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

2. 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
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3. 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
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4. 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
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5. 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
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6. 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
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7. The Team’s Project Scope: Cardiac Surgery Clinic & Echo Lab
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8. 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
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9. Methods for Data Collection
Literature Search
Observations
Clinic
Echo tests
Clinic time studies
Clinic patient forms
Medical staff interviews
Clinic
Echo tests
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10. Cardiac Surgery Clinic
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11. 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
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12. Findings: Clinician Interviews
Conducted throughout our project, as needed
Rooming MAs
Nurses
Echo Lab staff
Validated observations and data with clinician perceptions of clinic
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13. 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
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14. 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

15. Findings: Clinic Time Studies
March
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
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16. Findings: Clinic Patient Forms
March
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
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17. A. B.

18. 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
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
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19. Validation of patient form data
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20. Future Plans No statistically significant differences between surgeons
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21. 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
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22. Echocardiography (Echo) Lab
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23. 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
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24. Transthoracic Echo (TTE or surface) Flow (Draft)

25. 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
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26. 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
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27. Thank You! Any Questions?
Chanmee Chung Jishnu Desai Julie Merz Greyson Schultz
Team 5 IOE 481 Senior Design Final Presentation

28. Appendix
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29. 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: (16) + 5 = min

30. 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

31. 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) (9) + .17(9) + .08(9) = min.

32. 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(11) = 9.48 min.

33. A. B.

34. 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

35. 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

36. 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

37. 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