Lean Healthcare: Evaluation of the Scheduling and Prior Authorization Process in a Mid-Sized Hospital

Introduction: A patient’s journey in diagnosis or healing frequently includes referral to a hospital system for images or ancillary services, wherein the authorization and scheduling process for those services can cause delays, threatening patient outcomes. Reducing these delays improves patient care and the hospital revenue. In this study, a team trained in LEAN healthcare quality improvement methodologies sought to analyze the referral and authorization processes of a midsized urban hospital to identify root causes of delays and propose solutions for C-suite's consideration.

Methods: A team of eight osteopathic medical students and one graduate student were trained in LEAN methodologies via lecture and simulation. The LEAN process improves care by standardizing operations and minimizing waste. A LEAN expert supervised the team. The team observed and interviewed staff in the targeted departments of physical therapy, interventional radiology, authorizations, and scheduling (DEPTS) and mapped their workflow, including EPIC electronic health record processes. Particular attention was paid to referrals taking longer than 72 hours. The team created maps reflecting the DEPTS’ current state. Documentation was obtained for DEPTS work queues, and crossover workflows were mapped to reveal interdependence. Inefficiencies were mapped as “storm clouds” to signify problem areas. After analyzing inefficiencies, the team evaluated potential solutions based on solutions’ degree of benefit versus effort, controllability versus non-controllability, and cost versus no cost to determine C-Suite recommendations.

Results: The investigation found improvements needed in work processing, EPIC information management/queues, and employee training and management. The analysis revealed multiple critical inefficiencies in scheduling and authorization workflows, including delays caused by non-standardized protocols, redundant work queues, and poor interdepartmental communication. Workflow mapping identified areas of waste and rework such as redundant excel files created and managed by employees trying to keep work better organized than the EPIC system provided. The team recommended standardizing protocols, sorting work queues by appointment date, and refining triage processes with visible authorization dates. Processes needed real-time synchronization of work queue updates and integration of management dashboard metrics into team workflows. Many of the recommended improvements included designing new processes within the EPIC system: consolidating or eliminating unnecessary work queues. Because an EPIC Boost Specialist was onsite during investigation, some recommendations were implemented immediately to streamline scheduling and prior authorization processes. Workforce training gaps surfaced, exemplified by the universal misunderstanding of the "Cancel Request" button’s function in reducing bottlenecks. The team proposed staff training, development of reference manuals, where additional staff could be located, and interdepartmental communication.

Conclusion: Through a LEAN healthcare investigation including detailed electronic medical record system informatics mapping, systemic root causes of referral delays at a midsized urban hospital and promising resolution strategies were identified. Recommended solutions were aimed at redundant work in queues, non-standard procedures, and poor interdepartmental communication. The LEAN team implemented some immediate system changes, improving work queue communication during investigation, mapped ideal workflows to establish a standard protocol for post investigation use, and emphasized the importance of open departmental collaboration.