Angela M. Wills (Project Leader, Outpatient Practice Operational Manager, Division of Cardiovascular Diseases)
Randal J. Thomas, MD (Director of CVHC, Division of Cardiovascular Diseases)
Henry H. Ting, MD (Practice Chair, Division of Cardiovascular Diseases)
David L. Hayes, MD (Chair, Division of Cardiovascular Diseases)
Jonathan Curtright, MBA (Administrator, Division of Cardiovascular Diseases)
Thomas Allison, PhD
Martha Mangan, CNP
James L. Ryan
Nicole Wolters
Julie Borland
Brenda Button
Heidi Williams
Michelle Holmes
Cynthia Nixa
Lezlie Braaten, RN
Karen Salz, RN
LaMae Fritze
Sharlene Sorensen
Jennifer Bland
Randi Campbell
Jane Biers
Tonya Klapperick
Juliann Jenniges
Deanna Constans

The Cardiovascular Health Clinic (CVHC) aimed to improve operational effectiveness for multiple customers including patients, referring providers, CVHC providers, CVHC allied health staff, and CVHC appointment coordinators.

• Process time (value-added)
• Wait time
• Appointment fill rates
• No-show and cancellation rates

• Redesigned and standardized provider capacity for new and established patients.
• Standard triage criteria for “green light” diagnoses to be used by appointment coordinators so that consultations can be scheduled on first medical contact with patient or referring provider.
• Standard diagnostic tests pre-scheduled based on patient diagnosis and indication for referral.
• Developed patient Risk Assessment intake triage process utilizing existing RN staff.
• Standardized protocol for diagnostic testing, evaluation and treatment based on cardiovascular risk: Low, Moderate, High, Early Arthrosclerosis, Metabolic Syndrome.
• Standardized care model for each risk category utilizing multidisciplinary care team including: MDs, NPs, PhDs, RNs, Exercise Technicians, and dieticians.
• Standardized process for preparing pre-visit patient information for providers: eliminated rework and duplication of efforts and information.
• Standardized consult process inclusive of patient education, clinical consultation, and communication of patient handoffs.
• Implemented “pull scheduling” for diagnostic testing “just-in-time” including: treadmill stress test, echocardiogram, dietary consults, and exercise consults.
• Consolidated two allied health staff functions into one team with cross coverage responsibilities — Appointment Coodinators and Clinical Assistants.

By applying the Lean methodology, we improved process time (value-added time for patients) from 240 to 284 minutes and decreased wait time from 33 to 3 days. Cancellation and no-show appointment rates were also decreased, and the appointment fill rate increased.

The Cardiology Outpatient Value Stream Map, an outcome of this project, now functions as a framework for determining applicability and appropriateness of future Lean initiatives in the outpatient setting. Examples of Lean standardized process outcomes disseminated from this project to other subspecialty clinics within Cardiology include:

• Standard triage for “green light” diagnoses — right patient to the the right subspecialty clinic
• Appointment given at first medical contact
• Standard protocol for prescheduled diagnostic tests based on patient diagnosis and indication for referral
• One team of Appointment Coordinators and Clinical Assistants
• "Pull scheduling" for diagnostic tests
• Standard diagnostic evaluation and treatment based on patient risk assessment
• Optimize value-added processes and eliminate waste
• Continuous Lean  “CLEAN” concept

Angela Wills, Operations Manager
Mayo Clinic Division of Cardiovascular Diseases
wills.angela@mayo.edu

[Storyboard presentation at IHI's National Forum, December 2005]