Determining Direct Patient Utilization Costs in the Cardiovascular Clinic Team 5 Final Presentation April 14, 2017 Chanmee Chung Jishnu Desai Julie Merz Greyson Schultz

Introduction Project Location: UM Frankel Cardiovascular Center (CVC) Client: Mrs. Cathy Twu-Wong Project Manager, Michigan Medicine Clinical Design and Innovation Coordinator: Mr. Andrei Duma Industrial Engineer, Project Manager, CVC Icon Credit: www.flaticon.com

CVC Costs = Direct Variable Clinic Costs + Fixed Costs The CVC would like to better understand the costs it incurs at each stage in patient treatment process CVC Costs = Direct Variable Clinic Costs + Fixed Costs Icon Credit: www.flaticon.com

Key Issues Only MA times are currently captured Currently no way to pull this time data discretely Other provider and staff times are not recorded at all Times needed for cost analysis No documented cardiac surgery clinic process or echo lab process Icon Credit: www.flaticon.com

Develop Swimlane Diagrams Project Goals Develop Swimlane Diagrams Document provider and staff times in clinic & use of supplies for future financial analysis Provide standardized data collection methods for similar future studies VSM of provider time, specifically for mitral valve patients Document the standard workflows in the CVC Provide standardized methods for data collection which will be used in future applications in the CVC Icon Credit: www.flaticon.com

Objectives Observe and understand the clinic and testing processes Interview and shadow providers Implement time data collection techniques Data collections techniques: patient form, time studies Icon Credit: www.flaticon.com

The Team’s Project Scope: Cardiac Surgery Clinic & Echo Lab Icon Credit: www.flaticon.com

DV Costing Methodology Big Picture DV Clinic Costs = 𝚺 (Clincian Time * $/hr) + 𝚺 Supplies Used + (Supplies Used = Ø) DV -> Sum of time for each provider * $/hr CVC Costs = Clinic Costs + Other Current Projects + Other Future Projects Clinic Costs = 𝚺 (Provider Time * $/hr) + 𝚺 Supplies Used Supplies Used = Ø DV -> Sum of supplies used (later in another slide, there are no supplies) Focus on the first bullet point Icon Credit: www.flaticon.com

Methods for Data Collection Literature Search Observations Clinic Echo tests Clinic time studies Clinic patient forms Medical staff interviews Clinic Echo tests Icon Credit: www.flaticon.com

Cardiac Surgery Clinic Icon Credit: www.flaticon.com

Findings: Literature Search Insight into conducting effective time data collection techniques Time studies Patient form Direction for when and how to use value stream maps As a result, decided not to use this tool Understand similar clinic operations Icon Credit: www.flaticon.com

Findings: Clinician Interviews Conducted throughout our project, as needed Rooming MAs Nurses Echo Lab staff Validated observations and data with clinician perceptions of clinic Icon Credit: www.flaticon.com

Findings: Observation of Clinic January 26, 30 and February 6, 20 Gained an understanding of clinic flow at the CVC Helped establish time studies techniques Created flow diagrams Helped to create swimlane diagrams Icon Credit: www.flaticon.com

Example: Clinic Flow New Patient Swimlane Diagram Patient checks in Clinic Flow - Health & Physical (H&P) Sample Size: 7 patients in 3 clinic days Accumulated average times: Patient Average Time: 74min. 0 minutes 10 12 14 49 72 Patient Wait Times Patient leaves w/o check out 6 6 Total Average Times: Clerk Not Involved Intake MA 12 min Vitals are taken (10) Puts patient in room (2) Rooming MA 4 min Delivers patient info to huddle room (2) Preps room for next patient (2) NP or PA 29 min Discuss with patient (29) MD Not Involved Research: Discuss and bring supplies, if needed RN Not Involved MAS 17 min Discuss with patient (17) * Total average times are calculated by finding average times for each process and summing them across each provider/staff. For processes that happen a % of the time, the % x extra time is included. ** For a CABG H&P, Surgical Scrub (2 bottles) were given to patient

Findings: Clinic Time Studies March 6 - 27 Mondays from 8:30AM to 3PM Collected time data from 26 patient visits encompassing: Two surgeons Multiple procedure types Different visit types Intake bay data Check-out times Icon Credit: www.flaticon.com

Findings: Clinic Patient Forms March 10 - 27 Team handed out over clinic days Collected data forms from 49 patients Validated with effort from MAs, team members, and patients 3 iterations Go right to next slide to talk this over while seeing form Icon Credit: www.flaticon.com

A. B.

Findings: Data Analysis Table I. Average time spent with patient by each provider for each visit type (minutes). Total Sample Size: 49; Source:Patient Form data, IOE 481 Team; Collection Period: March 6-March 27 2017 Average Time and Std. Dev. spent with Patient per Visit Type (min.) New Patient Sample Size: 22 Health & Physical Sample Size: 7 Postoperative Sample Size: 12 Return Visit Sample Size: 7 Checkout Staff 5 ± 4 - Intake MA 18 ± 7 12 ± 7 12 ± 8 11 ± 2 Rooming MA 5*** 5 ± 3 5 ± 1 MAS 17 ± 3 RN 16 ± 9 17 ± 10 NP or PA 33 ± 0 29 ± 10 25 ± 15 16 ± 2 MD 16 ± 8 9 ± 7 10 ± 9 ADD STD DEVS Note the sample size: 49 ‘-’ means the provider is not involved with that particular visit type NP/PA actually spends the most time throughout each visit type This information is important for our client * Blank values indicates where the provider or staff is not involved with that particular visit type ** Checkout Staff data did not include visit type *** Only 1 data point for H&P Rooming MA Icon Credit: www.flaticon.com

Validation of patient form data Icon Credit: www.flaticon.com

Future Plans No statistically significant differences between surgeons Icon Credit: www.flaticon.com

Conclusion: Cardiac Surgery Clinic There are no statistically significant differences between: Procedure type and time clinicians spend with patients Surgeon and the time clinicians spend with patients There are statistically significant differences between: Visit type and time clinicians spend with patients Total appointment time and time providers spend with patients There is not a significant amount of supplies used for patient care Icon Credit: www.flaticon.com

Echocardiography (Echo) Lab Icon Credit: www.flaticon.com

Findings: Observation of Echo Lab March 27, 30 and April 4 Gained a better understanding of different tests Transthoracic (TTE) Transesophageal (TEE) Stress tests: Dobutamine, Treadmill Created flow diagrams for each detailing patient-provider/staff interaction Icon Credit: www.flaticon.com

Transthoracic Echo (TTE or surface) Flow (Draft)

Conclusion: Echo Lab Standard work flows can be documented for each type of test Need further investigation to quantify clinician time Similar methods as cardiac surgery clinic can be applied No time data captured currently Icon Credit: www.flaticon.com

Next Steps Time data used by finance and clinical design teams to attribute cost to clinician time Data collection methods applied to other clinics in CVC and other Michigan Medicine departments Continue Echo study Validate draft swim lanes with echo lab staff Collect time data through clinicians Reminder: Beginning of an effort to better understand costs related to time providers and staff spend on patient care Icon Credit: www.flaticon.com

Thank You! Any Questions? Chanmee Chung Jishnu Desai Julie Merz Greyson Schultz Team 5 IOE 481 Senior Design Final Presentation

Appendix Icon Credit: www.flaticon.com

Clinic Flow - New Patient (NP) Sample Size: 22 patients in 4 clinic days Accumulated average times: Patient Average Time: 158 min. 0 minutes 50 52 53 86 103 119 141 151 Patient Wait Times 34* 16 17 6 5 Total Average Times: * Ranges from 4 min. to 1.5 hours Clerk Checks patient in Checks patient out (5) 5 min Intake MA Takes vitals (16) Puts patient in room (2) 18 min Rooming MA Puts patient in room (2)* Delivers patient info to Team Room (1) 5 min Preps room for next patient (2) * When clinic is busy and understaffed, the Rooming MA may perform this duty NP or PA Consult patient (17) NP, MD, RN debriefs in Team Room (17)* Consult patient (16) 50 min MD 33 min RN * Assuming time between NP/PA consulting patient and MD entering room is used to debrief about the particular patient Discuss with patient* (16) 44.08min Prints medications if needed (5) * 38% of time RN consults patient with MD and NP/PA, due to team differences MAS Not Involved * Total average times are calculated by finding average times for each process and summing them across each provider/staff. For processes that happen a % of the time, the % x extra time is included. Example: RN Average time calculation: 17 + 16 + .38(16) + 5 = 44.08 min

Clinic Flow - Health & Physical (H&P) Patient checks in Clinic Flow - Health & Physical (H&P) Sample Size: 7 patients in 3 clinic days Accumulated average times: Patient Average Time: 73 min. 0 minutes 10 12 13 48 71 Patient Wait Times Patient leaves w/o check out 6 6 Total Average Times: Clerk Not Involved Intake MA 12 min Vitals are taken (10) Puts patient in room (2) Rooming MA Puts patient in room (2)* 5 min Delivers patient info to huddle room (1) Preps room for next patient (2) * When clinic is busy and understaffed, the Rooming MA may perform this duty NP or PA 29 min Discuss with patient (29) MD Not Involved Research: Discuss and bring supplies, if needed RN Not Involved MAS 17 min Discuss with patient (17) * Total average times are calculated by finding average times for each process and summing them across each provider/staff. For processes that happen a % of the time, the % x extra time is included. ** For a CABG H&P, Surgical Scrub (2 bottles) were given to patient

Clinic Flow - Postoperative (PostOp) Sample Size: 12 patients in 4 clinic days Accumulated average times: Patient Average Time: 133 min. 0 minutes 52 54 55 80 97 106 126 Patient Wait Times 42* 9 17 9 Total Average Times: * Ranges from 3 min. to 1.5 hours Clerk Checks patient in 50% of patients checks out 33% of patients checks out 5 min Checks patient out (5) Intake MA 12 min Takes vitals (10) Puts patient in room (2) Rooming MA Puts patient in room (2)* Delivers patient info to Team Room (1) 5 min Preps room for next patient (2) * When clinic is busy and understaffed, the Rooming MA may perform this duty NP or PA 27.25 min Consult patient (16) NP, MD, RN debriefs in Team Room (17)* Consult patient (9) Sample size: 12 patients MD: 17% (2/12) MD, NP: 17% (2/12) MD, MAS: 8% (1/12) PA: 8% (1/12) MD 27.34 min Consult patient (16) Consult patient (9) Sample size: 12 patients NP: 42% (5/12) MD: 33% (4/12) MAS: 17% (2/12) MD, RN, NP: 8% (1/12) RN Consult patient (16) Consult patient (11) 19.16 min Sample size: 12 patients RN: 8% (1/12) MAS: 8% (1/12) MAS 4.32 min Consult patient (16) Consult patient (9) Consult patient (11) * Total average times are calculated by finding average times for each process and summing them across each provider/staff. For processes that happen a % of the time, the % x extra time is included. Example: MD Total Average time calculation: .33(16) + .08(16) + 17 + .17(9) + .17(9) + .08(9) = 27.34 min.

Clinic Flow - Return Visit (RV) Sample Size: 7 patients in 3 clinic days Accumulated average times: Patient Average Time: 99 min. 0 minutes 25 27 28 57 62 67 92 Patient Wait Times 16* 18 5 14 Total Average Times: * Ranges from 4 min. to 46 min. Clerk 5 min Checks patient in 43% of patients checks out 28.5% of patients checks out Checks patient out (5) Intake MA 11 min Takes vitals (9) Puts patient in room (2) Rooming MA Puts patient in room (2)* Delivers patient info to Team Room (1) 5 min Preps room for next patient (2) * When clinic is busy and understaffed, the Rooming MA may perform this duty NP or PA Consult patient (5) 7.24 min Consult patient (11) NP, MD, RN debriefs in Team Room (5)* MD Sample size: 7 patients NP: 14% (1/7) MD: 57% (4/7) Resident: 14% (1/7) RN: 14% (1/7) Sample size: 7 patients MD: 14% (1/7) MD, RN: 14% (1/7) MD, NP: 14% (1/7) RN: 14% (1/7) 13.37 min Consult patient (11) Consult patient (5) RN 9.48 min Consult patient (11) Consult patient (5) Consult patient (11) Sample size: 7 patients RN: 14% (1/7) MAS: 14% (1/7) MAS 1.54 min Consult patient (11) * Total average times are calculated by finding average times for each process and summing them across each provider/staff. For processes that happen a % of the time, the % x extra time is included. Example: RN Total Average time calculation: .14(11) + 5 + .14(5) + .14(5) + .14(11) = 9.48 min.

A. B.

Transthoracic Echo (TTE or surface) Flow (Draft) Sample Size: 3 patients in 1 clinic day *indicates not in room with patient Patient checks in Transthoracic Echo (TTE or surface) Flow (Draft) MD *Reads echo and signs report Sonographer No Is Saline Requested? Prepares patient report Pages patient, brings back to room Performs Echo Performs Echo Walks patient out, cleans equipment *Writes report *Transcribe and submit report Yes RN Pushes Saline during Echo Exits System Exercise Physiologist Not Involved Fellow Not Involved

Dobutamine Stress Test Flow (Draft) Sample Size: 1 patient in 1 clinic day *indicates not in room with patient Patient checks in MD *Reads echo and signs report (On stand-by in case something goes wrong) Sonographer *Transcribe and submit report Surface Echo and Baseline Images Drug Stress Test performed (including recovery, post pictures, and post EKGs *Writes report Prepares patient report and other set -up RN Prepares paperwork Pages patient, brings back to room Set up, patient consent, EKG and IV in Drug set up and prep Exits System Exercise Physiologist Not Involved Fellow Not Involved

Transesophageal Echo (TEE) Flow (Draft) Inpatient? Transesophageal Echo (TEE) Flow (Draft) Sample Size: 3 patients in 3 clinic days *indicates not in room with patient No Yes MD Writes report while monitoring echo process Exits System No Sonographer Surface Echos Needed? Surface Echo Performs Echo *Transcribes and finishes report *Report setup Yes RN No Patient Recovery Another Procedure? Gets patient from downstairs Gets patient from lobby Medical set up (IV, patient dressed etc. Page Fellow Standby--monitoring vitals Patient to next procedure Yes Exercise Physiologist Not Involved Fellow Numbs and Sedates patient, calls attending MD Performs Echo Exits System

Treadmill Stress Test Flow (Draft) Sample Size: 1 patient in 1 clinic day *indicates not in room with patient Patient checks in MD (On stand-by in case something goes wrong) *Reads report Sonographer *Prepares patient report and other set up Surface Echo and Baseline Images Wait in patient room Takes Ultrasound after test is complete *Writes report *Transcribe and submit report RN Not Involved Exercise Physiologist Pages patient, brings back to room Explains procedure and gets consent Wait in patient room Performs exercise stress test Wait in patient room Exits System with patient Fellow Not Involved