1. Joslin Diabetes Center Affiliated Programs Annual Meeting Sarah O’Neill Ambulatory Director Beth Israel Deaconess Medical Center Oct. 25, 2011 Exam Room Utilization: Simple Analysis for Constructive Discussion

2. Background Tertiary Care Teaching Hospital 631 licensed beds  429 medical/surgical beds  77 critical care beds  60 OB/GYN beds Beth Israel Deaconess Medical Center

3. Background 625,000 outpatient visits annually  15% Primary Care  85% Specialty Care 350,000 (56%) of outpatient visits  Med/Surg office practice  BIDMC owned facilities BIDMC Ambulatory Services

4. Background Faculty physicians part of separate partner organization Faculty physician schedules complex – Clinical, Teaching, Research MD Trainee education integrated into outpatient practice  83 Fellows  257 Residents and Interns Academic Medical Center

5. Context Medical office practice growing on average 4% a year 2007 three year strategic development – MD recruitment in many ambulatory areas Market analysis indicated optimal location in Boston GME credentialing required expanded outpatient experience

6. Context Space tight on campus Increased need for additional space for on campus off practice Cost of significant renovations prohibitive

7. The Goal Understand utilization – are we truly using what we have Develop standard and fair measure to inform decision making

8. Decision Making to Date Based on room reservation schedules Anecdotal reports of actual practice sessions  Ad hoc site visits range from overflowing to empty Little detail beyond # of planned physician recruits Failed efforts to assess use based on patient time in room

9. Beginning the Conversation Initial analyses reviewed  Weekday use  Reservation use

10. Weekday Use Request for more space based on peak usage Is usage even across the week?

14. Weekday Use Helped identify unused capacity – reduced the anecdotal “noise” Data for analysis not readily available  Analysis at the appointment level – huge amount of data  Limited ability to dig in to detail by service or provider

15. Reservation Use Exam room “reserved” for regular weekly session Reserved session = 4 hours

16. Utilization of Reserved Exam Room Time Use of Reserved Hours red bold = >92% or 48 weeks worked green bold = < 85% or 44 weeks worked practice location Annualized Reserved Hours FY 07 Total Actual SCHED Hours % of time in the year reserved hours open % of time in the year reserved hours used Equivalent weeks worked out of 52/yr Weeks Open Shapiro 5b12,45013,082-5% 105% 55 (3) Shapiro 8a16,00016,154-1% 101% 53 (1) Shapiro 6,160,05053,06912% 88% 46 6 Shapiro 2c11,3009,60815% 85% 44 8 Shapiro 7b19,30014,84523% 77% 40 12 Shapiro 8b32,40020,52037% 63% 33 19 Rabb 18,6505,37438% 62% 32 20 Shapiro 2a4,4002,31048% 53% 27 25 Shapiro 3a6,4003,27749% 51% 27 25 Shapiro 7c18,4008,22355% 45% 23 29 252,400191,05324% 76% 3913 LMOB 74,1754,638-11% 111% 58 (6) LMOB 5a2,9502,8414% 96% 50 2 LMOB 55,5004,9829% 91% 47 5 LMOB 48,0507,05112% 88% 46 6 LMOB 3a2,7502,32915% 85% 44 8 LMOB 15,4503,61934% 66% 35 17 LMOB 63,8002,28340% 60% 31 21 LMOB 3b4,0001,33267% 33% 17 35 LMOB 2a3,00044585% 15% 8 44 65,25045,96930% 70% 3715 Annualized Reserved Hours (50 weeks) Actual Scheduled Hours red bold = >92% or 48 weeks worked green bold = < 85% or 44 weeks worked Range 15% - 105%

17. Reservation Use Helpful Highlights wide variation  Clinical contract oversight – length of sessions, cancellations, make ups, etc.  Ongoing review of space available for others to reserve Reinforced existing space still available Long term usefulness Evaluates reserved time only More provider use of reserved time versus space use Depends on managers providing schedules Based on a snapshot in time (schedules change)

18. Finding a Simpler Metric Use more readily available data  Not dependent on practice management  Evaluates 12 months – level seasonal and academic variation  From scheduling system – existing data extract  Available at clinic and provider level  Analyses exam room versus provider use

19. Premise of Metric Physician schedule reliable - needs to reflect real average time needed for each visit type Begin generously  Scheduled versus kept activity  All visits – within session or add on  Based on weekday use – any extended hours improves metric

20. Exam Room Availability Assume room available 8 hours, M-F  Two 4 hours sessions  250 days a year (less 10 holidays)  One room available 2,000 hours/year For each practice suite - include all clinics/ providers (MDs, NPs, etc.) using exam room space in that location

21. Calculation at Practice Level % Utilization = Annual Scheduled Hours # exam rooms x 2,000 hrs PROVIDER TIME IN ROOM

22. Practice LocationAvailable Exam RoomsTotal Actual Scheduled Visits% of time exam room used by provider (b,e) Shapiro 2c 924,99751% Shapiro 8b 1828,60253% Shapiro 9 2132,37554% Shapiro 7a 89,69848% Shapiro 6,1 60114,49844% Shapiro 3b 1424,82634% Shapiro 7c 1319,54636% Shapiro 2a 1014,80231% Shapiro 5a 66,12520% Shapiro 3a 33,13526% TOTAL EAST205372,20444% LMOB 4 711,97045% LMOB 1 34,24050% LMOB 8b 47,98638% LMOB 7 57,71540% LMOB 8a 510,13833% LMOB 0B 910,67933% LMOB 5 78,85125% LMOB 3b 32,86024% LMOB 6 65,48918% LMOB 2a,b 21,35113% TOTAL WEST6795,13929% % Time Provider in Room Range 13% - 54%

23. Calculation at Practice Level % Utilization = Annual Scheduled Hours + Room turnover # exam rooms x 2,000 hrs PROVIDER “PLUS” TIME IN ROOM  Simple standard/ average factor  Based on variety of observations

24. Practice Location Available Exam Rooms Total Actual Scheduled Visits % of time exam room used by provider (b,e) Average Minutes/ Visit Exam Room Utilization Shapiro 2c 924,99751%3786% Shapiro 8b 1828,60253%5269% Shapiro 9 2132,37554%5267% Shapiro 7a 89,69848%6161% Shapiro 6,1 60114,49844%3860% Shapiro 3b 1424,82634%3653% Shapiro 7c 1319,54636%3949% Shapiro 2a 1014,80231%3543% Shapiro 5a 66,12520%3338% Shapiro 3a 33,13526%4237% TOTAL EAST205372,20444% 62% LMOB 4 711,97045%4463% LMOB 1 34,24050%5362% LMOB 8b 47,98638%3355% LMOB 7 57,71540%4153% LMOB 8a 510,13833%3050% LMOB 0B 910,67933%4342% LMOB 5 78,85125%3941% LMOB 3b 32,86024%4032% LMOB 6 65,48918%3325% LMOB 2a,b 21,35113%3118% TOTAL WEST6795,13929% 42% % Time Provider in Room Range 13% - 54% Provider plus turnover time Range 18% - 99%

25. The New Metric Adding turnover time helped  Appropriately adjust for shorter visit, higher room turnover time needed  Shift focus to relative variation versus absolute % The relative outcomes passed the “smell” test – fit known practice experience Discussion turned to use of existing space Increased interest in ways to use space more efficiently

26. Why the Range? Review of space model  Offices integrated into practice  Practice suite separate from offices Optimal practice size  Small (5 or less) suites less flexible  10 to 12 exam rooms with proper support space most efficient Critical for specialties balancing OR/ procedure and office visit time Physician clinical commitment oversight

27. Options for maximizing Space Move support functions out of exam rooms Limit physicians to 2 rooms per session Start and end sessions on time Shared space use Schedule meetings outside of practice hours Rearrange commitments so full session used Shift session to offsite facilities Extend hours – evenings and weekends

28. Further Analysis at MD Level KEPT VisitsUnigue Patients/ PANEL Throughput (Based on scheduled activity) Provider Total Kept % Not Kept New to Clinic (b) % New (b) Panel Last 12 Mos Panel/ RESERVED ROOM Avg. Visits/ Patient Annual visits/ RESERVE D ROOM at 50 weeks/ year (h); Visits/ RESERVED ROOM Avg. Weeks Worked per RESERVE D ROOM at avg. weeks worked; Visits/ RESERVE D ROOM Provider 931421%19261%221 1.43146.3556 Provider 841816%24258%2601731.62795.6446 Provider 673721%21830%3611202.02464.9357 Provider 331620%7724%240 1.33166.33210 Provider 735824%10830%2141071.71793.6277 Provider 21,37313%13810%6951162.02294.62210 Provider 585820%14016%342682.51723.4218 Provider 11,71915%23314%1,1781681.52464.91814 Provider 423722%2711%172861.41192.4148 Total6,33018%1,37518%3,683 1.71192.4255

29. Outcome from use of new metric Generated a broad guideline to begin to filter/ prioritize space requests Eventually moved to kept rather than scheduled hours

30. Utilization Guideline Current guidelines using KEPT VISITS as base >60%50% TO 60%40% TO 50%< 40% Approaching maximum use - request space and or implement decompression opportunities Optimal space utilization - usage that adjusts for peaks and allows for urgent add on sessions without difficulty. Reasonable use but with potential for growth or sharing underused sessions Under use - consider consolidation with other services

31. Exam Room Utilization Practice Exam Rooms FY 08FY 09FY 10 Shapiro 7b1460%61% cannot add sessions Shapiro 2c1749%51%54% limited ability to add Shapiro 8a1856% 53% room for growth Shapiro 8b2257%61%51% Shapiro 92143% 52% Shapiro 3b1346% 48% Shapiro 7a853% 47% Rabb 1939%43% Shapiro 2b413%39%47% Shapiro 2a1043%39%40% 23446%48% LMOB 8a548%60% limited ability to add LMOB 1547%49%48% room for growth LMOB 7643%44%49% LMOB 4949%52%55% Deac 1 58%11%49% LMOB 8b444%51%55% LMOB 5435% 38% B/P Span 3640% 37% LMOB 6525%34%32% LMOB 3a521%19% 7341%43%46%

32. Outcome – Improved use of existing space Simplified/standardized use of scheduling templates Reduced cancellations due to competing commitments in research and teaching Encouraged creative options for existing space  Better sharing across divisions  Office/exam room for more full time clinicians Minimized/delayed the need for renovations

33. Outcome – Improved use of existing space Annual Volume increased by 64,000 visits 14 exam rooms added during that time

34. Questions?