Efficiency In Office Practice

1. Efficiency In Office Practice Barbara S. Boushon, RN, BSN Mark Murray and Associates

2. 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

3. 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

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

6. 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

7. 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

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

9. How Processes Support Flow Dr. in to Dr. out Check-in to Nurse Nurse to Room Check-out to leave

10. Check-in to Nurse • Greet • Register • Routing slip • Update information • Obtain directions to clinic nurse • Obtain chart • Go to clinic • Wait

11. 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

12. Doctor In to Doctor Out • Greet • Open chart/computer • History • Exam • Assessment • Education • Plan • Documentation

13. Check Out to Leave • Review orders • Pharmacy education? • Nurse education? • Send for more lab/XR? • Set up referrals? • Set up next appointment?

14. How Processes Support Flow Dr. in to Dr. out Check-in to Nurse Check-out to leave Nurse to Room

15. Lead Time Example

16. How do we decrease the waiting in the office…. And keep the value added time?

17. Frameworks • High Leverage Changes • Change Concepts

18. 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

19. 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

20. 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

21. 10:00 10:30 11:00 Staff

22. 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.

23. 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

24. 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

25. Communication Overview • 14% of each 40 hour work week is wasted in miscommunication • Over 50% of errors in VA’s 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

26. 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

27. 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

28. 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?

29. 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

30. Change Concepts from Industry • Identify value, then eliminate waste • Improve the flow of work • Optimize the work environment • Manage variation

31. 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

32. …and Eliminate Waste (Lean Thinking) • Eliminate • Things that aren’t used • Multiple entry • Overkill • Intermediaries • Sample

33. Improve the Flow of Work • Synchronize • Minimize hand-offs • Move steps closer together • Automate • Do tasks in parallel • Practice continuous flow • Use pull systems

34. Optimize the Work Environment • Improve access to information • Train • Cross-train • Reduce set-up time

35. Manage Variation • Standardize • Create contingency plans • Manage peak demand

36. 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