FY’02 ASA Presentation Occupational Medical Service, DS “Medical Care in a Timely Fashion”

1. FY’02 ASA Presentation Occupational Medical Service, DS“Medical Care in a Timely Fashion” Presented by:James Schmitt Team Members: Alpha Bailey James Burger Robert Ostrowski (Team Leader) James Schmitt Office of Research Services, NIH 18 November 2002

2. Table of Contents Introduction ……………. …………………………………………………. ASA Template …………………………….……………………………….. Customer Perspective……………………….……………………………… Customer Segmentation …………………….………………………………….. Customer Satisfaction……………………….………………………………….. Internal Business Process Perspective……………………………………… Process Map……………….…………………………………………………….. Conclusions from Discrete Services Deployment Flowcharts…………………… Process Measures………………………………………………………………… Learning and Growth Perspective…………………………………………… Conclusions from Turnover, Sick Leave, Awards, EEO/ER/ADR Data………… Analysis of Readiness Conclusions……………………………………………… Financial Perspective………………………………………………………… Unit Cost………………………………………………………………………….. Asset Utilization………………………………………………………………….. Conclusions and Recommendations…………………………………………. Conclusions from FY02 ASA..…………………………………………………… Recommendations…………………………………………………………………

3. Introduction

4. Occupational Medical Service (OMS) The OMS mission is to provide: • Work-related medical care • Preplacement medical evaluations • Occupational injuries and illnesses • Surveillance for health hazards at the worksite • Return to work evaluations • Care for personal medical emergencies • Health promotion activities

5. OMS Quality Improvement (QI) Efforts • 1991 - QI training is part of OMS orientation • 1992 - Each employee completes a QI project • 1992 - Cross-functional QI Teams formed • Customer satisfaction surveys • Computer application development • Review of the preplacement evaluation process • Review of clinic hours • Review of services available for occupational injuries • 1992 - External audit of the OMS QI program

6. OMS QI Efforts (cont.) • Customer Satisfaction Surveys prior to the ASA • External customer (employee) surveys • April 1995, November 1995, April 1996, May 1997, April 1999, March 2001 • External customer (supervisor) survey • October 1997 • Internal customer (OMS) surveys • August 1995, June 1996

7. ASA Template

10. “Care in a Timely Fashion” • Our team elected to examine more closely the timeliness of clinical care provided in the OMS Building 10 clinic for: • Routine work-related visits (both with and without appointments) • Personal medial emergencies • Personal urgent medical problems

11. Customer PerspectiveCustomer Segmentation

13. Customer Segmentation (cont.) • NIH occupational injury/illness data FY’02 • 23% Clinical Center employees • 18% Office of the Director employees • 7% DES • 6% ORS, non-DES • 5% OD, non-ORS • 17% Contractors • 11% NCI • 6% NIAID • 31% Other 22 ICs and the FDA

14. Customer PerspectiveCustomer Satisfaction

15. External Customer Survey • Is based upon the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) criteria for outpatient medical care • Employees’ top 5 priorities • Competent, safe medical care • Care in a timely fashion • Effective communications with staff • Clean, organized environment • Respect and caring

17. Customer Satisfaction (cont.) • Percent of OMS customers that ‘agreed’ or ‘strongly agreed’ that medical care was provided in a timely fashion (wait < 15 min.) • 1995, April 96.5 % of 361 • 1995, November 97.5% of 332 • 1996, April not surveyed • 1997, May not surveyed • 1999, April 99.4% of 314 • 2001, February 98.0% of 100

18. Internal BusinessProcess Perspective

19. Block Diagram of Service Group • Service Group and discrete service are one and the same: • A more meaningful high-level view is provided on the next page

21. Deployment Flowchart

23. Conclusions from OMS Discrete Services Deployment Flowchart • The OMS triage nurse plays a pivotal role in the operation of the Building 10 clinic. • The triage nurse is responsible for determining: • whether the request for service falls within OMS’ scope of services, • the relative urgency of the visit, and • the level of care required.

24. Process Measures

26. Visits With Appointments • Prior surveys set 15 minutes as a reasonable time a customer with an appointment may wait to be evaluated by an OMS provider. • This survey redefined a reasonable wait as 5 minutes. • The average wait in this survey was 7.5 minutes • The average was skewed by the time taken for preplacement medical evaluations and related laboratory visits.

28. Visits Without AppointmentsTriage • The expected wait to be evaluated by the OMS triage nurse is less than 1 minute for emergencies and 5 minutes or less for all other visits. • The actual waiting time to be evaluated by the triage nurse was 0 minutes for emergencies and 5 minutes for all other visits.

30. Visits Without AppointmentsNext Available Appointment • Ideally, a visitor with a medical emergency will receive an appointment within 2 minutes. • The median wait time for an appointment was 9 minutes. The most frequent reported wait was 0 minutes. • Ideally, a visitor with an urgent medical problem will receive an appointment within an hour. • The median wait time for an appointment was 20 minutes.

31. Visits Without AppointmentsNext Available Appointment (cont.) • Ideally, a visitor with a routine medical need will be offered an appointment within 3 hours. • The median wait time for an appointment was 20 minutes.

32. Learning and Growth Perspective

33. Conclusions from Awards Data • Annual bonus program for OMS employees. • Awards based upon the employee’s • Performance and • Significant contributions that significantly • enhanced the quality of OMS services, or • made OMS a more enjoyable worksite • 100% received a performance-based bonus. • 30% received a bonus for a significant contribution.

34. Analysis of Readiness Conclusions What is the correct mix of skills and abilities to work in OMS? • Customer service mentality - “people skills” • Communication skills • Common sense • Commitment to being part of a team • Technical skills (e.g., clinical competency, experience with OWCP, etc.,)

35. Analysis of Readiness Conclusions • Implications of the wrong mix of skills, abilities or tools to carry out OMS’ mission? • Longer waits, less efficient, and possibly, less competent care. • Compromise OMS’ role in providing a safe and healthy work environment. • In many instances this may only be an inconvenience. However, in some situations workers’ lives may be jeopardized (i.e., care for chest pain, asthma, anaphylaxis, exposures to HIV-1 and herpes B virus.)

36. Financial Perspective

37. Unit Cost Measures • The units for OMS are the number of patient visits recorded. • Consultations, medical reviews, presentations, and other services that do not involve direct patient care were not included. • Costs for the OMS contract include the following: • Contract staff costs • Computer application developer • NIH personnel costs • IT expenses • Supplies and materials

38. Unit Cost Measures (cont.)

41. Asset Utilization Measures • OMS has 28.48 FTE • Asset utilization = 90% • The 10% shortfall is the anticipated consequence of staffing OMS so that there are always clinicians available to attend to medical emergencies and requests for urgent care • This percentage would be higher, if the OMS triage nurses routinely declined employee requests for immediate care for non-emergent medical complaints

42. Conclusions and Recommendations

43. Conclusions from ASA FY02 • OMS has a well established QI program. • Customer satisfaction for each of their 5 top priorities has been exceptionally high for the last 7 years. • The increased average wait for appointments was largely due to the time required to construct a clinical record for workers receiving preplacement exams and language barriers. • The triage system is working.

44. Conclusions from ASA FY02 (cont.) • The OMS triage nurse routinely accommodates employees’ desire to be seen immediately for routine services. • The mechanism for capturing “appointment time” for emergency medical care in this study was faulty. • OMS staff increasingly rely on a customized software application for the operation of the Building 10 clinic.

45. Recommendations • Repeat the study within the next two years and broaden the types of visits examined (e.g., return visits for occupational injuries, international travel, surveillance program visits). • Request that individuals receiving a preplacement medical evaluation report to OMS 20 minutes before their scheduled evaluation.