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Optimizing Value Utilizing Toyota Kata Methodology in a Multidisciplinary Clinic
Paul A. Merguerian, MD MS FAAP, Jeffrey Avansino, MD, Richard Grady, MD FAAP, Arlene Libby, MHA, Whitney Murphy, MHA, Lilah Melzer, MS, John H.T. Waldhausen, MD FAAP.
Seattle Children's Hospital, Seattle, WA, USA.

Introduction: Value in health care is measured in terms of patient outcomes achieved per dollar expended. Outcomes and cost must be measured at the patient level to optimize value. Multidiscilinary clinics have been shown to be effective in providing coordinated and comprehensive care with improved outcomes, yet tend to have higher cost than typical clinics. We sought to lower individual patient cost and optimize value in a pediatric multidisciplinary Reconstructive Pelvic Medicine (RPM) clinic.
Materials and Methods: The RPM clinic is a multidisciplinary clinic that takes care of patients with anomalies of the pelvic organs. The specialties involved include Urology, General Surgery, Gynecology, and Gastroeneterology/Motility. Since May 2012 we performed time-driven activity-based cost (TDABC) analysis by measuring provider time for each step in the patient flow. Using observed time and the estimated hourly cost of each of the providers (MD, RN, MA, ARNP), we calculated the final cost at the individual patient level, targeting clinic preparation. We utilized Continuous Process Improvement (Toyota Kata methodology) to enhance operational efficiency in an effort to optimize value. Variables measured included cost, time to perform a task, number of patient seen in clinic, percent value added time (VAT) to patients (face to face tme) and family experience scores (FES).
Results: At the beginning of the study period, clinic costs were $619 per patient. We reduced conference time from 6 min/patient to 1 minute/pt, MD preparation time from 8 min to 6 mins and increased MA preparation time from 9.5mins to 20 mins, achieving a cost reduction of 41% to $366 per patient. Continued improvements further reduced the MA preparation time to 14 minutes and the MD preparation time to 5 minutes with a further cost reduction to $301/patient(51%). During this study period, we increased the number of appointments per clinic. Value added time was increased from 60% to 70%. We demonstrated sustained improvement in FES with regards to the families overall experience with their providers. Despite an increase in VAT, caregiver perception of wait time remained unchanged.
Conclusion: Time-based cost analysis effectively measures individualized patient cost. We achieved a 51% reduction in clinic preparation costs. Despite reductions in costs, we were able to increase VAT and sustain improvements in Family Experience. Lean management methods enables optimization of value in a multidisciplinary clinic in caring for complex patients.

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