The Pulse | Wednesday, September 5, 2018

How One GI Division Increased Efficiency With a Complete Process Overhaul

When Kelly Osborne MSN APRN CNS-BC CGRN, Clinical Nurse Specialist, and Sara Johnson, MBA PMP, Senior Strategic Services Associate, met at Duke University Health System, they knew they would make great partners, as they both identified ways to increase efficiencies in the GI Division. In this interview, learn how they kicked off the process to overhaul multiple systems and protocols, and what they did — and continue to do — to see great success.

SGNA: Can you both give a brief overview of what your roles are at Duke University Health System?

Sara Johnson: I’m the Senior Strategic Services Associate, which is kind of a catch-all title at Duke. Mainly I do clinical administration, so that means I focus on operational efficiency, standardization and process improvement. I work closely with our providers and Kelly, as our Clinical Nurse Specialist, to try to increase efficiency and make our overall clinical program run better.

Kelly Osborne: I always say I’m the other half of Sara’s brain because we work together so much. She does a lot of business and process-related work and is MBA-oriented, where I, as the CNS, focus on any clinical issues or problems that affect patients, providers and nursing.

SGNA: When and how did you realize the need for an overhaul in your department’s processes?

SJ: When I first started with Duke almost five years ago, I met Kelly within the first few months and immediately we knew we’d make a really good partnership. We recognized that there were inefficiencies in how we were managing our clinical program and that there was a duplication of efforts.

KO:  When Sara joined Duke GI, we had just been through the pain of transitioning to a new EHR. We were just barely getting our hands around how it functioned on an everyday basis. It was just so inefficient. We were duplicating so many processes and then we had to figure out how to duplicate the processes we were doing on paper into the EHR. I think the best way to figure out these electronic health records (EHRs), though, is to test them and play around with them. Thinking, “If this works, could that work?” And then pushing the envelope. That’s what we do on a daily basis. We ask “why?” or “why not?” a lot.

SGNA: How did you both first approach this project?

SJ: I think everyone in our division realized we had a lot of opportunities, so we had a rapid improvement event back in March 2014. We left that event with a laundry list of opportunities — I think there were 22 — and we just methodically approached them, figuring out what makes the most impact to our patients and providers. We prioritized those opportunities and just worked our way through. Kelly was able to look at it from a nursing perspective and I was able to look from the administrative perspective. But it all started in the rapid improvement event with all of the managers around the table.  

KO: In that rapid improvement event, I think the biggest thing was that we brought everyone to the table. Managers, scheduling, finance, performance services and GI leadership.  This allowed us to put our hands around everything. We brought in every piece of the puzzle to make sure we looked at the bigger picture of things; and it’s not just us, it’s about our division, providers referring practices, staff and patients. 

SGNA: Can you give a high-level breakdown of the specific processes you created?

SJ: Mainly, the processes surrounded communication with our referring providers, and also making sure we’re taking really great care of our patients. That includes faxing procedure reports to referring providers the same day the procedure is done, making sure we have the health record updated to reflect when the next repeat colonoscopy is due, updating health maintenance so primary care can see what’s going on, standardizing letters and templates with discreet data elements for reporting purposes, a pre-procedure call policy, so we are contacting patients to confirm their procedures date/time/location/etc.. We were standardizing templates, questionnaires, visit-types and blocks, and training our staff to make sure they are familiar with all the new systems and processes.  

KO: In addition to those processes, we developed a centralized nurse triage team. With this team’s implementation, we then worked with current support staff (staff assistant, scheduling and medical assistants) to outline and match staff roles with processes to ensure that staff was working to the top of their scope of practice and not duplicating efforts. We connected the teams so no one worked in a silo, to ensure they knew how integral they are to the GI team, providers and patients.

SGNA: How long did it take to create these processes? When did you implement them?

SJ: I don’t think there’s ever an end. We’re always trying to make improvements. The EHR comes with upgrades every year. Then we figure out how we can make them better. If we ever say there’s an end to this work, we should go find other jobs. We’re also adding new providers and starting new procedures and launching new programs. It’s a continual work in progress.

SGNA: How has the feedback been for those who are now following these processes?

SJ: I think now everyone would definitely say our practice is running more smoothly. Kelly and I also have thick skin. We are really passionate about the work we do, so I think we can be overwhelming. We were so gung-ho and excited that we rolled out all these processes really fast, but in hindsight, I think we could have been more thoughtful about how we did it. It definitely took some time and continual education, being accessible for questions and revisiting processes that didn’t work as well as we hoped, and also being open to that feedback.

KO: I think there will always be negative comments like, “Oh here’s another process, another thing to do or remember.” Overall, though, it’s definitely been positive. I know the Chief of the division said that the number one satisfier for providers this year has been having an assigned Resource Nurse who can follow a protocol and process and assist them with their patients. Then I think of other things like when I walk into a unit, I overhear staff say, “Oh I heard Kelly is here – I heard her voice.” They know they can come to me if they have a question, and if I don’t have the answer, I will find out the answer. I think it’s nice for everyone to know there is a point person, so they’ll come to us. The providers typically go to Sara and the nursing staff contacts me.

SGNA: Are these processes moldable enough that they could be implemented within other health systems?

SJ: Yes and no. Yes in the way that the idea behind it could definitely be replicated, but I think each health system and each division needs to figure out what is going to work best for them and how to best manage their patient care. We can share what we did, but it may not be applicable for everyone. Like Kelly said, as long as people are invested and engaged and willing to do the work there’s so much that can be done to make improvements.

KO: A lot of people say it’s very visionary of the GI division to hire these two positions and pay for two people to manage these processes. And we’ve added even more support staff like ourselves.  The GI leadership realize if they invest in the people that will manage these processes, the division will certainly benefit financially but most importantly improve patient care exponentially.

SJ: In addition, so much of that relies on your leadership. Your chief, your clinical chief, your business manager — they need to support the work you are trying to do with funding. We couldn’t do any of what we’re doing without the support of our leadership.

SGNA: What advice would you give to other health systems looking to make big changes in processes?

KO: You have to have people like Sara and myself in charge. You can’t have nurse managers who are already trying to run a clinic or an endoscopy center, try to also manage all these processes. You just can’t; something is going to fail. Hiring the right people with the skillset to be able to manage these things is key. You need to have somebody that can always watch the process and follow through and test it and educate people along the way, otherwise, you’ll never get to launch anything new. I think that’s the big thing, but also being involved. People say all the time, “Scheduling doesn’t work, nobody knows how to schedule for us.” Even here at Duke with all the divisions, I ask, “Are you involved? Are you meeting with them? Do you educate them?” So those are the big things – you have to be involved and you have to have dedicated people who can actually help you to watch every project and follow through with it.