title: Optimizing value utilizing Toyota Kata methodology in a multidisciplinary clinic.
abstract: BACKGROUND
  Value in healthcare is measured in terms of patient outcomes achieved per dollar expended. Outcomes and cost must be measured at the patient level to optimize value. Multidisciplinary clinics have been shown to be effective in providing coordinated and comprehensive care with improved outcomes, yet tend to have higher cost than typical clinics. We sought to lower individual patient cost and optimize value in a pediatric multidisciplinary reconstructive pelvic medicine (RPM) clinic.
  
  
  METHODS
  The RPM clinic is a multidisciplinary clinic that takes care of patients with anomalies of the pelvic organs. The specialties involved include Urology, General Surgery, Gynecology, and Gastroenterology/Motility. From May 2012 to November 2014 we performed time-driven activity-based costing (TDABC) analysis by measuring provider time for each step in the patient flow. Using observed time and the estimated hourly cost of each of the providers we calculated the final cost at the individual patient level, targeting clinic preparation. We utilized Toyota Kata methodology to enhance operational efficiency in an effort to optimize value. Variables measured included cost, time to perform a task, number of patients seen in clinic, percent value-added time (VAT) to patients (face to face time) and family experience scores (FES).
  
  
  RESULTS
  At the beginning of the study period, clinic costs were $619 per patient. We reduced conference time from 6 min/patient to 1 min per patient, physician preparation time from 8 min to 6 min and increased Medical Assistant (MA) preparation time from 9.5 min to 20 min, achieving a cost reduction of 41% to $366 per patient. Continued improvements further reduced the MA preparation time to 14 min and the MD preparation time to 5 min with a further cost reduction to $194 (69%) (Figure). During this study period, we increased the number of appointments per clinic. We demonstrated sustained improvement in FES with regards to the families overall experience with their providers. Value added time was increased from 60% to 78% but this was not significant.
  
  
  CONCLUSIONS
  Time-based cost analysis effectively measures individualized patient cost. We achieved a 69% reduction in clinic preparation costs. Despite this reduction in costs, we were able to maintain VAT and sustain improvements in family experience. In caring for complex patients, lean management methodology enables optimization of value in a multidisciplinary clinic.
authors.affiliation: Division of Urology, Seattle Children's Hospital, Seattle, WA, USA. Electronic address: Paul.merguerian@seattlechildrens.org.
authors.forename: Paul A
authors.initials: PA
authors.lastname: Merguerian
authors.affiliation: Division of Urology, Seattle Children's Hospital, Seattle, WA, USA.
authors.forename: Richard
authors.initials: R
authors.lastname: Grady
authors.affiliation: Division of General Surgery, Seattle Children's Hospital, Seattle, WA, USA.
authors.forename: John
authors.initials: J
authors.lastname: Waldhausen
authors.affiliation: Division of Urology, Seattle Children's Hospital, Seattle, WA, USA.
authors.forename: Arlene
authors.initials: A
authors.lastname: Libby
authors.affiliation: Division of Urology, Seattle Children's Hospital, Seattle, WA, USA.
authors.forename: Whitney
authors.initials: W
authors.lastname: Murphy
authors.affiliation: Division of Urology, Seattle Children's Hospital, Seattle, WA, USA.
authors.forename: Lilah
authors.initials: L
authors.lastname: Melzer
authors.affiliation: Division of General Surgery, Seattle Children's Hospital, Seattle, WA, USA.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Avansino
mesh_terms: D002648:Child; D003362:Cost-Benefit Analysis; D003695:Delivery of Health Care / Q000191:economics*; D017048:Health Care Costs / Q000639:trends*; D006801:Humans; D010342:Patient Acceptance of Health Care; D012189:Retrospective Studies; D014481:United States; D014564:Urogenital Abnormalities / Q000191:economics / Q000628:therapy*; D014572:Urology / Q000191:economics*
keywords: Cost; Quality improvement; Toyota Production Systems; Value