Efficiency In Office Practice

Barbara S. Boushon, RN, BSNMark Murray and Associates

Office Efficiency (work flows)

The right person doing the right task at the right timeBarrier-freePatient-centeredPredictable, standardizedBased on systems, not peopleBased on team structure

Capacity: The Link Between Access and

Efficiency

Increased capacity leads to improved accessImproved access leads to more efficient office processesMore efficient processes increase capacity

Cycle Time MeasurementCheck in MA to Room Check outMD LeavesMD Enters

Process•Greet

•Check in/registration

•Get chart

•Prepare information

•Vital signs

•Interview

•Prepare information

•Greet interview

•Exam

•Closure

•Prepare information

•Closure

Over-arching•Information transfer

•Communication, pre, during, post visit

•Synchronize patient, provider, information, equipment

•Standardize rooms

•Choreography

Measurement- cycle time

Audit

The MetricsLead Time = start to end

The sum of the cycle times + delaysFor the whole process

The visitThe referralMedical 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

System:Group of processes working together to achieve aim

Process:Group of tasks working in an orderly fashion to achieve an aim

Tasks:A specific job or piece of work

Tools:Workflow analysis/work task analysis

Terms

Flow Through the Office

Check-in to Nurse

Nurse to Room

Dr. in to Dr. out

Check-out to leave

Lead Time

How Processes Support Flow

Check-in to Nurse

Nurse to Room

Dr. in to Dr. out

Check-out to leave

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Check-in to Nurse

GreetRegisterRouting slipUpdate informationObtain directions to clinic nurseObtain chartGo to clinicWait

RN/MA/LPN to Exam Room

GreetGather chartReview/update preventative health informationEducate/treat for prevention as indicatedGo to clinic room, vitals Wait

Doctor In to Doctor Out

GreetOpen chart/computerHistoryExamAssessmentEducationPlanDocumentation

Check Out to Leave

Review ordersPharmacy education?Nurse education?Send for more lab/XR?Set up referrals?Set up next appointment?

How Processes Support Flow

Check-in to Nurse

Nurse to Room

Dr. in to Dr. out

Check-out to leave

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Lead Time ExampleCycle Time

0

10

20

30

40

50

60

70

Week Ending

Min

ute

s

Average Goal

AM HUDLE

Align Patients, Providers, Staff

Decreased Appointment Types

Real Time Work

Separated Tasks Lab in Exam Room

How do we decrease the

waiting in the office….

And keep the value added time?

FrameworksHigh Leverage ChangesChange Concepts

Medical Office Efficiency High Leverage Changes

Balance Capacity and DemandSynchronize Patient, Provider, and InformationPredict and Anticipate Patients NeedsOptimize Rooms and EquipmentManage Constraints

Balance Capacity and Demand

Predict daily demand for non-appointment services

Understand the components of demand for services:-documentation-medication refills-lab review- messages-referrals-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

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

I n fo rm a tio n

R o o m

P a tie n t

P ro v id e r

S yn c h r o n izatio n T im e fo r O ffic e V is it

E q u ip m e n t

10:00 10:30 11:00

Staff

Synchronization “Truisms”

The whole process can only go as fast as the slowest stepIf 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

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 proceduresAlign expertise of care teams with patient needs; plan the visit

Predict and Anticipate Patient Needs

Visit level approachCommunication is harder than you think“Huddle” – dialogue among team intended to get everyone “on the same page”

Stand up meeting of less than 5 minutesUsed to plan clinic session; prior to procedure; at a “hand off”Promotes familiarity, shared expectations

Communication Overview

14% of each 40 hour work week is wasted in miscommunicationOver 50% of errors in VA’s Root Cause Analysis traced back to miscommunicationCommunication basics

Familiarity of staff – call each other by nameListen to understand, not to plan next comebackCommunicate what you see and knowExplicitly ask everyone for input

Optimize Rooms and Equipment

Adequate number of roomsOptimize Rooms

Open roomingFully stocked roomsStandardize layout, supplies

Move equipment to the patientOptimize SpaceSignals for equipment

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

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 ConstraintPut resources around the constraint to optimize their outputEven if other steps work below their maximal capacityAllow no down-time for the constraint

Change Concepts from Industry

Identify value, then eliminate waste

Improve the flow of workOptimize the work environmentManage variation

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)

EliminateThings that aren’t usedMultiple entryOverkillIntermediaries

Sample

Improve the Flow of WorkSynchronizeMinimize hand-offsMove steps closer togetherAutomateDo tasks in parallelPractice continuous flowUse pull systems

Optimize the Work Environment

Improve access to informationTrainCross-trainReduce set-up time

Manage Variation

StandardizeCreate contingency plansManage peak demand

ReferencesVA Delays ManualThe 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