Lisa Humphrey, Senior Performance Improvement Consultant at TriHealth Heart Institute in Cincinnati, Ohio, tells LMJ how the hospitals improved patient throughput.

TriHealth, a large multi-hospital healthcare system, wanted to use the synergy among its existing hospitals and newly-acquired physician practices to create a Heart Institute to better serve the community.

One the things we had to do in order to get closer to this goal was to merge two cardiology office practices, each with different physicians, staff and processes. The organisations were competitors in the market, and staff from the offices had never met.

Both practices were already providing high quality clinical care, but each operated differently. Both were receiving multiple patient complaints about long waiting times. Some patients were even leaving the office without being seen. Physicians and staff were also unhappy with the unpredictable, chaotic work flow. We knew lean was the pathway to a single office practice with standard, efficient processes that would create a seamless experience for the patient and a satisfying work environment for the employees.

The team started with six hours of training in lean principles and change management, which provided a common language for the two offices to objectively discuss opportunities for improvement. After spending three days creating a value stream map and current state flow charts and identifying issues, the group developed mutual understanding of the processes and problems of each office. This formed the foundation on which two competitors could build upon to start working in unison towards a common goal.

The VSM revealed 40% of office visit activities were non-value added: patients spent an average of 18 to 22 minutes in the waiting room and then waited another 10 to 18 minutes for the physician to enter the exam room. Although the average office visit lasted 77 minutes, more than 50% of visits extended beyond 60 minutes, with a full 15% taking over 124 minutes.


Patients must be “roomed” before the physician can complete their exam. Rooming involves the medical assistant (MA) taking the patient’s blood pressure and pulse, gathering current and past medical history, and documenting all current medications. Our physicians were frustrated because the MA was still rooming the patient when they were ready to complete the exam. We discovered the rooming process varied widely among individual practitioners.

Each MA roomed the patient in a different manner, and each physician had different expectations for how a patient should be roomed. We designed a standard process with exacting details of the information to be gathered and where it would be documented in the electronic medical record.

Standardisation was helpful, but other inefficiencies in the rooming process remained. Many patients need a routine heart rhythm screening test during the visit. The current process required the MA to find the physician and request permission to perform the test for each patient. To increase efficiency, physicians developed criteria outlining patients for whom the test was necessary. Medical assistants followed the criteria and proactively completed the screening without wasting time finding and consulting the doctor.

Further efficiencies were gained by leveling the work within the rooming process for first-time patient visits. It took twice as long to room new patients, because additional information had to be gathered.

To remedy the situation, nursing staff called new patients two days before the appointment to gather and document all information. This created a more even and predictable work flow.


Physicians, a key resource, were spending time performing duties that could be taken on by the MA.  This prevented them from moving quickly to the next patient. After performing the exam, the doctor retrieved the discharge instructions from the printer, walked back to the room to review it with the patient, and then walked the patient to the check-out desk. The team redistributed this work to the medical assistant. To absorb these tasks, we had to change the MA-to-physician ratio to provide two MAs for each physician (instead of 1:1). Schedules were juggled to prevent the need for additional hiring.

The physician also spent a great deal of time entering orders for simple medication refills and follow up tests. This duty was given to the MA, who entered the preliminary order during the rooming process.  When the physician completed the exam, all orders were “teed up” and only required the physician’s review and signature.


Although standardisation and work-leveling improved our efficiency, we still had long patient waiting times when we did not begin the day’s patient schedule on time. The first set of patients was to arrive at 8am. The patient was roomed at 8, so they were not ready for the physician until 8:15.

Further delays happened if patients arrived late for their appointment. Physicians started arriving late to the office because patients were rarely roomed on time. Once the day got off to a late start, the entire day’s schedule ran behind. To ensure patients were ready for the physician, all patient appointments were moved back 15 minutes to allow the MA plenty of time to prepare the patient before the office start time.

The key was to inform the 8am patient that their appointment time was at 7:45. We tried telling patients to come 15 minutes early, but of course they did not comply since we were frequently running late. Physicians arrived promptly once they trusted patients would be ready at 8am. This one small change helped the clinic run on time almost every day. Patients waited less, and staff and physicians left work on time.


The results were remarkable. The average office visit time was decreased from 77 minutes to just 55 minutes and the percentage of patients getting through under 60 minutes rose from 41% to 87%. The average time spent in the waiting room decreased from 22 minutes to just nine minutes.

56% spend five minutes or less in the waiting room. Patients wait four minutes less for the physician to enter the exam room. Patients are extremely happy and comment daily on the office’s new found efficiency.

Staff and physicians are happier as well because the work day runs smoothly and everyone gets finished with clinic on time.