Efficiency In Office Practice

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Efficiency In Office Practice

• Barbara S. Boushon, RN, BSN
• Mark Murray and Associates

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Office Efficiency (work flows)

• The right person doing the right task at the
  right time
• Barrier-free
• Patient-centered
• Predictable, standardized
• Based on systems, not people
• Based on team structure

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Capacity The Link Between Access and Efficiency

• Increased capacity leads to improved access
• Improved access leads to more efficient office
  processes
• More efficient processes increase capacity

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Cycle Time Measurement
Check in
MA to Room
Check out
MD Leaves
MD Enters
Process

• Greet
• Check in/registration
• Get chart
• Prepare information

• Vital signs
• Interview
• Prepare information

• Greet interview
• Exam
• Closure

• Prepare information
• Closure

Over-arching

• Information transfer
• Communication, pre, during, post visit
• Synchronize patient, provider, information,
  equipment
• Standardize rooms
• Choreography

Measurement- cycle time
Audit
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The Metrics

• Lead Time start to end
• The sum of the cycle times delays
• For the whole process
• The visit
• The referral
• Medical record retrieval
• Each segment of the process cycle time
• Appointment booking, reminder, registration,
  greeting, waiting room, rooming, vital signs,
  value added vs non-value added time

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Terms

• System
• Group of processes working together to achieve
  aim
• Process
• Group of tasks working in an orderly fashion to
  achieve an aim
• Tasks
• A specific job or piece of work
• Tools
• Workflow analysis/work task analysis

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Flow Through the Office
Check-in to Nurse
Dr. in to Dr. out
Nurse to Room
Check-out to leave
Lead Time
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How Processes Support Flow
Dr. in to Dr. out
Check-in to Nurse
Nurse to Room
Check-out to leave
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Check-in to Nurse

• Greet
• Register
• Routing slip
• Update information
• Obtain directions to clinic nurse
• Obtain chart
• Go to clinic
• Wait

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RN/MA/LPN to Exam Room

• Greet
• Gather chart
• Review/update preventative health information
• Educate/treat for prevention as indicated
• Go to clinic room, vitals
• Wait

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Doctor In to Doctor Out

• Greet
• Open chart/computer
• History
• Exam
• Assessment
• Education
• Plan
• Documentation

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Check Out to Leave

• Review orders
• Pharmacy education?
• Nurse education?
• Send for more lab/XR?
• Set up referrals?
• Set up next appointment?

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How Processes Support Flow
Dr. in to Dr. out
Check-in to Nurse
Check-out to leave
Nurse to Room
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Lead Time Example
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How do we decrease the waiting in the office.
And keep the value added time?
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Frameworks

• High Leverage Changes
• Change Concepts

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Medical Office Efficiency High Leverage Changes

• Balance Capacity and Demand
• Synchronize Patient, Provider, and Information
• Predict and Anticipate Patients Needs
• Optimize Rooms and Equipment
• Manage Constraints

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Balance Capacity and Demand

• Predict daily demand for non-appointment services
• Understand the components of demand for services
• -documentation
• -medication refills
• -lab review
• - messages
• -referrals
• -forms management
• What is the matching process?
• Batch vs. one piece flow
• Match the demand to the correct resource
• For all non-appointment services

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Synchronize Patient, Provider, and Information

• Start on time and stay on time
• Identify and maximize the value stream
• Synchronize Patient
• Synchronize Provider
• Synchronize information
• Registration process
• Closure of last visit
• Chart check
• Rooming criteria
• Document, do work in real time

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1000
1030
1100
Staff
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Synchronization Truisms

• The whole process can only go as fast as the
  slowest step
• If the process starts 15 minutes late each
  session (AM and PM), a full time clinic can
  waste 400 appointments per year.
• Must work backwards from sync time to make sure
  everything is ready on time.

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Predict and Anticipate Patient Needs

• Practice level approach
• Plan for seasonal demand changes
• Flu season, Vacation season, Snowbird season
• Plan for the unexpected but predictable daily
  demands
• Admissions, procedures, consults, information
  needs
• Understand and standardize common procedures
• Align expertise of care teams with patient needs
  plan the visit

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Predict and Anticipate Patient Needs

• Visit level approach
• Communication is harder than you think
• Huddle dialogue among team intended to get
  everyone on the same page
• Stand up meeting of less than 5 minutes
• Used to plan clinic session prior to procedure
  at a hand off
• Promotes familiarity, shared expectations

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Communication Overview

• 14 of each 40 hour work week is wasted in
  miscommunication
• Over 50 of errors in VAs Root Cause Analysis
  traced back to miscommunication
• Communication basics
• Familiarity of staff call each other by name
• Listen to understand, not to plan next comeback
• Communicate what you see and know
• Explicitly ask everyone for input

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Optimize Rooms and Equipment

• Adequate number of rooms
• Optimize Rooms
• Open rooming
• Fully stocked rooms
• Standardize layout, supplies
• Move equipment to the patient
• Optimize Space
• Signals for equipment

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Identify and Manage Constraints

• Person constraint for non-appointment work
• Maximize the care team what is the work?
• Put inspection step in front of the constraint
• All work to highest level of skill, expertise,
  and licensure
• Standard Protocols
• Process constraint
• No idle time
• Separate phone flow, patients flow, and paper
  flow
• Continuous flow
• Specific processes

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Identify the Constraint

• Constraint the rate limiting step
• (Theory of Constraints-TOC)
• Who is the person (role) in front of whom most
  waiting occurs?
• What is the process in front of which most
  waiting occurs?

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Maximize the Constraint

• Put resources around the constraint to optimize
  their output
• Even if other steps work below their maximal
  capacity
• Allow no down-time for the constraint

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Change Concepts from Industry

• Identify value, then eliminate waste
• Improve the flow of work
• Optimize the work environment
• Manage variation

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Identify Value (from customer view), then add
value

• Patients say
• Treat me with respect
• Be friendly and caring
• Give me a long-term healthcare relationship
• Make your services convenient
• (Education, skill, and training are assumed)
• Focus Group

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and Eliminate Waste (Lean Thinking)

• Eliminate
• Things that arent used
• Multiple entry
• Overkill
• Intermediaries
• Sample

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Improve the Flow of Work

• Synchronize
• Minimize hand-offs
• Move steps closer together
• Automate
• Do tasks in parallel
• Practice continuous flow
• Use pull systems

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Optimize the Work Environment

• Improve access to information
• Train
• Cross-train
• Reduce set-up time

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Manage Variation

• Standardize
• Create contingency plans
• Manage peak demand

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References

• VA Delays Manual
• The Improvement Guide A Practical Approach to
  Enhancing Organizational Performance.
• G. Langley, K. Nolan, T. Nolan, C. Norman, L.
  Provost. Jossey-Bass Publishers., San Francisco,
  1996,
• Chapter 7 and Chapter 13