Increasing Charge Capture Using Scheduling Techniques for a Hospital-Based Ancillary Service

Transcription

1 Increasing Charge Capture Using Scheduling Techniques for a Hospital-Based Ancillary Service Michelle P. Taveras, MSIE University of Miami, School of Medicine Society of Health Systems Conference 2005

2 Outline Introduction Data gathering and analysis Design Implementation Results 2

3 Project Objectives Increase hospital revenue by increasing charge capture Increase access to care for patients 3

4 Benefits of Project Patients: more access to care for Glaucoma (second leading cause of blindness in the U.S. and the first leading cause of preventable blindness - Physicians: more accessibility to diagnostic testing 4

5 Benefits of Project Visual Fields Technician: more organization and increased control over workday Hospital: increase in revenue 5

6 Introduction: Visual Fields Visual Fields test is used for diagnosis and management of eye diseases especially Glaucoma (disease that damages the optic nerve) Visual Fields test has the eye focus on a central point and checks peripheral vision 6

7 Introduction: Current State schedule for all department 8:00 am to 4:00 pm No staggered start times for technicians Two patient visit types which include follow up appointment (FUV) and new patient appointment (NPV) 7

8 Introduction: Current State Start Patient Registers at Front Desk Does patient have a visual fields appointment? 8

9 Yes Patient is arrived in system for Visual Fields and physician appointment POD notification prints from system inside POD Medical Record (contains visual fields order form) is pulled and placed in Visual Fields queue Patient is seen and testing administered 9

10 No Patient is arrived in system for physician appointment only Patient is seen by physician Does physician order same day visual field? 0

11 No Patient checks out End

12 Yes Patient is sent to Visual Fields Department with visual fields order form POD Coordinator places patient paperwork in visual fields queue and patient waits to be called in waiting room Patient is seen and testing administered 2

13 Does patient need to see physician? No Yes Patient is seen by physician with visual field results Patient checks out End 3

14 Problems with Current State Limited access to Visual Fields appointments No process for add-on/walk-in patients 4

15 Problems with Current State Different tests with different durations and resources being lumped into visit type (i.e. Humphrey-30 minutes-any tech vs. Goldmann-60 minutes- only tech) 5

16 Data Gathering and Analysis 3 main parts to data gathering: Visual Fields Technician Service Time Patient Volumes and Departmental Revenue Customer Requirements: physicians, patients, technicians, and schedulers 6

17 Data Gathering and Analysis Part : Visual Fields Tech Service Times Dotplot of Tech (C), Tech 2 (E), Tech 3 (V), Tech 4 (M) Minutes Each dot is equal to one patient. Data comes from productivity logs completed by all four technicians and help determine slot time for new design 7

18 Data Gathering and Analysis Part : Visual Fields Tech Service Times Tech (C) Control Chart Individual Value UC L= _ X= LC L= Observation Moving Range UC L= MR= LC L= Observation

19 Data Gathering and Analysis Part : Visual Fields Tech Service Times Tech 3 (V) Control Chart UC L= Individual Value _ X= LC L= Observation Moving Range UC L= MR= LC L= Observation

20 Data Gathering and Analysis Part : Visual Fields Tech Service Times Tech 2 (E) Control Chart UC L= Individual Value _ X= LC L= Observation UC L=0.06 Moving Range MR= LC L= Observation

21 Data Gathering and Analysis Part : Visual Fields Tech Service Times Tech 4 (M) Control Chart UC L= Individual Value _ X= LC L= Observation Moving Range UC L= MR= LC L= Observation

22 Data Gathering and Analysis Part 2: Patient Volumes and Departmental Revenue Arrived Appointments Charges Captured $70,000 $60,000 $50,000 $40,000 $30,000 $20,000 $0, /03 07/03 08/03 09/03 0/03 /03 2/03 $- 06/03 07/03 08/03 09/03 0/03 /03 2/03 Six months of data was used for baseline data. 22

23 Data Gathering and Analysis Part 3: Customer Requirements Customer requirements for the new scheduling design were gathered through interviews with at least 3 people belonging to the different customer groups: physicians, patients, technicians, and scheduler. 23

24 Data Gathering and Analysis Part 3: Customer Requirements The four questions answered by the customer groups are as follows: What are the physician needs from the visual fields department? What are the patient needs from the visual fields department? What are the main complaints from the visual fields technician? What are the main complaints of the schedulers? 24

25 Designing the new schedule The new schedule has the following design specs: 25

26 Design Each technician has own schedule 4 schedules Increased accountability Productivity report available from system Management control over vacations and unplanned leave 26

27 Design Schedules are available for add-on patient and scheduled patients 3 schedules and add-on schedule Real-time appointment scheduling from anywhere in the hospital 27

28 Design Staggered schedules for technicians Working hours from 7:00 am to 6:00 pm Increase in accessibility from the current slots to over 42 slots per day 28

29 Design Time Schedule A Schedule B Schedule C Schedule D 7:00 X 7:30 X 8:00 X X 8:30 X X X 9:00 X X X 9:30 X X X 0:00 X X X X 0:30 X X X X :00 X X X :30 X X X 2:00 X X X 2:30 X X X :00 X X X :30 X X X 2:00 X X X 2:30 X X X 3:00 X X X 3:30 X X X 4:00 X X 4:30 X 5:00 X 5:30 X 6:00

30 Design New Visit types created for Visual Fields Department Aide schedulers to choose correct test (Humphrey (HVF, HVN) vs. Goldmann (GVF)) Provide increased access to new patients, hence the differentiation of follow up visits (HVF) and new patient visits (HVN) 30

31 Design System enhancements HVN slots will switch to HVF slots 7 days prior Available frozen slots High volume appointment times for front desk Utilized by Master Scheduling Department for rescheduling bumped patients Thaw 5 days prior to appointment date if they are not booked 3

32 Implementation Training Over 50 users in 4 different locations Training Document- cheat sheets, scheduling rules, and system refresher 32

33 Implementation Operations Quick Pick Electric stapler 33

34 Implementation Loading of new schedules Completed over the weekend Moved over 000 appointments 34

35 08/ Results Arrived Appointments $20,000 $00,000 $80,000 $60,000 $40,000 $20,000 $- Charges Captured 35 08/2003 0/2003 2/ / / / / /2003 0/2003 /2003 2/2003 0/ / / / / / / / / / /2003

36 Results 85% revenue increase Projected increased revenue = $500,000 20% increase in appointments and resource utilization 36

37 Follow up Plans PDSA on all processes Plan-Do-Study-Act should be executed after a 6 months evaluation period has been completed. Validate usability of schedules Adjust to new customer requirements 37

38 Follow up Plans Continuous training for all 50 users Address turn over, bad habits, and introduction of changes generated by continuous PDSA. 38

39 Follow up Plans Quality control on process of booking appointments: same day and future QA plan calls for a 30 day, 5 day, 2 day prior to implementation and a 30 day, 90, every 6 months day post implantation of scheduled appointments. Check for overbooks, underutilization of slots, user history 39

40 Follow up Plans Volume and Revenue run charts to monitor departmental growth. Monthly plot of departmental volumes Monthly plot of departmental revenue 40

41 Acknowledgements Cindy Ethier, Beacon Partners John McSolely, OD Charles Pappas, OD All Visual Fields Technicians 4

42 THANK YOU Questions and Answers 42

43 INCREASING CHARGE CAPTURE USING SCHEDULING TECHNIQUES FOR A HOSPITAL-BASED ANCILLARY SERVICE Michelle P. Taveras, MSIE Healthcare Management Engineering, School of Medicine, University of Miami, FL mtaveras@med.miami.edu Introduction One of the main ancillary services used for diagnosing eye diseases is Visual Fields. Visual Fields are used to confirm, evaluate, and monitor Glaucoma, defined as a disease of the optic nerve, by having the eye focus on a central point while checking peripheral vision. ( The Visual Fields Department at the Anne Bates Leach Eye hospital is part of a facility that sees over 50,000 outpatient visits and performs 9000 surgeries a year. Due to a steady increase in patient volume, the Visual Fields Department has outgrown the scheduling model it currently works under. The main focus of this project is design a new scheduling model for the Visual Fields Department that will enhance its productivity and increase revenue. The current process flow for a visit to the Visual Fields Department is as follows:

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45 Data Gathering and Analysis In order to identify the variables critical to quality for the new scheduling design, there were three main parts to the data gathering:. Visual Fields Technician Service Time 2. Patient Volumes and Departmental Revenue 3. Customer Requirements: physicians, patients, technicians, and schedulers 2 Dotplot of Tech (C), Tech 2 (E), Tech 3 (V), Tech 4 (M) Visual Fields Technician Service Times Visual Fields Technician Times measure current technician capacity. This is measured by a productivity log completed daily by the visual fields techs. The log captures the following data: Patient MRN number and name Technician performing test Time technician picks up patient chart Time technician completes patient Type of testing completed Any special comments or situations that occur during, before, and after testing (i.e. repeating test) The productivity log is completed everyday by each of the four technicians in visual fields. If a replacement technician covers any of the permanent visual fields techs, they too will complete log. Control charts and dot plots were used to evaluate the productivity of the four technicians. The dot-plot compares the speed of the technicians when performing a test. There are two types of visual fields test: Humphrey Visual Field and the Goldmann Visual Field. This dot-plot considers the most common test, which is the Humphrey Visual Field. In Figure 2, it is noted that Technicians 2, 3, and 4 have a normal curve peaking around 7 to 2 minutes per patient. Technician has a different distribution peaking around 30 minutes. The speed is directly linked to the technician productivity. Taking the higher end of the speeds, at 30 minutes per patient, the technician should be able to see a comfortable 4 patients a day. They are currently seeing between 0 and 2 patients a day. Figure : Dot Plot for Visual Fields Tech The control charts determine what the average times for each technician are to complete a patient. This chart helps document how many special cases are seen by each technician. Special cases are important because they take more time to test. An example of a special case is a disabled patient. Individual Value Moving Range Each dot is equal to one patient Minutes Tech (C) Control Chart Observation Figure 2: Control Chart- Visual Fields Tech Observation Tech 2 (E) Control Chart UC L= _ X= LC L= UC L= MR= LC L=0 UC L= Individual Value _ X= LC L= Observation UC L=0.06 Moving Range MR= LC L= Observation Figure 3: Control Chart- Visual Fields Tech 2

46 Individual Value Tech 3 (V) Control Chart Observation UC L= _ X= LC L= $70, $60, $50, $40, $30, $20, Total Charges Captured Visual Fields Department Moving Range UC L= MR= $0, $- 06/ / / /2003 0/2003 /2003 2/2003 Figure 4: Control Chart- Visual Fields Tech 3 Individual Value Moving Range Figure 5: Control Chart- Visual Fields Tech 4 Patient Volumes and Departmental Revenue Patient volumes for the Visual Fields were collected for the fiscal year Six month of data was used for baseline data Tech 4 (M) Control Chart Observation Observation Observation Total Arrived Appointments Visual Fields Department 06/ / / /2003 0/2003 /2003 2/2003 Figure 6: Patient Volume- 6 month Baseline LC L=0 UC L= _ X= LC L= UC L= MR= LC L=0 Figure 7: Department Revenue 6 month Baseline Through the data analysis, it was found that 27% of the daily volume was add-on (walk-in) patients, while 73% where scheduled patients. This finding led to a design specification in order to address that need of add-on patients. Customer Requirements: physicians, patients, technicians, and schedulers The following questions were used to identify the customer demands:. What are the physician needs from the Visual Fields Department? Answer: The physicians requested the following; a. Available appointments earlier in the morning and later in the day. b. Reserved available slots for new patients since this type of patient usually needs surgery. 2. What are the patient needs from the Visual Fields Department? Answer: The patients requested the following: a. Decreased patient wait times b. Specific wait time until seen c. Access to Visual Fields appointments 3. What are the main complaints of the Visual Fields technicians? Answer: The technicians complained about the following: a. Uneven workload b. Unclear order of patients c. No real use of current schedule 4. What are the main complaints of the schedulers? Answer: The schedulers complained about the following: a. Limited availability of appointments b. No differentiation between the two types of testing (Humphrey visual field and Goldmann visual field) Each customer group had three people that were interviewed.

47 By combining the data analysis on the visual fields technician service log, patient volumes, departmental revenue, and customer requirements, a new schedule for the Visual Fields Department was designed. Design The current Visual Fields schedule has the following characteristics: One schedule for the whole department 2 patient visit types which include a follow up appointment (FUV) and a new appointment (NPV) available slots from 8am to 4pm no staggered schedules for visual fields technicians The following is a discussion of the main changes to the schedules. Each technician will have one schedule assigned to them. This 4-schedule model will make the technicians more accountable to their patients, as well as facilitating patient flow. It will also provide management with the ability to run productivity reports per technician because each technician will own a schedule. The 4 schedules also allow management to control the availability of appointments in case one of the technicians is on vacation or on unplanned leave. Within the 4 schedules, 3 schedules will be open for future appointments and scheduled will be available for same day appointments only. These same day appointments will be scheduled by any Pod Coordinator (a flow facilitator assigned to each clinic with access to a computer) or front desk personnel from anywhere within the hospital. The same day appointments will be used for real-time appointment scheduling by physicians, support staff and patients. This will allow for real-time information on availability of testing. This characteristic was not available with the prior scheduling model. The staggered schedules were implemented from 7 am to 6 pm as a result of physician demand. The first available appointment is at 7:00 am and the last one is at 5:30 pm. Moreover, this design provides local patients more accessibility to Visual Fields. Also, expanding the working hours will increase the number of appointment slots from a current average of 32 patients to a proposed average of 42 patients a day excluding the walk-in schedule (contains 4 more slots). The new schedules would have the following distribution: Three Visit types where incorporated into the revamped schedules: HVN (Humphrey New Patient) 30 minute duration HVF (Humphrey Follow Up Patient) 30 minute duration GVF (Goldmann) 60 minute duration The durations for these visit types were calculated using time study data and productivity log data. These three types provide the schedulers with more information in order to facilitate scheduling of patients. These visit types also specifically reserve appointments for new patients with the potential to be surgery candidates. In addition, switching is a feature offered by the scheduling system. It was incorporated into the schedules in order to optimize the use of all visits. For example, new patient slots that have not been used 7 days prior to the appointment date will switch to follow up appointments. This feature provides schedulers with more availability and patients with more access to care. Implementation and Results The implementation of the new schedules was conducted the last week of February. This date was chosen due to other IT upgrades. There were three phases to the implementation:. Training: Over 50 users located in 4 different sites where trained. The users included schedulers, physician secretaries, Pod coordinators, front desk staff, and check out staff. A training document was prepared with learning tools, such as cheat sheets for the new visit types. It also included new

48 scheduling rules for scheduling processes, for example, if a visual field appointment was being scheduled with a physician appointment. 2. Operations: To aide the physicians in choosing the correct visit type for the correct procedure they want their patient to get, a QUICK PICK list was developed. It will be attached to the patient encounter form, and the physician checks off the testing the patient will get. This provides the checkout staff a clear scheduling direction. 3. Loading of new schedules: This task was completed over the weekend. It was an arduous task because the institution schedules patients 365 days into the future. No users could be touching the schedules that needed to be edited. This was the most cumbersome part of the implementation, because over 000 patients were moved to the new schedules. The new process flow developed is as follows:

49 Start Patient Registers at Front Desk Patient is arrived in system for physician appointment only No Does patient have a visual fields appointment? Yes Patient is arrived in system for Visual Fields and physician appointment Patient is seen by physician POD notification prints from system inside POD Patient checks out End No Does physician order same day visual field? Yes POD coordinator schedules and arrives patient for a walk in appointment and informs patient of next available slot and approximate waiting time Patient can choose to reschedule if waiting time for next available appointment is unacceptable for him/her Medical Record (contains visual fields order form) is pulled and place in Visual Fields appropriate schedule queue (A,B,C,D) Patient is seen and testing administered Patient order is placed in appropriate queue (D) Patient walks to visual fields department with visual fields order form Patient is seen and testing administered Does patient need to see physician? Yes No Patient is seen by physician with visual fields resutls Patient checks out End

50 The flowchart shows the immediate charge capture of all the add-on patients. The revenue cycle for this hospital is initiated at the time of scheduling. Where as before, the patient was seen and the revenue cycle was started after the patient exited the system, with this model, the revenue cycle is started at the immediate time and location of the originating doctor s order. Through the process flow, it can also be noted that once the patient is scheduled, same day or prior to, the patient is immediately assigned to a technician that will provide the service. This part of the design cuts down the confusion felt by the technicians in the old process. Furthermore, the technician working area was equipped with racks that provide a holding place in the order the patients are scheduled for their appointments. These racks are available for each of the four schedules. The results of the new schedules are clearly outlined in Figures 9 and 0. In these charts, everything before 02/2004 follows one trends, and all data after 03/2004 follows another trend. A slight drop is seen on 07/2004 because of a staff shortage. As soon as another Visual Field Technician is hired, it is projected that the number of visual field appointments will start forming an uptrend / /2003 Total Arrived Appointments Visual Fields Department 08/ /2003 0/2003 /2003 2/2003 0/ / / / / / / /2004 Figure 8: Total Arrived Appointments 06/ /2004 $20, $00, $80, $60, $40, $20, $- 06/2003 Total Charges Captured Visual Fields Department 08/2003 0/2003 2/ / / / /2004 Acknowledgements The implementation and design were completed in conjunction with Cindy Ethier from Beacon Partners Inc., as well as the support and participation of Dr. John McSoley, Dr. Charles Pappas, and all of the Visual Fields staff. References. Klassen, Kenneth J. et al., Outpatient appointment scheduling with urgent clients in a dynamic, multiperiod environment, International Journal of Service Industry Management; 2004, Vol.5 Issue 2, p. 67, 20p 2. Murray, Philip, Waiting Times in an Ophthalmic Outpatient Clinic, BMJ 94 Oct ;309(6958): Lanto, Andrew et al., Anatomy of an Outpatient visit. An evaluation of clinic efficiency in general and subspecialty clinics, MGM Journal 995 Nov- Dec;42(6):8-25 Biography Michelle P. Taveras is a Healthcare Management Engineer at the University of Miami, School of Medicine. She has four years of experience in healthcare (medical devices and hospitals), logistics and transportation, as well as, management and finance. Her core competencies include evaluation of processes and systems within healthcare organizations, identification of root causes for system failures, design of efficient and effective processes by using a variety of quality improvement techniques (Six Sigma certified), and establishment of standard operating procedures. Michelle holds a Bachelor and Master of Science in Industrial Engineering from the University of Miami. She was the recipient of the College of Engineering Graduate Scholarship (2000), Marcel Schaps Award, Alpha Pi Mu Award, Tau Beta Pi Student of the Month; and is a member of the Golden Key, Tau Beta Pi, and Alpha Pi Mu honor societies. She has published two articles on healthcare system improvement in the Proceeds from the 0 th Commemorative International Conference on Productivity and Quality Research, February 6 9, 2004, Miami, Florida. Figure 9: Total Charges Captured 06/ /2004 There has been an 85% revenue increase for the department of Visual Fields. This year alone, the projected increased revenue is about $500,000.