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The American Journal of Managed Care February 2019
Impact of Hepatitis C Virus and Insurance Coverage on Mortality
Haley Bush, MSPH; James Paik, PhD; Pegah Golabi, MD; Leyla de Avila, BA; Carey Escheik, BS; and Zobair M. Younossi, MD, MPH
Does CMS’ Meaningful Measures Initiative Boil Down to Cost-Benefit Analysis?
Jackson Williams, JD
The Drug Price Iceberg: More Than Meets the Eye
A. Mark Fendrick, MD; and Darrell George, BA
From the Editorial Board: Sachin H. Jain, MD, MBA
Sachin H. Jain, MD, MBA
Value-Based Arrangements May Be More Prevalent Than Assumed
Nirosha Mahendraratnam, PhD; Corinna Sorenson, PhD, MHSA, MPH; Elizabeth Richardson, MSc; Gregory W. Daniel, PhD, MPH, RPh; Lisabeth Buelt, MPH; Kimberly Westrich, MA; Jingyuan Qian, MPP; Hilary Campbell, PharmD, JD; Mark McClellan, MD, PhD; and Robert W. Dubois, MD, PhD
Medication Adherence as a Measure of the Quality of Care Provided by Physicians
Seth A. Seabury, PhD; J. Samantha Dougherty, PhD; and Jeff Sullivan, MS
Why Aren’t More Employers Implementing Reference-Based Pricing Benefit Design?
Anna D. Sinaiko, PhD, MPP; Shehnaz Alidina, SD, MPH; and Ateev Mehrotra, MD, MPH
Does Comparing Cesarean Delivery Rates Influence Women’s Choice of Obstetric Hospital?
Rebecca A. Gourevitch, MS; Ateev Mehrotra, MD, MPH; Grace Galvin, MPH; Avery C. Plough, BA; and Neel T. Shah, MD, MPP
Are Value-Based Incentives Driving Behavior Change to Improve Value?
Cheryl L. Damberg, PhD; Marissa Silverman, MSPH; Lane Burgette, PhD; Mary E. Vaiana, PhD; and M. Susan Ridgely, JD
Validating a Method to Assess Disease Burden From Insurance Claims
Thomas E. Kottke, MD, MSPH; Jason M. Gallagher, MBA; Marcia Lowry, MS; Pawan D. Patel, MD; Sachin Rauri, MS; Juliana O. Tillema, MPA; Jeanette Y. Ziegenfuss, PhD; Nicolaas P. Pronk, PhD, MA; and Susan M. Knudson, MA
Performance of the Adapted Diabetes Complications Severity Index Translated to ICD-10
Felix Sebastian Wicke, Dr Med; Anastasiya Glushan, BSc; Ingrid Schubert, Dr Rer Soc; Ingrid Köster, Dipl-Stat; Robert Lübeck, Dr Med; Marc Hammer, MPH; Martin Beyer, MSocSc; and Kateryna Karimova, MSc
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Process Reengineering and Patient-Centered Approach Strengthen Efficiency in Specialized Care
Jesús Antonio Álvarez, PhD, MD; Rubén Francisco Flores, PhD; Jaime Álvarez Grau, PhD; and Jesús Matarranz, PhD

Process Reengineering and Patient-Centered Approach Strengthen Efficiency in Specialized Care

Jesús Antonio Álvarez, PhD, MD; Rubén Francisco Flores, PhD; Jaime Álvarez Grau, PhD; and Jesús Matarranz, PhD
Improving efficiency is complex and requires a multimodal approach. Health information systems, patient feedback, and multidisciplinary teams are components that can improve clinical processes.

Objectives: To improve multiple levels of utilization and efficiency in specialized outpatient consults using information technology–based systems, process reengineering, and patient-centeredness.

Study Design: Prospective research from 2008 to 2014 conducted in a hospital in Madrid, Spain. Quantitative analysis of 1,162,477 consecutive consultation requests and qualitative techniques of 72,368 surveys using a structured questionnaire.

Methods: Key performance indicators were evaluated: operational outcomes (productivity, time gap between requested consultations and performance, staffing accuracy, wait time, and underlying variability), administrative burden (downtime losses; no-show, drop-in, cancelled, and rescheduled visits), perceived quality scores, and income. Data mining, modeling seasonality in demand, process reengineering, and a patient-centered approach were incorporated as strategies to drive changes.

Results: Productivity increased 34% for the entire period, closing the gap between consultation request and performance from 43.7% to 8.7%. Wait time decreased from 82.7 to 7.9 days, with an 82.9% reduction in interservice variability. Staffing adjustments prevented understaffing situations; more accurate modeling reduced understaffing from 282 to 4 full-time equivalent staff. A seasonal autoregressive integrated moving average (1,0,0)(0,1,0) model explained 90.3% of forecasted data variability with an absolute percentage error between 2.4% and 8.3%. The project reduced administrative burden, inefficiency, and downtime losses by 47.3%, 53.7%, and 54.5%, respectively. Perceived quality indices improved by 19.6%, and complaints were reduced from 63 to 10 per 10,000 consultation-years. Hospital incomes rose by 49.4%.

Conclusions: Improving efficiency is complex and requires a multimodal approach. Health information systems, patient feedback, and multidisciplinary teams are components that can improve clinical processes.

Am J Manag Care. 2019;25(2):e50-e57
Takeaway Points

Our study shows that process reengineering and a patient-centered approach are demonstrable ways to achieve tangible and positive administrative and health service–related outcomes. Predictive modeling reliably forecasts the demand for consultation for specialist care.
  • Patient-centered approaches allow hospitals to prioritize action plans and to engage professionals in workforce planning and modeling future needs.
  • Strategies including process reengineering and a patient-centered approach achieved successful targets in efficiency and perceived quality.
  • Developing a multifaceted concept of a global change management system puts hospitals in a better position to deal with exceptional situations.
Innovation is increasingly necessary in the costly and highly demanding national healthcare systems worldwide. In particular, innovative medical services are essential to drive and stimulate the efficiency and sustainability of public services.1 However, discrepancies in opinion exist on where to focus efforts to improve healthcare while raising awareness about the importance of monitoring the use of resources and reducing ever-growing healthcare spending.2 Many hospitals are focusing on enhancing efficiency through a process reengineering (PR) strategy.3 PR has been implemented worldwide, although the long-term effects on organizational performance, costs, and competitiveness have not yet been proven. Some authors have called for the integration of reengineering and quality management systems to achieve more robust outcomes.4-6 Nevertheless, experience in process improvement has demonstrated that the solution often does not improve the outcome of individual activities, but, instead, leads to an entirely new work approach.7

Recently, electronic health records (EHRs) and health information systems (HIS) have become primary sources of data to potentially support improvements in the efficiency of healthcare processes. However, traditional analysis tools, such as relational databases and statistical tools, have failed to prove their adequacy in evaluating the massive influx of data collected in EHRs. New methodology for big data analysis has broadened the opportunities to discover patterns in complex and heterogeneous data.8-10 However, the knowledge gained from high volumes of data is not enough to help hospitals develop new ways to provide their services, and so the impacts of EHRs and HIS on quality, efficiency, and outcomes of care are currently questionable. Furthermore, although patient-centered approaches in every step of the process are increasingly advocated, limited data exist to assess the effects of interventions on patients’ health status; even fewer data exist on the effects on healthcare service utilization.11-13

Prior studies using EHR data have examined process improvement tools, both concurrent with and independent from quality improvement initiatives.14-20 Most studies have attempted a single-intervention approach (eg, changing referral forms), but these procedural changes almost invariably fall short of expectations to improve quality of healthcare.21,22

As the use of specialized outpatient consult (SOC) divisions is outpacing other types of healthcare provision, wait times in terms of days and the expenses associated with specialized services have increased.23-26 Our study reports the results of a multiyear project to improve utilization and efficiency in an SOC as part of the overall management of a general hospital. In our SOC, the following issues were explored: long wait times for appointments after referrals, low patient satisfaction, seasonal variability in referral volume, fluctuations in provider availability, and income losses. The change strategy described here incorporates PR and patient-centered considerations through multiple approaches, including modeling low- and high-volume periods and staffing accordingly, incorporation of patients’ preferences (as expressed in structured surveys), collaboration with referring primary care physicians (PCPs), and expanding the use of HIS. In doing so, we provide tactical and operational strategies, which, in turn, may boost organizational and process efficiency and effectiveness.


The goal of this research is to evaluate the efficiency of SOC interventions after the implementation of a global change management strategy to address PR using information technology–based systems and patient surveys. Table 1 describes the activities and objectives of the program, which had the overall goals to (1) optimize the current systems to increase their efficiency and productivity by enhancing cross-functional performance and (2) build a clinical management model to guide long-term staffing and maximize productivity, ensuring competitiveness.

Further, the secondary objectives of this research are ensuring appropriate referrals from primary care, identifying and solving bottlenecks and non–value-added activities from a patient’s perspective, and shortening the time between the date an appointment is requested and the date for which the appointment is scheduled (eAppendix Figure 1 [eAppendix available at]).

This study used data from 2008 to 2014, with 2008 being a 1-year preintervention period prior to implementation. The study site was the Hospital Universitario del Tajo, a public general hospital in Madrid, Spain, which serves 100,000 people. The SOC provides specialist services for allergies, anesthesiology and perioperative medicine, cardiology, dermatology, endocrinology, gastroenterology and hepatology, internal medicine, general surgery, hematology, laboratory medicine and pathology, nephrology, neurology, obstetrics and gynecology, medical oncology, ophthalmology, orthopedic surgery, otorhinolaryngology, physical medicine and rehabilitation, pulmonary medicine, radiology, rheumatology, specialized pediatric and adolescent medicine, and urology. Patient services at the SOC are funded by the Spanish National Health Service (NHS). Like many other European NHS programs, the Spanish NHS has a service portfolio defined by the healthcare authorities. There is no patient co-payment except for a partial amount required for the purchase of medications. Similar to other NHS programs, patients need their PCP’s referral to have access to specialized care. Hospitals are required to respond to specialist consultation requests within a maximum period of 30 days; otherwise, they are penalized. Furthermore, patients can freely visit any other medical center if the referral process takes longer than 30 days.

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