Lean Six Sigma Black Belt Project Improving Throughput to Provider Neurology Outpatient Clinic Visits July 22, 2017 Sue Warshal

Throughput to Provider in Room Overview Healthcare System Managing more than 850,000 patient visits annually at 3 hospitals and 27 ambulatory care (outpatient) facilities Neurology Outpatient 8,233 completed patient visits Neurology Outpatient Event Date Sample Size Total Throughput Throughput to Provider in Room 1st Time Study – Conducted by Process Improvement (PI) Team July 2016 31 patient visits 82 40 Rapid Process Improvement – Led by PI Team 26 initiatives identified 2nd and 3rd Time Study – Conducted by Neurology Staff August 2016 November 2016 21 patient visits 22 patient visits 94 92 58 57 EPIC Data Analysis 2016 5,638 patient visits 1,831 on-time visits 102 46 43

Define – Voice of the Customer Wait list Scheduling from October 2016 referrals 3,236 New Patients 918 Recall Patients Limited Schedule releases Patient Surveys Long waiting list for initial appointment Long appointments Extensive wait to see Provider (simulated) Patient Satisfaction Score vs. Wait Time Staff Surveys / RPI Reduce Door to Doctor Time

Define – SMART Goal Broad Goal: Improve patient throughput for Neurology clinic visits. Specific: Identify inputs that significantly affect the variability in time between when the patient enters the waiting room to when the patient has first interaction with the provider. Alter processes that would provide meaningful decreases in throughput times. Measurable: Shadow staff and providers to understand process steps. Analyze EPIC data for on-time patients, to identify statistical significant input variables. Identify throughput goal by evaluating effect on patients/healthcare system. Compare improvement in throughput to baseline of 43 minutes on average. Attainable: EPIC data is available for analysis. Throughput goal will be attained by evaluating throughput needed to accommodate demand of services. Relevant: There is on average a two week waiting list for Neurology appointments. Improving throughput will decrease the probability of patients seeking services elsewhere, will improve patient satisfaction, and will increase revenue for the department. Time-Based: Shadowing and current data will be analyzed within three months. Processes improvement changes will be implemented and analyzed for another three months. SMART Goal: Within six months, will shadow staff and use EPIC data to identify inputs that meaningfully influence variability in Throughput to Provider for Neurology patients arriving on-time for their clinic visits. Will reduce throughput to 35 mins/average and eliminate upper 22% of variance within three months of implemented improvements. This will eliminate clinic waiting lists and improve patient satisfaction.

Define – Neurology Appointment Flowchart

Define – Throughput Times (minutes) Current Throughput to Provider = 43 minutes

Define – Throughput Goal (simulated) Average Throughput Goal: 35 minutes Clinic Capacity: Total current minutes = 8,233 x 43 = 354,019 To accommodate 10,000 patients per year / capacity = 35 minutes on average Upper Limit Goal: 59 minutes = eliminating current upper 22%

Measure – Cause and Effect Diagram

Measure – Variation in Scheduling

Measure – Variation in Appointment Type

Measure – Variation in Provider (Only B.W. & J.H-C)

Check-In – Voice of the Customer Providers

Analyze – Shadowing Analysis Scheduling Students Waitlists / Released schedules General vs Specialty Clinic availability Double Booking Hour of Day Registration Confirming information Intake Form Medical Assistant 6+ within an hour Nurse By-pass nursing (med check) Provider Employee (NP) vs Medical Group (MD) Provider Wait On-Time Review charts Discharge notes

Analyze – Student influence NP ( ), Resident ( ) vs MD

Analyze – Scheduling Appointment Availability 75% General on Wait/Recall Lists (estimate) Number of Scheduled Patients

Analyze – Scheduling Double Booking Hour of Day 44 times during year 43 days (17%) 16 providers (67%) Significant (p=0.005) throughput difference before vs after double booked appointments Fridays No students Less patients

Improve - Recommendations

Improve – Baseline vs Post Changes (simulation) Accurate patient status within EMR NP’s complete discharge notes in patient room Intake form shorter and direct input into EMR NP reviews all referrals Schedules available 3 months out No double booking Printers at each registration station Student identification with EMR General Session slots increased to 75% MD mtg twice per week; Friday AM slots available “Catch-up” appts scheduled once per session NP available for initial “catch-up” appointments

Improve – Throughput Change (simulated) Baseline Throughput: 43 minutes Average Throughput Goal: 35 minutes; upper limit goal of 59 minutes Post Implementation: 33 minutes

Improve – Variance Change (simulated)

Control – Monthly Dashboard (simulation)