Analysis of New Patient Access to Appointments in the Adult and Child Ambulatory Psychiatry Clinics. Project Final Report.

Transcription

1 Analysis of New Patient Access to Appointments in the Adult and Child Ambulatory Psychiatry Clinics Project Final Report Project 1 To: Ms. Annemarie Lucas, Director of Operations Rachel Upjohn Building, East Medical Campus 4250 Plymouth Rd Ann Arbor, MI Ms. Whitney Walters, Lean Coach University of Michigan Health Services 2301 Commonwealth Blvd Ann Arbor, MI Dr. Mark Van Oyen, Associate Professor Industrial and Operations Engineering (IOE), University of Michigan 1205 Beal Ave Ann Arbor, MI From: IOE 481 Project Team, Industrial and Operations Analysis An Cao, Senior IOE Student Sam Ditter, Senior IOE Student Ryan Minnema, Senior IOE Student Maria Morales, Senior IOE Student 1205 Beal Ave Ann Arbor, MI Date of submission: April 19 th, 2010

2 TABLE OF CONTENTS Executive Summary 5 Analysis and conclusions 5 Child Clinic 5 Adult Clinic 5 Recommendations for NP Access Improvement 6 Child Clinic Solution Summary 6 Solution1- Reduce No-Sow Rate 6 Solution2- Limit the Number of Visits per Patient 6 Solution3- Supply Management 6 Solution4- Demand Management 7 Adult Clinic Solution Summary 7 Solution1- Reduce No-Sow Rate 7 Solution2- Limit the Number of Visits per Patient 7 Solution3- Supply Management 7 Solution4- Demand Management 7 Introduction 8 Background 8 Sub-Specialty Clinics 9 Intake and Scheduling Processes 9 Key Issues 11 Goals and Objectives 11 Project Scope 11 Approach 12 Conducted Literature Search 12 Conducted Literature Search Preliminary Findings 12 Observed Call Center 13 Observed Call Center Preliminary Findings 13 Observed Evaluation Clinic 14 Observed Evaluation Clinic Preliminary Findings 14 Interviewed Key People 14 Interviewed Key People Preliminary Findings 14 Received Data 15 Child Clinic Analyzed Data Findings and Conclusions 16 Lead Time by Clinic Findings 16 Lead Time by Clinic Conclusions 17 Panel Size and Number of Appointments Findings 18 Panel Size and Number of Appointments Conclusions 19 Number of Visits per Patient Findings 19 Number of Visits per Patient Conclusions 20 Clinic Occupancy Findings 20 Clinic Occupancy Conclusions 21 2

3 No-Show/ Late Cancel Rate- Findings 22 No-Show/ Late Cancel Rate- Conclusions 22 Child Clinic Recommendations 23 Solution 1 Reduce No-Show Rate 23 Solution 2 Limit the Number of Visits per Patient 25 Solution3- Supply Management 26 Solution4- Demand Management 27 Adult Clinic Analyzed Data Findings and Conclusions 27 Lead Time by Clinic Findings 27 Lead Time by Clinic Conclusions 28 Panel Size and Number of Appointments Findings 29 Panel Size and Number of Appointments Conclusions 30 Clinic Occupancy Findings 30 Clinic Occupancy Conclusions 32 No-Show/ Late Cancel Rate- Findings 32 No-Show/ Late Cancel Rate- Conclusions 33 Number of Visits per Patient Findings 33 Number of Visits per Patient Conclusions 34 Off Team Breakdown Findings 34 Off Team Breakdown Conclusions 35 Impact of Evaluation Clinic on Lead Time Findings 35 Impact of Evaluation Clinic on Lead Time Conclusions 35 Adult Clinic Recommendations 36 Solution 1 Reduce No-Show Rate 36 Solution 2 Limit the Number of Visits per Patient 38 Solution3- Supply Management 40 Solution4- Demand Management 40 Recommendation to Make Analysis a Repeatable Process 40 Appendices Appendix 1: Bibliography 42 Appendix 2: Adult Anxiety Clinic Findings Summary 43 Appendix 3: Child Anxiety Clinic Findings Summary 44 Figures Figure 1: Ambulatory Psychiatry Clinic Specialty Breakdown 9 Figure 2: Process Flow Chart of Adult and Child Psychiatry Clinics 10 Figure 3: Comparison of 2008 and 2009 NP Average Lead Time by Clinic 17 Figure 4: Number of Visits per 2008 New Patient between the January 2008 and December

4 Figure 5: Clinic New Patient Supply vs. Demand in Figure 6: Comparison of 2007 and 2009 NP Average Lead Time by Sub-specialty Clinic 28 Figure 7: Adult Clinic New Patient Supply vs. Demand in Figure 8: Number of Visits per 2008 New Patient between the January 1 st 2008 and December 31 st Tables Table 1: Breakdown of New Patient Wait Time from Scheduling to Appt. 10 Table 2: Percent of New Patients Seen Within Four Weeks for each Sub-Specialty Child Clinic 17 Table 3: Panel Size in 2009 vs. Panel Size in Table 4: Number of Appointments in 2008 and Table 5: Ratio of data between 2008 and Table 6: No-Show Rate in 2009 vs. No-Show Rate in Table 7: 2009 Child Clinic Breakdown of Appts. Needed to Meet FGP Standard 23 Table 8: 2009 Child Clinic New Patient No-Show/Late Cancel Breakdown 24 Table 9: 2009 Child Clinic No-Show Analysis 24 Table 10: Hours Saved Breakdown 25 Table 11: Breakdown of Patients and Appts. Affected by Limiting Revisits 26 Table 12: Additional Clinician Hours Needed to meet the FGP Standard 27 Table 13: Percent of New Patients Seen Within Four Weeks for each Sub-Specialty Adult Clinic 29 Table 14: Panel Size in 2008 vs. Panel Size in Table 15: Number of Appointments in 2008 and Table 16: Ratio of data from 2008 to Table 17: Occupancy By Sub-specialty Clinic in 2007 vs Table 18: No-Show Rate in 2009 vs. No-Show Rate in Table 19: Breakdown of Patient Visits by Each Type of Provider for 2007 and Table 20: 2009 Adult Clinic Breakdown of Appointments Needed to Meet FGP Standard 36 Table 21: 2009 Adult Clinic New Patient No-Show/Late Cancel Breakdown 37 Table 22: 2009 Adult Clinic No-Show Analysis 37 Table 23: Hours Saved Breakdown 38 Table 24: Breakdown of Patients and Appts Affected by Limiting Revisits 39 Table 25: Additional Clinician Hours Needed to Meet FGP Standard 40 4

5 EXECUTIVE SUMMARY As of the end of the 2009 fiscal year, the Ambulatory Care Operations Committee (ACOC) at the University of Michigan Health System reported that access to new patient appointments in the Ambulatory Psychiatry Clinic ( the Clinic ) is not meeting the Faculty Group Practice s (FGP) standard that 80% of new patients need be seen within four weeks. Because demand for the clinic s services is so high, the Adult and Child Psychiatry Sub-Specialty Clinics only see 68% and 59% of new patients within four weeks, respectively. To address this issue, the Director of Operations at the Clinic has asked the IOE 481 team to analyze the current lead time, from initial clinic contact to day of appointment, for new patients in both the Adult and Child Psychiatry Sub-Specialty Clinics. In addition, the Director of Operations asked to know if the Evaluation Clinic (EVC), added in May 2008 to the Clinic schedule, achieved its intended purpose of increasing new patient access to appointments. Lastly, the Director of Operations asked for an analysis of the current panel size, defined as the total number of unique patients receiving care at the Clinic during a calendar year. In response to these issues, the team has collected data, analyzed the situation, and developed recommendations to increase new patient access so that greater than 80% of new patients are seen within four weeks. Analysis and Conclusions To analyze the current situation at the Clinic and develop recommendations to increase new patient access, the team used the following methods: conducted literature search, observed the EVC and call center, interviewed key people, and received patient scheduling data for 2008 and Child Clinic The team analyzed data provided by the Director of Operations to determine the following: Average new patient (NP) lead time increased from 22.8 to 23.6 days over 2008 and 2009 Panel size of unique patients decreased from 2,393 to 2,318 patients over 2008 and 2009 o Ratio of NP to total appointments decreased between 2008 and 2009 o Ratio of NP to unique patients decreased between 2008 and 2009 Panel size of NP if the 2009 ratio of NP to total appointments is doubled requires a total NP population of 2,388 patients Child Clinic is booked at 82% occupancy (arrived patients to total supply of appointments) Average number of visits per patient is 8.1 New patients seen within four weeks in the Child Clinic is only 55% Adult Clinic The team analyzed data provided by the Director of Operations to determine the following: Average NP lead time decreased from 23.0 to 20.6 days over 2007 and 2009 Panel size of unique patients increased from 4,855 and 5,221 patients over 2007 and

6 o Ratio of NP to total appointments remained the same between 2007 and 2009 o Ratio of NP to unique patients remained the same between 2007 and 2009 Panel size of NP if the 2009 ratio of NP to total appointments is doubled requires a total NP population of 4,715 patients Adult Clinic is booked at 80% occupancy, decreased in 2009 compared to 2007 Average number of visits per patient is 9.6 Off team composition in 2009 consists of a smaller percentage of social workers and nurse practitioners compared to Off team appointments are defined as NP appointments scheduled outside of the sub-specialty clinic hours NP seen within four weeks in the Adult Clinic is only 72% Recommendations for NP Access Improvement From the findings, the team has determined three possible sources of the NP access problem: (1) the demand for services is greater than the supply of available clinician hours at the Clinic, (2) the patients continue care within the Clinic resulting in a throughput rate that does not match demand, and (3) the new patient no-show rate is high. No-show rate is defined as the total number of patients who do not show up for a scheduled appointment to the total number of scheduled patients. The team proposed four solutions to improve new patient access and increase the number of new patients seen at the Clinic. Child Clinic Solution Summary To meet the FGP standard with the current panel size, the Clinic must add 297 new patient appointments. To meet the FGP standard when the new patient population is doubled, 1,252 new patient appointments are needed. Solution 1 Reduce No-show Rate The no-show rate in the 2009 child clinic for new patients was 7.1% and the late cancel rate for the same clinic was 10.9%. A late cancel is a patient who canceled an appointment within zero or one day of the scheduled appointment time. Reducing the combined rate (18.0%) by 18 percentage points would yield 262 incremental appointment slots. This would increase the number of NPs seen and the NP access at the Clinic assuming these incremental patients can be seen within the four weeks of their schedule date. Solution 2 Limit the Number of Visits per Patient The second solution is to limit the number of return visits per patient. To meet the FGP standard with the current panel size, the Child Clinic would need to limit the number of visits per patient to 14 visits. To double the number of NPs in the Child Clinic, the number of visits would have to be limited to approximately five visits per patient. Limiting the visits would save enough hours to see enough incremental patients for their new patient evaluations and corresponding return visit appointments to increase NP access so that the FGP standard is met. Solution 3 Supply Management The third solution is to refer new patients who cannot be scheduled within four weeks to outside clinics. To be clear, this means that if the next available appointment is five weeks out, NPs 6

7 calling to be scheduled at that time would not be seen at the Clinic, but instead referred to an outside clinic. This would improve the NP access at the Clinic. Solution 4 Demand Management Solution four is to hire more staff to fill with the incremental NPs. Therefore, to create the necessary number of appointments to see the incremental 297 patients, the Child Clinic would need to supply 2,638 more clinician hours. To see an incremental 1,252 patients, the Child Clinic would need 11,122 more hours. This would improve NP access, as well as, increase the NP panel size. Adult Clinic Solution Summary To meet the FGP standard with the current panel size in 2009, the Adult Clinic must add 189 new patient appointments. To meet the FGP standard when the new patient population is doubled, an additional 2,075 new patient appointments are needed. Solution 1 Reduce No-show Rate In the 2009, the no-show rate at the Adult Clinic for new patients was 7.3% and the late cancel rate for the same clinic was 12.4%. A late cancel is a patient who canceled an appointment within zero or one day of the scheduled appointment time. Reducing the combined rate (19.7%) by approximately 7 percentage points would yield 189 incremental appointment slots to see new NPs. Solution 2 Limit the Number of Visits per Patient The second solution is to limit the number of return visits per patient. To meet the FGP standard with the current panel size, the Adult Clinic would need to limit the number of visits per patient to 30 visits. To meet the FGP standard when the NP population is doubled, the Adult Clinic would need to limit the number of visits per patient to approximately six visits. Solution 3 Supply Management The third solution is to refer new patients who cannot be scheduled within four weeks to outside clinics. To be clear, this means that if the next available appointment is five weeks out, a NP asking to be scheduled would not be seen at the Clinic, but instead referred to an outside clinic until the next available appointment is less than four weeks out. This would improve the NP access at the Clinic. Solution 4 Demand Management Solution four is to hire more staff to fill with the incremental NPs. Therefore, to create the necessary number of appointments to see the incremental 189 patients needed to meet the FGP standard, the Adult Clinic would need to supply 1,826 more clinician hours. To see an incremental 2,075 patients, the Adult Clinic would need 20,044 more hours. This would improve NP access, as well as, increase the NP panel size. 7

8 INTRODUCTION As reported by the Ambulatory Care Operations Committee (ACOC) of the University of Michigan Health System, new patient demand is overwhelming the Adult and Child Psychiatry Sub-Specialty Clinics at the University of Michigan Ambulatory Psychiatry Clinic ( the Clinic ), resulting in only 68% and 59% of new patients being seen within four weeks for Adult and Child Clinics, respectively. In addition, the Scheduling Supervisor at the Clinic reports that new patients are being referred to outside clinics due to the long lead time to the day of the appointment. Therefore, the Clinic s Director of Operations would like to increase new patient access, defined as the availability of appointments for new patients, to meet the standards set by the Faculty Group Practice (FGP) that 80% of new patients are seen within four weeks. To address this issue, the Director of Operations has asked the team to analyze the current lead time, from initial clinic contact to day of appointment, for new patients in both the Adult and Child Psychiatry Sub-Specialty Clinics. In addition, the Director of Operations would like to know if the Evaluation Clinic (EVC), added in May 2008 to the Clinic schedule, achieved its intended purpose of increasing new patient access to appointments. Lastly, the Director of Operations asked for an analysis of the current panel size, defined as the total number of unique patients receiving care at the clinics during a calendar year. In response to these issues, the team has collected data, analyzed the situation, and developed recommendations for four Child and Adult Clinic solutions to increase new patient access so that greater than 80% of new patients are seen within four weeks. This report presents the methods, findings, conclusions, and recommendations for this project. In addition, the report includes the analysis of the current wait time for new patient appointments in the Adult and Child Psychiatry Sub-Specialty Clinics, and of the impact of the EVC on wait time (time between the appointment being scheduled and the actual appointment date). The report is broken down into two sections; Child Clinic and Adult Clinic. Each section is written such that they can be read and understood independent from each other. Background In October, 2006, after completion of the Rachel Upjohn Building, all ambulatory (outpatient) psychiatry disciplines at the University of Michigan became integrated to gain synergies of a centralized operation (Figure 1 below). 8

9 Figure 1: Ambulatory Psychiatry Clinic Specialty Breakdown Today, the Ambulatory Psychiatry Clinics have more than 55,000 patient visits per year consisting of approximately 33,000 visits in adult service; approximately 14,000 visits in child service; and approximately 1,000 other visits not classified within adult and child service, according to the Director of Operations at the Clinic. Demand for these services has increased over the last few years; however, the true panel size at the Clinic is unknown. To meet the demand, an Industrial and Operations Engineering (IOE) project at the University of Michigan conducted in 2007 recommended that the Clinic establish an Evaluation Clinic in their schedule to improve access and complement the sub-specialty psychiatry clinics. According to the Scheduling Supervisor at the Clinic, the EVC has increased the number of patients seen, but has not completely corrected the access problem. According to the ACOC, in FY09, approximately 68% of new patients in adult service and 59% of new patients in child service were seen in 4 weeks or less, but some new patients waited more than 8 weeks. Sub-Specialty Clinics As shown in Figure 1, five major clinics exist under the Ambulatory Psychiatry Department: Addiction, Child, Neuro-Psychiatry, Adult, and Sleep. In this project, the team focused on the Adult and Child Clinics. The clinics are broken down further into seven sub-specialty psychiatry clinics for both adult service and child service. New patients are scheduled for evaluations at one of these sub-specialty clinics. The normal new patient evaluation is done by social workers, nurse practitioners, and residents, and takes approximately 90 minutes in the general clinic and up to two hours in the other sub-specialty clinics for adult service. For child service, normal evaluations take between two and three hours. Physicians and social workers are dedicated resources to one of these clinics. Intake and Scheduling Processes The process of scheduling appointments for new patients is described in Figure 2 below. 9

10 Figure 2: Process Flow Chart of Adult and Child Psychiatry Clinics As shown in Figure 2, the processing of scheduling appointments begins with intake. The intake process occurs at the Clinic Call Center, where three clerical FTE (full time equivalent) staffs answer 300 calls per day and 3.5 FTE social workers answer 70 calls per day. Patients call to schedule an appointment either because they were referred by a physician or because they believe they require the services offered by the Clinic. Referring physicians sometimes send faxes for appointment requests. Most of the intake process is done over the phone with calls lasting on average minutes according to the Scheduling Supervisor. The intake process has five steps during which a general diagnosis is confirmed by social workers or clerks. Collecting personal demographic information Confirming payment process Collecting health problems and history Scheduling an appointment with appropriate sub-specialty clinic Completing patient diagnosis and scheduling information to update records Also included in the lead time shown in Figure 2 is new patient wait time from the day of scheduling to the day of the appointment. Table 1 below details a percentage breakdown of new patient wait time for Adult and Child psychiatry. Table 1: Breakdown of New Patient Wait Time from Scheduling to Appointment Source: FY09 New Patient Lead Time Report, Faculty Group Practice, Jan 2010 w/in 4 wks 0-2 wks 0-4 wks 0-8 wks 8+ wks Adult Psychiatry 67.9% 39.4% 28.6% 30.2% 1.9% Child Psychiatry 58.7% 34.4% 24.3% 38.3% 3.0% As shown in Table 1, approximately 32% of new patients in the Adult Clinic and 41% of patients in the Child Clinic are waiting longer than four weeks to be seen. According to the current FGP 10

11 standard, only 20% of new patients should be waiting longer than four weeks to be seen. Also, according to the Scheduling Supervisor, patients are dissatisfied with these long wait times. Key Issues The following key issues drove the need for this project: Access to appointments is a problem; on average, approximately 65% of new patients are seen within four weeks in the Adult and Child Psychiatry Sub-Specialty Clinics. FGP requires that 80% of new patients be seen within four weeks. Ambulatory Psychiatry Clinics throughput is too low to meet the demand of new patients. Impact of the Evaluation Clinic is unknown. Patients and referring physicians are dissatisfied because the wait time for appointments is several weeks. Goals and Objectives The primary project goal was to evaluate access for new patients in the Adult and Child Psychiatry Sub-Specialty Clinics and recommend the number of new patient appointment slots needed to meet demand so that 80% of new patients are seen within four weeks. To accomplish the goal, the team achieved the following tasks: Determined the current wait time for new patient appointments in the Adult and Child Psychiatry Sub-Specialty Clinics Measured the impact of the Evaluation Clinic on wait time Determined current panel size for Adult and Child Psychiatry Sub-Specialty Clinics Determined ideal panel size with double the current percentage of NP Determined the number of visits per patient in the Adult and Child Psychiatry Sub- Specialty Clinics With the information, the team developed recommendations on the following: Number of new patient appointment slots needed to meet demand Optimal appointment slots ratio of new-patients to return-visit patients Discharge rate necessary to double the number of new patients seen Project Scope This project included the analysis of the: Intake and scheduling processes. This process begins when the patient calls to schedule an appointment and ends when the patient arrives at the clinic to be seen. Wait times of Adult and Child Psychiatry Sub-Specialty Clinics. Impact of the Evaluation Clinic on new patient wait time for appointments. Current and optimal panel size, appointment slots ratio of new-patients to return-visit patients, and patient discharge rate. 11

12 This project excluded: Any task not connected to the scheduling and intake processes. Recommendations related specifically to the activities observed in the Evaluation Clinic. The analysis and study of the Sleep, Neuro-Psych, and Addiction Clinics. APPROACH The team performed this project in three phases: acquiring data, analyzing data, and developing recommendations. During the first phase, acquiring data, the team conducted a literature search, observed the call center and evaluation clinic, interviewed key people, and obtained historical data. During the second phase, analyzing data, the team analyzed supply and demand for both ambulatory adult psychiatric services and child psychiatric services and evaluated new patient access to appointments in these clinics. In the final phase, the team developed alternatives to maximize patient throughput and minimize wait times for new patients. Additionally, the team developed a recommendation that determined the number of new patient appointment slots needed to meet demand and the optimal new to return-visit patient appointment slot ratio to double the number of new patients in the panel. Conducted Literature Search The team conducted a literature search, including three articles: (1) a previous IOE481 project report on scheduling for Ambulatory Psychiatry Clinic titled Analysis of Lead Time to Day of Appointment in Adult Ambulatory Psychiatry Clinics (Chan & Chow & Leow, December 10, 2007), (2) an article titled Evaluating the Design of a Family Practice Healthcare Clinic Using Discrete-Event Simulation (Swisher & Jacobson, June 2001), and (3) on article titled Optimal outpatient appointment scheduling (Kaandorp, May 2007). Conducted Literature Search Preliminary Findings From the literature search, the team gained information on how a general ambulatory Psychiatric Clinic works, what methods can be used to determine the supply and demand of physicians, and what approaches can be used to analyze the data. Previous IOE481 project report The team read the Analysis of Lead Time to Day of Appointment in Adult Ambulatory Psychiatry Clinics prepared in 2007 on scheduling for Ambulatory Psychiatry Clinic. From the reading, the team developed a better understanding of the current project. In addition, the team gained information on the methods that can be used to analyze the data. Article on using simulation to evaluate a clinic The team read an article titled Evaluating the Design of a Family Practice Healthcare Clinic Using Discrete-Event Simulation (Swisher & Jacobson, June 2001). The article describes a methodology for determining appropriate staffing and physical resources in a clinical environment using a simulation model constructed by Visual Simulation Environment. This 12

13 methodology uses several simulation-based statistical techniques, including batch means, fractional factorial design, simultaneous ranking, selection, and multiple comparisons. Article on optimal outpatient appointment scheduling The team read an article titled Optimal Outpatient Appointment Scheduling (Kaandorp, May 2007). The article introduces a method, local search, which can be used to optimize outpatient scheduling. In addition, the Bailey-Welch rule, a mixed block-individual appointment rule that is identified as one of the basic scheduling principles, is found to be the optimal appointment schedule under the condition that: (1) service time durations are exponentially distributed, (2) patients arrive on time, and (3) no-shows are allowed to happen. However, for the current project, the service time durations are not exponentially distributed but fixed. Therefore, the team did not use the Bailey-Welch rule for the project, but the article provided good perspective of methods that can be used to solve the optimization appointment scheduling problem. Observed Call Center The team observed the Clinic s call center once in the morning for two hours and once in the afternoon for two hours. The call center schedules appointments for new patients and revisit patients, as well as, conducting the intake process for new patients. The calls are taken by social workers and clerks. During a call from a new patient, the social worker or clerk collects the following information: Demographic information Payment method information Reason for appointment request, including health problems and history After collecting the information, the social worker or clerk assigns and schedules the patient to a sub-specialty using the scheduling software called EWS. After the call, the social worker or clerk usually completes paperwork, which can involve ing the physician about an appointment scheduled or completing the intake form in M-Strides (the software used for intake). A call from a revisit patient involves only scheduling the appointment. Observed Call Center Preliminary Findings The observation revealed key issues relating to the intake and scheduling processes. First, the average call varies between 10 to 15 minutes for both new patient and return-visit patient calls. The majority of these calls can be handled by the clerks; however, some calls are wrongfully directed to the social worker resulting in wasted resources. If a social worker did not have to answer calls, the social worker could see patients. Lastly, social workers and clerks find it is difficult to always assign the patient to the correct sub-specialty clinic. As a result, the physicians are frustrated because they prefer to see patients of their sub-specialty. 13

14 Observed Evaluation Clinic The team observed the Evaluation Clinic on a Friday from 8 am to 11 am. During this time, physicians conducted five new patient evaluations, as well as four of return visit sessions. The Friday s Evaluation clinic is run by the Chair of the Department of Psychiatry and is staffed by two attendings, two third-year residents, a social worker, and a nurse practitioner. At 8 am, the physician team meets to briefly discuss the schedule of the day s Evaluation Clinic. The residents and social workers see the patient during the clinic hours. The Department Chair and attendings observe the residents work with new patients through a one-way mirror window and give feedback to the resident. For about ¾ of a new patient appointment session, the attending observes. In the last ¼ of the session, the attending pages the resident to discuss the patient s case in a separate room. Following the discussion, both the resident and the attending return to the patient s room to discuss the patient s situation and treatment. This process is different for return visit patients where residents see patients alone without an attending. After all the appointment sessions are complete, the physician team meets again to discuss the patients cases. Observed Evaluation Clinic Preliminary Findings From the observation, the team gained valuable insights into the roles and responsibilities of each of the staff members at the Evaluation Clinic. In addition, the team identified that the lengths of appointments vary between 30 minutes to 90 minutes depending on the severity of the case and the type of patient. However, all new patient evaluations take 120 minutes. Lastly, the team found that the attendings main responsibility in the clinic is to educate the person who is doing the evaluation. Typically, they do not see patients on their own. Residents are the physicians who see patients in this clinic. Interviewed Key People The team interviewed four individuals: Psychiatrist specializing in Depression Chair of the Department of Psychiatry Medical Director of the Anxiety Clinic Director of the Child Psychiatry These interviews helped the team understand the processes and root causes of the problems. Interviewed Key People Preliminary Findings The interview with the Psychiatrist indicated the following findings: Length of stay is an important metric to assess throughput. Fundamental problem at the Clinic is an artificially created mismatch between demand and society s willingness to pay. The University Health System requires Ambulatory 14

15 Psychiatry to accept insurance, which sets a low price ceiling and creates more demand for the services than supply available. Patient no-shows add to the new patient access problem resulting in appointment slots that go unfilled. According to the Depression Psychiatrist, the no-show rate is estimated to be approximately 20-25%. The interview with the Department of Psychiatry indicated the following findings: EVC can be overbooked to reduce the impact of patient no-shows. New patient appointment schedules can be created with staggered appointment times so that the attending can observe more new patient evaluations. The interview with the Medical Director of the Anxiety Clinic indicated the following findings: Panel size calculation will be impacted by the approximately 10% of patients who are seen only once a year. The team assumed that if the patient was last seen over a year ago, the patient is no longer considered part of the Clinic s current patients. Patients in the Anxiety Clinic are categorized based on length of stay: o Short Patients who come for only one appointment. o Average A typical patient, who seeks care for only 6-12 months. o Long Patients who have anxiety embedded in abuse and stay longer than one year The interview with the Director of Child Psychiatry indicated the following findings: Demand for Child Psychiatry physicians at UM hospital is high, due to the shortage of child psychologists in Michigan. Discharge rate at Child Psychiatry Clinics is low due to lack of child physician care facilities. Resources at Child Psychiatry Clinics need to be deployed in a more flexible way than adult resources because child patients have a schedule based on both the child s and guardian s availability. Certain patients who need psycho therapy choose medical therapy over psycho therapy because wait time for psycho therapy appointment is 21.5 days. Received Data The team acquired the following data from the Director of Operations: Twenty-four months (January 2008 to December 2009) of patient realized demand data Schedule of 2009 Adult and Child Sub-Specialty Clinics Current scheduling guidelines used in intake process Call center metrics: o Average number of calls and faxes per day o Average length of calls minutes Twenty-four months (January 2008 to December 2009) of new patient intake data to measure actual demand data Data from past IOE 481 project completed in 2007 on scheduling for Ambulatory Psychiatry Clinic 15

16 Number of available new patient appointment slots by physician for Adult and Child Sub-Specialty Clinics Schedule of 2008 Adult and Child Sub-Specialty Clinics CHILD CLINIC - ANALYZED DATA FINDINGS AND CONCLUSIONS The findings presented in this report for the Child Clinic and its sub-specialty clinics are based on the analysis of 2008 and 2009 scheduling data. The sample size of the data in 2008 and 2009 was 2,393 and 2,318 unique patients respectively, which includes new and revisit patients. By analyzing this data the team determined the following: Lead time by clinic Panel size and number of appointments Number of visits per patient Clinic occupancy No-Show/ late cancel rate Lead Time by Sub-Specialty Clinic Findings To determine lead time by sub-specialty at the Child Clinic, the sub-specialty clinic, for which each new patient attended, had to be determined. As a result, the scheduling data provided by the Director of Operations was sorted by three metrics: (1) appointment day of week, (2) appointment time, and (3) clinician. After sorting the data, a patient was determined to be seen in a sub-specialty clinic by matching the appointment day of week, time, and clinician to the schedule of the Child Sub-Specialty Clinics obtained from the Director of Operations. A column was then added in the data to track the clinic where a patient was seen. After the sub-specialty clinic for each patient was determined, functions and Macros in Microsoft Excel were used to determine the lead time by sub-specialty clinic a patient attended. An Excel Macro is a small computer program that can be used to perform a repeatable process. Again, lead time is defined as the time between the day of appointment and the day when the appointment was scheduled. For the overall Child Clinic, the lead time for a new patient appointment increased from 2008 to In addition, the number of arrived patients decreased by 64 patients between 2008 and Arrived patients are the patients who showed up for their scheduled appointments. The lead time and number of arrived patients by sub-specialty clinic can be seen in Figure 3 below. 16

17 Days and 2009 Child NP Average Lead Time by Clinic In Days ADHD Anxiety ASD Depression General Off Team Parent Child Relationship TRD YYAM Total Clinic Number of Arrived Patients Figure 3: Comparison of 2008 and 2009 NP Average Lead Time by Clinic Source: 2008 and 2009 Scheduling Data, IOE 481, Jan-Apr 2010 Lead Time by Clinic - Conclusions The findings above revealed that with this high lead time, the percent of new patients being seen in each sub-specialty clinic is well below the FGP standard of 80%. Table 2 below shows that none of the sub-specialty clinics are currently at or above this standard, and therefore, the percentage of new patients seen within four weeks for the Child Clinic is only 55%. This value needs to increase by 25% to meet the FGP standard. Table 2: Percent of New Patients Seen Within Four Weeks for each Sub-Specialty Child Clinic Source: 2008 and 2009 Scheduling Data, IOE 481, Sample size = 1,194 new patients, Jan-Apr weeks 0-4 weeks 0-6 weeks 0-8 weeks ADHD 33.8% 48.8% 83.8% 98.8% Anxiety 24.9% 53.7% 86.6% 100.0% ASD 14.3% 54.3% 80.0% 100.0% Depression 16.3% 45.2% 82.8% 98.2% General 16.1% 43.2% 77.4% 96.8% Off Team 38.5% 67.9% 88.2% 96.9% Parent Child Relationship 36.4% 59.1% 77.3% 100.0% TRD 31.4% 54.3% 100.0% 100.0% Total 28.2% 55.2% 85.3% 98.5% 17

18 Panel Size and Number of Appointments Findings To determine the current panel size of the entire Child Clinic, which is defined as the number of unique patients seen in a calendar year, the team used a Macro in Excel. The Macro goes through all the scheduled appointments in one year and counts the number of unique patient keys. The team found the panel size for the year 2008 and Table 3 shows that from 2008 to 2009, the number of unique patients decreased by 3.1%. In addition, the number of new patients seen decreased by 6.1%. Table 3: Panel Size in 2009 vs. Panel Size in 2008 Source: 2008 and 2009 Scheduling Data, IOE 481, Jan-Apr % Increase Number of Patients Unique 2,393 2,318 (3.1%) New 1,272 1,194 (6.1%) Revisit Only 1,121 1, % NP Scheduled 0-1 day lead time (10.6%) Another way to look at the size of the Child Clinic is by the total number of appointments at the Child Clinic in 2008 and Table 4 below summarizes the total number of appointments. Each arrived appointment (an appointment where a patient arrived) was classifed into seven categories: RV Group, RV Family, RV-Full, RV-Half, RV Meds, RV Miscellaneous, or New Patient. Then, using an Excel function the counts of each category were determined. Table 4: Number of Appointments in 2008 and 2009 Source: 2008 and 2009 Scheduling Data, IOE 481, Jan-Apr % Increase Number of Appts RV Group (30.5%) RV Family (3.5%) RV-Full 9,636 11, % RV-Half 1, (17.3%) RV Meds (80.6%) RV Miscellaneous (24.2%) NP 1,272 1,194 (6.1%) Total Appts 13,456 14, % The table shows that the number of total appointments from 2008 to 2009 increased by 9% mostly as a result of an increase in RV-Full appointments. 18

19 Panel Size and Number of Appointments Conclusions The panel size and number of appointments findings show that new patients are becoming less of the total appointments and less of the unique patients at the Child Clinic. The increase in the number of appointments between 2008 and 2009 coupled with the decrease in new patients over the same time period, has led to a 1.4 percentage point decrease in the ratio of new patients to total appointments. Also, based on the same rational, there has been a decrease of 1.7 percentage points in the ratio of new patients to unique patients at the Child Clinic (Table 5). Therefore, it can be concluded that individual patients were seen for more return-visits in 2009 than in The Director of Operations is interested in increasing the number of new patients seen, therefore, fewer appointments should be devoted to revisit patients and more should be devoted to new patient appointments. Table 5: Ratio of data between 2008 and 2009 Source: 2008 and 2009 Scheduling Data, IOE 481, Jan-Apr Ratios %NP / Total Appts 9.5% 8.1% %NP / Unique 53.2% 51.5% %RV Only / Unique 46.8% 48.5% Number of Visits per Patient Findings The average number of visits per patient was determined using an Excel Macro which located the patient key for a new patient and counted how many times that specific patient arrived to the Child Clinic. The average number of visits was calculated using all the new patients in 2008 and their corresponding revisit appointments in 2008 and The average number of visits for the Child Clinic is 8.1 (1 new patient appointment and 7.1 return-visit appointments). In total, 42 patients were seen for more than 34 appointments. Figure 4 below indicates the number of patients that arrived for each number of visits. 19

20 Number of Visits per 2008 NP from 1/1/ /31/2009 Child Clinc Number of Patients Average Number of Visits = 8.1 Population of NPs Population of Appts n = 1272 Number of Visits Figure 4: Number of Visits per 2008 New Patient between January 2008 and December 2009 Source: 2008 and 2009 Scheduling Data, IOE 481, Jan-Apr 2010 Number of Visits per Patient - Conclusions The average lead time coupled with the number of visits per patient findings suggest patients continue care such that the throughput rate does not match the current demand rate at the Child Clinic. Since resources are being used for revisit patient appointments, fewer resources are available for new patient appointments. Therefore, limiting the number of revisit appointments per patient could potentially create time to see more new patients. Clinic Occupancy Findings The team determined the number of arrived new patients divided by the number of available new patient appointment slots, or occupancy rate, for the Child Clinic. For 2009, the number of available appointment slots, or known supply, was determined from data provided by the Director of Operations. The data consisted of the gross number of monthly appointment slots categorized by providing clinician and sub-specialty clinic. To find the net number of monthly appointment slots the net number excludes physician time-off for vacation, conferences, sick days, and other acceptable reasons the gross number of available slots was reduced by 15%. The 15% reduction from gross to net appointment slots was used based on the Director of Operations request. Figure 5 shows the total clinic occupancy. The chart is split into two columns: scheduled patients and supply. 20

21 1, Child NP Supply vs Demand Number of Patients/Appointments 1,600 1,400 1,200 1, ,456 1,456 Late Cancel, 262 Arrived, 1,194 Specially Arranged, 99 Known, 1, Scheduled Figure 5: Clinic New Patient Supply vs. Demand in 2009 Source: 2008 and 2009 Scheduling Data, IOE 481, Jan-Apr 2010 Supply In Figure 5, scheduled patients are new patients who arrived at the Clinic and new patients who were scheduled but canceled late. A late cancel is a patient who canceled an appointment within zero or one day of the scheduled appointment time. Within the late cancel count are also new patients who did not show up to the clinic for their scheduled appointments. The 2009 Child Clinic contained 104 new patients who did not show up for their scheduled appointment. Supply consists of both known supply and specially arranged supply. Known supply is the annualized number of net new patient appointment slots discussed above. Specially arranged supply is the difference between scheduled appointments and known supply. The specially arranged supply is known as off-team appointments, which are appointments in which the time the patient was seen at the Clinic does not match any time on the scheduling grid during a sub-specialty clinic. The 2009 Child Clinic had 99 new patient appointment slots that were specially arranged. Comparing known supply to arrived patients, the 2009 Child Clinic was booked at 82% occupancy. Clinic Occupancy Conclusions Based on the clinic occupancy findings, the 2009 Child Clinic is functioning at about 82% occupancy. This occupancy is the total arrived new patients to total supply both known and specially arranged. Reducing the late cancel rate would improve overall clinic occupancy. However, as occupancy rate increases, wait time will also increase due to the variability in the system. 21

22 No-Show/ Late Cancel Rate - Findings The team determined the number of new patients who did not show up for their appointment no-show patients and divided that by the total number of scheduled appointments to determine the no-show rate for the Child Clinic. Also, the late cancel rate was determined. This is the number of new patients who cancelled their appointment within zero to one day before their scheduled appointment date late cancel patients and divided that by the total number of scheduled appointments. In addition, the team determined the no-show rate and late cancel rate for return visit patients. Table 6 shows that from 2008 to 2009, the no-show rate for revisit patients increased by 1.9%, and late cancel rate decreased by 1.2%. Also, for new patients, noshow rate and late cancel rate increased by 1.6% and 2.1% respectively. Table 6: No-Show Rate in 2009 vs. No-Show Rate in 2008 Source: 2008 and 2009 Scheduling Data, IOE 481, Jan-Apr Return Patient Visits No show 1,100 1,545 Late cancel excluding no show 1,718 1,725 Arrived 12,184 13,476 Total scheduled (no s how + late cancel + arrive d) 15,002 16,746 New Patient Visits No show Late cancel excluding no show Arrived 1,272 1,194 Total scheduled (no s how + late cancel + arrive d) 1,485 1,456 Return Patient Visits - Ratios No show rate 7.3% 9.2% Late cancel rate 11.5% 10.3% New Patient Visits - Ratios No show rate 5.5% 7.1% Late cancel rate 8.8% 10.9% No - Show/ Late Cancel Rate Conclusions As presented in the findings above, the no-show rate increased for both new patients and return visit patients in Child Clinic from 2008 to A high no-show rate leads to unused supply, which affects new patient access at the Child Clinic. All the clinicians whose patient did not show up could have seen another patient during that time. Providing more supply but not reducing the no-show rate will cause more supply to be unused. 22

23 CHILD CLINIC RECOMMENDATIONS Based on the findings, there are three potential reasons for long lead times between the time a patient schedules an appointment and the actual appointment date: (1) demand for services is greater than the supply of available by clinicians; (2) patients continue care within the clinic, such that the throughput is not high enough to meet demand; (3) the new patient no-show rate is high. Improving these three problems will help increase: (1) the new patient access from 55% of new patients seen within four weeks to the FGP standard of 80%, (2) the number of new patients seen at the Clinic. Table 7 below shows the incremental number of new patient appointments needed to be scheduled with four week lead time or less to meet the FGP standard of 80% of new patients seen within four weeks for both the current panel size and a doubling of the number of new patients. The table shows that for the current panel size, 297 new patient appointments are needed to meet the standard. To double the new patient population and still meet the FGP standard, 1,252 new patient appointments are needed. Table 7: 2009 Child Clinic Breakdown of Appointments Needed to Meet FGP Standard Source: 2008 and 2009 Scheduling Data, IOE 481, Jan-Apr Target Total NP Population 1,194 2,388 % NP/Total Appt 8.1% 16.3% Patients seen w/in 4 weeks Current % 55.2% 27.6% Current # FGP Standard % 80.0% 80.0% FGP Standard Implied # 956 1,911 # NP appts needed to meet standard 297 1,252 To improve the three problems described above, the team developed four solutions: (1) reduce the no-show rate, (2) limit the number of revisit appointments per patient, (3) refer patients to outside clinics, and (4) hire more staff. To achieve the FGP standard of 80% new patients seen in less than four weeks, the Child Clinic should implement a combination of these solutions. Solution 1 Reduce No-Show Rate No-show new patients create unused supply at the Child Clinic. Every no-show new patient represents one additional new patient the Child Clinic could have seen and, potentially, an earlier appointment time for a new patient who was seen at the Child Clinic but not seen within four weeks. Table 8 below details the no-show and late cancel breakdown for the 2009 Child Clinic. No-show new patients include patients whose cancelation description in the appointment data received from the Director of Operations reads, Patient did not show up. A late cancel occurs 23

24 when patient canceled an appointment within zero to one day of the scheduled appointment date and whose cancelation description read Canceled. Table 8: 2009 Child Clinic New Patient No-Show and Late Cancel Breakdown Source: 2008 and 2009 Scheduling Data, IOE 481, Jan-Apr NP no show 104 NP late cancel 158 NP arrival 1,194 Total NP scheduled 1,456 Current no show rate 7.1% Current late cancel rate 10.9% Combined no s how and late cancel rate 18.0% From Table 8, the no-show rate in the 2009 Child Clinic for new patients is 7.1% and the late cancel rate is 10.9%. Reducing the combined rate (18.0%) by 18.0 percentage points would only yield 262 appointment slots. These 262 appointment slots would not be enough to help the Child Clinic achieve the FGP standard of 80% new patients seen within four weeks. However, it would increase the number of new patients seen and the new patient access. To achieve this improvement, the assumption is that the newly created appointment slots can be filled with new patient slots currently scheduled but with a lead time longer than four weeks or new patients who are not scheduled but can be scheduled with a lead time shorter than four weeks. Another way to look at the current no-show rate is having all of the already scheduled no-show patients arrive at the Child Clinic. Table 9 below shows this analysis. Table 9: 2009 Child Clinic No-Show Analysis Source: 2008 and 2009 Scheduling Data, IOE 481, Jan-Apr Current NP w/in 4 weeks 659 No show NP w/in 4 weeks 42 Total adjusted NP w/in 4 weeks 701 Total arrived NP 1,194 Total no show NP 104 Total adjusted arrived NP 1,298 %w/in 4 weeks/total (7.1% no show) 55.2% %w/in 4 weeks/total (0% no show) 54.0% FGP Standard 80.0% From the table, if all no-show patients arrived, an additional 104 patients would arrive at the Child Clinic. However, although the number of new patients at the Child Clinic increases, the 24