Clinical operations for better care and happier patients

Last fall, Dr. Todd Astor nearly tripled the volume of patients treated in his lung transplant outpatient clinic, which cares for more than 200 transplant recipients.

The clinic, at Massachusetts General Hospital, is a busy place, with new patients visiting as frequently as twice a week and longer term patients checking in every three months. With a growing number of transplants occurring, Astor’s clinic was struggling to keep up.

Increasing numbers of patients was not the only problem. Last summer, the clinic staff was seeing an average of seven patients in a half-day session—only 26 percent of “ideal utilization” based on the number of patients who could be treated if the clinic were 100 percent booked. The average patient visit lasted more than two-and-a-half hours and typically included laboratory testing, X-rays, pulmonary function testing, and visits with a nurse practitioner and a doctor. As part of his Organizations Lab class in the MIT Executive MBA program, Astor sought to increase the clinic’s efficiency.

He tracked 71 patients over nine clinic visits and found that there were problems before patients even arrived. The clinic is located in downtown Boston, in the middle of a complex traffic pattern dense with cars and pedestrians, which caused many patients to be delayed. Some patients never even left home—they had forgotten their appointments.

Once at the clinic, problems continued. Laboratory and X-ray visits were shorter in the morning, but the pace of afternoon appointments slowed, causing a domino effect during patients’ visits. Testing time varied. Visits with nurse practitioners and doctors were repetitive and lacked coordination, with exam room scheduling causing delays.

The need for change was clear. But Astor wanted to ensure that patient health and satisfaction was not sacrificed in the name of efficiency. So he plotted and implemented changes in a step-by-step three-month rollout.

The fixes: phone calls to remind patients of appointments; medication reviews conducted by phone; lab schedule adjustments; a reduction in the number of full pulmonary function tests; time limits on exam rooms; and the combination of nurse practitioner and doctor exams to reduce overlap.

After making the modifications, the team increased patient flow, adding two more patients every two weeks. In September, the clinic staff were seeing seven patients a session. By mid-November, the number was up to 19.

Incremental increases were “an important decision,” Astor said. “We could have easily said ‘OK, we saw nine patients this first week; we’re going to do all these changes and next week we’re going to see 18 patients and see how it goes.’ And I think that would have been a huge mistake. I think the staff would have gotten discouraged and I think the patient satisfaction would have been very poor.”

“As quickly as we moved, we actually moved slowly,” Astor said. “Patient care could not be sacrificed. That was absolute top of the list, that there couldn’t be this rushing through, making mistakes.”

“Patients actually perceived that they were getting better care,” he said. “I think the increased organization or the appearance of a more organized process seemed to equate to the perception that this was better care. And in some ways, I think it’s true.”

Astor plans to develop a patient satisfaction survey this summer, after most patients have had multiple visits under the new system.

“The ultimate in fixing a problem”

At Massachusetts General Hospital, Astor serves as medical director of lung and heart-lung transplantation. He manages inpatient critical care and outpatient management of patients with end-stage lung disease. Most transplant surgeries are performed by a colleague, with Astor’s support.

Transplant work was attractive to Astor because it is “the ultimate in fixing a problem,” he said. “There was something very appealing about that to me, the finality of being able to fix a diseased organ.”

But as health care costs in the United States continue to rise and the industry changes in the face of the Patient Protection and Affordable Care Act, the transplant field will need to change as well, Astor said.

“The care of these patients requires a tremendous infusion of resources,” he said. “How are we going to be able to deliver that type of health care in that environment? I want to be able to have the ability to mold that future. You really need to have a good understanding of finance, of operations in general, of strategy, [and of] business principles."

Astor attended the MIT Executive MBA program because of its strengths in quantitative modeling and analytics, MIT’s strong connections with industry, and because it was not a health care-specific MBA.

“Part of the pioneering part is being able to come up with new approaches to diagnosing and treating your patients with organ transplant,” Astor said. “And the best model right now is developing some of these therapies as partnerships with industry. So the academic-industry partnerships, which MIT of course is top notch at, are really the model for the present and the future, being able to rapidly bring some of the stuff that we’re developing here in the lab quickly to development for patients."

Professor Nelson Repenning, the faculty director for the MIT Executive MBA program, said the curriculum emphasizes the connection between theory and practice and between classroom learning and the workplace. Astor’s work, he said, is an example of a project designed to create rapid organizational change.

“I sometimes call it the ‘last mile’ problem, which is taking all this good stuff that we’re teaching and getting right down to how you make change,” Repenning said. “Because of the time frame, you have to do something small. But that means you actually have to do it. [Students] have to get their hands dirty.”

“What inevitably happens is that by trying to do something smaller and more concrete, they often end up making a much bigger change,” Repenning said.

And 26 percent of the MIT Executive MBA class of 2016 is from the health care and life sciences industries.

“In some sense, Todd’s project is sort of the demonstration of why they’re coming,” Repenning said. “These are very smart people, they are very technically savvy. I don’t think it’s any secret that health care in the US is a big mess. And they have strong intuition [that with an MIT education] they can make a difference.”

A short setback, then recovery

The clinic’s efficiency efforts were dealt a major setback in January and February, when Boston was hit with a series of snowstorms that snarled traffic and caused shutdowns in public transportation. That made scheduling a challenge and impeded some of Astor’s efficiency gains. But he reasons that the extra clinic space created in the fall helped his staff catch up without further delaying appointments.

Astor continues to search for improvements across the whole of an outpatient visit, including in laboratory and radiology appointments. He is also seeking similar process improvements in other inpatient and outpatient components of the transplant program, as well as at the hospital’s transplant center as a whole.

“The changes we’ve made to this point have given us enough breathing room for another year or so,” he said. “I think for now we’re in pretty good shape.”