Reducing Delays at the Appointment Mark Murray, MD, MPA Mark Murray & Associates 2209 Capitol Avenue Sacramento, CA (fax)

Lead Time Measurement Check inMA to RoomCheck 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 - means to an end….universal room usage Choreography - co-location, multi-processing staff Batch vs. continuous flow processing Measurement- cycle time/lead time Audit - sampling

The Metrics Lead Time = start to end –The sum of the cycle times + delays –For the whole process The visit The referral Medical 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

Check-in to Nurse Greet Register Routing slip Update information Obtain directions to clinic nurse Obtain chart Go to clinic Wait

Nurse/Medical Assistant to Exam Room Greet Gather chart Review/update preventative health information Educate/treat for prevention as indicated Go to clinic room, vitals Wait

Doctor In to Doctor Out Greet Open chart/computer History Exam Assessment Education Plan Documentation

Check Out to Leave Review orders Pharmacy 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

Lead Time Example

Cycle Time Study: 10/03

How do we decrease the waiting in the office…. And keep the value added time?

Office Efficiency Change Concepts Balance Supply and Demand for Non- appointment Work Synchronize Patient, Provider, and Information Predict and Anticipate Patient Needs Optimize the Environment Manage the Constraint

Balance Supply and Demand for Non-Appointment Work Predict daily demand for non-appointment work  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

Office Efficiency Change Concepts Balance Supply and Demand for Non-appointment Work Synchronize Patient, Provider, and Information Predict and Anticipate Patient Needs Optimize the Environment Manage the Constraint

Synchronize Patient, Provider, and Information Start on time and stay on time Harmonic convergence –Patient –Provider –Room –Information –Equipment –Staff Document: do the work in real time

10:0010:3011:00 Staff

Synchronization “Truisms” The whole process can only go as fast as the slowest step If 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.

Office Efficiency Change Concepts Balance Supply and Demand for Non-appointment Work Synchronize Patient, Provider, and Information Predict and Anticipate Patient Needs Optimize the Environment Manage the Constraint

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 procedures Align expertise of care teams with patient needs; plan the visit

Predict and Anticipate Patient Needs Visit level approach Communication is harder than you think “Huddle” – dialogue among team intended to get everyone “on the same page” –Stand up meeting of less than 5 minutes –Used 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 miscommunication Over 50% of errors in VA’s Root Cause Analysis traced back to miscommunication Communication basics –Familiarity of staff – call each other by name –Listen to understand, not to plan next comeback –Communicate what you see and know –Explicitly ask everyone for input

Office Efficiency Change Concepts Balance Supply and Demand for Non- appointment Work Synchronize Patient, Provider, and Information Predict and Anticipate Patient Needs Optimize the Environment Manage the Constraint

Optimize the Environment Adequate number of rooms Optimize Rooms –Open rooming –Fully stocked rooms –Standardize layout, supplies – Kanban Move equipment to the patient Optimize Space Signals for equipment

Office Efficiency Change Concepts Balance Supply and Demand for Non-appointment work Synchronize Patient, Provider, and Information Predict and Anticipate Patient Needs Optimize the Environment Manage the Constraint

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