Office Efficiency Improving Office Processes and Task Analysis

Office Efficiency Improving Office Processes and Task Analysis

Contents Office Efficiency... 3 Office Efficiency Aim... 3 Sample Office Efficiency Aims... 3 Key Efficiency Measures... 4 Balance Supply and Demand (for Non-Appointment Work)... 4 Value and Waste... 5 The Eight Wastes of DOWNTIME... 6 Examples of Waste in Healthcare... 6 Synchronize Patient, Provider and Information... 6 Tool for Constraint Identification... 7 Cause and Effect Diagrams... 7 What do we do to get the provider there on time?... 8 What do we do to get the information to the room on time?... 8 What do we do to get the equipment to the room on time?... 9 Summary: Synchronization... 9 Predict and Anticipate Needs... 10 Optimize Room, Equipment and Staff... 10 Rooms and Equipment... 11 Kanban... 11 Lean 5 S s... 11 Additional Tips:... 11 Staff as a Constraint or Optimization... 11 The 4 T s - Keep in mind when reassigning tasks or redeveloping processes... 13

Office Efficiency Improving Office Processes and Task Analysis Opportunities to improve the efficiency of our processes can lead to increased system capacity / supply which leads to opportunities to improve access for appointments. As our access improves, the overall efficiency of our office processes also improves. The two are unescapably tied together as the principles of demand and supply balance are Increased supply leads to improved access More efficient processes increase supply Improved access leads to more efficient office processes Office Efficiency Aim The aim for office efficiency should reflect a goal to reduce the patients waiting time as they traverse the office. This office aim should be appropriate, measurable, quantitative and achievable. A cycle time aim can be broken into various "cycle times"/delays from one process step to another. Sample Office Efficiency Aims Decrease total cycle time by 30%, from xx minutes to xx minutes by June1 st, 2013 at the Family Medical Centre Reduce patient total cycle time from 1 hour to 30 minutes by June 1 st, 2013 In order to see the patient s journey best, through each of the process steps, and to see where and how to measure, a flow map has great value. Map out the steps from one process to another along the journey. Read the Five Levels of Mapping paper. The flow map across the office from check in to check out is a "Level 4 map". Many SC programs have hand-offs from one provider type or discipline to another that occur within the same day. These hand-offs are captured with a Level 3 A map. If there are within day hand-offs, since the hand-offs between disciplines occur within that day, these hand-offs are also captured within the Level 4 map. Since the Level 3 map depicts only provider steps, the Level 4 map is "bigger" and contains more steps (provider plus all the non- provider steps).

Minutes Key Efficiency Measures Cycle time Check in to Check out (see example below - Baseline average cycle time of 50 minutes. Through various improvements - annotated graph, were able to reduce the average cycle time to 40 minutes. Still have not achieved goal of 30.) Individual processes (steps) time within the larger cycle time Delays between the steps Cycle Time Average Goal 70 60 50 40 30 20 10 0 AM Huddle Aligned Patients, Providers, Staff Decreased Appointment Types Real Time Work Separated Tasks Lab in Exam Room Week Ending Balance Supply and Demand (for Non-Appointment Work) The goal in the office efficiency arena is to reduce the patient s waiting time as he/she journeys across the office. The goal is not to reduce the patient s time with the provider (although in some cases this may be indicated if some portion of that time is agreed upon by the team to be non-value added.) We recognize that this journey is a series of steps, seen through the eyes of the patient, each of which involves a process and each of which involves a match and balance of demand and supply. We also recognize that some of these steps involve competition in the sense that a number of patients are competing for the same supply time at each step. Not only is there a process time that the patient needs to get through, but there is also waiting for that process time to occur if there is competition at that step. We want to reduce the total process time, and to ensure that resources are utilized effectively and efficiently.

Identify the steps patient s use as they traverse the office Flow map the entire patient journey and processes within Add measures to the map and identify the constraints (where the supply is not keeping up with the demand for work and therefore delays are occurring) Focus on improving the major constraint first Balance Demand and Supply at the constraint and then work through all the constraints sequentially from greatest to lowest constraint Completion of tasks or processes will give us a quantitative, measurable view of the office flow this is a retrospective view. The constraints will govern the overall velocity of the overall cycle time. We can only proceed as fast as the slowest step, the constraint. While eventually we need to focus improvement strategies on all steps and processes, we need initially to focus on the delays at (in front of) the major constraint. If we do not focus here, we could just sub-optimize a sub-system and not improve the patient s overall flow and experience. The change strategies that we need to apply are described below. Once we flow map, measure and identify constraints, then we can alter the demand and supply at each step. This alteration is accomplished primarily through the Care team Workload Analysis which is described in the last of the change categories. Value and Waste Optimizing flow also involves identifying value and waste. We must adopt the view of the patient to understand value. Value can be defined as anything the customer (patient) is aware of and is of worth to them. And we must identify any process steps, activities or task that adds value to the patient experience and resulting care. This is the defined as value added.

There are some process steps that while non-value added, in the sense that do not visibly add worth from the patient view are required to in order to meet regulatory, legal or other specific requirements. Ultimately these are necessary steps and do indirectly add value to the patient via meeting needs that may for example protect patient confidentiality or allow for collection and reporting of data. The opposite of value is waste. Waste is any process step that either directly (seen by the patient) or indirectly (regulatory or legal) does not add value to the patient experience or care in anyway. The Eight Wastes of DOWNTIME Defects, errors and rework Overproduction Waiting and delays Not fully utilized (underutilized human capability) Transportation Inventory Motion Excessive Processing Examples of Waste in Healthcare Providing services not requested or required Providing services that are not evidence based Uncoordinated services Lack of appropriate services and providers to meet the needs of patients when required Services provided by the wrong person (scope of practice) Time that patients don t spend with a care provider (sitting in the waiting room) Lack of or wrong tools/equipment to complete what s needed Inadequate or inappropriate hours of services to meet patient s needs Redundant processes without clearly defined purpose Synchronize Patient, Provider and Information Synchronization is the key strategy to an efficient office, and this is where we can have the biggest impact on patient delays. We want to get the patient, the provider, the information, staff and the equipment to an open room on time, every time.

Room Provider Equipment Patient 10:00 Appt. Information If we assume that our synchronization time is 10:00 am, and that is the time that the patient, the provider, the information, staff and the equipment all need get to the room at the same time, then what do we have to do to ensure that we get the patient there on time? We have to look at the processes that take place in front of that visit: the check-in reception process and the medical assistant process. If, for example, the check in process takes 7.5 minutes and the medical assistant process takes 7.5 minutes, we cannot start the visit at 10:00 unless the patient arrives at 9:45. Understanding the average process time helps determine the difference between the expected arrival time and the synchronization time. We need to set an explicit arrival time in light of the expected process time. This arrival time is different and is scheduled in front of the scheduled visit time as a "scheduled arrival time". In addition, there may be a waiting time that occurs between these two processes and we have to look for any competition that occurs for any of these steps (demand supply mismatch). Often patients will have to compete with other patients for a restricted resource time at the reception desk. For example, we often see eight patients checking in for a 1:00 appointment. If the average process time is 7.5 minutes, the last patient cannot get into the room until all patients have had their 7.5 minutes process time and that last patient has had, in addition to that 7.5-minute check-in process time, the process time for the medical assistant, and the patient is starting about an hour late. Some practices have reviewed the reception process and moved some of the redundant steps either to the initial phone call or to a separate kiosk in the office. Other practices have explored the idea of not having waiting time between the receptionist and the medical assistant and/or staggering the arrival times in order to eliminate patients competing at a single process. In addition, other groups will add supply at crucial times in order to reduce that bottleneck. Tool for Constraint Identification Cause and Effect Diagrams Sometimes called a fishbone diagram, cause and effect diagrams can be a helpful tool for constraint identification. It shows the relationship of all factors (causes) that lead to the given situation (effect), in this case delay. It identifies major causes of delay which can be further broken down into sub-causes. In health care systems our experience informs us that delay or late starts are usually caused by elements in six categories or lack thereof; patient, room, staff, provider, information and equipment/supplies.

This visual tool allows improvement teams to further identify the sub-causes in each category and tally the number of occurrences. The category with the highest number of occurrence is a good indicator of the chief cause of delay. Based on this teams can then apply strategies accordingly. What do we do to get the provider there on time? The key to getting the provider to the room on time for the second and subsequent visits is to make sure that the provider gets out of the room from the previous patient on time, and that the provider is not doing non-appointment work from yesterday or previous appointments. In addition, it is critical that the provider begin each session on time, so that they can stay on time through the entire day. Tips: Start the first morning and afternoon appointments on time and endeavor to start every appointment on time Limit or eliminate provider interruptions Use scheduled pauses for catch up Assure the red zone time (value added time with provider) is less than/equal to the stated length of the appt. What do we do to get the information to the room on time? We need to predict and anticipate those information needs far in advance. A fully developed Electronic Health Care record aids in getting the information to the visit on time. However, for those practices with paper records, there are many challenges. For example, when the patient calls to talk to the appointment scheduler, develop a streamlined process with the medical records department to alert them in advance that this patient is arriving and that that information must arrive in anticipation of that visit. Some practices have an electronic alert that is immediately sent directly to the medical records

department at the time the appointment is made, saving a step in the process. Other groups have worked quite extensively on continuously filing loose material and having a standard location for all charts, all of the time. Information needs in SC programs often involve crucial information from the referring PC provider or information needed from a test or procedure. Agreements with the entities responsible for generating, processing, and sending that information are vital to SC practice. Tips: Do a "chart" check prior to the appointment to be sure that needed information is available Develop agreements with information providers Utilize team huddles to communicate information needs to the entire team What do we do to get the equipment to the room on time? By anticipating equipment needs and having a planned communication from the reception to the medical assistants prior to the patient s arrival groups can ensure that the required equipment is available in the room at the start of the appointment. Team huddles are a very useful strategy in order to communicate this to the entire team. Tips: See Optimize Environment below Utilize team huddle to ensure all members are aware of special equipment/supplies needed for appointment Summary: Synchronization Synchronization is the key to an efficient office and to reducing the patient s waiting times across the office. This is, in a sense, a harmonic convergence of five factors; patient, provider (may include other staff), information, equipment, and room. The teams with the most informed communication strategies, not encumbered by yesterday s work, will do the best in this regard. Starting the first visit on time, then the second and the third requires a convergence of all the required components. At some point there will be a delay. Identify the cause of the delay. The delay can only be caused by the relative lack of one of the five components lack of synchronicity. Remember that the principle of demand and supply balance at each of the process steps plays a role in optimizing synchronicity. The "least available" of the components governs the flow and determines the velocity. Use a Pareto Analysis to stratify the causes of delay. Start with the most common and identify the cause of that cause of delay. Using the change ideas and strategies outlined above and below, fix that least available component first and then move on to the second most common. This approach fuses the quantitative and the qualitative analysis of the situation.

Predict and Anticipate Needs Align expertise of care team with patient needs Use "Huddles" to anticipate and plan the day and each visit Plan for expected and unexpected bottlenecks and interruptions in flow Use health prompts to anticipate full potential of today's need Communicate within the team throughout the day/week Use communication short-cuts and signals Use message boards or task boards Employ electronic alerts and messaging Explore SBAR communication tool (Situation Background Assessment Recommendation) Commit to weekly planning meetings with the team Plan for seasonal demand and supply variation Clarify and plan roles and tasks of SC team Review and analyze practice and population level data Plan improvement test cycles and implementation Plan care coordination and management at practice and population level This strategy is all about communication: On a monthly basis in anticipation of predicted supply and demand needs over the next month On a weekly basis in order to fine-tune plans for that week On a daily basis with huddles and pre-visit planning for daily adjustments On a minute-to-minute basis in order to be flexible to ever changing needs. Data and information helps this communication. Some groups use a rolling four-week demand average to predict and look at seasonal demand variation and changes in the practice dynamic. In addition, upto-date cycle time data, summarized and broken down into the various steps and components, helps a great deal in looking at the patient experience and the areas on which to focus improvement efforts. Remember, however, that we want to reduce the patient s total cycle time from check in to check out. Looking at various steps is valuable, but be careful of optimizing a sub-process such as fixing the waiting time between steps 2 and 3, but having the patients wait for step 4, which may not improve the entire cycle time. Therefore, breaking the cycle time down into its components is helpful only if we can reduce the total cycle time from check in to check out time. Optimize Room, Equipment and Staff This strategy focuses on elimination of rooms, equipment or staff as constraint. We do not want to let the absolute or even relative lack of examination rooms, or equipment and supplies become the constraint or the rate-limiting step. We want to standardize the rooms so that even though there may be preference rooms, any provider can use any room. This means that each room needs to have the same equipment in the same place in each of the rooms, and need to be fully stocked at all times.

Rooms and Equipment Kanban In each pile or grouping of a particular item/form, place a tag at the mid-point in the stack, which describes the item, the room number and the number to restock. The staff member or provider who reaches the tag removes it and either restocks themselves (replacing the tag) or places the tag in a agreed upon central location for restocking by a designated staff member. Lean 5 S s Sort Straighten - Identify and remove unnecessary items - Place things within easy reach and the most frequently used items close by Shine and Scrub - Visual sweeps of areas, eliminate dirt, dust and scrap Standardize Sustain - Work to standards, maintain them, use safety equipment - Make 5S a strong habit, solve immediate problems and make them disappear Additional Tips: Use inventory control methods, which allow items to be restocked only as needed, just in time, saving staff inspection time that is typically required when trying to restock multiple items in multiple rooms at once. Ensure frequently use equipment is stocked in every room Standardize room set-up/footprint Expensive, rapid expiration or rarely used equipment (e.g. prep kits, OR trays) should be made mobile or brought in just in time to ensure synchronization with other appointment elements Common equipment should be stored in the same place with a checkout function that details where the equipment is when it is not at its pre-determined station. Alert team members to information that predicts the need for equipment at every potential step along the way; utilize advance alerted systems of communication. If equipment is needed after the provider starts the visit, develop a simple signaling system that does not require the provider to leave the room to get it to the room If technological tools or equipment can take work away from the physician and other care providers, then all efforts must be made to do obtain them. Staff as a Constraint or Optimization In terms of optimizing staff, it is crucial to do a Care Team Workload Analysis: what is the work that each of the staff members are doing? Once we determine the work that they are doing, then we can start to divide those tasks appropriately. This strategy could be called manage constraints, optimize the care team, or can also be looked at as increase the supply. Within the access section of categories for

suggested change, we discussed methods to enhance the appointment capacity of the providers. Within this strategy for office efficiency we want to use the same form of analysis but focus on the nonappointment work. The two approaches work in parallel and reinforce each other. We want to look specifically at the non-appointment work for which each of the work group categories/disciplines is responsible. Once we ve retrospectively measured that work (through CTWLA) and determined if there is a balance between that work and that worker, then we need to ask the fundamental question, is this the right work for this person? We want to take unnecessary work away from the constraint or the rate-limiting step (the person that governs the rate of the flow of value in the system). The system of care can only proceed as fast as they can work. If we start at the nonconstrained worker, we may neglect to address the constraint. While we want no idle time for the provider (the provider should not wait for any process, for any information, equipment, or room, etc.), we also want to free the providers to do work that only they can do and take all unnecessary work away from them. Once we perform this analysis at the provider constraint then proceed across all disciplines and staff. The classic Care Team Workload Analysis that segments work into non patient care work, appointment work and non-appointment work provides the framework for this analysis and shift. (See example below) We focus here on the segment of non-appointment work. Sometimes this means not necessarily taking all the work away, but taking parts of the work away or changing the way it`s done. For example, a provider looking through piles of laboratory tests in order to review those tests is a fairly inefficient way of doing lab review. However, if the laboratory returns are packaged in a way that the provider can immediately move to action, then sorting time is saved for the provider, but the provider still reviews all that work. Recognize that the provider is the constraint and what we want to do is take the unnecessary non-appointment work away from the provider, freeing them up to do the things that are uniquely essential to the patient/provider relationship. Non Patient/Provider Related Activity 0% 3% 2% 4% 3% 6% 2% 12% 19% 6% 3% 1% 1% 7% 2% 6% 5% 18% Conference Inservice Research/ Lit Review Educational Resource Development Quality Improvement to Current Resources Meetings Meeting Preparation Informal Conversations Mileage Form Completion Timesheet Completion Staff Activity Report Completion Committee Work Email: Reading/ Writing Providing Orientation Receiving Orientation Team Lead Scheduling: Staff / Service Staff Scheduling: Outlook/ Webview Other

The 4 T s - Keep in mind when reassigning tasks or redeveloping processes The composition of your team, the timing of the task, the environmental terrain 1. Task what is the task you need to accomplish? Start with how you would ideally accomplish it and then move through the following to identify how you should best accomplish it 2. Team actual team vs. ideal i.e. - Small practice without a pharmacist the physician must deal with all Rx needs in ideal team a pharmacist could take care of the majority of Rx needs (refills, interactions) 3. Timing sometimes having the wrong person do the task at the right time makes sense i.e. - Dr. able to complete, print and give a form to pt. on the spot vs. send the pt. down the hall to have assistant do the same thing but with a built in delay (note: avoiding delay sometimes the wrong person does the task) 4. Terrain if handoff goes to a person who is not in the right location this causes delay i.e. - assistant who needs to walk down the hall to accomplish a task then consider the resulting delay who is there and available to do the task? Bottom line Match the right task with the right team member at the right time in the right place to avoid delay!