Lean processes decrease wait times, increase efficacy in VA

The last few years have not been kind to the Department of Veterans Affairs (VA) with stories about scheduling delays, long wait times and lack of patient access. As a way to deal with such issues, VA medical centers are implementing lean processes. A new study published by JAMA Surgery evaluated just how efficient these lean processes are, and if the VA is up to the challenge of caring for a growing number of veterans.

As the largest integrated healthcare network in U.S., the Veteran Health Administration is responsible for the care of over nine million veterans and this number isn’t decreasing any time soon. The growing number of aging veterans along with the number of veterans returning from foreign conflicts have taxed the VA system. This study examined if implementing lean processes could improve wait times for VA patients awaiting surgery and give the VA the ability to care for its growing population.

The study analyzed data from four different VA databases to assess changes in wait times for elective general surgery procedures as well as measuring the volume of patients before, during and after the implementation of lean process over a period of three years. The factors of wait time, clinic and telehealth volume, number of missed appointments and operative volume were all tabulated in the study. From October 2011 through September 2014, patients were evaluated using outpatient clinics, video teleconferencing and e-consultations.

Results included:

Patient wait time: Patient wait times in 2012 started at 33.4 days and fell to 26 days in 2013. By 2014, wait times had fallen by half at 12 days, a threefold decrease from 2012.

Operative volume: As predicted by the rising number of veterans, the number of operative volume increased from 931 in 2012 to 1090 in 2013 and 1,072 in 2014.

Use of e-consultations: E-consultations steadily rose from 50 in 2012 to 64 in 2013 before doubling to 129 in 2014.

Use of video conferencing: Though not available in 2012, video conferencing gained much popularity in 2013 with 155 visits and jumping to 304 visits in 2014.

Total clinic, telehealth and e-consultation encounters: As the technological age continues to evolve more patients are taking advantage of telehealth services with the number of encounters growing from 3,131 in 2012 to 3,460 in 2013 and 3,517 in 2014.

Clinic volume: Thanks to the increase in use of telehealth services the volume of patients in the clinic bounced around from 3,131 in 2012 to 3,241 in 2013 before decreasing to 3,084 in 2014.

Number of missed appointments: Even with the number of patients increasing, the number of missed appointments decreased form 366 in 2012 to 346 in 2013 to just 227 in 2014.

“Multidisciplinary collaboration using lean techniques can result in significant and sustained gains in multiple areas within the VA system. By reducing systemic inefficiencies, we achieved increased patient throughput, decreased wait lists, and improved patient access in a cost-neutral manner. This can translate into improved satisfaction for the patients as well as for physicians, residents, nurses, and nurse practitioners in the VA,” concluded Nakul P. Valsangkar, MD, the study's author. “Improvement in the overall surgical patient experience can stem from multidisciplinary collaboration among systems redesign personnel, clinicians, and surgical staff to reduce systemic inefficiencies. Monitoring and follow-up of system efficiency measures and the employment of lean practices and process improvements can have positive short- and long-term effects on wait times, clinical throughput, and patient care and satisfaction.”

“These results support the conclusion that [VA] and other large health care delivery systems may benefit from lean process. Implementing such change requires multidisciplinary collaboration. The stakes are high, and process, organization, and infrastructure must be reformed to ensure that health care delivery, research, education and training proceed at the highest standard,” said Juliet June Ray, MD, MSPH, and author of the commentary Building a Lean, Mean Patient Care Machine.