Using Simple Tools in the Solo or Small Practice to Improve Efficiency. L. Gordon Moore, MD Sharon McCoy George, MD

Transcription

1 Using Simple Tools in the Solo or Small Practice to Improve Efficiency L. Gordon Moore, MD Sharon McCoy George, MD

2 Objectives Describe efficiencies that are key to the success of a small or solo practice in today s environment. Identify and use tools to design, implement, and assess efficient systems which support Patient Centered Collaborative Care, information flow, and physician/staff routines. Understand how to measure overall efficiency Explain several techniques used by practicing family physicians to improve efficiency

3 Take Home Points The least cumbersome way to measure office efficiency from a patient centered perspective is by using a patient web-based survey instrument (HowsYourHealth.com). Create breathing room for change before embarking on major practice efficiency overhaul. Use your patients as a resource to help improve efficiency. Eliminating waste and improving efficiency is an ongoing, rather than one-time, process.

4 Outline for Efficiency and Lean Production Identifying waste Flow mapping Measurement Forms of waste

5 What is happening in your practice(s)? Flow mapping/spaghetti diagram Constraint analysis Interruption analysis Cycle time Focus groups/patient advocates

6 Helpful tools Cycle time, measurement and graphing tools available on look under Access and Tools Click on Assessing Your Practice Green Book Fishbone & flowchart templates p. 24 Cycle time tool p. 17 Interruption analysis p. 22 Walk your practice tool p. 23

7 Identifying Waste/ Learning to See Flow mapping: examine patient visits A variety of visits Careful observation through the patient s eyes Details to look for Constraints/bottlenecks Total cycle time and patient-provider time Customer service Facility barricades, equipment inadequacies Paperwork Waste, duplication, rework Value-added and non-value added activities Handoffs

8 Walk Through 11 "Walk Through" Your System as a Patient Date: Your work in this collaborative will lead you to fundamental system change, but even with a strong aim you may not know where to begin. One simple way to understand where major impediments lie is to experience your service delivery through the eyes of a client. We are strongly recommending that two members of your team do a "walk through" of your system prior to the First Learning Session. Tips for making the "walk through" most productive: 1. Determine with your team where the starting point and ending points should be, taking into consideration issues of appointment making, the actual office visit process, follow-up, and other issues you may suspect are problems. 2. Two members of the team should do the walk through together if at all possible, with each playing a role-patient and partner or parent and child. 3. Set aside a reasonable amount of time to do this. Consider the usual amount of time patients spend in your clinic. Walk Through Begins When: Team Members: Ends When: 4. Make it real. Have a real appointment with a real clinician. Include time with lab tests and arranging for reports to be available. Sit where the patients sit. Wear what patients wear. Make a realistic paper trail of chart, lab reports, referrals, payment arrangements, etc. 5. During the walk through, note both positive and negative experiences, as well as any surprises. What was frustrating? What was gratifying? What was confusing? 6. If possible, debrief your team on what you did and what you learned. Report at least two key lessons on your storyboard. Positives Negatives Surprises Frustrating/Confusing Gratifying Your Practice

9 One view of a patient visit Pt arrives Check in Vitals Exam room Check Out Register Arrive Verify insurance Print encounter Match encounter to chart Chart to MA Take chart Call patient back BP, Ht, Wt, +/- Temp Room pt Notify provider Provider reviews chart Provider visit Phlebotomy Neb, BG, EKG Take encounter form Collect copay Print receipt Make referrals Schedule return

10 How to Measure Encounter Flow Two individuals from the office Note every step First we then we. Differentiate between process steps (something happens) and queues (waits & delays) Measure time in minutes

11 Typical 15 minute office visit Step Feet Time Front door to check-in Wait at check-in Check-in 0 6 Walk to chair in waiting room Sit in waiting room 0 23 Walk to nursing staging area Vitals 0 4 Walk to exam room Sit in exam room Interaction with provider 0 11 Walk to check-out Wait at check-out Check-out Totals Value-added time 20%

12 Measuring Total Cycle Time Identifies movement toward the goal of improved efficiency Operational definition = the time in minutes from when a patient arrives in your office until they leave after all is done Sampling strategy example: the patients scheduled at 10A and 3P once per week for each provider Average the cycle times per provider per month and plot as a time series

13 Jan-99 Feb-99 Mar-99 Apr-99 May-99 Jun-99 Jul-99 Aug-99 Sep-99 Oct-99 Nov-99 Dec-99 Jan-00 Feb-00 Mar-00 Apr-00 May-00 Jun-00 Minutes Total Cycle Time Fairport Patient cycle time for a 15 minute follow up visit JG WJ

14 Spaghetti diagram Draw a floor plan Watch one person perform their work, noting where they go and what they do Do this for each person in the process of focus Map the process steps

15 Track each individual in process Step Provider 1 Notified of patient ready in room 2 Reviews chart on door 3 Retrieves patient labs from desk 4 Commences encounter 5 Looks up other labs on computer 6 Asks secretary to have lab fax results 7 Back with patient 8 Drug samples 9 Back with patient 10 Asks secretary to arrange referral 11 Back to provider office to document visit

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17 Streamlined flow Steps Feet Time Pt walks to greeting area Pt greeted and directed to room Clinical support (CS) person obtains demos, vitals, documents 0 5 Provider enters room with patient and commences encounter 0 15 CS reviews education materials, assists in goal setting, problem solving, arranges referrals, follow-up, collects co-pay 0 15 Pt leaves Totals Value added time (counting 2/3 of time with CS) 78%

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19 Same process analysis for other processes Prescription refill Clinical questions Non clinical questions Referral management Dictations Labs/imaging results ED or hospital calls Phone calls

20 Rx refill process Step Feet Time Secretary takes message 0 3 Message placed in Rx bin Waits in Rx Bin 0 60 Sec'y takes Rx bin & pulls cht Charts put in RN Rx refill area Charts wait in RN area 0 90 RN sorts by doctor 0 5 RN sorts by "Urgent" 0 10 Urgent go to MD's nurse 15 1 MDs nurse places urgent in the chart rack of the next patient room 20 2 MD reviews between patients MD finds nurse 25 2 MD communicates plan for Rx Nurse carries Rx to nursing area Rx waits until nurse can phone pharmacy 0 15 Nurse phones pharmacy 0 5 Non-urgent are placed on MD's desk Rx waits on MD desk until end of session MD reviews Rx 0 30 MD puts Rx in nurse "To do" pile Rx waits in "to do" pile Nurse sorts by pharmacy 0 5 Nurse makes pharmacy calls 0 30 Charts placed in "To be filed" bin Charts wait in "To be filed" bin Charts filed Urgent totals Non-urgent totals

21 Cross training Step Rooming person 1 Notified of patient in room 2 Greets, registers, vitals, documents 3 Notifies provider patient is ready 4 Re-enters to arrange referral, review patient education materials, assist in individual goal setting regarding chronic disease, arrange follow-up, collect co pay, print receipt 5 Back to work station

22 Interruption analysis Any individual in the practice Card method or tape/zone method 3x5 card in the pocket Brief description of interruptions Create categories Use categories as column headings and count with tick marks the frequency over a short period of time Tape/zone Make a note every time you leave your zone

23 Examples from interruption analysis Provider Chart info missing Supplies missing Supplies in poor proximity to the work No team member available Nurse Chart info missing Lack of equipment/tools Lack of information Secretary Lack of information Too many conflicting tasks Cumbersome or missing tools

24 Continuous flow: Tools at your fingertips From the interruption analysis Everything you need frequently is within arm s reach examples: Electronic health records including real registry Broadband internet connection with bookmarked medical knowledge sites, patient education materials Hanging file with top 20 forms

25 Continuous Flow Do the work as it comes along (including nonvisit care) It s the intra-day equivalent of Open Access Do this twenty minute s work in this twenty minutes. Continuous flow saves time ( hidden supply arises) Continuous flow decreases errors and increases satisfaction

26 Continuous Flow Estimate time and resource necessary to complete the work Allow appropriate time for direct care and non-visit care Look at the deployment of appointment slots (and appointment lengths) and actual team work hours, and try for a better match Don t batch work (dictation, refills, referrals, phone backs, etc.)

27 Rx refill process Step Feet Time Secretary takes message 0 3 Message placed in Rx bin Waits in Rx Bin 0 60 Sec'y takes Rx bin & pulls cht Charts put in RN Rx refill area Charts wait in RN area 0 90 RN sorts by doctor 0 5 RN sorts by "Urgent" 0 10 Urgent go to MD's nurse 15 1 MDs nurse places urgent in the chart rack of the next patient room 20 2 MD reviews between patients MD finds nurse 25 2 MD communicates plan for Rx Nurse carries Rx to nursing area Rx waits until nurse can phone pharmacy 0 15 Nurse phones pharmacy 0 5 Non-urgent are placed on MD's desk Rx waits on MD desk until end of session MD reviews Rx 0 30 MD puts Rx in nurse "To do" pile Rx waits in "to do" pile Nurse sorts by pharmacy 0 5 Nurse makes pharmacy calls 0 30 Charts placed in "To be filed" bin Charts wait in "To be filed" bin Charts filed Urgent totals Non-urgent totals

28 New Rx process Patient calls with Rx request Feet Minutes Who, what, where? Pull up chart 0 4 Assess if it meets protocol 0 1 Meets protocol/approved Faxed to pharmacy 0 5 Nurse documentation 0 2 Waits for MD review 0 60 MD review and sign-off 0 1 Total 0 73 Does not meet protocol Message to MD 0 1 Waits for MD response 0 60 MD review 0 2 MD message to nurse 0 1 Waits for Nurse response 0 30 Nurse faxes to pharmacy 0 5 Documentation by nurse 0 2 Total 0 106

29 Visit Planning: Huddles Five minutes max Don t sit down Entire microsystem/care team: provider, clinical and clerical support Typical short term contingency plans for unexpected visit demand: Deflect some demand to other providers Deflect to urgent care/ed Team stays late Increase non-visit care Delay some demand until tomorrow

30 Standardization Standardize work Standardize rooms and equipment Standardize procedures

31 Summary of big concepts Create your ideal care team Work toward a common goal Meet regularly Huddle Plan for the work Get good information on how you are doing Ask your patients what they want and need and figure out how to deliver Data on process and outcomes

32 Resources & References The Machine that Changed the World Womack, Roos, and Jones Lean Thinking Womack and Jones Learning to See Shook, available from the Lean Enterprise Institute Theory Of Constraints Goldratt The Goal Goldratt Lean.org Lean Enterprise Institute great tools in the Green Book

33 Optimizing Patient Flow Using Simple Tools in Solo or Small Practice To Improve Efficiency (Part 2) L. Gordon Moore, MD Sharon McCoy George, MD

34 PATIENT EFFICIENCY Patient perception of smooth operation during and between visits Measured by Ideal Micropractices (IMPs) using the How s Your Health (HYH) survey.

35 How s Your Health Survey When you visit your doctor's office, how often is it well organized, efficient, and does not waste your time? Most of the time Some of the time Almost never is it efficient. It often wastes my time. Does not apply to me. I seldom visit a doctor's office.

36 NON PATIENT EFFICIENCY Back office efficiency: billing, handling results, phone messages What time do you go home?

37 Patient and Non-Patient Efficiency Patient and non-patient (back office) efficiency are interrelated. Patient efficiency issues can be rolled over into the time non-patient efficiency time. Poor efficiency leads to burnout.

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39 IMPROVING EFFICIENCY What are the underpinnings of the efficient back office? How to start and proceed? What does my redesigned office look like?

40 OFFICE INFRASTRUCTURE Digital trumps paper

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42 EFFICIENCY PRINCIPLE Continuous flow beats batch and queue Do this minute s work this minute. Do it once beats do it twice Avoid re-work

43 PAPERLESS OFFICE A goal to work towards.

44 WORKFLOW CHANGES Changes in workflow: proactive changes that leverage maximal efficiency from your system.

45 OUTSOURCE WORK PATIENT ENTERED DATA: Online appointment portal Web or office kiosk based histories and ROS

46 Framework for Improving Efficiency Measure efficiency using the HowsYourHealth survey

47 HowsYourHealth Cumulative Care Summary Data

48 Framework for Improving Efficiency Measure efficiency using the HowsYourHealth survey Zero in on processes that need improvement

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50 Framework for Improving Efficiency Measure efficiency using the HowsYourHealth survey Zero in on processes that need improvement Make breathing room for change

51 Breathing Room Close practice to new patients In a mature practice, space existing appointments further out

52 Framework for Improving Efficiency Measure efficiency using the HowsYourHealth survey Zero in on processes that need improvement Make breathing room for change Muster resources for change

53 Use Local Solutions Patients Personal strengths Personal preferences

54 Framework for Improving Efficiency Measure efficiency using the HowsYourHealth survey Zero in on processes that need improvement Make breathing room for change Muster resources for change Re-evaluate and continue to tweak processes

55 PROCESSES NEEDING WORK Phones Note Generation Handling Results Billing

56 PROBLEM PROCESS: Phone SOLUTION: let the answering machine do its job Allows completion of task in progress Leaving messages focuses patient Some messages require action without callback Message directs patients to web site for online appointment booking

57 ANSWERING MACHINE

58 PROBLEM PROCESS: Handling Volume of Phone Messages SOLUTION: Unload phone demand web based patient self-scheduling communication rapid turnaround time for messages

59 PROBLEM PROCESS: Note Generation SOLUTION: patient entered automated history taking software

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61 Patient Generated Automated Histories Web-based and office based portals Saves time obtaining and documenting the HPI and ROS Focuses the diffuse patient Obtains patient rating scales Takes a standardized patient history Allows billing at a higher level of service Dr. John Bachman, FPM, July/August 2007, p 39.

62 PROBLEM PROCESS: Handling Results SOLUTIONS: workflow changes; document management software sends results via

63 HANDLING RESULTS Best: arrange for results to arrive before visit is fastest provides hard copy for patient Document manager acts as a digital aggregator to bundle items such as lab orders, prescriptions, results, then sends as and saves to EMR

64 PROBLEM PROCESS: Billing SOLUTION: Go electronic SOLUTION: Hire someone to do the things you hate!

65 % Patients Reporting "No Time Wasted" % Patients Reporting "No Time Wasted" COMPARISON OF NATIONAL AND Dr. Lynn Ho S IMP PATIENT EFFICIENCY DATA National Standard Speaker's Ideal Micropractice 100% 100% 90% 90% 80% 80% 70% 70% 60% 60% 50% Usual Care 50% Pre During Post Stages in Efficiency Study DATA FROM HOWSYOURHEALTH SURVEY

66 Take Home Points Efficiency is easily measured by HYH survey Front and back end efficiency can both be improved Breathing room is essential before making changes Exploit resources inherent in yourself and your practice for improvement Improvement is an iterative process

67 Moore LG and Wasson JH, The Ideal Medical Practice Model: Improving Efficiency, Quality and the Doctor-Patient Relationship, Fam Pract Manag, Sept 2007, p.20. Ho L, Seven Strategies for Creating a More Efficient Practice, Fam Pract Manag, Sept 2007, p Timothy Cook

68 Resources & References The Machine that Changed the World Womack, Roos, and Jones Lean Thinking Womack and Jones Learning to See Shook, available from the Lean Enterprise Institute Theory Of Constraints Goldratt The Goal Goldratt Lean.org Lean Enterprise Institute great tools in the Green Book