Final Report Julia Irwin Sarah Yang John Zwick Will Marchionni Team 9 Introduction Clients Dr Melissa Pynnonen Associate Professor of Otolaryngology Ms Stephanie Renwick Administrative Manager Associat ID: 756772
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Current State Assessment of Clinic Flow and Patient Scheduling Final Report
Julia Irwin
|
Sarah Yang
|
John Zwick
| Will
Marchionni
Team 9Slide2
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-IntermediateSlide3
General Patient Flow
Check in at
Front Desk
Vitals, Tests and Patient InterviewProvider ConsultationCheckout
Schedule AppointmentSlide4
Current Process Flow has Several Issues
Patient encounter cycle time is too long
Discrepancy
between scheduled and actual timeAreas of non-value added timeSlide5
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 processSlide6
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 flowSlide7
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 TeamSlide8
MethodsObservations
Literature Search
MiChart Data
InterviewsTime StudiesSlide9
ObservationsBetween January 17th, 2017 and February 24th, 2017
2 hour long observations
Observed:
Clinic operations and flowInteractions between patients and clinic staffWitnessed known bottlenecksSlide10
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 productivitySlide11
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 AMSlide12
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 DataSlide13
Scheduled Appointment Lengths - RV
RV on Average
15
RV Post op on Average15Test/Treatment30Procedure15Injection15RV Extended30Slide14
Scheduled Appointment Lengths - NP
NP
30
Preoperative H&P30NP Ears30NP Head & Neck30NP Balance Disorder45NP Ears Second Opinion30NP Pediatrics30NP Sinus30Slide15
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, 2017Slide16
MiChart Data
2,468 patient records from October 1, 2016 to January 31, 2017
662 patient records from February 27 to March 24, 2017Slide17
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 clinicSlide18
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 scribeCommentsSlide19
Stratified by:Visit typeScribe vs. no scribe
Physicians vs. physicians with PAs
Analyzed to identify:
Wait timeEncounter timeEffect of scribesEffect of PAsTime StudiesSlide20
Encounter Cycle Time BreakdownSlide21
Current State: New Patient Value Stream
Collection Dates:
Feb. 27 - Mar. 24, 2017
Source:Time Study DataSlide22
Current State: Return Visit Value Stream
Collection Dates:
Feb. 27 - Mar. 24, 2017
Source:Time Study Data Slide23
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 DataSlide24
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 = 492Slide25
Source: Time Study Data 2/27/17 - 3/24/17, N = 492Slide26
Source: Time Study Data 2/27/17 - 3/24/17, N = 492Slide27
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 = 492Slide28
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 increaseSlide29
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 = 43Slide30
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 rateSlide31
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 bookingSlide32
Recommendations - In Clinic
Morning Huddles
Buffer Room
Flag SystemSlide33
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 normalSlide34
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 firstSlide35
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 downSlide36
Recommendations - Call Center
Clinic Staff Schedule RV
Review Schedule Guideline
Create Realistic Scheduling GridSlide37
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 CenterSlide38
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 followSlide39
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 gridsSlide40
Recommendations - Further Scribe Study
Scribe data was inconclusive
Increased consultation time
Decreased charting timeScribes’ effectiveness should be studied further to determine their valueSlide41
Questions?Slide42
ExtraSource: MiChart Data, Collection Time: October 1, 2016 - January 31, 2017 and February 27 - March 24, 2017 n = 2,978 Slide43
Extra
Source: MiChart Data, Collection Time: October 1, 2016 - January 31, 2017 and February 27 - March 24, 2017 n = 2,978 Slide44
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