Using Simple Tools in the Solo or Small Practice to Improve Efficiency L. Gordon Moore, MD Sharon McCoy George, MD
Objectives Describe efficiencies that are key to the success of a small or solo practice in today s environment. Identify and use tools to design, implement, and assess efficient systems which support Patient Centered Collaborative Care, information flow, and physician/staff routines. Understand how to measure overall efficiency Explain several techniques used by practicing family physicians to improve efficiency
Take Home Points The least cumbersome way to measure office efficiency from a patient centered perspective is by using a patient web-based survey instrument (HowsYourHealth.com). Create breathing room for change before embarking on major practice efficiency overhaul. Use your patients as a resource to help improve efficiency. Eliminating waste and improving efficiency is an ongoing, rather than one-time, process.
Outline for Efficiency and Lean Production Identifying waste Flow mapping Measurement Forms of waste
What is happening in your practice(s)? Flow mapping/spaghetti diagram Constraint analysis Interruption analysis Cycle time Focus groups/patient advocates
Helpful tools Cycle time, measurement and graphing tools available on www.ihi.org, look under Access and Tools www.clinicalmicrosystem.org Click on Assessing Your Practice Green Book Fishbone & flowchart templates p. 24 Cycle time tool p. 17 Interruption analysis p. 22 Walk your practice tool p. 23
Identifying Waste/ Learning to See Flow mapping: examine patient visits A variety of visits Careful observation through the patient s eyes Details to look for Constraints/bottlenecks Total cycle time and patient-provider time Customer service Facility barricades, equipment inadequacies Paperwork Waste, duplication, rework Value-added and non-value added activities Handoffs
Walk Through 11 "Walk Through" Your System as a Patient Date: Your work in this collaborative will lead you to fundamental system change, but even with a strong aim you may not know where to begin. One simple way to understand where major impediments lie is to experience your service delivery through the eyes of a client. We are strongly recommending that two members of your team do a "walk through" of your system prior to the First Learning Session. Tips for making the "walk through" most productive: 1. Determine with your team where the starting point and ending points should be, taking into consideration issues of appointment making, the actual office visit process, follow-up, and other issues you may suspect are problems. 2. Two members of the team should do the walk through together if at all possible, with each playing a role-patient and partner or parent and child. 3. Set aside a reasonable amount of time to do this. Consider the usual amount of time patients spend in your clinic. Walk Through Begins When: Team Members: Ends When: 4. Make it real. Have a real appointment with a real clinician. Include time with lab tests and arranging for reports to be available. Sit where the patients sit. Wear what patients wear. Make a realistic paper trail of chart, lab reports, referrals, payment arrangements, etc. 5. During the walk through, note both positive and negative experiences, as well as any surprises. What was frustrating? What was gratifying? What was confusing? 6. If possible, debrief your team on what you did and what you learned. Report at least two key lessons on your storyboard. Positives Negatives Surprises Frustrating/Confusing Gratifying Your Practice
One view of a patient visit Pt arrives Check in Vitals Exam room Check Out Register Arrive Verify insurance Print encounter Match encounter to chart Chart to MA Take chart Call patient back BP, Ht, Wt, +/- Temp Room pt Notify provider Provider reviews chart Provider visit Phlebotomy Neb, BG, EKG Take encounter form Collect copay Print receipt Make referrals Schedule return
How to Measure Encounter Flow Two individuals from the office Note every step First we then we. Differentiate between process steps (something happens) and queues (waits & delays) Measure time in minutes
Typical 15 minute office visit Step Feet Time Front door to check-in 38 0.5 Wait at check-in 0 2.5 Check-in 0 6 Walk to chair in waiting room 12 0.1 Sit in waiting room 0 23 Walk to nursing staging area 25 0.5 Vitals 0 4 Walk to exam room 15 0.5 Sit in exam room 0 14.5 Interaction with provider 0 11 Walk to check-out 35 0.5 Wait at check-out 0 3.5 Check-out 0 1.5 Totals 125 68.1 Value-added time 20%
Measuring Total Cycle Time Identifies movement toward the goal of improved efficiency Operational definition = the time in minutes from when a patient arrives in your office until they leave after all is done Sampling strategy example: the patients scheduled at 10A and 3P once per week for each provider Average the cycle times per provider per month and plot as a time series
Jan-99 Feb-99 Mar-99 Apr-99 May-99 Jun-99 Jul-99 Aug-99 Sep-99 Oct-99 Nov-99 Dec-99 Jan-00 Feb-00 Mar-00 Apr-00 May-00 Jun-00 Minutes Total Cycle Time Fairport Patient cycle time for a 15 minute follow up visit 40 35 30 25 20 JG WJ 15 10 5 0
Spaghetti diagram Draw a floor plan Watch one person perform their work, noting where they go and what they do Do this for each person in the process of focus Map the process steps
Track each individual in process Step Provider 1 Notified of patient ready in room 2 Reviews chart on door 3 Retrieves patient labs from desk 4 Commences encounter 5 Looks up other labs on computer 6 Asks secretary to have lab fax results 7 Back with patient 8 Drug samples 9 Back with patient 10 Asks secretary to arrange referral 11 Back to provider office to document visit
Streamlined flow Steps Feet Time Pt walks to greeting area 25 0.5 Pt greeted and directed to room 25 0.5 Clinical support (CS) person obtains demos, vitals, documents 0 5 Provider enters room with patient and commences encounter 0 15 CS reviews education materials, assists in goal setting, problem solving, arranges referrals, follow-up, collects co-pay 0 15 Pt leaves 50 0.5 Totals 100 36.5 Value added time (counting 2/3 of time with CS) 78%
Same process analysis for other processes Prescription refill Clinical questions Non clinical questions Referral management Dictations Labs/imaging results ED or hospital calls Phone calls
Rx refill process Step Feet Time Secretary takes message 0 3 Message placed in Rx bin 3 0.1 Waits in Rx Bin 0 60 Sec'y takes Rx bin & pulls cht 75 30 Charts put in RN Rx refill area 25 0.5 Charts wait in RN area 0 90 RN sorts by doctor 0 5 RN sorts by "Urgent" 0 10 Urgent go to MD's nurse 15 1 MDs nurse places urgent in the chart rack of the next patient room 20 2 MD reviews between patients 0 0.5 MD finds nurse 25 2 MD communicates plan for Rx 0 0.5 Nurse carries Rx to nursing area 15 0.1 Rx waits until nurse can phone pharmacy 0 15 Nurse phones pharmacy 0 5 Non-urgent are placed on MD's desk 25 0.5 Rx waits on MD desk until end of session 0 240 MD reviews Rx 0 30 MD puts Rx in nurse "To do" pile 25 0.5 Rx waits in "to do" pile 0 840 Nurse sorts by pharmacy 0 5 Nurse makes pharmacy calls 0 30 Charts placed in "To be filed" bin 25 0.5 Charts wait in "To be filed" bin 0 480 Charts filed 75 30 Urgent totals 278 735.2 Non-urgent totals 253 1855
Cross training Step Rooming person 1 Notified of patient in room 2 Greets, registers, vitals, documents 3 Notifies provider patient is ready 4 Re-enters to arrange referral, review patient education materials, assist in individual goal setting regarding chronic disease, arrange follow-up, collect co pay, print receipt 5 Back to work station
Interruption analysis Any individual in the practice Card method or tape/zone method 3x5 card in the pocket Brief description of interruptions Create categories Use categories as column headings and count with tick marks the frequency over a short period of time Tape/zone Make a note every time you leave your zone
Examples from interruption analysis Provider Chart info missing Supplies missing Supplies in poor proximity to the work No team member available Nurse Chart info missing Lack of equipment/tools Lack of information Secretary Lack of information Too many conflicting tasks Cumbersome or missing tools
Continuous flow: Tools at your fingertips From the interruption analysis Everything you need frequently is within arm s reach examples: Electronic health records including real registry Broadband internet connection with bookmarked medical knowledge sites, patient education materials Hanging file with top 20 forms
Continuous Flow Do the work as it comes along (including nonvisit care) It s the intra-day equivalent of Open Access Do this twenty minute s work in this twenty minutes. Continuous flow saves time ( hidden supply arises) Continuous flow decreases errors and increases satisfaction
Continuous Flow Estimate time and resource necessary to complete the work Allow appropriate time for direct care and non-visit care Look at the deployment of appointment slots (and appointment lengths) and actual team work hours, and try for a better match Don t batch work (dictation, refills, referrals, phone backs, etc.)
Rx refill process Step Feet Time Secretary takes message 0 3 Message placed in Rx bin 3 0.1 Waits in Rx Bin 0 60 Sec'y takes Rx bin & pulls cht 75 30 Charts put in RN Rx refill area 25 0.5 Charts wait in RN area 0 90 RN sorts by doctor 0 5 RN sorts by "Urgent" 0 10 Urgent go to MD's nurse 15 1 MDs nurse places urgent in the chart rack of the next patient room 20 2 MD reviews between patients 0 0.5 MD finds nurse 25 2 MD communicates plan for Rx 0 0.5 Nurse carries Rx to nursing area 15 0.1 Rx waits until nurse can phone pharmacy 0 15 Nurse phones pharmacy 0 5 Non-urgent are placed on MD's desk 25 0.5 Rx waits on MD desk until end of session 0 240 MD reviews Rx 0 30 MD puts Rx in nurse "To do" pile 25 0.5 Rx waits in "to do" pile 0 840 Nurse sorts by pharmacy 0 5 Nurse makes pharmacy calls 0 30 Charts placed in "To be filed" bin 25 0.5 Charts wait in "To be filed" bin 0 480 Charts filed 75 30 Urgent totals 278 735.2 Non-urgent totals 253 1855
New Rx process Patient calls with Rx request Feet Minutes Who, what, where? Pull up chart 0 4 Assess if it meets protocol 0 1 Meets protocol/approved Faxed to pharmacy 0 5 Nurse documentation 0 2 Waits for MD review 0 60 MD review and sign-off 0 1 Total 0 73 Does not meet protocol Message to MD 0 1 Waits for MD response 0 60 MD review 0 2 MD message to nurse 0 1 Waits for Nurse response 0 30 Nurse faxes to pharmacy 0 5 Documentation by nurse 0 2 Total 0 106
Visit Planning: Huddles Five minutes max Don t sit down Entire microsystem/care team: provider, clinical and clerical support Typical short term contingency plans for unexpected visit demand: Deflect some demand to other providers Deflect to urgent care/ed Team stays late Increase non-visit care Delay some demand until tomorrow
Standardization Standardize work Standardize rooms and equipment Standardize procedures
Summary of big concepts Create your ideal care team Work toward a common goal Meet regularly Huddle Plan for the work Get good information on how you are doing Ask your patients what they want and need and figure out how to deliver Data on process and outcomes
Resources & References www.howsyourhealth.org The Machine that Changed the World Womack, Roos, and Jones Lean Thinking Womack and Jones Learning to See Shook, available from the Lean Enterprise Institute Theory Of Constraints Goldratt The Goal Goldratt Lean.org Lean Enterprise Institute www.clinicalmicrosystem.org great tools in the Green Book
Optimizing Patient Flow Using Simple Tools in Solo or Small Practice To Improve Efficiency (Part 2) L. Gordon Moore, MD Sharon McCoy George, MD
PATIENT EFFICIENCY Patient perception of smooth operation during and between visits Measured by Ideal Micropractices (IMPs) using the How s Your Health (HYH) survey. www.howsyourhealth.org
How s Your Health Survey When you visit your doctor's office, how often is it well organized, efficient, and does not waste your time? Most of the time Some of the time Almost never is it efficient. It often wastes my time. Does not apply to me. I seldom visit a doctor's office.
NON PATIENT EFFICIENCY Back office efficiency: billing, handling results, phone messages What time do you go home?
Patient and Non-Patient Efficiency Patient and non-patient (back office) efficiency are interrelated. Patient efficiency issues can be rolled over into the time non-patient efficiency time. Poor efficiency leads to burnout.
IMPROVING EFFICIENCY What are the underpinnings of the efficient back office? How to start and proceed? What does my redesigned office look like?
OFFICE INFRASTRUCTURE Digital trumps paper
EFFICIENCY PRINCIPLE Continuous flow beats batch and queue Do this minute s work this minute. Do it once beats do it twice Avoid re-work
PAPERLESS OFFICE A goal to work towards.
WORKFLOW CHANGES Changes in workflow: proactive changes that leverage maximal efficiency from your system.
OUTSOURCE WORK PATIENT ENTERED DATA: Online appointment portal Web or office kiosk based histories and ROS
Framework for Improving Efficiency Measure efficiency using the HowsYourHealth survey
HowsYourHealth Cumulative Care Summary Data
Framework for Improving Efficiency Measure efficiency using the HowsYourHealth survey Zero in on processes that need improvement
Framework for Improving Efficiency Measure efficiency using the HowsYourHealth survey Zero in on processes that need improvement Make breathing room for change
Breathing Room Close practice to new patients In a mature practice, space existing appointments further out
Framework for Improving Efficiency Measure efficiency using the HowsYourHealth survey Zero in on processes that need improvement Make breathing room for change Muster resources for change
Use Local Solutions Patients Personal strengths Personal preferences
Framework for Improving Efficiency Measure efficiency using the HowsYourHealth survey Zero in on processes that need improvement Make breathing room for change Muster resources for change Re-evaluate and continue to tweak processes
PROCESSES NEEDING WORK Phones Note Generation Handling Results Billing
PROBLEM PROCESS: Phone SOLUTION: let the answering machine do its job Allows completion of task in progress Leaving messages focuses patient Some messages require action without callback Message directs patients to web site for online appointment booking
ANSWERING MACHINE
PROBLEM PROCESS: Handling Volume of Phone Messages SOLUTION: Unload phone demand web based patient self-scheduling e-mail communication rapid turnaround time for messages
PROBLEM PROCESS: Note Generation SOLUTION: patient entered automated history taking software
Patient Generated Automated Histories Web-based and office based portals Saves time obtaining and documenting the HPI and ROS Focuses the diffuse patient Obtains patient rating scales Takes a standardized patient history Allows billing at a higher level of service Dr. John Bachman, FPM, July/August 2007, p 39.
PROBLEM PROCESS: Handling Results SOLUTIONS: workflow changes; document management software sends results via email
HANDLING RESULTS Best: arrange for results to arrive before visit Email is fastest Email provides hard copy for patient Document manager acts as a digital aggregator to bundle items such as lab orders, prescriptions, results, then sends as email and saves to EMR
PROBLEM PROCESS: Billing SOLUTION: Go electronic SOLUTION: Hire someone to do the things you hate!
% Patients Reporting "No Time Wasted" % Patients Reporting "No Time Wasted" COMPARISON OF NATIONAL AND Dr. Lynn Ho S IMP PATIENT EFFICIENCY DATA National Standard Speaker's Ideal Micropractice 100% 100% 90% 90% 80% 80% 70% 70% 60% 60% 50% Usual Care 50% Pre During Post Stages in Efficiency Study DATA FROM HOWSYOURHEALTH SURVEY
Take Home Points Efficiency is easily measured by HYH survey Front and back end efficiency can both be improved Breathing room is essential before making changes Exploit resources inherent in yourself and your practice for improvement Improvement is an iterative process
Moore LG and Wasson JH, The Ideal Medical Practice Model: Improving Efficiency, Quality and the Doctor-Patient Relationship, Fam Pract Manag, Sept 2007, p.20. Ho L, Seven Strategies for Creating a More Efficient Practice, Fam Pract Manag, Sept 2007, p. 27. 2007 Timothy Cook
Resources & References www.howsyourhealth.org The Machine that Changed the World Womack, Roos, and Jones Lean Thinking Womack and Jones Learning to See Shook, available from the Lean Enterprise Institute Theory Of Constraints Goldratt The Goal Goldratt Lean.org Lean Enterprise Institute www.clinicalmicrosystem.org great tools in the Green Book