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A few days ago I called my provider to make an appointment for an annual exam. Pretty standard stuff. I got routed through 6 or 7 electronic menus, pressing "1" and pressing "5" until I finally got to centralized scheduling for the whole hospital. I asked for an appointment, and the first one that was available was over two months away. I booked it, and wished for a brief, intense moment that I was in Lamar, Colorado.

Lamar is a small town southeast of Denver with a population of less than 11,000 people. At the High Plains Community Health Center, patients can get an appointment with the provider they want to see on the same day they call. And, the patient can expect to spend no more than 30 minutes in the clinic. Sounds like heaven, doesn't it?

In 2002, High Plains Community Health Center participated in a Patient Visit Redesign™ Collaborative conducted by Coleman Associates. Prior to redesign, the average cycle time (the total time a patient spends in the clinic) was 52 minutes, and productivity averaged 1.82 patients per provider per hour. Although these numbers seemed good when compared with other clinics and hospitals, "We were really struggling financially," said Jay Brooke, the Executive Director. "We were just floundering." High Plains Community Health Center was in a position that many clinics are in—they weren't making enough money, even though there were plenty of patients that needed to be seen.

With direct coaching from Coleman Associates' Melissa Stratman, High Plains Community Health Center selected a strong redesign team: Team Journey. Redesign teams are comprised of the "best and brightest" staff—five or six people who develop a new patient visit model. The redesign team then conducts multiple test clinics, called Rapid Redesign Tests or RRTs, to perfect the new model. Team Journey's goal was to see 90% of all patients in 30 minutes or less—a goal which they achieved handily. The average productivity for all Team Journey's RRTs was 3.5 patients per provider per hour—nearly twice the number of patients typically seen at the clinic.

Fast forward to over two years later...

But what happens after the redesign model has been rolled out across the whole clinic, and two years have passed by? Many teams achieve great results during Patient Visit Redesign™ Collaboratives. What is really outstanding is to see a clinic that not just maintains, but actually improves upon its collaborative results over time. High Plains Community Health Center was able to do just that. Average visit cycle time is now even lower, an impressive 28 minutes. Productivity stays right around 3.0 patients per provider per hour. And all areas of the clinic are working in the redesigned way. A few elements really stand out as contributing to the success of the Health Center: The redesign team, the board of directors, and Executive Director Jay Brooke's keen judgment.

Three of the five original team members are still at the site. Losing staff is difficult for any clinic. Hiring and training take time and money. But if a staff member leaves after they've gone through highly specialized training like Patient Visit Redesign™, all that knowledge leaves with them, too. So, by retaining 60% of the original team, High Plains Community Health Center has been able to maintain a real historical perspective and deep pool of knowledge.

The board of directors is very supportive, requesting cycle time and productivity data at the beginning of every board meeting. This sends a powerful message to the clinic about the board's expectations and gives clinic managers and staff a strong incentive to maintain or improve upon the gains they made during the collaborative. Since cycle times have dropped since the collaborative, and productivity rates are at a very respectable 3.0 patients per provider per hour, the board must be pretty happy.

It's nearly impossible to get great leaders to talk about themselves, and Brooke is no exception. "He's very even-keeled, very thoughtful in pretty much anything he does. He thinks about something, and then makes a decision," said Stratman.

In the early stages of the redesign collaborative, Brooke made it clear to staff and managers that redesign was the way of the future: "We are going to do this, and there'll be some of you that don't like it and will leave." If staff members weren't willing to change their work habits and work on patient care teams, they would have to look for other jobs. "I don't think I ever gave any kind of message that it was OK not to go along," Brooke said. Not everyone was comfortable working in the new way. Brooke said everyone knew that "it was OK to leave if they didn't agree." As a result, High Plains lost a nursing supervisor and their Medical Director midway through the collaborative.

Once the clinic met the cycle time goal of 30 minutes, and productivity rose to more than three patients per hour, Brooke knew there was no going back. "I had the expectation that we've figured this out, we're doing it successfully, and now we need to keep it up," Brooke said "Cycle times needed to stay at 30 minutes or under, and productivity needed to stay at three per hour at a minimum." And they have.

High Plains Community Health Center knew everything would be lost if new staff was not adequately trained. Before redesign, the center was like most clinics across the country: each staff member had his or her job, and each staff member did that job in virtual isolation from what other staffers were doing. Now, after redesign, more than two years later, "Everybody's cross-trained, and everybody has the same job description," said Brooke. Simply stated, "Everybody needs to do everything that needs to be done for the patient."

Now Brooke says that when new staff is hired, he insists on the following mantra: "Hire for attitude, and train for skill". He's certain this stipulation is making a difference. The expectation is clear from the beginning: new hires know that they're coming into a team-based environment, and everything hinges on patient satisfaction. And, managers know they are free to—in fact expected to—hire someone based on their potential first, and their skills second.

Brooke reinforces the importance of working cooperatively, and not just within teams. Recently Brooke noticed that the patient care teams had lost some of their enthusiasm. So he instituted an incentive plan where if a team maintains an average productivity of 3.0 patients per provider per hour for a full month, each team member receives a $30 bonus. If the patient care team is able to maintain an average 3.2 patients per provider per hour for a month, team members make a little more. Brooke said it sends the message that "we're all in this together, and we help each other out."

But it's not only the high-achieving team that benefits. Everyone in the building receives $30 whenever a patient care team meets the productivity goal. It's like a cooperative competition. "My sense is that giving a bonus motivates everybody to help one another out, if everybody benefits from it," said Brooke.

Because Brooke knows his staff, he was able to create a way to motivate everyone. One provider who hadn't been meeting the productivity goal asked to be scheduled more patients because she thought she could meet the goal. Instead of feeling punished for her low productivity, she was instead inspired to pitch in to meet the goal, with the hearfelt support of her team.

How do the teams keep it up? "By building on their successes they see what they can do", said Brooke. And, because patients are able to be seen when they want to be seen, by the provider they want to see, in a timely fashion, the patients are happy. "People are in this business to please patients," said Brooke, and High Plains Community Health Center really does please patients.