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Efficiency In Office Practice. Barbara S. Boushon, RN, BSN Mark Murray and Associates. Office Efficiency (work flows). The right person doing the right task at the right time Barrier-free Patient-centered Predictable, standardized Based on systems, not people Based on team structure.

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efficiency in office practice

Efficiency In Office Practice

Barbara S. Boushon, RN, BSN

Mark Murray and Associates

office efficiency work flows
Office Efficiency (work flows)
  • The right person doing the right task at the right time
  • Barrier-free
  • Patient-centered
  • Predictable, standardized
  • Based on systems, not people
  • Based on team structure
capacity the link between access and efficiency
Capacity: The Link Between Access and Efficiency
  • Increased capacity leads to improved access
  • Improved access leads to more efficient office processes
  • More efficient processes increase capacity
cycle time measurement

Check in

MA to Room

MD Enters

MD Leaves

Check out

Cycle Time Measurement


  • Greet
  • Check in/registration
  • Get chart
  • Prepare information
  • Vital signs
  • Interview
  • Prepare information
  • Greet interview
  • Exam
  • Closure
  • Prepare information
  • Closure


  • Information transfer
  • Communication, pre, during, post visit
  • Synchronize patient, provider, information, equipment
  • Standardize rooms
  • Choreography

Measurement- cycle time


the metrics
The Metrics
  • Lead Time = start to end
    • The sum of the cycle times + delays
    • For the whole process
      • The visit
      • The referral
      • Medical record retrieval
    • Each segment of the process = cycle time
      • Appointment booking, reminder, registration, greeting, waiting room, rooming, vital signs, value added vs non-value added time



  • Group of processes working together to achieve aim


  • Group of tasks working in an orderly fashion to achieve an aim


  • A specific job or piece of work


  • Workflow analysis/work task analysis
flow through the office
Flow Through the Office

Check-in to Nurse

Dr. in to Dr. out

Nurse to Room

Check-out to leave

Lead Time

how processes support flow
How Processes Support Flow

Dr. in to Dr. out

Check-in to Nurse

Nurse to Room

Check-out to leave

check in to nurse
Check-in to Nurse
  • Greet
  • Register
  • Routing slip
  • Update information
  • Obtain directions to clinic nurse
  • Obtain chart
  • Go to clinic
  • Wait
rn ma lpn to exam room
RN/MA/LPN to Exam Room
  • Greet
  • Gather chart
  • Review/update preventative health information
  • Educate/treat for prevention as indicated
  • Go to clinic room, vitals
  • Wait
doctor in to doctor out
Doctor In to Doctor Out
  • Greet
  • Open chart/computer
  • History
  • Exam
  • Assessment
  • Education
  • Plan
  • Documentation
check out to leave
Check Out to Leave
  • Review orders
  • Pharmacy education?
  • Nurse education?
  • Send for more lab/XR?
  • Set up referrals?
  • Set up next appointment?
how processes support flow14
How Processes Support Flow

Dr. in to Dr. out

Check-in to Nurse

Check-out to leave

Nurse to Room


How do we decrease the

waiting in the office….

And keep the value added time?

  • High Leverage Changes
  • Change Concepts
medical office efficiency high leverage changes
Medical Office Efficiency High Leverage Changes
  • Balance Capacity and Demand
  • Synchronize Patient, Provider, and Information
  • Predict and Anticipate Patients Needs
  • Optimize Rooms and Equipment
  • Manage Constraints
balance capacity and demand
Balance Capacity and Demand
  • Predict daily demand for non-appointment services
      • Understand the components of demand for services:


-medication refills

-lab review

- messages


-forms management

  • What is the matching process?
      • Batch vs. one piece flow
  • Match the demand to the correct resource
      • For all non-appointment services
synchronize patient provider and information
Synchronize Patient, Provider, and Information
  • Start on time and stay on time
  • Identify and maximize the value stream
  • Synchronize Patient
  • Synchronize Provider
  • Synchronize information
    • Registration process
    • Closure of last visit
    • Chart check
    • Rooming criteria
  • Document, do work in real time





synchronization truisms
Synchronization “Truisms”
  • The whole process can only go as fast as the slowest step
  • If the process starts 15 minutes “late” each session (AM and PM), a full time clinic can “waste” 400+ appointments per year.
  • Must work “backwards” from sync time to make sure everything is ready on time.
predict and anticipate patient needs
Predict and Anticipate Patient Needs

Practice level approach:

  • Plan for seasonal demand changes
    • Flu season, Vacation season, Snowbird season
  • Plan for the unexpected but predictable daily demands
    • Admissions, procedures, consults, information needs
  • Understand and standardize common procedures
  • Align expertise of care teams with patient needs; plan the visit
predict and anticipate patient needs24
Predict and Anticipate Patient Needs

Visit level approach

  • Communication is harder than you think
  • “Huddle” – dialogue among team intended to get everyone “on the same page”
    • Stand up meeting of less than 5 minutes
    • Used to plan clinic session; prior to procedure; at a “hand off”
    • Promotes familiarity, shared expectations
communication overview
Communication Overview
  • 14% of each 40 hour work week is wasted in miscommunication
  • Over 50% of errors in VA’s Root Cause Analysis traced back to miscommunication
  • Communication basics
    • Familiarity of staff – call each other by name
    • Listen to understand, not to plan next comeback
    • Communicate what you see and know
    • Explicitly ask everyone for input
optimize rooms and equipment
Optimize Rooms and Equipment
  • Adequate number of rooms
  • Optimize Rooms
    • Open rooming
    • Fully stocked rooms
    • Standardize layout, supplies
  • Move equipment to the patient
  • Optimize Space
  • Signals for equipment
identify and manage constraints
Identify and Manage Constraints
  • Person constraint for non-appointment work
      • Maximize the care team: “what is the work?”
      • Put inspection step in front of the constraint
      • All work to highest level of skill, expertise, and licensure
      • Standard Protocols
  • Process constraint
      • No idle time
      • Separate phone flow, patients flow, and paper flow
      • Continuous flow
  • Specific processes
identify the constraint
Identify the Constraint

Constraint= the rate limiting step

(Theory of Constraints-TOC)

  • Who is the person (role) in front of whom most waiting occurs?
  • What is the process in front of which most waiting occurs?
maximize the constraint
Maximize the Constraint
  • Put resources around the constraint to optimize their output
  • Even if other steps work below their maximal capacity
  • Allow no down-time for the constraint
change concepts from industry
Change Concepts from Industry
  • Identify value, then eliminate waste
  • Improve the flow of work
  • Optimize the work environment
  • Manage variation
identify value from customer view then add value
Identify Value (from customer view), then add value ……
  • Patients say:
    • “Treat me with respect”
    • “Be friendly and caring”
    • “Give me a long-term healthcare relationship”
    • “Make your services convenient”
  • (Education, skill, and training are assumed)

Focus Group

and eliminate waste lean thinking
…and Eliminate Waste (Lean Thinking)
  • Eliminate
    • Things that aren’t used
    • Multiple entry
    • Overkill
    • Intermediaries
  • Sample
improve the flow of work
Improve the Flow of Work
  • Synchronize
  • Minimize hand-offs
  • Move steps closer together
  • Automate
  • Do tasks in parallel
  • Practice continuous flow
  • Use pull systems
optimize the work environment
Optimize the Work Environment
  • Improve access to information
  • Train
  • Cross-train
  • Reduce set-up time
manage variation
Manage Variation
  • Standardize
  • Create contingency plans
  • Manage peak demand
  • VA Delays Manual
  • The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.

G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey-Bass Publishers., San Francisco, 1996,

Chapter 7 and Chapter 13