1. PATIENT FLOW: FOLLOW – UP REPORT Agoncillo, Asperas, Cosalan, Tanbonliong ASMIP 2009

2. BACKGROUND

3. OBJECTIVES General Objective This follow-up study seeks to evaluate the current operation system of American Eye Center in terms of waiting lines and patient flow.

4. Specific Objectives Determine statistical trends on patient volume according to: – Time interval in a day – Day of the week – Age group – Chart type Compare the current and previous trends on patient volume

5. Evaluate the general flow of patients in the clinic on light and heavy days within the period after the initial study on operations management Assess the utilization of examination rooms and relate it to patient volume and turnover from optometrist to ophthalmologist Identify changes in the operation system and relate these to the current patient flow and waiting time

6. Assess the recommendations from the previous study Provide recommendations that will improve the waiting lines and patient flow

7. SIGNIFICANCE OF THE STUDY Assess and evaluate the current patient flow system being employed Identify weak and strong points of the system to improve Provide tools and recommendations to keep the operations of the center as efficient as possible

8. SCOPE AND LIMITATIONS Study is based on changes made by a previous study conducted last year Statistical data from June 2008 to May 2009

10. DATA COLLECTION

11. PATIENT VOLUME All statistical data from June 2008 to May 2009 were taken from log books provided by the reception Categories – Time intervals – Age – Chart type

12. PATIENT DATA PROCESSING AT FRONT DESK PER PATIENT CATEGORY Reception Area Walk-ins Old Patient: Files are retrieved from the encoding system is retrieved from the 2 nd floor office New Patient: Fill out an information sheet With Appointment Files are retrieved from the 2 nd floor office beforehand Measured the time from when the patient first approaches the reception area until it is stacked in the chart box

13. TURNOVER FROM CHART BOX TO OPTOMETRIST Optometrist takes a file and starts to perform the routine or special procedures Measured the time interval when a patient’s file is stacked into the chart box until an optometrist can accommodate the patient

14. GENERAL SCREENING Routine tests: Automated Refractometry, Air Puff Tonometry, Corneal Topography and Specular Microscopy Start is when the optometrists calibrates the machine and end when the results are released

15. ROOM USE All 5 rooms are timed according to usage Availability of the rooms is an important factor to the patient’s waiting time

16. OPTOMETRIST ROOM USE Test the grade of the patient’s eyes using the Snellen and jaegger chart Specific tests done to patients include color blindness tests, pupillometry and contrast sensitivity test

17. TURNOVER FROM OPTOMETRIST TO OPHTHALMOLOGIST Measured by timing the end of the patient’s session with the optometrist until the ophthalmologist is ready to see them

18. OPHTHALMOLOGIST ROOM USE There are no private use for physicians, thus they are able to use any available room The time for room usage is measured from when the doctor meets the patient until their consultation is over

19. INTERVIEW Receptionist – Patient categories, scheduling of patients and general information Records Assistant – Filing system the clinic utilizes Optometrists – Routine patient flow and equipment being used Ophthalmologist – Services they offer, routine and special procedures

20. DATA ANALYSIS Frequency distribution – Patient category, age group, visit to the clinic according to the time and date Figures – Patient Volume by Time Interval per Weekday – Patient Volume by Time Interval per Month – Patient Volume by Weekday per Month – Patient Volume by Age Group per Month – Patient Volume by Age Group per Day in a Week – Patient Volume by Chart Type per Month – Patient Volume by Chart Type per Weekday

21. AVERAGE PATIENT VOLUME BY TIME INTERVAL PER WEEKDAY TIME INTERVALASMIP 2008ASMIP 2009 7:00 – 7:5901 8:00 – 8:59109 9:00 – 9:5918 10:00 – 10:591819 11:00 – 11:591718 12:00 – 12:591514 1:00 – 1:591516 2:00 – 2:5914 3:00 – 3:5910 4:00 – 4:5989 5:00 – 5:5933

23. AVERAGE PATIENT VOLUME BY TIME INTERVAL PER MONTH TIMEAVERAGE 7:00 – 7:5927 8:00 – 8:59212 9:00 – 9:59443 10:00 – 10:59458 11:00 – 11:59435 12:00 – 12:59342 1:00 – 1:59392 2:00 – 2:59325 3:00 – 3:59240 4:00 – 4:59175 5:00 – 5:5961 6:00 – 6:591 MONTHAVERAGE June250 July284 August259 September265 October261 November250 December194 January302 February259 March296 April232

25. PATIENT VOLUME BY WEEKDAY PER MONTH WEEKDAYASMIP 2008ASMIP 2009 Monday117114 Tuesday135137 Wednesday109112 Thursday105116 Friday134139 Saturday148156

26. PATIENT VOLUME BY AGE GROUP PER MONTH AGE GROUPTOTAL 0 – 182738 19 – 5920689 60 AND ABOVE10493 MISSING DATA301

27. PATIENT VOLUME BY AGE GROUP PER DAY IN A WEEK WEEKDAYASMIP 2008 ASMIP 2009 Monday117115 Tuesday146136 Wednesday109112 Thursday105115 Friday134138 Saturday148154 AGE GROUP ASMIP 2008ASMIP 2009 0 – 1810 19 – 598278 60 ABOVE3540

28. PATIENT VOLUME BY CHART TYPE PER MONTH CHART TYPE ASMIP 2008 ASMIP 2009 GC661794 FF16891956 LS162132 SX221231

29. PATIENT VOLUME BY CHART TYPE PER WEEKDAY WEEKDAYASMIP 2008ASMIP 2009 Monday117114 Tuesday146138 Wednesday109112 Thursday105116 Friday134139 Saturday148156 CHART TYPE ASMIP 2008 ASMIP 2009 GC3133 FF7681 LS86 SX1210

30. GENERAL FLOW OF PATIENTS

32. PATIENT DATA PROCESSING AT FRONT DESK Registration Patient given SmartQ number Reception desk processed their patient chart Chart is retrieved, updated and placed in chart box for optometrist Patients are grouped into 3 categories: new, follow-up, with appointment

33. Previous Current New PatientFollow-upAppointmentTotal Sample Size30 10 30 Mean3:02 0:120:290:090:16 Median2:37 0:130:300:070:15 Std. Deviation1:32 0:050:120:090:08 Minimum1:01 0:030:070:01 Maximum7:28 0:190:450:290:45 DATA PROCESSING AT FRONT DESK

34. TURNOVER FROM CHART BOX TO OPTOMETRISTS

35. GS: Automated Refractometry Previous Current Sample Size33 50 Mean1:05 0:59 Median1:08 0:50 Std. Deviation0:22 0:28 Minimum0:30 0:25 Maximum2:05 2:28 Increase in standard deviation and range of values Mean and median decreased Increase in dispersion can be attributed to the increase in sample size

36. GS: AIR PUFF TONOMETRY Previous Current Sample Size34 50 Mean0:41 0:35 Median0:33 0:35 Std. Deviation0:20 0:10 Minimum0:20 0:19 Maximum1:53 1:06 Takes the shortest time to complete Decrease in mean duration and standard deviation in this phase Maximum time observed in the later study decreased by a minute as compared to the initial study

37. GS: CORNEAL TOPOGRAPHY Previous Current Sample Size32 50 Mean1:49 2:05 Median1:36 1:56 Std. Deviation 0:46 1:02 Minimum0:59 0:31 Maximum4:09 5:31 Time increased to 2 min and 5 seconds Median also increased to 2 min Increase in standard deviation suggesting a more dispersed data which represents the time it takes for different optometrists to use the machine Considering the bulk of patients using the machine, there is a significant increase in turnover time

38. GS: SPECULAR MICROSCOPY Previous Current Sample Size32 50 Mean1:42 1:38 Median1:44 1:33 Std. Deviation0:44 0:30 Minimum0:30 0:50 Maximum3:06 2:46 There is a significant difference in the minimum and maximum times it takes to use the machine from the previous study Decrease in standard deviation Notable improvement in terms of time management and utility of the machine

39. OPTOMETRIST ROOM USE Previous Current Sample Size50 Mean06:03 06:12 Median06:00 06:07 Std. Deviation02:38 02:32 Minimum01:00 Maximum13:00 15:00 A high standard deviation from both studies Optometrist may take as long as 15min and as short as 1 min

40. TURNOVER FROM OPTOMETRIST TO OPHTHALMOLOGIST PreviousCurrent Sample Size3150 Mean00:33:1000:24:57 Median00:20:0000:21:24 Std. Deviation00:32:5500:10:36 Minimum00:01:4000:02:05 Maximum02:29:0000:42:11 The patient waiting for a room to be available Large improvement this year as compared to last year Decrease in the mean time and standard deviation

41. OPTHALMOLOGIST ROOM USE Previous Current Sample Size50 Mean06:47 06:52 Median06:50 06:43 Std. Deviation04:03 03:22 Minimum01:00 Maximum17:00 14:54 Ophthalmologists usually perform less tests than optometrists The maximum time may be attributed to consultations that patients and their family may have with the doctors thus resulting to a maximum time similar to that of the optometrists

42. ROOM UTILITY

43. CATARACT SURGERY DAY: MAY 26 Room 10:07 Room 20:07 Room 30:08 Room 40:09 Room 50:11 Average0:08

44. DURATION OF USE BY TIME INTERVAL PER EXAM ROOM: May 26 8:00 – 8:59 9:00 – 9:59 10:00 – 10:59 11:00 – 11:59 12:00 - 12:59 1:00 - 1:59 2:00 - 2:59 3:00 - 3:59 4:00 - 4:59 5:00 - 5:59 Room 10:000:060:080:050:060:050:080:100:260:10 Room 20:090:200:060:040:080:070:100:050:060:11 Room 30:090:080:090:070:060:130:070:08 0:06 Room 40:000:090:14 0:040:090:050:210:050:10 Room 50:060:230:070:060:210:150:060:110:130:43 AVE0:040:130:080:070:09 0:070:11 0:16

45. LASIK SURGERY DAY: May 29 Room 10:05 Room 20:12 Room 30:09 Room 40:11 Room 50:11 Average0:09

46. DURATION OF USE BY TIME INTERVAL PER EXAM ROOM: May 26 8:00 - 8:59 9:00 - 9:59 10:00 - 10:59 11:00 - 11:59 12:00 - 12:59 1:00 - 1:59 2:00 - 2:59 3:00 - 3:59 4:00 - 4:59 5:00 - 5:59 Room 10:250:100:040:080:060:020:030:06 0:02 Room 20:050:450:240:100:130:080:100:090:100:08 Room 30:090:150:080:07 0:140:090:110:140:08 Room 40:110:190:12 0:130:090:060:100:200:06 Room 50:100:170:090:120:180:230:080:110:130:05 AVE0:120:210:110:090:11 0:070:090:120:05

47. ROOM UTILITY ON A SATURDAY: May 30 Room 10:05 Room 20:08 Room 30:12 Room 40:09 Room 50:10 Average0:08

48. DURATION OF USE BY TIME INTERVAL PER EXAM ROOM: May 30 8:00 - 8:599:00 - 9:5910:00 - 10:5911:00 - 11:5912:00 - 12:591:00 - 1:59 Room 10:240:03 0:040:080:05 Room 20:100:120:08 0:060:07 Room 30:230:110:160:120:100:08 Room 40:070:140:060:090:110:00 Room 50:080:120:110:160:060:11 AVERAGE0:140:100:080:090:080:06

49. CONCLUSION Statistical trends on patient volume – Peaks before and after lunch – Saturday contains the highest volume of patients – Majority of patients are of working age (19 – 59) – Majority of patients are in the clinic for follow-up (FF)

50. Comparison of current and previous study – Increase in total number of patients – Increase in GC: 661 – 794 – Increase in FF: 1956 – 1689 – Increase in LS: 132 – 162 – Increase in SX: 221 – 231 – Change in trend according to time interval Previous study – Linear decline in patient volume Current study – Two peaks in patient volume (before and after lunch)

51. – Same trend according to workday Tuesday, Friday and Saturday = most number of patients – Same distribution according to age group Majority of patients from 19 – 59 age group Increase in percentage of patients from the 60 and above group Evaluate the general flow of patients in the clinic on light and heavy days within the period after the initial study on operations management

52. – Decrease in the processing time From 3:02 to 0:16 – Increase in turnover duration from chart to opto at 11:30am Charts started to pile up due to increase in patient volume Peak at 1:00pm due to a decrease in the number of optometrists – No significant change in general screening, opto and ophtha room use – Decrease in turnover from opto to ophtha

53. Assess the utilization of examination rooms and relate it to patient volume and turnover time from optometrist to ophthalmologist – Same trend – Increase in utilization More efficient, less periods of vacancy – Decrease turnover time from opto to optha – Increase in number of patients served per hour

54. Identify changes in the operation system and relate these to the current patient flow and waiting time – Charts from the box have numbers that are being followed – More efficient use of exam rooms – Generally, no change in the system; changes in the efficiency of people in the system (encoding, chart prioritization, room assignment and use)

55. ON LAST YEAR’S RECOMMENDATIONS... Repartitioning of rooms Expansion or satellite clinics ID system Centralized computer database Cut-off time for walk in patients Penalty system for late follow-up patients Surgery appointment penalties More doctors present on Tuesday mornings Scheduling surgeries in the morning Extended Saturday work hours Rescheduling patients based on maximum turnover capacity Monitoring personnel at the chart box or box management

56. RECOMMENDATIONS Adhere to an appointment based institution Scheduled breaks of optometrists Maintain a cut-off time – Lessen incoming late patients and limit the quota Hiring more personnel or training more employees to help with record keeping and retrieval of files Investment in machines Automation of files