1. Best Practice Strategies for Maximizing Clinic Efficiency: Part 2
Missouri Family Planning Conference Webinar Series
Elizabeth Jones, MPA
June 22, 2017

2. Learning Objectives
As a result of this session, participants will be able to:
Examine the relationship between clinic efficiency and sustainability
List best practices for appointment scheduling

3. Rationale for Focusing on Clinic Efficiency

4. Doing more with less
“The increased demand placed on public health organizations to perform better and improve health outcomes with less funding cannot be achieved under the design and operation of the current system.”
Riley, J et. al Realizing transformational change through improvement in public health. Journal Public Health Management Practice; 16 (1):72-78.

5. Enhancing the use of resources in order to achieve better outcomes
What is efficiency?
Enhancing the use of resources in order to achieve better outcomes

6. Clinic Efficiency SUSTAINABILITY
Increased capacity
More patients served
Improved patient access and experience

7. Appointment Systems

8. Appointment Scheduling
The ideal appointment schedule should:
Be responsive to the needs of both staff and patients
Create a steady stream of patients throughout the workday
Maximize staff productivity
Minimize wait time

9. Appointment Scheduling
An appointment schedule reflects both capacity and demand
Ultimately will impact:
Provider productivity
Cycle time
Clinic flow
Patient/staff wait time
Fiscal management
Patient/staff satisfaction
Patient health outcomes

10. Best Practices in Scheduling
Reducing schedule complexity
Reducing scheduling restrictions
Reducing appointment type variability
Standardizing appointment type/length
Considering average clinician time per visit, not total cycle time
Not scheduling too far out
Creating contingency plans
Establishing a policy for late patients
Gupta D, Denton B Appointment scheduling in health care: challenges
and opportunities. IIE Transactions; 40, 800–819.

11. How do you design an appointment template that maximizes capacity and access?

12. Sample Health Center: View Royal Family Planning
A standalone Title X family planning program operating out of a community-based organization
Staffing:
2 Full-time Nurse Practitioners
1 Medical Assistant, 2 Clerks, and 1 Program Director
Year
Unduplicated users
Visits
Average visits per user
2014
2066
4522
2.19
2015
2007
4215
2.10
2016
1925
3885
2.02
This example allow us to design a template that maximizes access, meets goals and ensures patient and staff satisfaction. Through out this process we will stop and use your pre –work to analyze and begin to redesign your appointment
Overall this is a typical FP program from what we have seen. Here is some basic data

13. Identified Challenges
Users and visits have been declining for the past three years
Not bringing in sufficient revenue to cover fixed costs
Data on "no shows” is limited
No show rate is estimated to be 35%
On average, new clients wait approximately 3 days for an appointment
As seen in the previous slides, further drill down of users and visits revealed that adolescents are declining too.
FPAR will show annual figures; will show decline by age, race, etc…
The site has not been collecting data regularly – the clinic director estimates no shows but she isn't sure and she looked at the template to see how long for a new appointment. In addition, the front desk registration clerk said it was about that much time.

14. Appointment Schedule Design
Develop family planning patient visit goals
Assess clinic capacity to ensure visit goals are realistic
Select schedule methodology
Select schedule framework
Incorporate scheduling principles that promote efficiency
This is a systematic approach to developing an appointment template that maximizes access
It is a data driven process that begins with meeting goals and achieving fiscal sustainability
Link to fiscal sustainability

15. Step 1: Set user targets
What is the target for unduplicated patients served and visits annually?
How many visits were there last year?
Have these visits and users been increasing or decreasing?
What is the number of women and men in need of family planning services in the community?
The first step in designing an appointment system is to establish the user and visit goals for the site. This starts with looking at any funder required goals for users. Then examining the historical pattern for visits
Need to work with your fiscal officer to establish goals….Key is to have program and fiscal work together.

16. View Royal Family Planning: Funder Expectations
Funded to provide 4,800 visits to 2,400 users annually
An average of 2.0 visits per user
Each clinician works 200 days per year
This assumes…
12 visits per day multiplied by 2 clinicians multiplied by 200 days per year
Total capacity is 4,800 visits per year
It is important to calculating Capacity that you understand the average contact time for the clinician
18 is created by each clinician is directly available to work for 6.5 hour in a day and that they can average 2.75 visits per hour….Based on contact time and discussion with clinician – Contact time is 16 minutes per visit….
Wow, why if the capacity is 7200 they are only seeing 3885….That is the demand…

17. Polling Questions
What do you think about View Royal Family Planning’s funder expectations?
Target capacity is too low
Target capacity is just right
Target capacity is too high and not realistic
Not sure

18. Step 2: Assess capacity & demand
Capacity is the number of clients that can be seen in a designated time frame
It is a function of the total resources of an agency
Demand is the total client requests for care
Basic definition….but it is important

19. Step 2: Clinic capacity & demand
Key Resources – Capacity
Number of clinician FTEs
Clinical hours available to provide services
Average clinician time per client visit
Other factors that impact capacity: physical facilities, equipment, and processes
Key Resources – Demand
Client request for services
Percent of users seen per day
Variation by day, season, and clinician
More details.

20. View Royal Family Planning: Calculating Capacity
Average Clinician Contact Time
16 minutes
Average Possible Visits per Hour
60 minutes / 16 minutes per patient = 3.75 patients per hour
Productive Hours per Day
7.5 hours X 80% = 6 hours
Maximum Capacity per Day
3.75 patients per hour X 6 hours = patients per day
Total Capacity per Year
22.5 patients per day X 200 days = 4,500 visits per clinician
With 2 clinicians, total capacity equals 9,000 visits per year
It is important to calculating Capacity that you understand the average contact time for the clinician
18 is created by each clinician is directly available to work for 6.5 hour in a day and that they can average 2.75 visits per hour….Based on contact time and discussion with clinician – Contact time is 16 minutes per visit….
Wow, why if the capacity is 7200 they are only seeing 3885….That is the demand…

21. Audience Question
Chat it in! What is a realistic daily goal of patients per day per clinician?

22. View Royal Family Planning: Calculating Capacity
Goal capacity is 18 visits per day per clinician
There are a 2 full-time clinicians (nurse practitioners)
Each clinician works 200 days per year
Thus, the total capacity is…
18 20-minute visits per day multiplied by 2 clinicians multiplied by 200 days per year
Total capacity is 7,200 visits per year
It is important to calculating Capacity that you understand the average contact time for the clinician
18 is created by each clinician is directly available to work for 6.5 hour in a day and that they can average 2.75 visits per hour….Based on contact time and discussion with clinician – Contact time is 16 minutes per visit….
Wow, why if the capacity is 7200 they are only seeing 3885….That is the demand…

23. What is happening that View Royal Family Planning is not operating at capacity?

24. View Royal Family Planning: Review of Key Operations
Open Monday through Friday 8:30am to 5:00pm
Visits in 2016 – 3,885
2 full-time Nurse Practitioners
Estimated no show rate is 35%
Estimated wait for a new client is close to 3 business days
Visits and users have been declining over the past 3 years
This a review of the clinic we are working on. Why is demand/visit of 3885 when capacity is 7200 visits per year? Before examining outreach efforts, need to examine the integral systems and the first system is the appointment template as it creates access. If the template is not designed to maximize access….could be reason for declining numbers
o calculating Capacity that you understand the average contact time for the clinician
18 is created by each clinician is directly available to work for 6.5 hour in a day and that they can average 2.75 visits per hour….Based on contact time and discussion with clinician – Contact time is 16 minutes per visit….
Wow, why if the capacity is 7200 they are only seeing 3885….That is the demand…

25. View Royal Family Planning: Current Clinician Schedules
Time
Visit Category
9:00
New Client Exam/Annual
9:30
10:00
Problem
10:30
11:00
11:30
Time
Visit Category
1:15
New Client Exam/Annual
1:45
Recheck/Method
2:00
Recheck/Method/Minor Problem
2:15
2:30
Pregnancy Test
2:45
3:00
3:15
Problem
3:45
What doesn't work about this schedule if they want to see 18 clients a day? How does this schedule impact adolescents
What are the factors
They schedule 18 appointment – what about no shows
No appointments for new clients after 2:15
No late hours
No lunch time hours
Does the MA have the capacity – does it become a bottle neck
No Shows
Limiting visits by type
So how do you go about changing…Lets look at the basics
Note: Schedules are the same for each nurse practitioner

26. Chat it in! What potential issues do you see with this schedule?
Audience Question
Chat it in! What potential issues do you see with this schedule?

27. Step 3: Select schedule methodology
Appointment Visit
Single Interval
Multiple Interval
Design of Schedule
Block or Wave Interval
Modified Wave
This is an overview of the two areas that you look at when designing a template…first how you set up your appointments….how long they take and then the design of the appointment template. The time you start..when you end if you double book….

28. Step 3: Appointment methodology
Single Interval – Each visit receives the same amount of time on the schedule regardless of the type of visit
Multiple Interval – Different visit types receive different amounts of time on the schedule
Recommendation: Single interval without limits to maximize flexibility and access
This is an overview of the two areas that you look at when designing a template…first how you set up your appointments….how long they take and then the design of the appointment template. The time you start..when you end if you double book….

29. Step 3: Appointment methodology
Wave Interval – Appointments are double booked during the first portion of the session with no appointments scheduled during the later hours; often called “front loading”
How do you set up the start end and number of appointments in the actual template
Block-pros- clients arrive at the same time; minimal administrative effort; slightly more predictable than all walk ins.
Cons- excessive client waiting time; chaotic at start of clinic; staff-centered to the detriment of clients
WAVE
Pros- this ‘double-booking” can allow the clinician to begin serving the revisit while clinical assistant prepares the longer visit. Allows for smoothing out of schedule; limits the impact of running behind; flexibility. Low administrative effort.
Cons Could have long client waiting time; need to make sure first client is seen on time; periodically chaotic.
STREAM—
Pros-- steady flow of clients and limited client wait time
What would a stream look like
Would we need to add M
Cons—limited time for clinician to catch up if there is a longer client.

30. Wave Interval Schedule
Time
Visit Category
9:00
New Client Exam/Annual
Problem
10:30
Time
Visit Category
1:15
New Client Exam/Annual
Recheck/Method
Recheck/Method/Minor Problem
2:45
Pregnancy Test
Problem
What doesn't work about this schedule if they want to see 18 clients a day? How does this schedule impact adolescents
What are the factors
They schedule 18 appointment – what about no shows
No appointments for new clients after 2:15
No late hours
No lunch time hours
Does the MA have the capacity – does it become a bottle neck
No Shows
Limiting visits by type
So how do you go about changing…Lets look at the basics
Note: Schedules are the same for each nurse practitioner

31. Step 3: Appointment methodology
Wave Interval – Appointments are double booked during the first portion of the session with no appointments scheduled during the later hours; often called “front loading”
Modified Wave Interval – Appointment times are double booked, but over shorter time frames to allow for traffic control
How do you set up the start end and number of appointments in the actual template
Block-pros- clients arrive at the same time; minimal administrative effort; slightly more predictable than all walk ins.
Cons- excessive client waiting time; chaotic at start of clinic; staff-centered to the detriment of clients
WAVE
Pros- this ‘double-booking” can allow the clinician to begin serving the revisit while clinical assistant prepares the longer visit. Allows for smoothing out of schedule; limits the impact of running behind; flexibility. Low administrative effort.
Cons Could have long client waiting time; need to make sure first client is seen on time; periodically chaotic.
STREAM—
Pros-- steady flow of clients and limited client wait time
What would a stream look like
Would we need to add M
Cons—limited time for clinician to catch up if there is a longer client.

32. Wave Interval Schedule
Time
Visit Category
9:00
New Client Exam/Annual
Problem
9:45
10:30
11:15
Time
Visit Category
1:15
New Client Exam/Annual
Recheck/Method
2:00
Problem
Recheck/Method/Minor Problem
2:45
Pregnancy Test
3:30
What doesn't work about this schedule if they want to see 18 clients a day? How does this schedule impact adolescents
What are the factors
They schedule 18 appointment – what about no shows
No appointments for new clients after 2:15
No late hours
No lunch time hours
Does the MA have the capacity – does it become a bottle neck
No Shows
Limiting visits by type
So how do you go about changing…Lets look at the basics
Note: Schedules are the same for each nurse practitioner

33. Step 3: Appointment methodology
Wave Interval – Appointments are double booked during the first portion of the session with no appointments scheduled during the later hours; often called “front loading”
Modified Wave Interval – Appointment times are double booked, but over shorter time frames to allow for traffic control
Stream Interval – Clients given appointments with equal intervals between appointments; limited double booking
Recommendation: Stream as much as possible
How do you set up the start end and number of appointments in the actual template
Block-pros- clients arrive at the same time; minimal administrative effort; slightly more predictable than all walk ins.
Cons- excessive client waiting time; chaotic at start of clinic; staff-centered to the detriment of clients
WAVE
Pros- this ‘double-booking” can allow the clinician to begin serving the revisit while clinical assistant prepares the longer visit. Allows for smoothing out of schedule; limits the impact of running behind; flexibility. Low administrative effort.
Cons Could have long client waiting time; need to make sure first client is seen on time; periodically chaotic.
STREAM—
Pros-- steady flow of clients and limited client wait time
What would a stream look like
Would we need to add M
Cons—limited time for clinician to catch up if there is a longer client.

34. Single Stream Interval Schedule
Time
Visit Category
9:00
New Client Exam/Annual
9:20
9:40
Problem
10:00
10:20
10:40
11:00
Recheck/Method/Problem
11:20
Time
Visit Category
1:20
New Client Exam/Annual
1:40
Recheck/Method
2:00
Recheck/Method/Minor Problem
2:20
2:40
Pregnancy Test
3:00
3:20
3:40
Problem
What doesn't work about this schedule if they want to see 18 clients a day? How does this schedule impact adolescents
What are the factors
They schedule 18 appointment – what about no shows
No appointments for new clients after 2:15
No late hours
No lunch time hours
Does the MA have the capacity – does it become a bottle neck
No Shows
Limiting visits by type
So how do you go about changing…Lets look at the basics
Note: Schedules are the same for each nurse practitioner

35. Step 4: Select a scheduling framework
Traditional – “Do last month’s work today”
Carve Out – “Do some of today’s work today”
Open Access – “Do today’s work today”
Recommendation: Strive for open access
Traditional: “Do last month’s work today”
Saturated schedules
Triage and rework often necessary with high intensity of resources
Multiple appointment types
Needs for “urgent” “routine” and “intermediate” patients not met
Capacity: overbook and send patients elsewhere
Continuity: if patient is able to wait for appointment
Carve-Out Model: “Do some of today’s work today”
Predict demand for “urgent” visits and protect future appointment times for urgent needs”
Reserve space for “urgent” in attempt to meet demand
Open Access or Advanced Access – “Do Today’s work today”
Paradigm shift – protect the future
No distinction made between urgent and routine
Backlog eliminated
One or a few appointment types

36. Open Access
A patient’s ability to schedule an appointment with their provider the same day or within a couple of business days
Based on one guiding principle: “Do today’s work today”
Requires a systematic paradigm shift in clinic operations and culture
Some basics about Open Access….A real paradigm shift ..This does not mean a walk in clinic….Clients are given an appointment

37. Single Stream Interval Schedule (Before)
Time
Visit Category
9:00
New Client Exam/Annual
9:20
9:40
Problem
10:00
10:20
10:40
11:00
Recheck/Method/Problem
11:20
Time
Visit Category
1:20
New Client Exam/Annual
1:40
Recheck/Method
2:00
Recheck/Method/Minor Problem
2:20
2:40
Pregnancy Test
3:00
3:20
3:40
Problem
What doesn't work about this schedule if they want to see 18 clients a day? How does this schedule impact adolescents
What are the factors
They schedule 18 appointment – what about no shows
No appointments for new clients after 2:15
No late hours
No lunch time hours
Does the MA have the capacity – does it become a bottle neck
No Shows
Limiting visits by type
So how do you go about changing…Lets look at the basics
Note: Schedules are the same for each nurse practitioner

38. Single Stream Interval Schedule: Clinician 1
Time
Visit Category
8:40
New Client Exam/Annual
9:00
9:20
Problem
9:40
10:00
10:20
10:40
11:00
Recheck/Method/Problem
11:20
11:40
Time
Visit Category
1:00
New Client Exam/Annual
1:20
1:40
Recheck/Method
2:00
Recheck/Method/Minor Problem
2:20
2:40
Pregnancy Test
3:00
3:20
3:40
Problem
4:00

39. Single Stream Interval Schedule: Clinician 2
Time
Visit Category
8:40
New Client Exam/Annual
9:00
9:20
Problem
9:40
10:00
10:20
10:40
11:00
Recheck/Method/Problem
11:20
11:40
Time
Visit Category
12:00
New Client Exam/Annual
12:20
12:40
Recheck/Method
2:00
Recheck/Method/Minor Problem
2:20
2:40
Pregnancy Test
3:00
3:20
3:40
Problem
4:00

40. Step 5: Incorporate principles of efficiency
Reduce schedule complexity
Reduce scheduling restrictions
Reduce appointment type variability
Standardize appointment type/length
Consider average clinician time per visit
Limit availability of schedule
Don’t schedule too far out
Incorporate no show rate into appointment schedule template

41. Single Stream Interval Schedule: Clinician 1
Time
Visit Category
8:40
Family Planning Visit
9:00
9:20
9:40
10:00
10:20
10:40
11:00
11:20
11:40
Time
Visit Category
1:00
Family Planning Visit
1:20
1:40
2:00
2:20
2:40
3:00
3:20
3:40
4:00

42. Single Stream Interval Schedule: Clinician 2
Time
Visit Category
8:40
Family Planning Visit
9:00
9:20
9:40
10:00
10:20
10:40
11:00
11:20
11:40
Time
Visit Category
12:00
Family Planning Visit
12:20
12:40
2:00
2:20
2:40
3:00
3:20
3:40
4:00

43. Step 5: Incorporating clinic no-show rate
Target Capacity: 18 visits per day
No Show Rate: 35%
18 visits per day x .35 no show rate = 6.3 visits will not show
In order to operate at capacity, the appointment schedule should make 24 appointments available each day per clinician
However, if 24 clients showed on one day, would staff be able to serve them all?
Traditional: “Do last month’s work today”
Saturated schedules
Triage and rework often necessary with high intensity of resources
Multiple appointment types
Needs for “urgent” “routine” and “intermediate” patients not met
Capacity: overbook and send patients elsewhere
Continuity: if patient is able to wait for appointment
Carve-Out Model: “Do some of today’s work today”
Predict demand for “urgent” visits and protect future appointment times for urgent needs”
Reserve space for “urgent” in attempt to meet demand
Open Access or Advanced Access – “Do Today’s work today”
Paradigm shift – protect the future
No distinction made between urgent and routine
Backlog eliminated
One or a few appointment types

44. Single Stream Interval Schedule: Clinician 1
Time
Visit Category
8:40
Family Planning Visit
9:00
9:20
9:40
10:00
10:20
10:40
11:00
11:20
11:40
Time
Visit Category
12:50
Family Planning Visit
1:10
1:30
1:50
2:10
2:30
2:50
3:10
3:30
3:50
4:10
4:30

45. Single Stream Interval Schedule: Clinician 2
Time
Visit Category
8:40
Family Planning Visit
9:00
9:20
9:40
10:00
10:20
10:40
11:00
11:20
11:40
Time
Visit Category
12:00
Family Planning Visit
12:20
12:40
1:50
2:10
2:30
2:50
3:10
3:30
3:50
4:10
4:30

46. Step 5: Incorporate principles of efficiency
Establish a script
Customer service skills are essential
Create contingency plans
Establish a policy for late clients
Establish policy for early clients
Information to be shared with client:
Appt policies
How much time to expect
What to bring
How to get there
Cost/payment details including donation policy,
forms to complete prior to arrival,
partners welcome,
kid policy,
food/drink policy
Use the following script if a patient is late for an appointment:
"Your scheduled appointment was at _____ and it is now ______.  Your doctor has moved on to his next patient. He/She would be happy to work you in between patients or at least by the end of the session (morning/afternoon). 
You also have the option of rescheduling to another day or time or if you would like I could check to see if there is another provider that could see you

47. Summary of Changes: View Royal Family Planning
Calculated visit capacity per provider
All appointments 20 minutes versus 15 and 30 depending on visit type
Spread schedule throughout the day
Removed visit type restrictions
Expanded schedule to reflect open access and account for no shows
So lets see what we did to the schedule to make it work
Visit capacity of goal of 18 visits per day based on 2.75 visits per hour during 6.5 hours per day (16 minutes per client)
Expanded the time of appointment and made all appointments consistent
Expanded from 18 visits to 22 to account for no shows
Average contact time of

48. Other Considerations Managing “no shows” Using scripts for scheduling
Assigning scheduling-related tasks to a call center or dedicated staff member
Example: Reminder calls
Gupta D, Denton B Appointment scheduling in health care: challenges
and opportunities. IIE Transactions; 40, 800–819.

49. Questions?
Type questions on the panel to your right or raise your hand

50. Elizabeth Jones ejones@nfprha.org 202-251-2645
Thank you!
Elizabeth Jones