Background: Patient Throughput

1. Assessing Patient Throughput at Kosair Children’s Hospital ClinicsCraig JohnsonUniversity of KentuckyMartin School of Public Policy and AdministrationMasters in Health AdministrationCapstone ProjectSpring 2008

2. Background: Patient Throughput • 67 million annual visits at hospital-based teaching ambulatory clinics (McCaig, 1997) • Teaching organizations = longer waits (Leddy et al., 2003) • Unorganized patient flow processes = increased wait times and decreased patient satisfaction (Roundeau, 1998) • Interruptions during a patient’s exam negatively impact workflow(Brixey et al., 2007)

3. Background: Patient Throughput • Up to 40% of outpatient time could be spent inefficient processes(Patel et al., 2002) • High patient no show rates = drained resources, hindered productivity, and loss revenues(Ginwala, 2004) • Significantly reduce resident physician learning opportunities (Guse et al., 2003) • Strategies to improve: • Mailed reminder cards (Croomer et al., 1987) • Automated telephone reminders (Almog et al., 2003) • Termination and charge policies (Ginwala, 2004) • Open access scheduling (Murray et al., 2000)

4. Project Purpose • Assess the clinic’s current throughput processes through direct observations and data collection AND • Assist clinic leadership with data analysis, industry benchmarking, and recommendations for improvement

5. Background: KCH Clinics • 5 outpatient clinics all operate in one suite • Neurology • Genitourinary (GU) • Dermatology • Ear, Nose, & Throat (ENT) • Surgery • Clinics rotate throughout the month, morning & afternoon clinics

6. Background: KCH Clinics • KCH employs a clinic staff which operates all 5 clinics • 2 Registered Nurses (RNs) • 3-4 Clinic Office Specialists • KCH does not directly employ the physician staff • University of Louisville

7. Background: Patient Population • Children ages 0 – 18 • Participants of medical assistance programs or self paying • Visits FY2007 4,038 FY2008 4,100

8. Methods • Patient Flow Analysis • Flowchart • Time Study • Process, Wait, & Face times • Patient Satisfaction Survey • Point of service technique • No Show Rates • Existing data • General Observations • General flow, communication, & traffic

9. Once RN exited exam room, noted time a clinician entered and exited the patient’s room All times a patient spent in exam room without clinician defined as wait time Foreign Element column used to track exam room interruptions Methods: Time Study Observation Form

10. Questions grouped into five categories: Appointment Scheduling Patient Registration Waiting Room Satisfaction Exam Room Satisfaction Wait times Methods: Patient Satisfaction Survey

11. Results: Patient Flow Analysis • Patients do not schedule their own appointments • Clinic currently waiting for online referral access • If physician is late, bottlenecks occur • Bottlenecks occur during chart breakdown process Is the call from PCP? Is the referral found? Resident reviews chart & enters exam room Is there anything to schedule?

12. Results: Time Study • Patients spent majority of time waiting • ENT: 64% • Derm: 74% • Necessary prep/exit time: • Registration = 7 min • Treatment = 1 min • Discharge = 2 min Total Cycle Time

13. Results: Time StudyWaiting Room • Industry standard acceptable time for Registration and Wait = <15 minutes(NACHRI Presentation Mattel Children’s Hospital, 2007) • KCH Clinic Average Registration & Wait using average values = 29 minutes • Median values = 26 minutes

14. Results: Time StudyWaiting Room

15. Results: Time StudyFace Time vs. Wait Time • Institute for Healthcare Improvement (IHI) Generic Clinic Benchmark: • Total visit time = clinician time x 1.5 • KCH Clinic goal total visit time based on this benchmark: • 31 minutes = 21 min x 1.5 • KCH Clinic actual total visit time using average values = 70 minutes • Median values = 62 minutes

16. Results: Time StudyFace Time vs. Wait Time

17. Results: Patient Satisfaction Survey • Total sample size = 74 • Neurology & Surgery collected 2/3 of total • KCH clinics now have a baseline to measure against future surveys • Satisfaction scores could be used to measure the success of future changes

18. Results: No Show Rates

19. Results: No Show Rates • 2006 and 2007 show no all-clinic pattern for the entire year • There is no one ‘good’ or ‘bad’ month for all clinics

20. Results: No Show Rates • Some individual clinics do show a monthly pattern from 2006 to 2007 • KCH could anticipate ‘bad’ and ‘good’ months on a clinic by clinic basis • However, averaging 40 – 50%, are they all ‘bad?’

21. Results: General Observations • We tracked clinician traffic in and out of exam room for unordinary occurrences (n = 46) • Future analysis should discover the impact on wait and face times these interruptions cause

22. Results: General Observations • Observed patient charts could provide a visual cue for patient and process handoffs • Charts often sat unattended on counter space • Implemented a new chart flow process using Lean theories

23. Current Chart Flow

24. New Chart Flow

25. New Chart Flow Process What it looks like today…

26. Recommendations • Team approach to capture the clinics’ momentum and ideas • Clinical Access Team • Physicians’ input is critical to move forward • Establish all-clinic goals regarding wait times and make this information transparent

27. Recommendations • Develop physician arrival policy • No longer does clinic start in the morning…clinic starts at 8:30am • Waiting room rounding • Monitor new chart flow process and analyze its impact to total visit time

28. Recommendations • Increase patient education regarding no shows • Define the clinics’ current scheduling process • Standardize desired patient volumes per specialty • Open Access scheduling • Potential to pilot test • Work off existing backlog

29. Acknowledgements • A special thanks to… • Martin School Capstone Committee: • Dr. Sarah Wackerbarth • Dr. Scott Hankins • Dr. Joseph Fink • KCH staff including: • Anne Long, Nurse Mgr KCH Clinics • All the KCH clinic & physician staff • Kyle Green, AVP Operations • Scott Stanton, Mgr Service Excellence • Nancy Wood, Mgr Management Engineering • University of Louisville Industrial Engineering Student Team

30. Questions??