj J, Olesen AV 2014, 9 (11) – [Picture -3]) were plotted to understand the pattern with 25 days of data collection. The run chart shows similar pattern with median values of 13.5 days. Only two postoperative patients were got the appointment within 5th day of the approval. It means the patient has to wait at least 17 days for the first physiotherapy session.
The patient experience was measured by the questions with the five-point scale. A total of 100 questionnaires were handed out to patients with 72 returned with answers. The overall answers were plotted with simple percentage pie chart. The pie chart (Black N. BMJ.2013 Jan 28 - [Picture -4]) shows the main bottlenecks identified with the booking system and waiting time of below 30% with a direct impact on the patient experience.
The objective of the analyze phase in a six sigma project is to identify the root causes of the problem so that appropriate strategies can be devised to eliminate the root causes (Gijo EV; 2011;11:27-9). The team decided to conduct a process analysis to identify the nonvalue added activities and bottlenecks of the process, followed by a cause-and-effect diagram to identify the potential causes. The each step of the process from sending the request to insurance to receive the approval from the insurance was critically examined by the microlevel flowchart. After that, the team categorized the value added and nonvalue added activity. During this analysis, few nonvalue added activities were identified and action plans were implemented to eliminate such activities. One such activity is “rework” with physiotherapy request. A typical form of waste in the lean management was identified. It leads to prolong the patient waiting time and dissatisfaction of the service. In addition, improper scheduling staff, irrelevant insurance queries, prints duplication approvals.
Cause-and-effect diagram (Hill. R 2017 July 2015- [Picture -5]) validated by the GEMBA investigation. In total of 21 root causes, the team consider only 12 root causes were has potential impact on the patient waiting time and dissatisfaction.
A few other findings were identified from the GEMBA (Suárez-Barraza, M.F., 2012 Vol. 4 pp. 28 [Table No-4]) investigation, the staffs were suddenly change the shift as per their convenience and the staff duty schedule was mismatched with the patient statistics. Some of the physiotherapists not effectively using the OARS and it increases the workload to the patient administrators. Moreover, the patient administrators were not closely monitor the duplication of the patient approvals and lead to rework with the appointment system (lean waste). The incomplete request and defective progress (i.e., Visual Analogue Scale) notes leads to delay and rejection of the approval from the insurance department. After the GEMBA investigation, some of the causes were identified not root cause and the action plan were implemented for the potential root cause and nonvalue added activity in the improvement phase of the study.
The improve phase is one of the important phases to achieve the goal of the organization as per the requirements of the VOC. It measures the changes between the existing process and the current process. The nonvalue added (lean waste) activities were eliminated from the process to reduce the delay in patient appointments. The Post control plan run chart (Anhøj J, Olesen AV 2014, 9 (11) – [Picture -6]) were plotted to understand the pattern with 25 days data collection. The run chart shows improved pattern with the median values of 1.5 days. The Post action plan pie Chart (Black N. BMJ.2013 Jan 28 [Picture -7]) shows significant improvements were identified with booking system & waiting time of 95 % with direct impact on the overall positive patient experience. The following recommendations are piloted, evaluated the risk, implemented, and closely monitor by the lead physiotherapist. The recommendations were classified into four categories: for clinician, for physiotherapist, for patient administrators, and for insurance coordinator.
- The physiotherapy request was completed, as per the insurance company requirement forms such as assessment form, authorization form, clinical documentation with their stamps, and double-checked by their auxiliary aids
- To avoid the unscheduled patient referring to physiotherapy, it delays the normal process and leads to long waiting time.
- To introduce them, self to patients before start the first session and give an education session about their clinical condition
- To give atleast 3 slots/day for the new patients and effectively utilizing OARS-Tuotempo for the follow-up visits of the patient
- To cooperate with the dynamic shift change and effective duty scheduling as per the patient statistics
- To reply the query and send the progress report within 24 h from the insurance request.
- After receiving the approval, check the expiry of the approval, and call and give the first appointment within 24 h as per the priority of the insurance card
- To comply with the FIFO policy, schedule the patients with physiotherapists with balanced statistics
- Effectively handled the patient complaints and inform to the HOD of the physiotherapy department and rectify the recurrence
- Remove the duplication of the approval from the file, after scheduling the patient.
- To align the patient scheduling with duty schedule of physiotherapists using the Appointment Reminder System (OARS-Tuotempo)
- If the patient missed the appointment or changes the appointment, coordinate with the physiotherapist, and make the scheduling of the patients.
- The insurance coordinator was requested to ensure fulfilled physiotherapy request and uploaded in the E-health insurance system within 24 h
- If any query or requested for the progress report, follow up and communicate and rectify the query within 24 h
- Printout the approvals and keep it in the file and communicate with the patient administrators every day and display the pending patient approval statistics
- To maintain friendly display system of the data regarding the waiting list, received requests, approved requests, and rejections.
The objective of the control phase in any Six Sigma Project is to ensure that the improvements made in the improve phase can be sustained over time(Breyfogle F.W, III, 2003). The recommendations which are piloted and applied during the improvement phase were trained, standardized, and institutionalized in the control phase. The control plan was to get consent from the hospital director and applied as an action plan in the physiotherapy department. The action plans were circulated to process owners to achieve the sustainability of the process. The following control mechanisms were applied to the process to achieve the sustainability
- The HOD continuously monitors the staff, for allocating three slots for new patient's every day
- The HOD has to monitor the patient waiting list and patient experience data, to make the necessary changes in the schedule of the staffs
- The template created for KPI to give appointments for patients within 4 days from the approval and to reply the insurance query within 24 h
- The average and standard deviation of the data were calculated every month and discussed in the monthly meeting and the MOM send the management team.
Discussion and findings
This study mainly focused on reducing the patient waiting time and improved the patient flow with optimized patient experience using LSS DMAIC methodological approaches.
During the define phase of the study, the lead physiotherapist and team focused on the VOC. After extracting the information from the VOC, the team developed the flow chart, process map, and define the case. The SWOT analysis was done to find our strengths and weaknesses in relation to the opportunities and threats. Then, the CTQ was identified and set the primary objective of reducing the waiting from 13.5 days to 4 days.
During the measure phase, the brainstorming session was conducted with the team members for making the checklist for data collection and selecting the quality tool. Then, the baseline data were measured to understand the current process and performance using run chart and questionnaire, it shows an average waiting time of 13.5 days in the run chart. The patient experience was analyzed by simple percentage pie chart by questions with the five-point scale.
During analyze phase, the main root causes were identified by the cause and effect diagram, then validated by the GEMBA investigation. The total of 21 root causes, the team consider only 12 root causes were has potential impact on the patient waiting time and dissatisfaction.
During the improve phase, the nonvalue added activities were eliminated from the process and comparing the current performance with the previous performance. To achieve the goal, the action plans were framed in four categories and piloted.
During the control phase, the piloted action plans were converted a control plan and circulated to the process owners the head of the department was informed to continuously monitor the data and train the staff to achieve sustainability.
There were lot of studies available related to outpatients waiting time. only few studies focused on lean initiatives, but methodologically these studies are not comparative and included often self-researchers observation. Most reviewed papers introduce only a limited view of the potential benefits and limitations of Lean Six Sigma in physiotherapy domain.
Effectively managing patient flow in an outpatient unit is a key to achieve operational excellence as well as ensuring clinical quality. The waiting time for patients is one of the important factors that should be considered in the management and organization of the health care system. It is one of prioritised tools to improve the quality of health care services is to reduce the long waiting time (Breyfogle F.W, III, 2003). Patients waiting time is not the only factor that affects patient satisfaction but it is one of the indexes to evaluate the quality of outpatient services. (Matthews F, Probert C, Battcock T; 991;105:239-42. & Sibbel, R., Urban, C. (2001)[27,28] Waiting time leads to the worsening of the patient's condition which leads to increase their health care cost. The optimized quality services in health care organizations are the right of every patient.
Further Multicentre studies are needed, such studies specifically addressing the Operational resource needs to achieving the bench marking standard to eliminating the bottle necks in the process to reduce the waiting time & improve the patient flow in physiotherapy services. In addition to that further studies need to focus on the value based healthcare for physiotherapy patients. Lastly, future studies need to give a priority on waiting time adverse effects & healthcare cost effective strategies and policies to ensure structured process to access the physiotherapy service.
The LSS DMAIC methodology is the valid and successful approach in reducing the patient waiting time and improving the patient flow with the optimum experience. The advantage of the LSS methodology is rapid improvement in the process and eliminating the nonvalue added process.
This study highlights the use of data-driven and scientific problem-solving methodologies such as LSS with the involvement of hospital staffs such as physiotherapists, clinicians, insurance coordinators, and patient administrators. The results of the study have provided greater inputs among the senior management team for deploying the use of DMAIC methodology for executing process and patient care-related problems in the outpatient department.
There is a significant reduction in the waiting time was achieved and improved patient flow and patient satisfaction marked in this study. The average patient waiting time was reduced form 13.5 days to 4 days and there is improved patient experience showed in the simple percentage analysis of the pie chart. The typical lean waste (i. e. rework and rejections) is eliminated from this process. The one of the important point noted in this project, the results were achieved with available resources and without any extra investment. As a result of this breakthrough improvement, the patients volume is increased the physiotherapy department which directly increase the patient flow and revenue and leads to increase hospital profitability and will also enhance patient satisfaction.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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