Current State Assessment of Clinic Flow and Patient Scheduling - PowerPoint Presentation

Current State Assessment of Clinic Flow and Patient Scheduling Final Report Julia Irwin | Sarah Yang | John Zwick | Will Marchionni Team 9

Introduction Clients Dr. Melissa Pynnonen Associate Professor of OtolaryngologyMs. Stephanie Renwick Administrative Manager Associate HealthcareCoordinatorMs. Mary Duck Industrial Engineer Expert, Lean Coach, Michigan Medicine IOE 481 Liaison Performance ImprovementMs. Olivia Detroyer Industrial Engineer-Intermediate

General Patient Flow Check in at Front Desk Vitals, Tests and Patient InterviewProvider ConsultationCheckout Schedule Appointment

Current Process Flow has Several Issues Patient encounter cycle time is too long Discrepancy between scheduled and actual timeAreas of non-value added time

Key Issues Providers’ schedules are underutilized Providers stated as low as 30% Patient wait time to get a new appointment slot appears too longSome longer than 2 weeksPatient encounter cycle time is too longSome longer than 1 hourPhysicians are completing tasks that are not part of their process

Objectives and Expected Impact Decrease p atient encounter cycle tim eMinimize non-value added steps in the current clinic flowDecrease patient wait time to 33% of their encounter cycle timeIncrease physicians’ utilizationIncrease efficiency of scheduling process and OTO’s care flow

Project Scope In scope: Scheduling process at the Call Center OTO clinic care flowOut of scope:Otolaryngology Clinic at the Taubman CenterImplementation of recommendations Will be completed by MDP Scheduling Team

MethodsObservations Literature Search MiChart Data InterviewsTime Studies

ObservationsBetween January 17th, 2017 and February 24th, 2017 2 hour long observations Observed: Clinic operations and flowInteractions between patients and clinic staffWitnessed known bottlenecks

Literature SearchAnalyzing Patient Flow and Process Waste at the Urology Clinic at the Livonia Center for Specialty Care Value Stream Mapping, Lean Principles Clinic Flow: Smoothing Clinic Schedule Reduces Additive Waste Reduction of additive waste & tardinessRelative Value Units (RVUs)Indicate the value of services and resources when providing different servicesTo calculate reimbursement for providers’ services and internal productivity

MiChart Data2,468 patient records from October 1, 2016 to January 31, 2017 662 patient records from February 27, 2017 to March 24, 2017 MRN DateTimeProviderTypeC/I TimeC/O TimeDeidentified1/31/171:15 PMDeidentifiedNP Sinus1:05 PM2:12 PMDeidentified1/27/178:45 AMDeidentifiedRV 8:28 AM 10:02 AM Deidentified 10/2/16 11:00 AM Deidentified NP General 10:44 AM 11:48 AM

Calculations:Encounter Cycle Time = Check-out Time - Check-in Time Time Early for Appointment A maximum of 10 minutes early was considered Compared to Time Study Sheets to fill in any missing areas MiChart Data

Scheduled Appointment Lengths - RV RV on Average 15 RV Post op on Average15Test/Treatment30Procedure15Injection15RV Extended30

Scheduled Appointment Lengths - NP NP 30 Preoperative H&P30NP Ears30NP Head & Neck30NP Balance Disorder45NP Ears Second Opinion30NP Pediatrics30NP Sinus30

MiChart Data Average = 51 Average = 60 2,468 patient records from October 1, 2016 to January 31, 2017662 patient records from February 27 to March 24, 2017

MiChart Data 2,468 patient records from October 1, 2016 to January 31, 2017 662 patient records from February 27 to March 24, 2017

Interviews Administrative Manager Provided big picture of clinic processes Call Center staff Provided patient scheduling processRecords ClerkShowed the process of receiving records before and during appointmentsPhysiciansIdentified communication errors, non-value added time and what led the clinic to be behind schedulePhysician AssistantsIdentified issues with the number of rooms assigned to PAs vs. Physicians in clinic

Time StudiesCollected 492 time study forms February 27th, 2017 to March 24th, 2017 Collected the following fields: Date and scheduled timeProviderVisit typeTime of each staff interactionScribe vs. no scribeComments

Stratified by:Visit typeScribe vs. no scribe Physicians vs. physicians with PAs Analyzed to identify: Wait timeEncounter timeEffect of scribesEffect of PAsTime Studies

Encounter Cycle Time Breakdown

Current State: New Patient Value Stream Collection Dates: Feb. 27 - Mar. 24, 2017 Source:Time Study Data

Current State: Return Visit Value Stream Collection Dates: Feb. 27 - Mar. 24, 2017 Source:Time Study Data

RV Encounter Cycle Time Longer than NP Encounter Cycle Time Significant Wait Times: Wait RoomFor ProviderCheckoutComparison:Longer RV Cycle TimeNP Wait Less for ProvidersNP Wait longer for CheckoutN = 384, Data Collection Period: February 27 - March 24, 2017Source: Time Study Data

Scribes Do Not Decrease Consultation Time or Wait Time Most likely due to communication between provider and scribe Interviews: providers often spend time making sure scribes note important information Observations: providers often spend time introducing scribes to patientsProviders spend time outside of OTO regardless of scribe useInterviews: providers spend ~10-15 hours/week without scribesInterviews: when using a scribe, providers spend ~6-7 hours per week reviewing scribe notesConsult Time Avg. (min)Total Wait Time Avg. (min)Scribe18.5 34.4No Scribe17.2 30.4Source: Time Study Data 2/27/17 - 3/24/17, N = 492

Source: Time Study Data 2/27/17 - 3/24/17, N = 492

Source: Time Study Data 2/27/17 - 3/24/17, N = 492

First Patient of the Day Waits to be Roomed, Seen, and Impacts the Rest of the Day First patient of the day has to wait on average 17.6 minutes before seeing a provider, 24.5 minutes including time with MA Physicians starting the day late will be behind schedule Wait Time in Waiting RoomMA TimeWait Time in Patient RoomConsult TimeCheck- Out Time10.2 minutes6.9 minutes7.4 minutes20.5 minutes2.5 minutesSource: Time Study Data 2/27/17 - 3/24/17, N = 492

Flag System not Standard Interviews provided the most insight into this practice Color codes not standard Inconsistencies in who uses the flagsMAs reported that all physicians use the flag system Most physicians reported rare use if at allPhysicians expect MAs to retrieve them when their patient is readyThis misunderstanding might cause average wait for providers to increase

Physician’s Assistants Often Wait for PhysiciansInterviews: PAs report that their schedules are pushed behind due to wait for Physicians Time Study Data: Average wait time for physicians = 5.3 minutesStandard deviation = 5.02 minutesSample size = 12Source: Time Study Data; Collection Date: 2/27/17 - 3/24/17; PAs w/ Physicians n = 12, PAs n = 43

Call Center Understaffed and Schedules Inconsistently Interviews: Call Center staff rarely consult scheduling guidelines given by providers Scheduling guidelines are complicated and lengthyResult: providers are scheduled with incorrect patient typesCall Center experiences a high turnover rate

Providers’ Grids Allow for Double Booking Appointment SlotsMiChart Data: Some providers have two or more patients scheduled for the same appointment slot Happens multiple times Many occurred at the first patient of the day Providers’ scheduling guidelines:Scheduling grids allow for overlapping appointments and double booking

Recommendations - In Clinic Morning Huddles Buffer Room Flag System

Introduce Morning Huddles at the Beginning of the WorkdayAllows physicians, PAs, MAs, and LPN to discuss schedule for the day and determine what will be needed of each member of the team during the day. Limitations: May need to come in earlier than normal

Introduce a Buffer RoomAllows PA to see next patient without waiting for the physician to complete consultation or wait for the room to be cleaned Keeps PA on schedule Limitations: The providers might need all rooms in order to get through all patientsSmooth transition may be difficult at first

Improve and Standardize Flag SystemKeep flag system Helpful information for MAs Improve and standardize flag system Make sure everyone uses the flags the same wayMAs should directly retrieve the physiciansLimitations:MA may need to track provider down

Recommendations - Call Center Clinic Staff Schedule RV Review Schedule Guideline Create Realistic Scheduling Grid

Clinic Staff Schedules RV PatientsClinic Checkout Staff should schedule RV patients instead of contacting the Call Center to do it Benefits: Lower call volume for the Call Center Patients get an appointment soonerFill more physicians’ schedulesLimitations:Uncomfortable scheduling all types of RV patientsIn which case, call the Call Center

Review Schedule GuidelineHave physicians review the scheduling guidelines that are given to the Call Center Re-evaluate guidelines, and perhaps simplify guidelines so scheduling guidelines can be more easily followed Limitations: Call Center may dismiss guidelines altogether even if they are simplified and easier to follow

Create a More Realistic Scheduling GridChange scheduling grids to prevent multiple booking of appointment slots Have MDP schedule planning team for OTO look further into this problem and create the new scheduling grids

Recommendations - Further Scribe Study Scribe data was inconclusive Increased consultation time Decreased charting timeScribes’ effectiveness should be studied further to determine their value

Questions?

ExtraSource: MiChart Data, Collection Time: October 1, 2016 - January 31, 2017 and February 27 - March 24, 2017 n = 2,978

Extra Source: MiChart Data, Collection Time: October 1, 2016 - January 31, 2017 and February 27 - March 24, 2017 n = 2,978

Otolaryngology (OTO) Provides surgery and treatment care for patients with diseases and disorders of the ear, nose, and throat (ENT), and related structures of the head and neck