Joslin Diabetes Center Affiliated Programs Annual Meeting

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

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

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

4. Background Academic Medical Center • 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

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. 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. % TimeProvider 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. % TimeProvider 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

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

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?