1. Clinic Patient Flow Study Final Report Presentation
Urology at Livonia Center for Specialty Care
Rebekah Andrews | Kaywee lian | Kristen Ydoate
Team 6
December 13th, 2016

2. Introduction Client: Clinic At Livonia Center for Specialty Care
Director: John Wei, MD Manager: Karen Moore
Professor of Urology Ambulatory Care Manager Intermediate
Coordinators: Process and Operations Analysis Office
Mary Duck Kyle Worley
Industrial Engineer Expert Lean Coach Industrial Engineer

3. Urology Clinic at Livonia Provides General Urologic Care8
Medical Assistants 4
Registered Nurses
1-5
Providers, depending on the schedule

4. General Patient Flow

5. Patient Stratification by Patient/Visit Type, and Patient Diagnosis
Urology Clinic Patient
Patient/Visit Type
Patient Diagnosis
New Patient
Return Visit
Consultation
Procedural
Kidney Stones
Benign Prostatic
Hyperplasia
Urinary Tract Infection
Incontinence
Erectile Dysfunction
Elevated Prostate-Specific Antigen
Hematuria
Others
Nurse Visit

6. Decision Tree for Patient Scheduling Time
Clinic utilizes a pre-arrival scheduling approach

7. Current Process Flow Has Several Issues
Disparity between scheduled and actual time
Lack of quantifiable data
Unknown areas of waste

8. Goals and Objectives
Background: Clinic wants to understand the patient flow process better through collecting information on timing of each step, and where waste resides in the current process.
Goals:
Mention of scope
Quantify Current Patient Flow
Identify Wastes and Opportunities for Improvement

9. Combined Time Study Form
Methods
Observations
Literature Review
MiChart Data
Combined Time Study Form
Interviews
Surveys

10. Data Analysis Value Stream Mapping MiChart Analysis
Pareto Chart of Wastes

11. 4 Value Stream Mapping New Patients Return Visit Consultations
Return Visit Procedural
Nurse Visits
Value Stream Maps

12. Value Stream Mapping Return Procedural Patient Flow Most Inefficient
Spend the most time waiting – 38.95% of visit is spent with staff
Can be attributed to additional amount of staff encounters
Other patients have 57% VA Time
Value Stream Map Summary Table Stratified by Patient and Visit Type
Source: Time Studies Data from 11/2/ /31/16, N = 594

13. Value Stream Mapping
Monday, Tuesday, and Wednesdays Experience Longer MA and Provider  (Mondays and Tuesday) Wait Times
Average MA wait time for M/T/W = min compared to min
Tuesday takes 1.23 times increase for Vitals/Tests time
M/T/W – clinic schedules more patients because more providers
Value stream map totals across day of the week
Source: Time study data 10/21/ /15/16, N = 513

14. Value Stream Mapping Excess Wait Time for MA, Nurse, and Provider
Under team assumption – 5 minutes is acceptable wait time
All 3 staff types exceed this time
High standard deviations
Nurse wait times because scheduled and spontaneous tasks
Value Stream Map Summary Table for Steps in the Patient Flow Process in Minutes
Source: Time Studies Data from 11/2/ /31/16, N = 548

15. MiChart Analysis
Patients with elevated PSA spend the longest time in the clinic
Interviews reveal a possible explanation is elevated PSA patients are often sensitive conversations and involve teaching
MiChart data shows that 6 is significantly higher than 5, 3 and 1
Source: Michart Data from 11/2/ /31/16, N = 7500; 1 = Stones, 2 = Benign Prostatic Hyperplasia, 3 = Urinary Tract Infection and Cysts. 4 = Incontinence, 5 = Erectile Dysfunction, 6 = Elevated PSA, 7 = Hematuria

16. Pareto Chart
Forms of waste identified from analyzing time study and process diagnostic form data are:
Wait times exceeding 5 minutes
Actual times exceeding allotted times
>2 provider interactions
Added-on procedures

17. Pareto Chart Top 3 Forms of Waste
Patients spend >60 minutes in the clinic
>5 minute wait for MA
> 5 minute wait for provider
Figure 6: Pareto chart of the frequency of waste within the clinic.
Source: Time study data 10/21/ /15/16; N = 594

18. Waste #1: Patients Spend >60 Minutes in the Clinic
Data Summary
Median = 61 minutes
Mean = minutes
54%
of patients spend > 60 minutes at the clinic
60%
patients who spend > 60 minutes, spend up to 90 minutes at the clinic
Time spent is defined as time the patient checks-out and pre-arrival time

19. Waste #1: Patients Spend >60 Minutes in the Clinic
Stratified by Provider – Large variation between providers
Certain providers have more than 50% of their patients spending more than 60 minutes at the clinic
Same providers have highest average patient clinic times
Goal is < 60 min – large area for improvement
Average time in clinic by provider
Source: Time study data 10/21/ /15/16; N = 240
Percent of patient visits greater than 60 minutes by provider
Source: Time study data 10/21/ /15/16; N = 240

20. Waste #2: >5 Minute Wait for MA
Data Summary
Median = 8 minutes
Mean = 11.2 minutes
49%
of patients experience > 5 minute waits for MA
41%
of wait times are over 10 minutes

21. Waste #2: >5 Minute Wait for MA
Stratified by Time of Day
Excess Wait Times for MA at start of day and during lunch breaks
Percent of MA wait times greater than 5 minutes across time of day
Source: Time study data 10/21/ /15/16; N = 296

22. Waste #3: >5 Minute Wait for Provider
Data Summary
Median = 3 minutes
Mean = 8.1 minutes
69%
45%
waited over 10 minutes*
waited over 15 minutes*
*of patients who had to wait over 5 minutes

23. Waste #3: >5 Minute Wait for Provider
Stratified by Provider - Large variation between providers
Providers 2,5, and 7 were higher than average
Providers 4,12, and 15 had significantly lower than average
Only 12 had an average < 5 minutes
Average wait time by provider
Source: Time study data 10/21/ /15/16; N = 79
Percentage of time providers are late to appointment
(Source: Time study data 10/21/ /15/16; N = 79)

24. Waste #3: >5 Minute Wait for Provider
Scheduled 15 Minutes Appointment Insufficient for All Patient Care Tasks for a Single Patient
Sufficient for 30 but conservative estimate
Indirect from staff surveys
Provider indirect and direct care time by provider, 15 minute appointment
Source: Time study data 10/21/ /15/16; N = 79
Provider indirect and direct care time by provider, 30 minute appointment
Source: Time study data 10/21/ /15/16; N = 79

25. Waste #3: >5 Minute Wait for Provider
Non-standardized Handling of Indirect Patient Care and Add-on Procedures another Source of Variability
Providers complete required tasks:
Before seeing a patient
While seeing a patient
During breaks in their schedule
Providers accept add-on procedures:
Perform immediately after consult
Reschedule different appointment

26. Summary of Conclusions
Value Stream Mapping
MiChart Data
Pareto Chart
RV procedurals spend the longest time in clinic
Mondays, Tuesdays, and Wednesdays see a higher average wait time for MA’s
Longest wait time occur while waiting for Nurse, MA for vitals, and Providers, respectively
RV patients with elevated PSA diagnosis spend the longest time in clinic
Top 3 Wastes:
Patients spend >60 minutes in the clinic
>5 minute wait for MA
> 5 minute wait for provider

27. Summary of Conclusions
#1: Patients spend >60 minutes in the clinic
#2: >5 minute wait for MA
#3: > 5 minute wait for provider
54 % spend > 60 minutes
Large variations by provider
Big opportunity for improvement (goal <60)
49% wait > 5 minutes
Large outliers
High wait times at the start of the day and lunch hours
Large outliers
Variation between providers
15 minute allotted time is exceeded when indirect care is considered
No standardization for indirect care or add-on procedures

28. Recommendations RV Procedural Patients Integration of Tasks
Currently there are 6 staff interactions
Cut down number of interactions by integrating tasks
Ex. MA’s are trained to obtain consent for procedures
Parallelization
Currently clinic is conducted serially
Conduct tasks concurrently to reduce wait times
Ex. Nurse obtains consent while MA finishes vitals and interview

29. Recommendations
Longer MA Wait Times on Mondays, Tuesdays and Wednesdays
Revise Staffing Levels
Cope with greater amount of patients
Reassign Providers
Move providers to less busy days
Smoothen out demand for MA’s

30. Recommendations Longer Nurse Wait Times
Assign Nurses to Roles Versus Providers
One role to assist any providers (obtain consent and nurse teaching)
Other role is nurse visits

31. Recommendations PSA Patient Spend Longer Times at the Clinic
Conduct a Follow-up Study
Clearly identify why these patients spend more time in clinic
May need to change scheduling of PSA patients

32. Recommendations Excess Wait Times for MA’s
Begin Appointments at 8:30 AM Versus 8:00 AM
Allow more time for MA’s to prepare exams rooms
Increase Staffing at the Start of the Day
Assign some MA’s to clinic set-up and others to attend to patients
Examine Assignment of MA to Patients for Vitals
Determine if there are any inefficiencies in the current MA assignment process

33. Recommendations Excess Wait Times for Providers
Increase 15 Minute Appointment Times
Increase by increments of 5 minutes
Evaluate wait-times as consultation time increases
Standardize Indirect Patient Care Tasks
Complete immediately after each patient is seen
Reduce variability between providers
Standardize Add-on Procedures
Schedule patients for add-on procedures during breaks in a provider’s schedule – not immediately after consult

34. Project Goals Goals: Quantify Current Patient Flow
Mention of scope
Quantify Current Patient Flow
Identify Wastes and Opportunities for Improvement

35. Expected Impact
Describe the current patient flow process and where waste resides
Provide clear visualization of the overall patient process
Guide the clinic in future process improvement efforts

36. Thank you!
Questions?

37. Appendix
Value Stream Maps
Staff Survey Results
References

38. Value Stream Map: New Patients

39. Value Stream Map: Return Visit Consultation

40. Value Stream Map: Return Visit Procedural

41. Value Stream Map: Nurse Visit

42. Waste #2: MA Wait Times Frequency chart of MA wait times
Source: Time study data 10/21/ /15/16; N = 519

43. Waste #3: Provider Wait Times
Wait time for provider when providers were late to the appointment
Source: Time Study Data 10/21/ /15/16, N = 79

44. Waste #5: Late Patients
Histogram of Patient Late Times for Patients That Arrived Past Pre-Arrival Time
Source: Time Study Data 10/21/ /15/16; N = 63

45. Staff Surveys

46. Staff Surveys

47. References
[1] Matt Bovberg et al., “Analyzing Patient Flow and Process Waste in the General Thoracic Surgery Clinic”, IOE Senior Design Projects, Winter 2014, April 2014
[2] Altarium Institute, “Applying Lean to Improve the Patient Visit Process at Three
Federally Qualified Health Centers”, July 2011
[3] Lori Rutman et al., “Improving Patient Flow Using Lean Methodology: an Emergency
Medicine Experience”, Springer International Publishing, October 28th 2015.
[4] B. T. Denton and D. T. Brian, Handbook of healthcare operations management: Methods and applications. New York, NY: Springer New York, 2013, ch. 3, sec. 2.
[5] L. Jiang and R. E. Giachetti, "A queueing network model to analyze the impact of parallelization of care on patient cycle time," Health Care Management Science, vol. 11, no. 3, pp. 248–261, Dec
[6] A. M. Association, "How to handle patients who are always late," [Online]. Available: Accessed: Dec. 6, 2016.
[7] R. R. Lummus, R. J. Vokurka, and B. Rodeghiero, "Improving quality through value stream mapping: A case study of a physician’s clinic," Total Quality Management & Business Excellence, vol. 17, no. 8, pp. 1063–1075, Oct