Analysis of Pediatric Acute Physical and Occupational Therapy Patient Care Delivery

Transcription

1 Analysis of Pediatric Acute Physical and Occupational Therapy Patient Care Delivery University of Michigan, Program & Operations Analysis Final Report Proposal Prepared For: Jose Kottoor, PT Occupational & Physical Therapy Director Lexanne Creitz, PT Occupational & Physical Therapy Supervisor Project Coordinator: Brendon Weil Lean Coach, Michigan Quality System IOE 481 Professor: Mark Van Oyen, PhD Proposal Submitted by IOE 481 Project 8 Team: Lauren Hood Amanda Metviner Andrew Nicholls Kristin Roth Date Submitted: April 5 th, 2010

2 Executive Summary Outpatient Pediatric Physical and Occupational Therapy through the University of Michigan Hospital system is located at two locations: at Mott Children s Hospital and at Milestones Clinic, which is an offsite location near the Briarwood shopping center in Ann Arbor. It has been reported that the current patient scheduling system at both facilities for outpatient physical, occupational and speech therapy is inefficient and unorganized. As a result, patient throughput is lower than optimal and many patients spend weeks waiting before they can be seen by a therapist. Additionally, the therapists feel they are spending too much time on non-patient care activities. The hospital and clinic staff wanted to know if there was a more efficient method to schedule patients and if there were any ways to allow therapists to spend more time working directly with patients. Goals and Objectives The primary goal of this project was to examine the current scheduling process and make any changes that would make it efficient and organized. The team that was going to accomplish this objective consisted of four seniors in the Industrial and Operations Engineering Department. These students were Lauren Hood, Amanda Metviner, Andrew Nicholls, and Kristin Roth. Additionally, the team wanted to find small changes that could be made to the clinic that would allow therapists to spend less time performing non patient-care activities. Methods Initially, the team conducted interviews with clerical staff and therapists to gain an understanding of scheduling operations at the clinics. Next, the team observed clerical staff and therapists performing their daily activities. Finally, the team collected data on how much time various steps in the scheduling process took. The team then analyzed the information and developed recommendations that will increase time for patient care and develop a better scheduling system. Finally, the team conducted a literature search using academic databases and peer-reviewed publications for material relevant to scheduling issues in the healthcare field. Findings and Conclusions The first step in the current scheduling process is a referral arrives at the clinic at the fax machine and a member of the clerical staff takes it and enters the information into the computer. The referral is then placed in a folder and a therapist takes it for triaging. The triaging step is where a therapist looks at what injuries the patient has and assigns that patient to a particular therapist who can work on those injuries. The referral is then returned to the clerical staff, who call the patient to schedule an appointment. To reduce the lead time between when a referral is received and when an appointment is scheduled, the team evaluated the current scheduling process. The team found that the referral spent approximately two business days in the triaging stage of the scheduling process. Through data analysis, the team found that therapists are spending approximately one third of their working hours on non-patient care. The team also noticed that most of the non patient-care time was devoted to documentation. Therapists often had to take documentation home to work on because they could not complete it when patients were around during the work day.

3 Throughout the project, the team also discovered that many distractions arise at the front desk causing the scheduling process to take longer than necessary. For example, staff members often had their work interrupted by children and parents coming over to have a conversation. The team observed that the clinic has a cancellation policy yet it is rarely followed. With 13 percent of all patients canceling their appointment, therapists often have large, unforeseen blocks of unscheduled time in their work. The team also noticed that therapists often waste time by struggling to move the splinting cart around the building. The current cart is difficult to maneuver around corners. Additionally, the team noticed that the therapists were having difficulty operating their laptops while conducting therapy with a patient. Recommendations To improve the patient scheduling process, the team recommends: Sending all patient referrals to the Milestones Clinic. Milestones staff will be put in charge of scheduling at both Milestone and Mott Giving Milestones building BW2 a private phone line so that patients can easily reach the building directly Remove restrictions on times that new patients can be scheduled, allowing more flexibility in patient scheduling In the short-term, training the clerical staff to be responsible for triaging referrals In the long-term, shifting the triaging responsibility to the office of the doctor who wrote the referral Altering the layout of the front desk staff so that they face less distractions throughout the day Implementing a stricter cancellation policy to reduce the cancellation rate To increase the time therapists have for patient care, the team recommends: Scheduling documentation time into appointment times. One possible example would be new patients would be scheduled for an hour and a half, with a half hour being for documentation. Existing patients will be scheduled for an hour, of which 15 minutes is for documentation Create documentation templates for different insurance companies so that therapists will not waste time filling out unnecessary information Purchase a smaller splinting cart so therapists will spend less time maneuvering around the office Provide therapists with tablet computers so that they can start documentation while therapy is occurring

4 Table of Contents Executive Summary...i Introduction...2 Background...2 Key Issues...3 Goals and Objectives...3 Project Scope...3 Approach and Methodology...4 Project Findings and Conclusions...5 Figure 1. Therapist Allocation as Reported on Billing Sheets...6 Figure 2. Therapist Allocation as Observed by Student Team...7 Figure 3. Elimination of Triaging will Reduce Lead Time by 2 Days...8 Recommendations...9 Action Plan...11 Expected Impact...12 Support Required by Operating Entities...12 Appendices Appendix A: Current State Map...13 Appendix B: Future State Map...14 Appendix C: Billing Sheet...15 Appendix D: Outpatient Tracking Form...16

5 Introduction Outpatient Pediatric Physical and Occupational Therapy through the University of Michigan Hospital system is located at two locations: at Mott Children s Hospital and at Milestones Clinic, which is an offsite location located near the Briarwood shopping center in Ann Arbor. The Director of scheduling for both Mott and Milestones reports that the current patient scheduling system at Mott Children s Hospital and Milestones Clinic for outpatient physical, occupational and speech therapy is inefficient and unorganized. Problems that have been noted are that referrals for therapy often expire before the patient is able to see a therapist at either location and that patients are unevenly distributed between the therapists. For example, there are days when one therapist has no patients, and another therapist has several patients. In addition, therapists report that they do not have enough time to complete therapy and accompanying paperwork in the scheduled timeslot with patients. Also, the therapists feel they are spending too much time on non-patient care activities. To address the issues that have been reported by the director of scheduling and the therapists, the Supervisor of the Mott Children s Hospital and Milestones Clinic asked the IOE 481 student team to analyze the current patient scheduling process, identify where and why problems arise with scheduling, and develop a better system for scheduling. In addition, the Supervisor asked the student team to analyze the therapists time allocation for each patient to determine if some lengthy tasks can be shortened and/or delegated to others to allow therapists to see more patients each day. The purpose of this report is to present the team s approach and methodology, findings and conclusions, and recommendations and the expected impact of the project. Background The Pediatric Physical and Occupational therapists at Mott Children s Hospital and Milestones Clinic are specifically trained to care for patients with a wide variety of pediatric medical conditions. However, a standardized process for scheduling patients at the two locations does not exist. The director of scheduling reports that scheduling delays often arise because Mott and Milestones each follow different processes for scheduling new patients. Second, lead times have been reported to be over a month long for new patient scheduling during the busy months. According to the scheduling clerks, most of the referrals for new patients are sent to Milestones Clinic; therefore, their appointments are at Milestones even if there is availability at Mott. The director of Milestones Clinic also reports that many times the schedulers are unaware of the skill set of each therapist and need to consult a therapist to determine which therapist is best suited to see the new patient. The long lead times cause billing and insurance problems when referrals are not scheduled within the allotted prescription period and the referral expires. Finally, therapists have noted that they spend significant amounts of time devoted to non-patient care activities such as paperwork, documentation, and assisting with scheduling.

6 Key Issues The hospital and clinic staff reported that the following key issues drove the need for this project: Mott and Milestones currently have no standardized process for scheduling patients at the two locations Lead times for new patient scheduling are unnecessarily long Long lead times cause patient referrals to expire before appointments are made Therapists spend significant amounts of time on non-value added work (documentation, travel time, etc.) Goals and Objectives To determine why the patient scheduling process may be unorganized and how much of the therapists time is spent on non-patient care activities, the student team performed the following tasks: Interviewed schedulers, therapists and Directors to determine shortfalls of the current process Analyzed the flow of information in the scheduling system Conducted a series of time studies on the tasks that therapists must perform for each patient Identified areas for improvement. With this information, the team developed recommendations to: Decrease patient time spent waiting for an appointment Increase time for patient care by decreasing therapist time spent performing nonpatient care activities Increase patient throughput Decrease the amount of wasted therapist time by evenly distributing patients. Project Scope This project included the patient scheduling process for the Outpatient Pediatric Physical and Occupational Therapy appointments for therapists located at Mott Children s Hospital and the Milestones Clinic. The scheduling process begins when a patient referral is ed or faxed to the clinic and ends when the patient has been scheduled for an appointment. The team also considered time spent by therapists on non-patient care processes. Any process involving direct patient care will not be analyzed. Also, the team cannot change the current computer system used for scheduling patients (EWS). While the team will observed and gathered ideas from the scheduling processes for the Pediatric Neurological Day Treatment Program and the Speech Therapy Programs, the project focused only on improvements and recommendations for the Outpatient Pediatric Physical and Occupational Therapy programs.

7 Approach and Methodology Through interviews, data collection, and observations, the team gathered and analyzed information, and developed recommendations that will create a more efficient scheduling system and increase time available for patient care. The team also performed an analysis of the data and determined areas of the clinic that needed improvement. Finally, the team conducted a literature search using academic databases and peer-reviewed publications for material relevant to scheduling issues in the healthcare field. Interviews The team interviewed the Mott and Milestones staff-including four clerical staff members, one technician, and seven therapists - to discuss problems and concerns. The team also interviewed the director of scheduling to obtain a more detailed description of the current process. The team asked all interviewees a variety of questions including, but not limited to, the interviewee s perception of the current scheduling process, the current scheduling system downfalls, and suggestions they have to improve the process. During interviews with the therapists, the team asked an additional set of questions to address the time they do not spend with patients. The therapists provided insight into the frustrations and benefits of their job and the approximate amount of time they spend on documentation. These interviews occurred over the week of February 15 th. Observations The team observed operations at the clinic for 54 hours of observations over the week of February 22 nd. Specifically, the team observed the current patient scheduling process to understand the current problem areas. The team observed the scheduling tasks at Mott and Milestones to gain a general overview of the scheduling process and to determine which steps of the process should be observed in greater detail. The team observed the therapists performing their daily set of tasks. This enabled the team to identify what types of activities the therapists were performing that did not relate to direct patient care. At least one set of observations was made during each day of the week so that all days of operation were observed. Time Studies The team completed time studies to determine the amount of time clerical staff spends scheduling new patients. The timing started when the schedulers first receive the request and ended when the patient has been scheduled. The team observed the scheduling process and broke it down into steps. These steps were used to accurately perform the time study.

8 The time studies were conducted on March 8 th and 9 th. The clerical staff had reported that approximately 15 to 20 requests are processed daily; therefore, by performing studies for two complete workdays, the team obtained data from 16 completed cycles. The time studies helped the team identify the parts of the current process that take the most time and develop methods to shorten these points. Current State Value Stream Mapping After interviews and observations, the team anaylzed the information and developed a current process value stream map of the Milestones Clinic and Mott Children s Hospital new patient scheduling process. The time studies were used to quantify each of the steps on the value stream map. The current state value stream map can be found in Appendix A. Work Measurement For this project, the therapists and scheduling clerks at Mott Children s Hospital and Milestones Clinic filled out productivity billing sheets that track the amount of time they spend on each of their daily activities. The team collected these billing sheets for the month of February. The team compiled and analyzed the data, and identified the non-patient care time categories to target for improvements. Root Cause Analysis After the team developed the current state value stream map, the team identified the root causes for the delays and inconsistencies in the current scheduling system for Mott Children s Hospital and Milestones Clinic outpatient staff. Using these findings, the team developed a future state value stream map, which appears in Appendix B. Final Recommendations The team developed final recommendations for Mott Children s Hospital and Milestones Clinic scheduling model to decrease patient wait times and decrease the amount to time therapists spend on non-patient care activities. Findings and Conclusions This section discusses the project findings from the data collected and the conclusions the team made from these findings. Therapists currently devote 36 percent of their time to non-value added work To evaluate how much time therapists spend on non-patient care, the therapists at Mott and Milestones filled out a Billing Sheet on which they recorded the allocation of their working hours. A copy of the billing sheet can be found in Appendix C. The team then summarized the results for February 1 February 29, 2010.

9 The billing sheets show that 63.77% of the therapists total working hours was spent on direct patient care. Non-patient care activities totaled 36.23% of the therapists total working hours. Documentation took up 19.45% of the total working hours, significantly more than any other non-patient care activity. Figure 1 shows the therapist's allocated time as per the billing sheets. However, team believes that this number does not reflect an accurate number of hours spent on documentation. This is because many therapists said that they spend time at home finishing documentation. Time at home was not recorded on the billing sheets. Additionally, every therapist interviewed mentioned that documentation time could be shortened. Figure 1. Therapist Allocation As Reported on Billing Sheets The student team observed operations at Milestones Clinic to check the validity of the data reported by the therapists. Through 1710 minutes of observations, the student team calculated that therapists are spending 26% of their time on documentation. This conflicted with the value of 19.45% documentation time that therapists reported on the billing sheets. A complete breakdown of therapist time is shown below in Figure 2.

10 Communicating with Patients/Therapists In Person 9% Traveling to Get Equipment 1% How Therapists Spend Their Time Phone Calls/ s 1% Triaging 0% Other 4% Documentation 26% Direct Patient Care 59% Figure 2. Utilization of Therapist Time As Observed by Student Team According to the observations made by the team, therapists spend 59% of their time on direct patient care. Documentation took up 26% of therapist time, the second largest portion. As a result, the student team concluded that time spent on documentation had the largest potential to be eliminated to reduce non-value added work. The team also noted that the observation data conflicted with information gathered during interviews with therapists. Therapists had reported that significant amounts of time were being devoted to triaging, but the student team did not observe a single instance of triaging. Scheduling process is inefficient yet standardized Through interviews, the team gathered the opinions of the therapists and clerical staff. In terms of the current scheduling process, the therapists thought the system could be improved with a few minor changes, including the clerical staff triaging referrals that arrive. Overall, the main concern was that there is not a standard, efficient process for the clerical staff to follow. However, the student team determined that there in, in fact, a standard process for the clerical staff to follow. Through observations performed in the office, it was determined that the clerical staff was involved in two steps of the referral process. The first step involved filling out the patient profile and demographics form. The second step involved entering patient information

11 into an outpatient tracking form and copying this information into the Excel patient tracker. These documentations help clerical staff understand where in the scheduling process each patient currently stands. A copy of the outpatient tracking form can be found in Appendix D. After observing 16 cycles of the referral process, the student team determined that the average time to complete step one was 3.5 minutes. Step two took an average of 5.6 minutes. From this information the student team determined that the steps in the referral process that involved the clerical staff were not significantly contributing to the long lead time in patient scheduling. In fact, the clerical staff contributed only minutes towards the scheduling lead time of days. The team also observed the patient scheduling processes for Mott and Milestones. Although Mott and Milestones follow very similar processes, differences exist. For instance, processing referrals and insurance information is handled by one person at Mott. At Milestones, these jobs are handled by separate staff members. A flowchart of the current patient scheduling process at the Milestones Clinic can be found in Appendix A. Lead Time for Scheduling Appointments is over 2 business days The primary delay for patient scheduling occurs as a result of the need for triaging. In the current state, scheduling a new patient takes approximately 48 hours. This delay occurs because the clerical staff typically needs to wait at least one business day for the therapists to take a referral for triaging and one business day for the referral to be returned. The student team intends to place the clerical staff in charge of triaging and thereby eliminate the 48 hour delay in the scheduling process. The immediate changes in takt time are depicted in Figure 3.

12 Figure 3. Elimination of Triaging will reduce lead time by 2 days Cancellation Rate is above 10 percent On the billing sheets, The therapists recorded the number of patients that were scheduled, the number of patients that actually arrived, and the number of patients who did not arrive for their appointment for each day. The team found that of the total number of patients that were scheduled for the month of February and 13.13% cancelled. Of those 13.13% that cancelled, 9.6% were patients who did not show up for their appointment and did not cancel in advance. These findings were validated using the fill and arrival rates which were calculated directly from the Enterprise Wide Scheduling (EWS) system. Recommendations The following recommendations are based on the team s observations and analysis of the Pediatric Acute Occupational and Physical Therapy units at Mott Children s Hospital and Milestones Rehabilitation Clinic. Change the New Patient Appointment Scheduling Process All referrals for appointments should be sent to Milestones. This means that the entire process from receiving the referral to scheduling the appointment will be accomplished at the front desk

13 at Milestones. Centralizing the system for referrals should simplify the system. Briarwood Building 2 (BW 2) of Milestones should have their own private phone line and their number should be given out to patients instead of them having to be transferred to BW 2. By creating a direct accessible phone line, referrals should be able to be processed much easier through BW 2. Each appointment made should include documentation time. The team developed one possible example of a scheduling system where documentation time was built into each appointment. For example, new patient appointments could be scheduled for 1.5 hours and existing patient appointments should be scheduled for 1 hour. For new patients, this will allow 1 hour for evaluation and ½ hour for documentation. For existing patients, this will allow for 45 minute therapy sessions and 15 minutes additional for documentation time. Although some patients will require additional time for paperwork, cancellations should allow for additional time for paperwork. However, patients should not be informed that their appointments are this long. New patients should be informed they have a 1 hour appointment while existing patients should be informed that they have a 45 minute appointment. This will ensure that therapists are allotted their time for documentation. The goal is to schedule each full-time therapist with 40 hours of appointments per week. There should be no limit on the number of new or existing patients each therapist has per week as long as the guidelines listed above for making appointments are followed. Therapists should inform schedulers the hours they prefer to work and then allow the clerical staff to schedule appointments within those times. Triaging, in the short term, should be performed by the clerical staff All triaging should be done at the front desk by the clerical staff. Clerical staff should be trained to triage by a therapist and should be given a triage help sheet to help triage correctly. The staff will able to look at the list of illnesses to determine which therapist should be assigned to a patient. Frequent keywords or symptoms should be explained to the clerical staff to help them triage. The triage sheet will list common diagnoses and corresponding treatment plans for each diagnosis. Additionally, a list of the strengths of each therapist will be provided to best match a patient with a therapist given their condition. Therapists should help triage patients while the clerical staff learns how to triage but eventually, the clerks should be able to triage without additional help. In extraordinary cases, either a therapist or the Day Treatment Case Manager should be consulted for help. Triaging, in the long term, should occur at the doctor's office Appointments should be made at the doctor s office where the referral was originally given. Doctors should notify their own clerical staff with information about what skill set is needed by the therapist giving medical attention. Therefore, the clerical staff in that particular office and not at Milestone can look in EWS and schedule an appointment with a therapist who is qualified to perform the therapy needed. As therapists gain skills that will allow them to treat new types of patients, they should update their profile on EWS. This will ensure that therapists will be assigned to as many types of patients as possible. Front desk layout should be altered

14 Only one person should sit at the front desk accessible to the waiting room. Having only one clerical staff member accessible will allow the other members of the clerical staff to work with minimal interruptions. The person sitting at the front of the desk will be responsible for meeting and greeting patients and parents. In addition, this person will be responsible for answering the telephones, responding to s, and rescheduling patient appointments with parents present in the facility. The other clerical staff will be sitting in more secluded areas with minimal interruptions, which will allow them to be much more productive during the day. Each member of the clerical staff should be cross-trained in the event of illness, special occasion or other obligation. Stricter cancellation policies should exist Every patient needs to be called by the clerical staff 2 days prior to their appointment. If the number of appointments per week for a certain patient is greater than 2, then this patient should be called only once at the beginning of the week to be reminded of his appointments. If the patient is not reached, a message should be left. All records of calls should be logged in an Excel tracker. The Excel tracker allows the clerical staff to check if a patient has been called, in case any confusion arises. If a patient does not show up at an appointment, does not call to cancel, and does not provide an excuse as to why that patient missed an appointment, then that patient should be dropped from the clinic. Patients should only be allowed to cancel an appointment with less than 24 hours notice three times before that patient is dropped from the clinic. Currently 9.6% of all cancellations are due to patients simply not showing up at their appointment. By calling the patient to remind them of their appointment, Milestones could potentially eliminate 9.6% of all cancellations. Documentation template can reduce documentation Time Different insurance companies require different information before paying a patient s bills. Therapists currently fill out as much information as possible so to meet the standards of all insurance companies. A template should be developed that explains what each insurance company requires. Following the template will allow therapists to only document the information that is needed for a particular insurance company. This will eliminate time spent filling out unnecessary details for insurance companies. Information that does not change from appointment to appointment should be automatically generated on subsequent documents. Templates of common insurance information should be compiled and put on each therapist s computer for use. Billing Sheets should be filled out twice a year Therapists have reported that billing sheet data could be more accurate if they were only required to fill them out every six months. The team suggests that the therapists be required to fill out the sheets once during the winter months, their slower traffic period, and once during the summer months, their reported busiest season. This would allow for more accurate data for senior management to visialize and use. A More Mobile Splinting Cart is Needed A smaller splinting cart should be made available so that more time is spent with patients and appointment times can be kept within their allotted time spot. This new splinting cart should be able to maneuver around corners and fit into each of the rooms with ease.

15 Tablet Computers could reduce Paperwork Time Tablet computers should be made available to a few of the therapists as a trial run to see how well these computers function in a therapy setting. If initial testing with tablet computers is successful, these tablet computers should be made available to all therapists in the hopes that documentation will be easier to fill out in each room instead of requiring therapists to complete documentation in their offices. Action Plan The team has decided that the first two recommendations of changing the new patient scheduling process and putting the clerical staff in charge of triaging should be implemented together to provide the most beneficial solution to the Pediatric Acute Occupational and Physical Therapy units at Mott Children s Hospital and Milestones Rehabilitation. These recommendations will improve the scheduling efficiency and the patient throughput of the facility. Then, the team suggests changing the blocks of time assigned to each therapist per appointment. With the team s suggestions, a full-time therapist will be able to see eight patients a day, with 25% of their day scheduled for documentation and other non-patient care requirements. To have the changes in the physical schedule result in the proper benefits, the clerical staff must be able to schedule patients in a quick, efficient manner. Efficient scheduling will be possible by minor changes made to the current process. By eliminating the triaging step and having the clerical staff trained to triage, the scheduling process will be shortened by up to 48 hours. Furthermore, by having a direct phone line and all appointments scheduled at Milestones, patients and primary care providers will be able to contact the clinic directly without multiple communication iterations. Additionally, this direct phone line will help distribute the number of patients seen at each location and could shorten lead time if a therapist at Mott is available before a therapist at Milestones. Furthermore, the layout of the clerical staff s desks will provide an environment in which they can be more productive. This, too, can contribute to a decrease in the scheduling process lead time. In the long term, the triaging of patients can occur at their primary care provider s office, given they are within the University of Michigan Health System (UMHS). Every physician and therapy center within UMHS schedules using EWS so they will be familiar with the process of scheduling new patients. Using EWS will allow the physicians to determine how much therapy is needed based on the condition of the patient. Expected Impact Based on the results, the team provided recommendations that will improve the scheduling system of the Outpatient Pediatric Physical and Occupational Therapy Department at Mott and Milestones. Specifically, the recommendations will result in: Improved scheduling process for outpatient appointments Reduced scheduling to appointment turn-around time Reduced therapist time spent on non-patient care Less patients missing appointments

16 Through these improvements the team anticipates: Increased patient throughput Improved patient and employee satisfaction Increased revenues Support Received from Operating Entities The project clients, Jose Kottoor and Lexanne Creitz, provided ongoing details of the problem, requirements, expectations, needed data (i.e. staff billing sheets), and contact information. The clients acted as liaisons between the student team and therapy staff to promote cooperation. For example, when the team needed therapist assistance in scheduling observations, the clients communicated the student team s needs to the therapy staff. Two therapists, Janet Santos and Michaela White, served as the lean leaders for this project. They provided a more detailed explanation of the daily problems that needed to be addressed and aided in scheduling observations and interviews. The team received support from therapists and clerical staff when conducting observations and interviews, and creating value stream maps. The team needed to be allowed to observe staff members as well as ask questions to develop recommendations. The project coordinator, Brendon Weil, served as the team s guide and mentor, and helped the team to maintain analytical quality and a positive client relationship throughout this project. Also, the project coordinator provided feedback on the project progress and helped with the team s professional skills.

17 Appendix A: Current State Clerical Outpatient Scheduling Process

18 Appendix B. Future State Clerical Outpatient Scheduling Process

19 Appendix C: Sample Billing Sheet

20 Appendix D: Outpatient Intake Form