1. University of Minnesota/St. Cloud Hospital Family Medicine Residency
Algebra and Clinic Scheduling Meet: How to Continually Adjust Residents' Clinic Schedules to Ensure Adequate Number of Patient Encounters
Long title
Tell you about a system we have developed to help residents meet their patient encounter numbers
Decreases time, energy, and angst
University of Minnesota/St. Cloud Hospital Family Medicine Residency

2. Objectives
Identify the factors that have an impact on the number of resident clinic sessions.
Develop an unique equation to predict the number of clinic sessions needed for each resident.
Continually adjust each resident's schedule to meet the patient encounter requirements.

3. Introductions Laura Loberg Laurie Schmidt Thomas Satre
Specialist, Patient Access
Laurie Schmidt
Residency Coordinator
Thomas Satre
Associate Director

4. ACGME Program Requirements for Family Medicine (Effective: July 2014)
“Residents must provide care for a minimum of 1650 in-person patient encounters in the FMP site.”
So let’s look at the ACGME requirements
No changes to overall number in July
Gone is the PGY-1 requirement

5. How Are We Doing?
Inadequate resident patient encounters in the FMC was the second most common citation for family medicine residencies in
1650 has been a requirement for number of years, how are we doing?

6. Deck Stacked Against Us
PGY-3 resident patient visits have decreased by 21% from 2000 to 2010
Lesko S, et al. Family Medicine 2012;44:83-89
University of Washington Family Medicine Network
Periodic surveys of WWAMI programs from 2000 to 2010
Probably many contributing factors – duty hours, EHR implementation, PCMH transformation, APPs
We have an ACGME requirement, many of us have trouble meeting it, and there are factors working against us

7. Our Program
University of Minnesota/St. Cloud Hospital Family Medicine Residency
Community based
Hospital financed
University affiliated
15 residents
Tell you about our program and the process we developed to help with this issue

8. Questions for the audience:
Largest program? Smallest program?
Who feels they devote too much time to ensuring residents’ meet the ACGME patient encounter numbers?
Who has had residents graduate with less than 1650 patient encounters?
Who has received an ACGME citation?
Who has 1650 patient encounters as a requirement for graduation?

9. Our Past Experience Numbers crisis
Graduation requirement – 1650 patient encounters
Monthly patient encounter reports
Numbers crisis
Put our residents on a production system
Unfortunately, instead of instant feedback on production, their feedback was many months to years down the road

10. Problems
Reactive decision making
The Big “What If?”

11. Need for a Better System
Proactive rather than Reactive
Set targets for each year group
Devised formula to determine number of clinic sessions needed to reach target
Monthly adjustments to number of clinic sessions for each resident
Start in the first year
Since curriculum is different for each year group, need unique equation for each year group
Discuss each of these three areas

12. Targets PGY-1……………170 patient encounters
First is the target numbers for each year
Based on historical averages for our program
Will likely differ from program to program

13. The Equation But… [(a – b)/c] d
= Number of Clinic Sessions Needed per Week
a = target number of patient encounters
b = current number of patient encounters
c = average number of patient encounters per clinic session
d = remaining weeks in academic year
But…
[(a – b)/c] d
Next is the formula to determine the number of clinic sessions each resident needs to reach target
Schedules are built week by week so we need to know how many clinics to put in each week. In the simplest form, here is the equation to determine number of clinic sessions a resident needs per week during each academic year.
Numerator – (determining number of patients left to be seen) divided by number of patients seen per clinic session = total number of clinic sessions needed to see remaining number of patients for academic year
Denominator – calculating available number of weeks left in academic year to put those clinic sessions into
a = target for respective PGY

14. Not Quite That Simple Need to:
Calculate average number of patient encounters per clinic session for each resident
Adjust for
PTO
Away rotations
Rotations with “special” clinic sessions
Rotations with set number of clinic sessions
Average patient encounters per clinic sessions – not as simple as counting appointment slots – procedures, no shows, different practice styles
Our theory was that this average would be different from resident to resident
Available weeks (denominator) – not as simple as counting number of weeks left in academic year – PTO, can’t flex number of clinic sessions during all weeks (Away rotations, set number of clinics, special clinics)
We will talk about each of these points in turn

15. Average Number of Patient Encounters Per Clinic Session
Weekly report of arrived patients per resident
Resident calendar of clinic sessions
Rotation schedule
Delete weeks with “special” clinic sessions
Invite Laura Loberg to discuss how we derived average number of encounters per clinic session

16. Calculations 86/12 = 7.17 patient encounters per clinic session
Dr Smith
86 arrived patients for Block #1
12 clinic sessions in Block #1
Rheumatology and Women’s Health (regular clinics)
86/12 = 7.17 patient encounters per clinic session

17. Report PGY-3s (Jul – Dec)
Resident
Regular Clinic Sessions
Patient Encounters
Average Patient Encounters per Clinic
Jones 39
245
6.28
Anderson 30
229
7.63
Brown 21
162
7.71
Smith 44
311
7.07
Johnson 27
200
7.41

18. PTO Adjustment [(a – b)/c] d
Subtract remaining PTO weeks from remaining weeks in academic year
[(a – b)/c]
Next, the adjustments to the simple formula - gets complicated, start with an easy one.
The simple formula
Numerator – calculating total number of clinic sessions needed to see remaining number of patients
Denominator – calculating available number of weeks left in academic year to put those clinic sessions into
Need to remove PTO weeks from denominator
d – e
e = remaining PTO weeks

19. Away Rotation Adjustment
[(a – b)/c]
d – e
Subtract remaining away rotation weeks from remaining weeks in academic year
[(a – b)/c]
d – e – f
Similarly, need to remove away rotation weeks from denominator – can’t add clinics to those weeks
How many of you allow rotations that do not include FMC clinic sessions?
This points out that you will likely need different equation for each year group.
We will demonstrate how we derived our PGY-3 equation
f = remaining away rotation weeks

20. “Special” Clinic Sessions
Inpatient Family Medicine rotation
PGY-1s have 1 clinic per week with 2 slots
ULRs have 2 clinics per week with 4 slots each
Night Float rotation
ULRs have 1 clinic per week with 4 slots
“No Show” adjustment
Certain rotations have unique clinic schedules – the average encounters per clinic session is not valid for these sessions
Like many of you, our clinic is plagued by high no show rate – this is calculated into the average encounters per clinic session but need to adjust special clinic encounters for no shows

21. “Special” Clinic Sessions
Inpatient Family Medicine rotation
PGY-1s have 1 clinic per week with 2 slots
ULRs have 2 clinics per week with 4 3 encounters each
Night Float rotation
ULRs have 1 clinic per week with 4 3 encounters
“No Show” adjustment
Slight overestimate

22. Special Clinic Session Adjustment
[(a – b)/c]
d – e – f
Subtract number of patients to be seen during remaining special clinic sessions weeks
Subtract remaining special clinic session weeks from remaining weeks in academic year
Numerator – subtract patient encounters in special clinics, the residents are virtually guaranteed to see these patients so will remove them from the equation
Denominator – subtract special clinic session weeks
{[(a – b) – (2gh) – (ij)]/c}
d – e – f – h – j
g = patients seen during Inpt Fam Med clinic session
h = Inpt Fam Med weeks remaining
i = patients seen during Night Float clinic session
j = Night Float weeks remaining

23. Rotations with Set Number of Clinic Sessions
Outpatient Family Medicine rotation
4 week rotation in PGY-3
7 “regular” clinic sessions per week
Certain rotations have set number of clinic sessions that cannot be flexed for various reasons
These will need to be subtracted
Residents may also have additional elective weeks of outpatient family medicine and those would need to be included

24. Set Number of Clinic Sessions Adjustment
{[(a – b) – (2gh) – (ij)]/c}
d – e – f – h – j
Subtract the number of clinic sessions that are set
Subtract remaining weeks with set number of clinic sessions from remaining weeks in academic year
{[(a – b) – (2gh) – (ij)]/c} – (7k)
Denominator – subtract the weeks you cannot flex
Numerator – subtract the clinic sessions in the rotations you cannot flex since you cannot flex during those weeks
Why is this outside the parentheses? – This is number of clinic sessions, not number of patients, they are regular clinic sessions
d – e – f – h – j – k
k = Outpt Fam Med weeks remaining

25. {[(a – b) – (2gh) – (ij)]/c} – (7k) d – e – f – h – j – k
Number of clinic sessions per week (excluding Outpt FM, Inpt FM, NF, and Away rotations) =
{[(a – b) – (2gh) – (ij)]/c} – (7k)
d – e – f – h – j – k
a = target number of patient encounters
b = current number of patient encounters
c = average number of patient encounters per clinic session
d = remaining weeks in academic year
e = remaining weeks of PTO
f = remaining weeks of away rotations
g = patients seen during Inpt Fam Med clinic session
h = remaining weeks of Inpatient Family Medicine
i = patients seen during Night Float clinic session
j = remaining weeks of Night Float
k = remaining weeks of Outpatient Family Medicine
Numerator
Within brackets – patients left to be seen to reach target, subtracting out patients that will be seen during special clinic sessions
Within braces – clinic sessions needed to reach target
Then subtract clinic sessions for rotations that you cannot flex
Denominator
Remaining weeks in academic year subtracting out PTO, Away rotation weeks, weeks with special clinic sessions, weeks that you cannot flex

26. Continual Adjustments
Patient encounter report
Number of patient encounters
Remaining PTO days
Average patient encounters per clinic
Rotation schedule
Away rotations
Special rotations
Rotations with set number of clinics
Invite Laurie Schmidt to discuss how we put this formula to work and continually adjust number of resident clinic sessions per week
Like to show you how to plug the numbers into the equation.
2 reports used as well as the block rotation schedule.

27. Patient Encounter Report
Jul 13
Aug 13
Sep 13
Oct 13
Nov 13
Dec 13
Jan 14
Feb 14
Mar 14
Apr 14
May 14
Jun 14
Total
Grand total
Visits
Actual
103 61 57
100 84 53
458
1158
Target 78 79
940
1650
NH Pts 3
Days Out Balance
Days Out
PTO 1 2 12
PTX
Target, Actual plus NH, and PTO.

28. Calculations {[(a – b) – (2gh) – (ij)]/c} – (7k) d – e – f – h – j – k
d – 3 – f – h – j – k
a = goal number of patient encounters
b = current number of patient encounters
c = average number of patient encounters per clinic session
d = remaining weeks in academic year
e = remaining weeks of PTO
f = remaining weeks of away rotations
g = patients seen during Inpt Fam Med clinic session
h = remaining weeks of Inpatient Family Medicine
i = patients seen during Night Float clinic session
j = remaining weeks of Night Float
k = remaining weeks of Outpatient Family Medicine
d – e – f – h – j – k
This is a PGY-3
From the encounter report we are going to pull information
1650 patients, actual, and 15 PTO days remaining.

29. Report PGY-3s (Jul – Dec)
Resident
Regular Clinic Sessions
Patient Encounters
Average Patient Encounters per Clinic
Jones 39
245
6.28
Anderson 30
229
7.63
Brown 21
162
7.71
Smith 44
311
7.07
Johnson 27
200
7.41

30. Calculations {[(a – b) – (2gh) – (ij)]/c} – (7k) d – e – f – h – j – k
{[(1650 – 1158) – (2gh) – (ij)] / 7.07} – (7k)
d – 3 – f – h – j – k
a = goal number of patient encounters
b = current number of patient encounters
c = average number of patient encounters per clinic session
d = remaining weeks in academic year
e = remaining weeks of PTO
f = remaining weeks of away rotations
g = patients seen during Inpt Fam Med clinic session
h = remaining weeks of Inpatient Family Medicine
i = patients seen during Night Float clinic session
j = remaining weeks of Night Float
k = remaining weeks of Outpatient Family Medicine
d – e – f – h – j – k

31. Hard to see from in the back.

32. Calculations {[(a – b) – (2gh) – (ij)]/c} – (7k) d – e – f – h – j – k
{[(1650 – 1158) – (2 x 3 x 1) – (3 x 0)] / 7.07} – (7 x 6.4)
26 – 3 – 6 – 1 – 0 – 6.4
a = goal number of patient encounters
b = current number of patient encounters
c = average number of patient encounters per clinic session
d = remaining weeks in academic year
e = remaining weeks of PTO
f = remaining weeks of away rotations
g = patients seen during Inpt Fam Med clinic session
h = remaining weeks of Inpatient Family Medicine
i = patients seen during Night Float clinic session
j = remaining weeks of Night Float
k = remaining weeks of Outpatient Family Medicine
d – e – f – h – j – k
FM-In: 2 clinic per week x 3 patients per clinic x 1 week remaining
NF: 3 patients per clinic x 0 week remaining
FM-Out 9 week (5 weeks elective and 4 weeks core) 13 days of PTO during elective. /by 5 – 2.6 weeks. Remaining weeks 6.4.
26 weeks remaining in academic year, 6 weeks away rotation, weeks remaining FM-In, remaining NF, remaining weeks of FM-Out.

33. Calculations {[(a – b) – (2gh) – (ij)]/c} – (7k) d – e – f – h – j – k
{[(492) – (6) – (0)] / 7.07} – (44.8) 26 – 3 – 6 – 1 – 0 –
d – e – f – h – j – k
= 2.5 clinics per week
492 remaining patients to see – 6 patients that will be seen during FM-In – 0 patients left to see during NF / 7.07 average patients per clinic - # of FM-Out Clinics Remaining
26 left in year – 3 weeks vacation remaining – 6 weeks away rotations – 1 week FM-In – 0 weeks NF – 6.4 weeks FM-Out
Tom comes back to finish up

34. Results Less crisis Less use of elective time for clinic rotations?
Clinic sessions more evenly spaced
Better access
Less unbooked slots
Efficient nurse staffing
Less crisis

35. Resident Perspective Introduction to a production system
Quarterly reports
Average number of patients per clinic session
Peer comparison
Work with advisor to increase average
Brings it down to daily view – instead of monthly view which can be affected by many more variables
Residents can compare average number of patients per clinic session with peers
Factors for low average – not just no-show rate, practice style, arranging follow-up appointments, double slots