Patient Flow and Clinic Efficiency Study

Boston University OM726 Operations Management

Ryan Evans Shailan Lala Sean Maher Chris Powers

To ascertain data and make recommendations to improve the efficiency of the patient flow with the VSSC goals in mind.◦ Volume, Safety, Satisfaction, Cost (VSSC)

In order to reach the objective, a time-effectiveness analysis was conducted through capturing patient times in the BMC Infectious Disease clinic.

Study Objective

•Project Management

•Organization

•Analysis Methods

•Process Analysis

•Feedback

•Recommendations

Presentation Overview

Task Best Estimate Complete Interval (Days)

Visit Clinic & Meet Staff 1

Develop Template for Observation 5

Perform Observations 5

Analyze Data 10

Draft Paper 17

Draft Presentation 13

Finalize Paper 7

Finalize Presentation 7

Deliver Final Paper & Presentation 1

Project Management

Project Management

Develop template

for observation

(5 Days)

BMC Clinic Observatio

n

Visit Clinic & Meet Staff

(1 Day)

Perform Observation

s(5 Days)

Draft Presentation

(13 Days)

Draft Paper(17 Days)

Analyze Data

(10 Days)

Finalize Paper

(7 Days)

Finalize Presentation

(7 Days)

Deliver Final Paper

& Presentation

0,0 0

0,0 0

5,5 0

10,23 13

0,0 0

5,5 0

10,23 13

0,4 4

1,5 4

10,10 0

40,40 0

40,40

20,33 13

20,33 13

23,33 10

10,10 0

40,40

33,33 0

30,40 10

33,33 0

20,33 13

03/06/09 04/15/09

Critical PathNotes:

The Organization

Clinic Type

HIV clinic Walk-in and Appt.

STD clinic Walk-in

Travel/Infectious Disease Appointment only

Refugee Appointment only

HIV/Substance Abuse * Appointment only

HIV/Pulmonary * Appointment only

Clinics Offered at BMC ID

* Indicates no data collected

Hours of Operation

Weekly Clinic Schedule

Monday Tuesday Wednesday Thursday Friday

Morning Hours 8:00AM - 11:00AM 8:00AM - 11:00AM 8:00AM - 11:00AM

Afternoon Hours 1:00PM - 4:00PM 1:00PM - 4:00PM 1:00PM - 3:00PM 1:00PM - 4:00PM

Evening Hours 4:30PM - 7:00PM

Clinic Types STDTravel

STDHIV

Hep. CSTD

Travel

STDHIV

Hep. CRefugee

STD

Primary FunctionsFunction Activities

Screening Help patients to determine if they have a disease through blood testing

Treatment Medical and Psychiatric treatment

Counseling • Inform travelers going to foreign countries on how to avoid illness

•Consultation for those newly diagnosed with illness, such as HIV

Research Academic studies at BMC

Measurement Objective

Volume Maximize throughput of the clinic

Safety Protect patients and staff from hazards

Satisfaction Send patients home content with service

Cost Minimize waste, maximize resources

Objectives - VSSC

StaffingStaffing Level Data Notes

Front Desk 2Check patients into the clinic, make appointments, and verify insurance information as well as other administrative functions

Medical Assistants 2 Call patients into the clinic, checks vital signs, makes follow up appointments

Team Coordinator 1 Manage front desks and paperwork

Phlebotomist 1 Draw & Analyze Blood

HIV/Travel Clinic Nurses 4 Perform and assist in examinationsSTD Nurses 3 Perform and assist in examinations

Clinician (MD) 26-30Perform examinationsEach MD only works a single AM or PM shift or a single day in the clinic per week

Case Managers 6 Provide STD & HIV counseling on a full-time basis

Methodology

Study objective Observe the patient flow throughout the process and

measure relevant task/wait times Process broken into two portions:

◦ Front of House: Check-in and waiting area Sample size n=91

◦ Back of House: Clinic area Sample size n=38

Two observers, one in each area◦ Clinic observer follows patient through each process

Study Design and Methodology

10 hours of observation◦ 6 hours morning clinic◦ 4 hours afternoon clinic

Quantitative data◦ Task times and process flow

Qualitative data◦ Feedback from clinic staff◦ Feedback from patients in waiting area

Data Collection

Process analysis

Data and Analysis

Performance StatisticsWait Area Min Task Time Max Task Time Avg. Task Time Cycle Time Capacity /

HourCapacity

Utilization

Get Number From Front Desk 0 545 32 303 11.00

Check-In Confirmation 0 900 123 302 11.00

Enter Clinic 0 4,455 1,981 377

Wait Area Totals - - 2,136 377 11.00 72.73%

Clinic Area Min Task Time Max Task Time Avg. Task Time Cycle Time Capacity / Hour Capacity Utilization

Vital Signs 120 1,534 295 587 24.00 33.33%

Time Spent with RN 160 4,990 1,325 716 8.00 100.00%

Time Spent with MD 608 5,694 1,641 615 8.00 100.00%

Phlebotomist 115 1,182 106 307 33.00 24.24%

HIV Counseling 375 760 64 N/A N/A N/A

Clinic Area Totals - - 3,431 716 8.00

BMC Travel & ID Clinic - - 5,567 716 8.00

* Times are in seconds

* Capacity are adjusted for average staffing levels

Patient Count/Hours vs. Clinic Capacity

8AM-9AM 9AM-10AM 10AM-11AM

1PM-2PM 2PM-3PM 3PM-4PM0

2

4

6

8

10

12

14

Patient Count / Hour vs. Clinic Capacity

Avg. Daily Patient CountCapacity

Staff Identification of Inefficiencies

Patie

nt b

ehav

ior

Check

-in a

nd w

aitin

g pr

oces

s

Differ

ing

prac

tice

styl

es o

f doc

tors

Lack

of r

esou

rces

Lunc

h br

eaks

slow

pro

cess

Need

to o

verb

ook

mor

e

Need

to o

verb

ook

less

0

1

2

3

4

5

6

7

Staffs Identification of Inefficiencies

# Of responses

Patient Identification of Inefficiencies

Confusion of check-in procedure

Long wait times Low staffing levels Ineffective use of idle time

No indication of wait times

0

1

2

3

4

5

6

7

Patients Identification of Inefficiencies

# Of responses

Recommendations

Reduce cycle time:◦ In response to the complaint that inefficiency is caused by

differing practice styles of the doctors Variation of task time time patients spent with doctors, which

ranges from 5,693 seconds (max) to 608 seconds (min) with a mean of 1,641 seconds.

MGH /CABG procedure:◦ Personal nature of medical practices versus systematic

standardization and guidelines for physicians. Benefits:

◦ Costs declined as doctor’s (time) variations reduced

Recommendations

Increasing time (labor) available:◦ When waiting room is operating over-capacity and the clinic is

operating under capacity that staff from the back of house assist in stabilizing the inflow of new patients in the waiting room

Task shifting:◦ Where tasks are moved to less specialized health workers.

Benefits:◦ “All hands on deck” sense of teamwork◦ Creating cross-skill functionality ◦ Reduce check-in times as the greatest bottleneck◦ Heightened patient satisfaction

Recommendations

Shifting demand:◦ Current demand exceeds capacity (early morning hours and

late afternoon) ◦ In-clinic advertising campaign

Signage informing patients when the best time of the day is to come for a lesser wait

Benefits:◦ Patients more aware of waiting times◦ Change behavior to set appointments to avoid waiting

Recommendations

Continue data collection within the clinic:◦ Determine patient demand patterns◦ Appointment no-show percentages◦ Clinic cost-effectiveness and ◦ Other efficiency measures

Benefits:◦ Accurate measurement lead to evidence-based decisions◦ Promote better management◦ Reach VSSC goals

Recommendations

Our team would like to extend a special thanks to Drs Metti Kanno, David Hamer and the BMC Infectious Disease Clinic staff for facilitating and supporting this project.

Questions and Answers

Acknowledgements