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Decreasing PatientThroughput Time andIncreasing OperationalEfficiency in an OutpatientFamily Medicine ClinicMATIANA GONZALEZ-WRIGHT, EDD, MEDJANUARY – JUNE 20141

TeamMembersCSE Team MemberPGY3PGY2PGY1Matiana Gonzalez-Wright, EdDEdurardo Candanosa, M.D.Gabriela Walsman, M.D.Vladimir Semilla, M.D.Cesar Garza, M.D.Isabel Reyna, M.D.Salvador Elizarraras, M.D.Pamela Venegas, M.D.Heidi Pareja, M.D.Mylien Huynh, M.D.Sr. Research AssistantYusef Mohamed, ALMOffice ManagerMarivel BarreraFront OfficeVerificationMedical AssistantLaboratoryCashierLetty MunozSylvia HernandezMarisa TrevinoRonnie MendozaGracie GarzaPete MartinezMaryanne Vargas2

Background Patient throughput optimization is an essential managementstrategy Cycling patients efficiently and effectively through a clinic assures efficient use of resources enhances patient access improves service Understanding throughput requires a systems perspectiveThe Chartris Group. (2007, Fall). White Paper. Retrieved March 31, 2014, fromhttp://www.chartis.com/files/pdfs/chartis group dfWillis, D (2005, April). Making every minute count: Tools to improve office efficiency. Family Practice Management, 12(4), 61-6.3

What We Are Trying to Accomplish?The aim of the project is to decrease total patient visittime (patient sign to check out) at the McAllen FamilyMedicine Residency Clinic by 60%, with the goal of 60min. and no more than 90 min. by December 2014.4

What is the problem? Patients, physicians and clinic staff have complained that patients arewaiting too long for their visit Physicians commented that they are ready to see a patient at 8:30 butwon’t see one until 10 am Patient Satisfaction survey comments Waiting always more than an hourDid not complete, left after 82 minTold by phone did not need appointment, to come in before 10AMLeft without being seenMinimize the paperwork; Marvin Baker patient since inception of this clinic!!!!!!!5

Understanding the ProblemInterdepartmental interdisciplinary team meetings Clinic administrative staff, physician faculty and residents, andnurses Brainstorming Process Map Cause and Effect /Fishbone Diagram6

Process Analysis – Process MapAttendingis asked tochoose aphysicianpatientwill seePhysicianassignmentsheet madefor patientAssignmentsheet is givento nurse toassign aphysicianForm is takenback to thefront deskInformationis enteredinto Cernerand SMS byfront staffEstablishedwalk-inNurseAssignsphysicianto patientMA reviewspatient info labs, meds,etcMDdocumentsvisit inCernerSchedulerschedules afollow upappointmentPatientSigns InPatient hasinsurancePatient mayneed PCPchangePatient goesto cashierfor copayPatient doesnot haveinsurancePatientrefered tosocial workerfor potentialcoveragePatientwaits to seeMD or visit isrescheduledPatientWaits to becalled byMAMA checksschedule andlist of patientsready to beseenMA callspatient inand checksvitalsMA putspatient inroom andinforms MDMD entersroom to seepatientMD informsMA thatvisit iscompleteMDcompletesvisitPatient takespaperwork tocashier/schedulerVerifyinsuranceWalk-inPrivate paypatients paybillIs patientOB?YesNOMA goesback in tosee patientNew walk-inPaperworkgiven topatientPatient returnscompletedpaperworkInformationis enteredinto SMS andEMD7

Process Analysis – Process MapMA reviewspatient info labs, meds,etcPatientSigns InScheduledPatient hasinsurancePatient mayneed PCPchangePatient goesto cashierfor copayPatient doesnot haveinsurancePatientrefered tosocial workerfor potentialcoveragePatientwaits to seeMD or visit isrescheduledPatientWaits to becalled byMAMA checksschedule andlist of patientsready to beseenMA callspatient inand checksvitalsMA putspatient inroom andinforms MDMD entersroom to seepatientMDdocumentsvisit inCernerSchedulerschedules afollow upappointmentMD informsMA thatvisit iscompleteMDcompletesvisitPatient takespaperwork tocashier/schedulerVerifyinsurancePrivate paypatients paybillIs patientOB?YesPaperworkgiven topatientPatient returnscompletedpaperworkInformationis enteredinto SMS andEMDMA goes back in to seepatient8

Process Analysis – Fishbone DiagramCommunicationLack of communicationPatient phone callsPharmacy CallsTrainingNumber of staff at front deskNumber of MasAttentiveness of MATaking or not taking vital signsStaffResidents & FacultyNumber of faculty available in clinicResidents as role modelsMultiple consults w/o document sharingFamiliarity with EMRMDs eating at nursing stationAbsent or late MDTextingNumber of patients seen per dayScheduled vs. walk-inAttitudeTimelinessMultiple Co-morbiditiesCompleting demographic sheetPatient educationFirst time patientPatientsMethodsProcedure schedulingInsurance izationPrice of service (change in pricing)Medications not in chartVolume in the labDouble chargesDouble registrationLabs not in fileAssign walk-in to resident or attendingRegistration process3 systemsAvailability of internetSMSPrinter not workingCerner trainingMachinesTime of dayDay of weekMeasurementEnvironmnentRooms AvailablePatientThroughputBP monitor not workingTrainingMaterials9

Baseline StatusRetrospective chart review (EMR)Stratified random sampleFebruary 11 to 28, 20145 am & 5 pm visits, M-F (n 119)Both genders, all ages and who had a physician visitCycle time measurement was performed to help reveal bottlenecks andwasteStatistical analysis using Excel10

Baseline Data Collection ToolMFPRC - Patient Throughput Data Collection ToolDate:Pt. Name:Physician Name:Time Intervals:TimeSign InCheck-inSeen by NurseCheck-outPatient Information (for completion by QI data collector)ScheduledAppointment time:Walk-inNew PatientPrivate PayEstablished PatientMedicareMedicaidFollow-upInsuranceLabMD Visit11

Baseline Data Collection SOPPatient Throughput: Chart Audit Form SOPOpen Cerner PM to access patient schedule1. Go to assigned date and randomly select 5 morning and 5 afternoon patients for each day, makingsure to only select patients that were fully checked out and were not here for just labs2. The name, MRN, physician, and insurance can recorded before selecting patient name3. After clicking on patient name, go to ‘Past Appointments’ tab, deselecting filters box ifappointment does not appear4. Right-click on appointment with physician as Resource (not lab), and select ‘Display AppointmentHistory’5. Select ‘Action History Details’ to record Check-in, Seen by Nurse, and Check-out times6. Vitals by Nurse time is the same as time of Chief Complaint on doctor’s note from PowerChart7. From PowerChart you can see whether patient is New/Established, Follow-Up/MD(initial visit)12

Decision MakingBaseline Data2/11 - 2/28; n 578 patients (excluding lab only)

No Show vs. Walk-in vs. Scheduled

Scheduled vs. Walk-In

Payment Type

Baseline PerformanceProcess Capability Report for Baseline Throughput TimeProcess DataLSL*Target60USL90Sample Mean 151.05Sample 0300350400Time (min)17

Baseline PerformanceI-MR Chart of Baseline11Individual Value300UCL 267.5200X 151.11000LCL 34.611529431Moving Range20015015771Observation859911312711UCL 143.010050MR 43.818

Baseline PerformanceMFMRP Clinic ThroughputTarget: 60 minUSL: 90 minn 140Yy1y2y3Clinic Sign-in to Check-outSign-in to Admission/Check-inAdmission/Check-in to Nurse receives patientNurse receives patient to Check-outBaselineTAT (min)MeanStd. Dev.151.143.44823.329.420.573.738.119

Baseline PerformanceData Collection Period2/11/14- 2/28/14n 140BASELINEMood's MedianY Patient Throughput nceP-ValueStatisticallySignificantDifferenceHo: There is no difference in throughput time by day ofweek0.301NO0.239NOHo: There is no difference in throughput time by time ofday (morning/ afternoon)0.310NO0.009YESHo: There is no difference in throughput time by patientstatus (established/new)0.353NO0.114NOHo: There is no difference in throughput time byinsurance class (Medicaid, Medicare, Hidalgo CountyIndigent, Commercial Insurance, & Private Pay)0.259NO0.264NOHo: There is no difference in throughput time by visit type(scheduled/ walk-in)0.314NO0.922NOHo: There is no difference in throughput time by visit type(initial/follow-up)1.000NO0.691NO20

Time of DayTest for Equal Variances: Y: Baseline Total Throughput Time vs Morn/AftrMultiple comparison intervals for the standard deviation, α 0.05Multiple ComparisonsP-Value0.023P-Value0.009Levene’s TestMorn/Aftram3035404550556065If intervals do not overlap, the corresponding stdevs are significantly different.21

Time of Dayn 140n 70n 70

Decision MakingAttendingis asked tochoose aphysicianpatientwill seePhysicianassignmentsheet madefor patientAssignmentsheet is givento nurse toassign aphysicianForm is takenback to thefront deskInformationis enteredinto Cernerand SMS byfront staffEstablishedwalk-inNurseAssignsphysicianto patientMA reviewspatient info labs, meds,etcMDdocumentsvisit inCernerSchedulerschedules afollow upappointmentPatientSigns InPatient hasinsurancePatient mayneed PCPchangePatient goesto cashierfor copayPatient doesnot haveinsurancePatientrefered tosocial workerfor potentialcoveragePatientwaits to seeMD or visit isrescheduledPatientWaits to becalled byMAMA checksschedule andlist of patientsready to beseenMA callspatient inand checksvitalsMA putspatient inroom andinforms MDMD entersroom to seepatientMD informsMA thatvisit iscompleteMDcompletesvisitPatient takespaperwork tocashier/schedulerVerifyinsuranceWalk-inPrivate paypatients paybillIs patientOB?YesNOMA goesback in tosee patientNew walk-inPaperworkgiven topatientPatient returnscompletedpaperworkInformationis enteredinto SMS andEMDRank Ordering23

Improvement EffortsPATIENT ADMITTING/REGISTRATIONBEFOREStaff members assumed specific tasksAFTERStaff were cross-trained to schedule appointments,verify benefits and enter patient information intothe EMRStaff had offices througout the clinicStaff were moved to front office so that they areeasily accessible/availableGreeter would sign in patient then be responsible foradmitting and registering the patientGreeter now signs in patient, gives patientpaperwork and asks patient if he/she requiresassistanceFront office staff (2-3) were responsible for entering all Completed paperwork it is handed to the first staffregistration into EMRmember (6) available to enter into the EMR24

Improvement EffortsSCHEDULING25

Improvement Efforts26

Improvement EffortsSCHEDULINGBEFOREScheduled and walk-in patients waitedappoximately the same time to be seen.Patients learned it was easier to come in as awalk-inAFTERScheduled patients are prioritized; separatetracking sheets help identify scheduled vs. walkin patientsPatients who had been seen were asked to callthe clinic to schedule a follow-up appointmentGoal is to make physician schedule available atleast 3 months outPatients who called the clinic were told to come Patients who call the clinic are given anin before 3pm if they wanted to be seen thatappointment, including same day appointmentsdayScheduler placed reminder calls the day before Automated appointment reminder calls nowscheduled appointmentsoccur in the evening before 6- 8 pm two daysbefore an appointmentNo-shows did not receive a follow-up call toreschedulePatient no-shows and cancelled appointmentsare rescheduled27

Pilot 1 Improvements: February 28 - March 10, 2014 Similar data collection methodology Retrospective chart review (EMR) Stratified random sampleMarch 11-24, 20145 am & 5 pm visits, M-F (n 119)Both genders, all ages and who had a physician visit28

Process Capability Report for Baseline Throughput TimePilot 1 - ResultsMETRICSBASELINEPILOT Maximum348minutes389minutesProcess DataLSL*Target60USL90Sample Mean 151.05Sample 0300350400Time (min)Process Capability Report for Pilot 1 Throughput TimeProcess DataLSL*Target60USL90Sample Mean 136.731Sample N119Shape2.83165Scale152.589Target USLHypothesis TestingP-Value(Baselineto Pilot 1)Levene’s Testp 0.920Mann Whitneyp 0.0050100150200250Time (min)30035040029