Workplace innovation at the clinic for Ophthalmology of the Amphia Hospital

2011 – As one of the largest general hospitals in the Netherlands, Amphia offers almost all medical specialties. The clinic for Ophthalmology deals with all types of eye disorders. Many patients have a chronic disability and come back every year. At the clinic there work ophthalmologists, orthoptists, optometrists, ophthalmic technical assistants, physician assistants and interns. The clinic has 80,000 visitors per year. This means about 500 patients a day and about 65 employees in two locations in Breda. The overall business results showed that productivity enhancement was important for the clinic. They learned about the ESF subsidy for ‘working smarter’ and meanwhile the pilot is completed successfully. During one month (the pilot month was January 2011) they have been working in a new way. This pilot provides many opportunities for innovation and offers prospects for the future. This is the main challenge now. An interview about this pilot with Yolanda van Grootel, team leader, and Trézanne Ammerlaan, business manager at the clinic for Ophthalmology delivers the insights presented below.

In the clinic the business manager together with the medical manager are responsible for the quality of care and for the outcome. Two years ago, the business manager started a number of changes; employees saw opportunities for improvement, but had no understanding of how to achieve them. Eighteen months ago, she came into contact with the ESF subsidy for ‘working smarter’ and she saw opportunities for the clinic. The management and the partnership of medical doctors Ophthalmology signed an agreement to cooperate in the project. Partly because of the shared risks, there grew a joint responsibility for the entire project.

The clinic for Ophthalmology has opted for a fundamental approach and the central objective was threefold:
• increasing labor productivity by 2%
• Increasing employee satisfaction
• increasing patient satisfaction.

Workplace innovation is used as a means to increase the involvement, the cooperation and the responsibility. In addition, it is a challenge to achieve the objectives by working smarter. The premise was full participation in the project of all parties involved in the clinic. Everyone was given the opportunity to provide input and to suggest ideas.

At the start of the project, a project structure was created. There was composed a steering committee, consisting of the director of Service, the medical manager and the business manager. Through this composition the steering committee is directly and hierarchically linked to the Board of Directors of Amphia Hospital. On March 1, 2010, the project started with a grand kick-off. This was to emphasize that it was a project of the staff ánd ophthalmologists and that everyone is a participant. Stage theater (acting out situations) is used to prepare the employees for breaking existing patterns. Subsequently, all employees played the management game: Lean Game. The aim of the game was to speed up the production line. This type of activity took place outside working hours. At the clinic it was agreed that the hours worked could be recorded at another moment (time for time).
During this initial period, there also was done a 0-measurement and an analysis of the bottlenecks. The following studies were used:
• Employee-ophthalmologist satisfaction;
• Patient satisfaction survey (executed when patients have visited ophthalmologists, optometrists and orthoptists);
• Processes, tasks and times were recorded and that revealed bottlenecks.

The results of these studies were presented interactively to all employees. There has been done a lot of measuring and this proved to be very useful for identifying the bottlenecks. Important conclusions were that the distortions of the consultation hours could be reduced,  file logistics could be improved, unnecessary actions diminished, the link between the assistant and the ophthalmologist could be made more efficiently and improvements in keeping to the work schedule were desirable.
Bottlenecks were clustered, prioritized and these were adopted by various working groups. Employees were asked to participate in these groups and there was much enthusiasm for participation. Working groups consisted of different disciplines, were given a clear mandate and met several times. Each working group came up with ideas for improvement. Regarding these ideas the steering committee ultimately made choices. In July 2010, the month of January 2011 was blocked in the planning to do the pilot.

During the month January 2011 they worked according to a new plan, which was developed by the working groups. During this month, the planning of the surgeries was adjusted and the ‘STOA team’ started its work. The STOA team meant that several technical ophthalmic assistants together worked for several ophthalmologists rather than working with fixed couples of a doctor and an assistant as it were before. For the purpose of the “one-stop visit’ for patients a flexible assistant was scheduled who directly could conduct additional research to prevent additional visits for the patient. At the clinic at Amphia Langendijk ophthalmologists exchanged rooms so they could work near the STOA Team during this month. Because of this new way of working and other adjustments (listed below as quick wins), the number of disruptions was greatly reduced in this month. And the division of labor between the assistants was better. In a well-furnished doctors office, this means a reduction of 50% of the interruptions compared to 2010.

During the project the staff have seen that it is possible to solve daily problems successfully. The result is that employees themselves start improvements more actively. The collaboration between the technical ophthalmic assistants has resulted in a great deal of time. During the pilot the patient flow was much more efficient. The patient satisfaction survey shows a higher appreciation for the expertise and better information providing than a year earlier. Internal measurements show a decrease in the number of disruptions, less extension of surgery hours and a reduction in the waiting time at the clinic. Measurements of surgeries per doctor revealed differences in efficiency, which can be traced back to the work organization.
Additionally, there are many so-called quick wins. Below are some examples of small changes that have led to a more efficient workflow:
• Recording forms are adapted: from six to one form.
• Records of new patients were created at the counter at the moment of registration of the patient. Now staff creates these in advance; that saves time at the counter.
• They now use readymade recipes, so there is no confusion by recipes that are difficult to read.
• Previously, doctors were regularly disturbed during office hours. Now there are hung so-called mailboxes at the door so that an employee can communicate with the doctor without disturbing anyone.
• Questions by telephone are collected and at a certain moment all these questions are answered by the doctors. As a result, doctors are not disturbed during the surgery.
• There are created posters for patients with clear information about the various jobs within the clinic showing the steps that patients will go through. Now patients know better what visiting the clinic for Ophthalmology means.
The results of this pilot indicate that there is a chance to achieve the objectives established if this new way of working with STOA teams is introduced structurally. Because clinics are planned six months in advance, structural changes in planning require half a year. So a longer lead time is required to realize structural results.

Trézanne Ammerlaan recommend such a trajectory to everyone. She has a few tips:
• Allow people to indicate what is not working and look for solutions, even during the pilot.
• Provide facts and figures and present them. When a phase was completed, the clinic organized a plenary meeting to share numbers, facts and experiences. This worked out very well.
• When a change occurs provide a trial period. If something does not work, reverse it.
• Celebrate successes after each stage in the process.
• Determine with each other what you never will do again.
• Check the willingness of employees for such a project in advance.
• Always cooperate with the medical doctors. Make sure that the doctors take the initiative in the process.
• Such a project requires that everybody in the organization takes a vulnerable position. Check whether this is possible.
• Do not be discouraged by the established order.
• It is important that you inform stakeholders in the project frequently. This will increase the commitment.
• Ensure that people can grumble in a safe environment
• Be clear and move on!
• In retrospect, it took much more time than expected. But the result is true!

This project has been realized through a grant from ESF action E. ESF action E provides subsidies to employers who organize work processes and working conditions in a smarter way in order to work more effectively.