+ DA Patient Flow Project – What have we achieved? Dr Andy CO Cheng (Assoc Cons) Dr Ben NM Lam (Cons) WISER HKEH

+ Acknowledgement All involved / affected staff in HKEH Administrative Appointment Finance / Shroff Medical MRO Nursing Optometry OT appointment

+ Morning DA (SOPD)

+ Define MeasureAnalyzeImproveControl

+ Project Charter Scope Morning DA old cases Aim Streamline patients’ flow in HKEH Reduce patients’ “in-hospital” time Overcrowding – conflicts Infection control issues Patients’ safety / hospital responsibility Methods TOCLSS (Theory Of Constraints, Lean, Six Sigma)

+ Team Project Sponsor: Dr Stanley Chi (DHCE) Project Leader: Dr Ben Lam (Cons) Facilitator: Dr Theresa Li (CM, Cons) Members: Dr Andy Cheng (Assoc Cons) Ms Phyllis Yim (WM, OPS) Ms Eva Lui (FO i/c) Ms June Kwok (DM, Optom) Mr Keith Lee (HM) Mr Ryan Fung (AHM) Mr Tony Lam (PSO / PRO) Special thanks: Dr L Wong (RS) Dr N Chan (Resident)

+ Measure Define Measure AnalyzeImprove Control

+ Current state flowchart Pharmacy Registration VAVA Investigation Doctor’s consultation room MP Treatment Appt booking OT booking Shrof f Average time in HKEH = 1:35:00 (0:45:00 – 2:36:00) Average number of stations = 6 (range 4 – 8) * % patients <90 minutes = 43% Average time in HKEH = 1:35:00 (0:45:00 – 2:36:00) Average number of stations = 6 (range 4 – 8) * % patients <90 minutes = 43%

+ Current state (selected variables + exclude outliers) InventoryWaiting timeProcess time No.MeanRangeNo.MeanRangeNo.MeanRange Registration :15:470:01:15 – 0:31:34370:00:21 0:00:08 – 0:00:40 VA :42:040:00:18 – 1:10:20350:03:39 0:01:58 – 0:12:00 Consultation - Total :36:120:00:05 – 1:33:30360:06:15 0:01:00 – 0:25:45 - (No MP)180:23:410:00:05 – 0:52:40180:05:11 0:01:00 – 0:25:45 - (With MP)170:49:280:19:01 – 1:33:30180:07:20 0:01:00 – 0:10:55 Treatment :03:250:00:05 – 0:11:20250:01:16 0:00:17 – 0:06:40 Appointment :08:480:00:04 – 0:20:26300:00:53 0:00:09 – 0:03:09 Pharmacy :08:260:01:30 – 0:28:55

+

+ Analyze Define Measure Analyze ImproveControl

+ Possible reasons (selected) Unnecessary stations Unnecessary / overdoing investigations (over- processing) Unpredictable workload Huge patient load Clinic design for patient flow

+ Waiting time for VA

+ Waiting time for doctors consultation

+ Waiting time for Appointment booking

+ Improve Define Measure Analyze Improve Control

+ What have we done for the bottleneck (TOC) - VA? Leveling Quota for VA / no VA for each time slot DA FU checklist Decide what investigations to be done next visit before seeing doctor Major change of work pattern in many parties! TL clinic Add 1 ECA VA only if necessary Change of optometrist break time (prn)

+ What have we done for the bottleneck (TOC) - VA? Enhanced IT system for appointment booking Allow checkbox for investigations next visit

+ Other improvements OT appointment counter help booking next appointment Less one station for patients OT appointment staff take up PM DSC admission Free up one more appointment staff at 11 am

+ Other improvements MP allergy data entry into record Risk management Drug payment Kiosk (Finance) Less one station for patients Nursing / ECA staff help promote Utilization rate now 18.9%

+ Current state flowchart Pharmacy Registration VAVA Investigation Doctor’s consultation room MP Treatment Appt booking OT booking Shrof f Exclude rebook cases

+ Barriers Change of workflow!! Staff acceptance More work initially Results not immediately seen Results not easily seen

+ Results for in-premises time Pre-ChangePost-changep- value Diff Mean total time in HKEH 1:35:00 (0:45:00 – 2:36:00) 1:19:00 (0:23:00 – 2:22:00) 0.66  20 % % less than 90 minutes 43%64%0.04  21 % Stations (excluding pharmacy) 6 (4 – 8) 4.4 (3 – 7) 0.01  27 % Total number of old cases booked

+ Results for in-premises time

+ Results for VA Pre-Change (n=36) Post-change (n=21) p- value Difference VA inventory56 (0 – 99) 25 (0 – 48) <0.01(?)  55% VA waiting time0:42:04 (0:00:18 – 1:10:20) 0:14:15 (0:00:00 – 0:31:00) <0.01(?)  66% VA process time0:03:39 (0:01:58 – 0:12:00) 0:05:20 (0:03:00 – 0:13:00) 0.15  46%

+ Results for VA

+ Results for doctors consultation Pre-Change (n=49) Post-change (n=39) p- value Dr consultation inventory 7 (0 – 24) 6 (1 – 12) 0.09 Dr consultation waiting time 0:36:12 (0:00:05 – 1:33:30) 0:39:08 (0:03:00 – 1:16:00) 0.26 Dr consultation process time 0:06:15 (0:01:00 – 0:25:45) 0:06:40 (0:02:00 – 0:33:00) 0.53

+ Results for doctors consultation

+ Results for other stations Pre-Change (n=33 / 28) Post-change (n=38) p- value Diff Registration process time 0:00:21 (0:00:08 – 0:00:40) 0:00:27 (0:00:15 – 0:01:52) 0.08 Appointment inventory31 (0 – 62) 3.82 (0 – 14) <0.01 Appointment waiting time 0:08:48 (0:00:04 – 0:20:26) 0:01:17 (0:00:00 – 0:03:36) <0.01 Appointment process time 0:00:53 (0:00:09 – 0:03:09) 0:00:18 (0:00:09 – 0:01:05) <0.01

+ Results for other stations

+ How do our patients react? No. of complains received / month Optometry Department in DA DA waiting timeTotal Jan 2009 to Jun Jul 2011 to Dec * Including both written and verbal complaints to PRO Complaints reduced by 81% ** Appreciations by patients

+ Control Define Measure AnalyzeImprove Control

+ Monitoring Yearly review Waiting time / in-premises time Complaints DA total quota Breakdown of systems No stat VA Incorrect transfer / data entry of DA FU checklist VA measurement in children Stat trial lens

+ Challenges Expect more and more patients New / expanding services e.g. Lucentis injection Manpower – down 3 doctors

+ Thank you