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    Otis Lewis
    Otis Lewis, MHA, CHFP, FACMPE

    Life can be viewed as one long process, our daily actions and encounters as steps toward or components of a larger process, with each step taking us closer to an overall goal. To reach the desired goal, insight into the actions taken within a process is necessary, as the output is a key driver of the input.

    Process standardization consists of the improvement of operational performance, quality and cost reduction. These facets are attainable through error reduction, effective communication, routine training, and educational opportunities, along with being flexible, adaptive, and dynamic. Establishing processes requires adoption of a clearly defined set of rules that set expectations for work performance.

    In healthcare, many job functions consist of core duties based on the employee’s title; for example, a registrar is expected to register patients. As a result, a standard process, workflow, or process map must be implemented and used as the foundation for training, evaluation, and accountability. This is a mission-critical function for the registrar — all mission-critical functions must be standardized.

    Standardization allows for a “plug-and-play” model of operations. The outcomes or expectations of a task should not be subject to the person who is completing it. Unintended outcomes are three times more likely when standardized processes are not followed.1 Uniformity yields specific results; when executed properly, this will not vary from person to person.

    Environmental factors

    Elements outside the span of our control should be anticipated. Within the ambulatory setting, medical practices encounter late patients, inclement weather, employee sick calls and other external factors that impact the daily routine. Despite the influence these factors may contribute to performance and results, standard processes account for these adverse circumstances to drive the preferred goal. Void of a process, results will be predicated on environmental factors.

    Inclement weather often adversely impacts the show rate at a medical practice. Establishing a process to conduct personal reminder calls 24 hours prior to a scheduled appointment has resulted in improved no-show rates. Studies of healthcare organizations such as the Robert Wood Johnson University Medical Group, the VA Medical Center and others, have shown up to a 50% decrease in no-show rates because of reminder calls.2 Based on these studies, a practice identifying a process to reduce the no-show rate due to weather will positively impact access, revenue, and the patient experience.

    Controlling the process

    Simply establishing and fulfilling a standard process does not provide consistent assurance of the desired outcome. However, when standardization is operationally absent, results will always vary, from person to person.

    Standardized processes must be clearly expressed in the form of process mapping, policy/procedures, training manuals, tip sheets and various forms of training media. These are “living, breathing” documents, sharing a common life cycle. Through identification of an existing process that requires improvements or a new strategic goal prompting creation of a process — from inception and training to implementation — these processes must be continuously reviewed. Once a process is defined, it can be measured; once measured, it can be improved. A cyclical procedure requires routine review, revisions and phases of application.

    Development of work standards facilitates training new staff and continued training of existing staff to maintain results. Each process must be expressly drafted, clearly outlining all required steps, person(s) responsible for completing each step and a champion who will take ownership of workflow implementation. A climate of autonomy and accountability will be fostered, eventually resulting in reduction of direct oversight, alleviating undue stress and burdens on management staff. Work stress affects more than 50% of all working people, resulting in negative health outcomes.3 There is a direct correlation between standard processes and the impact on stress levels for employees.

    Process standardization, or decreasing process variation, is an essential component of Lean methodology.4 The ability to reduce alternative methods to complete a process results in improved quality and cost efficiency. Today, U.S. healthcare expenditures exceed $3 trillion, with an estimated $1.2 trillion attributed to medical waste and rework. With the Affordable Care Act (ACA) requiring a $196-billion annual reduction in federal healthcare spending,5 organizations have adopted Lean operation principles. Pioneered by Taiicho Ohno, an industrial engineer for automobile manufacturer Toyota, Lean manufacturing focused on continuous learning with the intention of reducing operational inefficiencies and the elimination of waste. A fundamental tenet of Ohno’s Toyota Production System infers improvement is not possible unless a standard is enforced. Healthcare organizations have adopted this methodology to improve the delivery of care with maximum efficiency and cost effectiveness.

    Waste is eliminated when an organization develops a culture dedicated to continuous process improvement. Employees adhere to established steps, with a foundation in evidence-based practices established through implementation of PDSAs (plan-do-study-act) to identify elements that augment processes.

    The physician stake

    Founded in 1989, the Agency for Healthcare Research and Quality’s mission is to conduct research and produce evidence to improve the efficiency and quality of healthcare delivery. In the development of clinical guidelines, the goal is to define the appropriate level of care to be provided to patients diagnosed with comparable conditions and levels of disease, with similar demographics.6 A “best practice” was developed to treat a certain condition, as it is the most efficient and effective. There should be little to no deviation from this standard approach to medical treatments as the probability of achieving the anticipated and desired outcome is significant. Studies have proven patients benefit from more favorable health outcomes when best practices of care are applied consistently. This has been demonstrated to improve, but not be limited to mortality and morbidity rates, infections, readmissions and adverse drug events.7

    Physicians and administrative support staff spend at least 23 hours annually, per physician, completing credentialing forms. Developing a standardized national credentialing system, spanning public and private sectors, can potentially result in $1 billion in cost savings for healthcare expenditures.8 These types of radical reforms equate to time saved by the physician, which should translate to increased clinical time with patients, a sentiment shared by many physicians as a direct contribution to professional satisfaction and retention.

    Studies have shown 54% of physicians reported at least one symptom of burnout, twice the rate of non-physician employees in the nation. This burnout correlates to negative clinical outcomes for the patients they serve and the inability to meet targeted productivity outcomes, costing the healthcare system $4.6 billion annually or approximately $7,600 per employed physician.9

    Physicians are a primary stakeholder in the implementation and maintenance of standardized processes. Belief in and practice of these processes result in an optimal patient and physician experience, while financially benefiting the healthcare system.

    Case study

    Montefiore Medical Group (MMG), the primary care network for Montefiore Medical Center, is an ambulatory group of 20 practices providing adult, pediatric and specialty care to patients throughout the Bronx and Westchester County in New York.

    The COVID-19 pandemic’s impact devastated the nation, but for a period in 2020, NYC became the epicenter of the pandemic, with the Bronx holding the highest positivity rate among the boroughs.10 The shift in delivery of education, social interactions and extensive durations of isolation significantly impacted adolescents, resulting in heighted senses of loneliness, distress and anger — causing an increase in negative psychological outcomes.11 MMG holds a title of distinction as recognized by the National Committee for Quality Assurance for its Behavioral Health Integration Program (BHIP). This program provides behavioral health services to adult and pediatric patients provided by licensed social workers, psychologists and psychiatrists.

    The MMG Pediatric Psychology Department provides needed therapeutic care to the patients within the community. To ensure timely access to care following a referral from the patient’s primary care physician (PCP), a standardized workflow was adopted. Working closely during the development phase with primary stakeholders, including operational and medical leadership, in addition to consulting with the clerical associates responsible for scheduling the referral, six of the 20 MMG practices participated in a pilot to ensure patients received an appointment prior to exiting the practice following the PCP visit or within 48 hours of the referral creation date.

    This is accomplished by providing clear instructions for the provider to add the referral to the patient record and document the reason for follow up within the EHR. The patient is directed to the front desk to complete the checkout process; at this time the patient is scheduled for an intake with the pediatric psychologist. In the event the checkout process is not completed, an assigned associate manages the referral work queue. The assigned associate reviews the work queue daily, focused on identifying outstanding referrals to pediatric psychology. Patients referred to this service are contacted within 48 hours of the referral date and promptly scheduled for an intake appointment.

    Within two months of go-live, the pilot practices encountered a significant increase in referral follow-ups, defined as:

    1. A completed visit with a behavioral health provider; or
    2. Documentation of outreach to a referred patient to schedule an appointment.

    Figure 1. Referral follow-up in pediatric psychologyFollow-up on referrals to pediatric psychology increased by 30% from the January-May period to June and July. Implementation of this process afforded additional capacity for resources to support the control practices, resulting in positive (although unintended) results. The overall average for all practices (pilot and control) increased in June and July (see Figure 1). Lead time from referral creation date to appointment made date (see Figure 2) decreased from 25 days to three days, an 88% improvement.

    Figure 2. Lead time from referral creation date to appointment made dateThis pilot, within early stages, quickly demonstrated a proof of concept. Establishing a standard process through the involvement of primary stakeholders, clear communication and explanation of the benefits results in a positive patient experience with the goal to improve physical and mental health outcomes.


    Whether your role is a registrar conducting confirmation calls or patient check-in, a manager overseeing operations of an inpatient or ambulatory facility, a nurse or physician directly responsible for the outcomes of the patients you serve, or if you are a patient seeking routine care or having an acute occurrence, standardized processes will enhance your experience. Through direct training, accountability, resource availability and performance improvement, standardization positively impacts the operations and outcomes of healthcare in the United States and beyond. Manage the process, manage the results.


    1. Karr T. “Determining What Healthcare Should Be.” Industrial Engineer, Sept. 2011.
    2. Woods R. “The Effectiveness of Reminder Phone Calls on Reducing No-Show Rates in Ambulatory Care.” Nursing Economics, Sept.-Oct. 2011.
    3. Zhou H, Jin M, Ma Q. “Remedy for Work Stress: The Impact and Mechanism of Ethical Leadership.” Central European Journal of Public Health, 2015.
    4. Upshaw-Owens M. “Standardization: A Concept Analysis.” Med Surg Nursing, March-April 2019.
    5. Langell J. “Evidence-based medicine: A data-driven approach to lean healthcare operations.” International Journal of Healthcare Management, 2021.
    6. Lefton R. “Reducing Variation in Healthcare Delivery.” Healthcare Financial Management, July 2008.
    7. Ibid.
    8. Cutler D, Wikler E, Basch P. “Reducing Administrative Costs and Improving the Health Care System.” The New England Journal of Medicine, Nov. 2012.
    9. Han S, Shanafelt T, Sinsky C, Awad K, Dyrbye L, Fiscus L, Trockel M, Goh J. “Estimating the Attributable Cost of Physician Burnout in the United States.” American College of Physicians, 2019.
    10. Office of the New York State Comptroller. “Recent Trends and Impact of COVID-19 in the Bronx.” June 2021. Available from:
    11. Elharake A, Akbar F, Malika A, Gilliam W, Omer S. “Mental Health Impact of COVID-19 among Children and College Students: A Systematic Review.” Child Psychiatry & Human Development, Jan. 2022.

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