1. Supported by the Childrens Hospital Foundation Assessing Patient Throughput at Kosair Childrens Hospital Clinics Craig Johnson University of Kentucky Martin School of Public Policy and Administration Masters in Health Administration Capstone Project Spring 2008

2. Supported by the Childrens Hospital Foundation Background: Patient Throughput 67 million annual visits at hospital- based teaching ambulatory clinics (McCaig, 1997) Teaching organizations = longer waits (Leddy et al., 2003) Unorganized patient flow processes = increased wait times and decreased patient satisfaction (Roundeau, 1998) Interruptions during a patients exam negatively impact workflow (Brixey et al., 2007)

3. Supported by the Childrens Hospital Foundation Background: Patient Throughput Up to 40% of outpatient time could be spent inefficient processes (Patel et al., 2002) High patient no show rates = drained resources, hindered productivity, and loss revenues (Ginwala, 2004) Significantly reduce resident physician learning opportunities (Guse et al., 2003) Strategies to improve: –Mailed reminder cards (Croomer et al., 1987) –Automated telephone reminders (Almog et al., 2003) –Termination and charge policies (Ginwala, 2004) –Open access scheduling (Murray et al., 2000)

4. Supported by the Childrens Hospital Foundation Project Purpose Assess the clinics current throughput processes through direct observations and data collection AND Assist clinic leadership with data analysis, industry benchmarking, and recommendations for improvement

5. Supported by the Childrens Hospital Foundation Background: KCH Clinics 5 outpatient clinics all operate in one suite –Neurology –Genitourinary (GU) –Dermatology –Ear, Nose, & Throat (ENT) –Surgery Clinics rotate throughout the month, morning & afternoon clinics MondayTuesdayWednesdayThursdayFriday 4 NEURO: Puri GU: Casale 5 GU: Casale 6 ENT: Goldman DERM: Kasteler 7 NEURO: McKiernan SURG: Wiesenaur 8 NEURO: Farber

6. Supported by the Childrens Hospital Foundation Background: KCH Clinics KCH employs a clinic staff which operates all 5 clinics –2 Registered Nurses (RNs) –3-4 Clinic Office Specialists KCH does not directly employ the physician staff –University of Louisville

7. Supported by the Childrens Hospital Foundation Background: Patient Population Children ages 0 – 18 Participants of medical assistance programs or self paying VisitsFY2007 4,038 FY2008 4,100

8. Supported by the Childrens Hospital Foundation Methods Patient Flow Analysis –Flowchart Time Study –Process, Wait, & Face times Patient Satisfaction Survey –Point of service technique No Show Rates –Existing data General Observations –General flow, communication, & traffic

9. Supported by the Childrens Hospital Foundation Methods: Time Study Observation Form Once RN exited exam room, noted time a clinician entered and exited the patients room All times a patient spent in exam room without clinician defined as wait time Foreign Element column used to track exam room interruptions

10. Supported by the Childrens Hospital Foundation Methods: Patient Satisfaction Survey Questions grouped into five categories: 1.Appointment Scheduling 2.Patient Registration 3.Waiting Room Satisfaction 4.Exam Room Satisfaction 5.Wait times

11. Supported by the Childrens Hospital Foundation Results: Patient Flow Analysis »Patients do not schedule their own appointments »Clinic currently waiting for online referral access »If physician is late, bottlenecks occur »Bottlenecks occur during chart breakdown process Is there anything to schedule? Is the referral found? Resident reviews chart & enters exam room Is the call from PCP?

12. Supported by the Childrens Hospital Foundation Results: Time Study Patients spent majority of time waiting ENT: 64% Derm: 74% Necessary prep/exit time: –Registration = 7 min –Treatment = 1 min –Discharge = 2 min NeuroGUDermENTSurgery Min 0:561:220:59 0:44 0:46 Max 1:521:27 2:33 1:492:01 Sample Size 217241733 Total Cycle Time

13. Supported by the Childrens Hospital Foundation Results: Time Study Waiting Room Industry standard acceptable time for Registration and Wait = <15 minutes (NACHRI Presentation Mattel Childrens Hospital, 2007) KCH Clinic Average Registration & Wait using average values = 29 minutes Median values = 26 minutes

14. Supported by the Childrens Hospital Foundation Results: Time Study Waiting Room

15. Supported by the Childrens Hospital Foundation Results: Time Study Face Time vs. Wait Time Institute for Healthcare Improvement (IHI) Generic Clinic Benchmark: –Total visit time = clinician time x 1.5 KCH Clinic goal total visit time based on this benchmark: –31 minutes = 21 min x 1.5 KCH Clinic actual total visit time using average values = 70 minutes Median values = 62 minutes

16. Supported by the Childrens Hospital Foundation Results: Time Study Face Time vs. Wait Time

17. Supported by the Childrens Hospital Foundation Results: Patient Satisfaction Survey Total sample size = 74 Neurology & Surgery collected 2/3 of total KCH clinics now have a baseline to measure against future surveys Satisfaction scores could be used to measure the success of future changes QuestionScore Ease scheduling appt4.16 Appt when needed3.86 Info received prior to visit 4.16 Ease reg. 4.59 Wait time reg.4.29 Wt time wting room 3.85 Informed about delays wt. room 3.95 Keep child from boredom 4.12 Wt time exam room3.96 Informed about delays exam rm 3.95 Interruptions exam room 4.41 Wt time after exam3.99

18. Supported by the Childrens Hospital Foundation Results: No Show Rates

19. Supported by the Childrens Hospital Foundation Results: No Show Rates 2006 and 2007 show no all-clinic pattern for the entire year There is no one good or bad month for all clinics

20. Supported by the Childrens Hospital Foundation Results: No Show Rates Some individual clinics do show a monthly pattern from 2006 to 2007 KCH could anticipate bad and good months on a clinic by clinic basis However, averaging 40 – 50%, are they all bad?

21. Supported by the Childrens Hospital Foundation Results: General Observations We tracked clinician traffic in and out of exam room for unordinary occurrences (n = 46) Future analysis should discover the impact on wait and face times these interruptions cause

22. Supported by the Childrens Hospital Foundation Results: General Observations Observed patient charts could provide a visual cue for patient and process handoffs Charts often sat unattended on counter space Implemented a new chart flow process using Lean theories

23. Supported by the Childrens Hospital Foundation Current Chart Flow

24. Supported by the Childrens Hospital Foundation New Chart Flow

25. Supported by the Childrens Hospital Foundation New Chart Flow Process What it looks like today…

26. Supported by the Childrens Hospital Foundation Recommendations Team approach to capture the clinics momentum and ideas –Clinical Access Team Physicians input is critical to move forward Establish all-clinic goals regarding wait times and make this information transparent

27. Supported by the Childrens Hospital Foundation Recommendations Develop physician arrival policy –No longer does clinic start in the morning…clinic starts at 8:30am Waiting room rounding Monitor new chart flow process and analyze its impact to total visit time

28. Supported by the Childrens Hospital Foundation Recommendations Increase patient education regarding no shows Define the clinics current scheduling process –Standardize desired patient volumes per specialty Open Access scheduling –Potential to pilot test –Work off existing backlog

29. Supported by the Childrens Hospital Foundation Acknowledgements A special thanks to… Martin School Capstone Committee: –Dr. Sarah Wackerbarth –Dr. Scott Hankins –Dr. Joseph Fink KCH staff including: –Anne Long, Nurse Mgr KCH Clinics –All the KCH clinic & physician staff –Kyle Green, AVP Operations –Scott Stanton, Mgr Service Excellence –Nancy Wood, Mgr Management Engineering University of Louisville Industrial Engineering Student Team

30. Supported by the Childrens Hospital Foundation Questions??