Supported by the Childrens Hospital Foundation Assessing Patient Throughput at Kosair Childrens...

Supported by the Children’s Hospital Foundation

Assessing Patient Throughput at Kosair

Children’s Hospital Clinics

Craig Johnson

University of KentuckyMartin School of Public Policy and

AdministrationMasters in Health Administration

Capstone ProjectSpring 2008

Supported by the Children’s 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 patient’s exam negatively impact workflow (Brixey et al., 2007)

Supported by the Children’s 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)

Supported by the Children’s Hospital Foundation

Project Purpose

• Assess the clinic’s current throughput processes through direct observations and data

collection

AND

• Assist clinic leadership with data analysis, industry benchmarking,

and recommendations for improvement

Supported by the Children’s 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

Monday Tuesday Wednesday

Thursday Friday

4NEURO:Puri

GU:Casale

5GU:Casale

6ENT:Goldman

DERM:Kasteler

7NEURO:McKiernan

SURG:Wiesenaur

8NEURO:Farber

Supported by the Children’s 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

Supported by the Children’s Hospital Foundation

Background: Patient Population

• Children ages 0 – 18

• Participants of medical assistance programs or self paying

• Visits FY2007 4,038FY2008 4,100

Supported by the Children’s 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

Supported by the Children’s Hospital Foundation

Methods: Time Study Observation Form

• Once RN exited exam room, noted time a clinician entered and exited the patient’s room

• All times a patient spent in exam room without clinician defined as wait time

• Foreign Element column used to track exam room interruptions

Supported by the Children’s Hospital Foundation

Methods: Patient Satisfaction Survey

• Questions grouped into five categories:

1. Appointment Scheduling

2. Patient Registration3. Waiting Room

Satisfaction4. Exam Room

Satisfaction5. Wait times

Supported by the Children’s 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 & entersexam room

Is the call

from PCP?

Supported by the Children’s 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

Neuro GU Derm ENT Surgery

Min 0:56 1:22 0:59 0:44 0:46

Max 1:52 1:27 2:33 1:49 2:01

Sample Size 21 7 24 17 33

Total Cycle Time

Total Patient Experience -Average Values

Clinician20%

Waiting69%

Prep/Exit11%

Supported by the Children’s Hospital Foundation

Results: Time StudyWaiting Room

• Industry standard acceptable time for Registration and Wait = <15 minutes (NACHRI Presentation Mattel Children’s Hospital, 2007)

• KCH Clinic Average Registration & Wait using average values = 29 minutes

• Median values = 26 minutes

Supported by the Children’s Hospital Foundation

Results: Time StudyWaiting Room

Registration and Wait Time - Average Values

Reg0:06

Reg0:07

Reg0:07

Reg0:07

Reg0:06

Reg0:07

Wait0:16

Wait0:19

Wait0:38

Wait0:18

Wait0:21

Wait0:22

0:00

0:07

0:14

0:21

0:28

0:36

0:43

0:50

Neurology GU Dermatology ENT Surgery KCH ClinicAverage

Supported by the Children’s Hospital Foundation

Results: Time StudyFace 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

Supported by the Children’s Hospital Foundation

Results: Time StudyFace Time vs. Wait Time

Face Time vs. Wait Time - Average Values

Face 0:24 Face

0:16

Face 0:25

Face 0:23 Face

0:17

Face 0:21

Face 0:21

Wait0:49

Wait0:42

Wait1:04

Wait0:40

Wait0:51

Wait0:49

Wait0:10

0:00

0:14

0:28

0:43

0:57

1:12

1:26

1:40

Neurology GU Dermatology ENT Surgery KCH ClinicAverage

IHI Benchmark

Supported by the Children’s 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

Question Score

Ease scheduling appt 4.16

Appt when needed 3.86

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 room 3.96

Informed about delays exam rm

3.95

Interruptions exam room

4.41

Wt time after exam 3.99

Supported by the Children’s Hospital Foundation

Results: No Show Rates

Patient No Show Rate All Clinic Average2006 vs. 2007

0

10

20

30

40

50

60

70

80

90

100

Neurology GU ENT Surgery Dermatology

Clinic

% N

o S

ho

w R

ate

2006 Average

2007 Average

Supported by the Children’s 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

Patient No Show Rates 2006

25

30

35

40

45

50

55

60

65

Months

% N

o S

ho

w Neurology

GU

ENT

Surgery

Dermatology

Patient No Show Rates 2007

25

30

35

40

45

50

55

60

65

70

Month

% N

o S

ho

w Neurology

GU

ENT

Surgery

Dermatology

Supported by the Children’s Hospital Foundation

Results: No Show RatesNeurology No Show Rates 2006 vs. 2007

25

30

35

40

45

50

55

60

65

70

Januar

y

Febru

ary

Mar

chApril

M

ayJu

neJu

ly

August

Septe

mber

October

Novem

ber

Decem

ber

Month

% N

o S

ho

w

2007

2006

GU No Show Rate 2006 vs. 2007

25

30

35

40

45

50

55

60

65

70

Januar

y

Febru

ary

Mar

chApril

M

ayJu

neJu

ly

August

Septe

mber

October

Novem

ber

Decem

ber

Month

% N

o S

ho

w

2007

2006

• 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?’

Supported by the Children’s 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

Reasons Clinicians Left Exam RoomMid-Visit

44%

30%

15%

7%

4%

Supplies Consult

Ask patient a question Need physician signature

Equipment

Supported by the Children’s 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

Supported by the Children’s Hospital Foundation

Exam Room 1

Waiting Room

Check-in

Treatment Room

Exam Room 2

Exam Room 4

Exam Room 3

Physician Room

Office Specialist

Registration

Counter Space

Counter

SpacePt Ready to be called

back

Current Chart Flow

Supported by the Children’s Hospital Foundation

Exam Room 1

Waiting Room

Check-in

Treatment Room

Exam Room 2

Exam Room 4

Exam Room 3

Physician Room

Office Specialist

Registration

Counter Space

Pt Ready to be called

back

Nurses Discharges

Physicians

Discharges

To Be Seen By

Attending

To be seen by Physician

New Chart Flow

Supported by the Children’s Hospital Foundation

New Chart Flow Process

What it looks like today…

Supported by the Children’s 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

Supported by the Children’s 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

Supported by the Children’s 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

Supported by the Children’s 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

Supported by the Children’s Hospital Foundation

Questions??