This field research in outpatient service operations examines original quantitative data on appointments and analyzes a lean process improvement project that was conducted to increase capacity to admit new patients into a healthcare service operation system. Analysis of 1726 intake appointments for the year preceding and the full year following the lean project showed a 27% increase in service capacity to intake new patients and a 12% reduction in the no-show rate as a result of the transformation of service processes achieved by the lean project. This study's action research methodology leverages the researcher's involvement in redesigning a service system that greatly improved performance and led to reflection on traditional operations management (OM) approaches to appointment scheduling. The study generates insights about effective alignment of resources, develops new strategies for service operations to respond to no-shows, reveals time-related variables that have been overlooked in appointment scheduling research, and challenges traditional OM scheduling performance measures. We provide recommendations for effective and appropriate use of overbooking and identify avenues for future research to continuously improve and increase the capacity of service operations.
Service operations face the continuing challenge of matching consumer demand with provider supply, and healthcare services in particular have been the focus of much concern and attention. Timely access, responsiveness to patient needs, and availability are high priorities among healthcare system improvements that were called for by the Institute of Medicine (2001). Delays in obtaining healthcare appointments lead to patient dissatisfaction, higher costs, and possible adverse clinical consequences (Green et al., 2007). Longitudinal studies confirm that delayed access to care is associated with worse outcomes (Fontanarosa et al., 2007). Also contributing to higher costs are patients who have appointments but fail to show up for them. One clinic documented a total of 14,000 missed appointments in a year, causing estimated losses over $1 million (Kim and Giachetti, 2006). No-shows are a realistic consideration in clinic operations (Kaandorp and Koole, 2007), where they interrupt the flow of patient care and reduce clinic productivity. Another study estimated that resulting revenue shortfalls could constitute 3–14% of total clinic income (Moore et al., 2001). These two factors emphasize the importance of appropriate scheduling and resource allocation to meet healthcare demand (Brewer, 2008, Dolan, 2008 and Green and Savin, 2008).This study analyzes a real healthcare organization's service operations, reflects on new scheduling approaches that emerged from the organization's first lean process improvement project, and develops new directions to expand service capacity. The study uses action research methodology in which the researcher, who analyzed appointments at six clinic sites within the mental health center organization, was directly involved in the action that realigned system resources, changed operations, and developed new approaches to increase appointment scheduling effectiveness beyond those used in prior research. The lean process improvement project, rapid improvement capacity expansion (RICE), achieved dramatic results in expanding access to services. Analysis of 1726 intake appointments for the year preceding and the full year following the lean project showed a 27% increase in service capacity to intake new patients and a 12% reduction in the no-show rate as a result of the transformation of service processes achieved by the lean project. From here on, we refer to the recipients of the mental health center's services as consumers rather than patients to conform to recovery-oriented language used in outpatient community mental health care. This paper is organized as follows. The next section presents the background of the initial service capacity problem, which motivates the use of leaner practices. A summary of prior lean practices in healthcare provides context for migrating lean approaches from inpatient to outpatient healthcare settings. The third section discusses our research methodology, provides a description of the service operations where it occurred, analyzes appointment data, and diagrams the flows of the scheduling and appointment processes. The fourth section reports the results of the lean implementation, measured in the year following the startup of the reconfigured system, and describes feedback from participants and consumers. The fifth section reflects on insights developed in the lean project to realign resources and expand capacity, reveals variables that have been overlooked in prior appointment scheduling research, and considers the need to examine and revise the traditional emphasis of appointment scheduling research and its performance metrics. We conclude with a summary and identify new directions to continuously improve and increase the capacity of service operations.
By incorporating actual operations data to develop and test
new service processes, the RICE lean process improvement project
rapidly expanded service capacity. It demonstrated that no-shows
can be managed effectively through consumer engagement to
improve attendance, along with creative use of overbooking
to serve consumers in orientation groups followed by use of
flexible capacity. Scheduling orientation and intake assessment
appointments on the same day and realigning appointments to
better-attended days also proved effective.
The service operations system was quickly transformed to
achieve measurable performance improvement that motivated
further organizational commitment to conducting lean process
improvement projects. Encouraged by early positive results of the
RICE project, the organization updated its strategic plan with an
objective to conduct one lean improvement project every month.
Projectswereselectedfortheirpotentialtodeliversignificantoper-
ationalandfinancialimprovements,butthiscreatedanunexpected
lean paradox. Lean techniques help project team members quickly
reachagreementonthetargetstateandrequiredactionsforimple-
mentation, but completing the implementation was lengthy and
complex for the troubling and persistent problems selected for
improvement. These problems tend to share a common theme of
lack of systematic processes and inadequate technological sup-
port for their operations. Thus, the streamlining of workflow to
eliminate front-end delays introduced bottlenecks in the back-end
of the operations where implementation required the skills and
efforts of a limited number of programmers. The mental health
center recognized the need to adapt its approach, modified its
goals to sequentially complete lean projects, and carefully prior-
itized its scheduling and selection of candidate projects. In future
research, prioritization guidelines could be developed by study-
ing the factors that predict the overall and enduring value of
projects.
The lessons learned in this action research approach could
be applied to other organizations. The outpatient organization in
this study was inspired by an inpatient hospital to adopt lean
practices after a successful lean event that provided important
benefits to their shared customers. Reducing costs is crucial to
expanding access to necessary services. The project did not elim-
inate no-shows entirely, so there remains a need for research to
study and continuously improve appointment scheduling prac-
tices. The study develops avenues for future research by revealing
time-related variables associated with no-show rates as well as
capacity-oriented performance measures targeted toward serv-
ing more consumers. It also suggests other consumer-orientedvariables related to consumer preferences, clinical outcomes, and
perception of service quality. Recently, the organization began to
track the time of each appointment request and is analyzing the
elapsed time to the actual appointment, along with patient charac-
teristics and recovery outcomes, in data mining projects to predict
no-shows and optimize scheduling. This deepens understanding
of no-shows to further improve consumer access and, ultimately,
clinical outcomes. Improved outpatient access can reduce the need
for more expensive inpatient hospital services. This example can
encourage similar shared learning, continuous improvement, and
policy revision in other settings.
