The University of Michigan Health System. Geriatrics Clinic Flow Analysis Final Report

The University of Michigan Health System Geriatrics Clinic Flow Analysis Final Report To: CC: Renea Price, Clinic Manager, East Ann Arbor Geriatrics Center Jocelyn Wiggins, MD, Medical Director, East Ann Arbor Geriatrics Center 4260 Plymouth Road Ann Arbor, MI 48109 Tammy Ellies, Project Manager and Lean Coach, Department of Internal Medicine Domino s Farms, Lobby J, Suite 1200, SPC 5750 Ann Arbor, MI 48106 Virginia Walter, RN, Director of Clinic Operations Int Med Clinic, 3205 TC, SPC 5370 Dr. Mark Van Oyen, Associate Professor, Industrial and Operations Engineering Industrial and Operations Engineering, 2853 IOE Ann Arbor, MI 48109 From: Jun Young Choi, Claire Cook, and Kyle Moore IOE 481 Student Team Date of Submission: December 17, 2010

Executive Summary Patient wait time during a visit at The University of Michigan Turner Geriatrics Center Clinic is thought to be excessive, as determined by patient feedback and the clinic being consistently off schedule. The Clinic Manager and Medical Director are interested in analyzing the general flow of the Primary Care Clinic with dual focuses on Patient Wait Time and Primary Care Provider Time Utilization. The Clinic Manager and Medical Director are interested in analyzing the appointment process from the all perspectives to determine where and why bottlenecks occur. The Clinic Manager and Medical Director would also like to provide feedback to the Fellows The Clinic Manager and Medical Director are also interested in acquiring a Time Study tool that can be used to assess the general flow of the clinic biannually. The goals of the project are to develop a time study that can be used to analyze the general flow of the clinic with dual focuses on Patient Wait Time and Primary Care Provider Time Utilization. Using the results from the time study, the team will identify areas of the general flow of the clinic that waste time and formulate a recommendation to improve the general flow of the clinic. Results from the time study will provide quantitative feedback to the Fellows and Attendings regarding their use of time as part of their clinical evaluation. The team developed time study with dual focuses: Patient Wait Time and Primary Care Provider Time Utilization. Results from the time study were used to make recommendations on how to minimize areas of non value-added time that occur during a patient s visit. Primary Care Provider Time Utilization was analyzed specifically during areas of identified non value-added time that occur during a patient s visit to assess the value of activities occurring while the patient was waiting. Results were also used to assess how individual Fellows and Attendings use their time during clinic in order to provide quantitative feedback for their evaluations. In 2007, a time study entitled Turner Geriatric Clinic Time and Motion Study was conducted by an unknown party hired by the University of Michigan Turner Geriatrics Center to assess the general flow of the clinic and identify areas of non value-added time that occur during a patients visit. The study did not address how Primary Care Providers use their time while they are in the clinic. The team compared the data from 2007 to the current data to see how service and wait times have changed. The team identified three Primary Care Providers: Residents, Fellows, and Attendings. The team identified three categories of patients: New Patient, Returning Patient (Regular), and Returning Patient (Hospital Discharge). Each type of patient is processed uniquely during their visit. The process begins when a patient checks in at the main desk in the lobby. Patients can arrive early, on-time, or late for their scheduled appointment. As a patient is checked in, paperwork is printed in the Medical Assistant Office, and Primary Care Providers are alerted of the arrival via a monitor mounted in the Staff Room. The patient waits in the lobby until they are called by the Medical Assistant. The Medical Assistant measures the patient s height, weight, and blood pressure, and reviews their medication list. The Resident/Fellow meets with the patient and assess the patient s needs. The Resident/Fellow confers with the Attending regarding the patient diagnosis. Once the Resident/Fellow and the Attending have agreed on a diagnosis, they return to the patient to finish the consultation. If a patient requires procedures, they are completed before the patient checks out. Procedures are performed by Medical Assistants or Registered Nurses. Social Work is required for New Patients and Returning Patients (Hospital Discharge). Social Work is only required for Returning Patients (Regular) when the Primary Care Provider request

it. The need for Social Work is determined during the patient s visit. The patient checks out at one of two check out stations. Checking out includes reviewing a patient s billing paperwork and scheduling any future appointments that may be required. The team collected data over a period of six weeks. The team began with interviews. The team conducted interviews with the Patient Services Associate, Check-In and Check-Out Clerks, Medical Assistants, Registered Nurses, Residents, Fellows, Attendings, and Social Workers. Interviews were collected formally over a period of three days, and informally throughout the data collection process as questions arose. The team spent three days observing each aspect of the process involved in a patient s visit. Data was collected for three patients, one Fellow, and one Attending. The team then conducted the time study, conducted in three phases over a period of four weeks. During the first phase, team members collected data from 20 patients using a macro-enabled Excel program specifically designed to track patient movement. During the second phase, the team collected data using the macro-enabled Excel program while the clinic staff simultaneously filled out the Data Collection Sheet. The team developed and revised the Data Collection Sheet multiple times to reduce user error. During the third phase, the clinic staff filled out a Data Collection Sheet for each patient without simultaneous data collection by team members using the macro-enabled Excel program.. Data from 202 patients was collected during phases two and three. Only data from 124 patients was usable due to data collection error. The team collected data by observing the activities of the Residents, Fellows, and Attendings to analyze the general clinic flow from the perspective of the Primary Care Provider. The team used a macro-enabled Excel program specifically designed to track Primary Provider Care movement. The team recorded when the Primary Care Provider arrived, how long they interacted with a patient, how long they interacted with each other, and any other miscellaneous activity that occurred. Data was collected for three Residents, three Fellows, and six Attendings. The team performed extensive data analysis using Excel and Minitab. Results from the data analysis were used to make recommendations on how to improve the general flow of the clinic, evaluate Fellows and Attendings, and provide a repeatable time study tool. Patients can arrive early, on-time, or late. A patient is considered to be on-time if they show up within 5 minutes of their appointment. Based on a sample size of 103 patients, 52% of patients arrive early, 25% of patients arrive on time, and 22% of patients arrive late. Early arrivals increase wait time from the perspective of the patient. Late arrivals contribute to clinic delay. All patients are scheduled to spend 10 minutes with the Medical Assistant. Based on a sample size of 114 patients, the actual appointment time ranges from 8 to 11 minutes. New Patients are scheduled 80 minutes to meet with the Primary Care Provider. Returning Patients are scheduled 40 minutes to meet with the Primary Care Provider. This appointment time includes the Resident/Fellow Appointment, the Resident/Fellow and Attending Consultation, and the Resident/Fellow and Attending Appointment. Based on a sample size of 114 patients, the actual appointment time is 74 minutes for New Patients, and 45 minutes for Returning Patients. Based on a sample size of 22 patients, only 5 were delayed due to the Resident/Fellow and Attending consultation. Primary Care Providers often arrive late, causing delay at the start of the clinic. Based on a sample size of 8 Attendings, 62.5% were late to clinic by an average of 33 minutes. Based on a sample size of 5 Fellows, 60 % were late to clinic by an average of 19 minutes. Based on a sample size of 6 Residents, 16.6% were late to clinic by an average of 5 minutes. Delay accumulates between the first and second halves of the clinic. The average delay based on 40

patient visits was 23 minutes. Delay accumulates 12.8 minutes in the morning and 28.7 minutes in the afternoon. Based on the data collected, team developed the following recommendations: Request patients arrive 5 minutes early to Check-In Establish some type of accountability system for Primary Care Providers Have at least one Attending in clinic at start Establish clear lines of communication between clinic staff Utilize room tabs Page Social Work when a Patient is available Medical Assistants notify Residents/Fellows in person when a Patient is available Perform required procedures during Resident/Fellow and Attending consult Procedures to be performed only by Medical Assistant / Registered Nurse Provide a break between morning and afternoon clinics Build additional intake station in lobby Move Social Work appointment time before Medical Assistant appointment time Escort patients to Check-Out Reduce patient travel time Conduct phone screening Do not change current scheduled appointment times The team has three recommendations for a repeatable time study to be used by the clinic staff: Use observation sheets The advantages of using the observations are that the clinic staff are already familiar with sheets, the process has already been described and implemented, and it is inexpensive. The disadvantage is that using the observation sheets isn t very accurate. It doesn t depict the perspective of the Primary Care Provider, and many of the staff members forget to fill out the Data Collection Sheets properly. Hire another team The team would follow the patients and Primary Care Providers throughout the clinic. Data would be collected and analyzed by the team. Hiring another team would not disrupt clinic flow. The team can also observe the perspective of the Primary Care Provider. The disadvantage to hiring another team is that is may cost money. Install RFID system Installing an RFID system is the most expensive but most accurate option. Each physician would be provided an RFID tag. Readers indicate when a tag passes by them and records the data in a computer database automatically.

Table of Contents Introduction.. 1 Background.. 1 Current Process. 2 Figure 1: New Patient.... 2 Figure 2: Returning Patient (Regular).... 2 Figure 3: Returning Patient (Hospital Discharge). 2 Key Issues... 3 Previous Study... 3 Project Objectives.... 3 Project Scope.... 4 Support Provided.... 4 Methodology..... 5 Interviews... 5 General Clinic Flow Observation...... 5 Time Study...... 6 Patient Perspective.... 6 Primary Care Provider Perspective.. 7 Data Analysis..... 7 Data Comparison... 7 Formulate Recommendations.... 7 Time Study....... 7 Patient Perspective Service Time versus Wait Time.... 8 Findings......... 8

Figure 4: New Patient Service Time versus Wait Time... 9 Figure 5: Returning Patient (Regular) Service Time versus Wait Time.. 10 Conclusions.. 10 Recommendations... 11 Patient Arrival..... 11 Findings... 12 Table 1: Patient Arrivals.. 12 Figure 6: Patient Arrivals. 12 Conclusions.. 12 Recommendations 12 Primary Care Provider Perspective 13 Medical Assistant Appointment.. 13 Findings... 13 Table 2: Average Medical Assistance Appointment Time.. 13 Conclusions.. 13 Recommendations 13 Primary Care Provider Appointment Time 13 Findings... 13 Table 3: Primary Care Provider Appointment Time 13 Conclusions.. 14 Recommendations 14 Resident/Fellow and Attending Consultation... 14 Findings... 14 Table 4: Resident/Fellow and Attending Consultation 14

Conclusions.. 14 Recommendations 14 Primary Care Provider Lateness 14 Findings... 15 Table 5: Percentage Late Based on Doctor Type 15 Figure 7: Average Lateness. 15 Conclusions.. 15 Recommendations 16 Delay Accumulation 16 Findings... 16 Figure 8: Delay Accumulation. 16 Conclusions.. 16 Recommendations 16 Repeatability of Time Study... 17 Use Observation Sheet. 17 Hire Another Team.. 17 Install RFID System. 17 Expected Impact..... 17 Appendix..... 18

Introduction The University of Michigan Turner Geriatrics Center provides primary and specialty care for geriatric patients. The Clinic Manager and Medical Director are interested in analyzing the general flow of the Primary Care Clinic with dual focuses on Patient Wait Time and Resident, Fellow, and Attending Time Utilization. The Clinic Manager and Medical Director hope to identify and minimize areas of non value-added time that occur during a patient s visit. The team developed a time study to analyze the general flow of the Primary Care Clinic. The time study was designed with dual focuses: Patient Wait Time and Primary Care Provider Time Utilization. Results from the time study were used to make recommendations on how to minimize areas of non value-added time that occur during a patient s visit. Primary Care Provider Time Utilization was analyzed specifically during areas of identified non value-added time that occur during a patient s visit to assess the value of activities occurring while the patient was waiting. Results were also used to assess how individual Fellows and Attendings use their time during clinic in order to provide quantitative feedback for their evaluations. No feedback is provided for Residents, as they are not evaluated by the clinic. The time study will be presented as a repeatable tool that can be reused biannually by clinic staff members to analyze the general flow of the Primary Care Clinic. Clinic staff members will use the time study as a quantitative measure for evaluating Fellow time management as a part of their clinical evaluations, and Attending time utilization as a part of their annual review by the Chief of Geriatric Medicine. The report briefly discusses the background of the project, including an overview of the current process and key issues causing non value-added time to occur during a patient s visit. The report addresses the relevance of a previous study that assessed the general flow of the clinic, entitled Turner Geriatric Clinic Time and Motion Study. The project objectives are outlined, and the project scope is defined. The approach section outlines how data was collected and analyzed. The findings, conclusions, and recommendations are grouped by type of analysis: Patient Wait Time, Resident, Fellow, and Attending Time Utilization, and the Repeatability of the Time Study. The appendices include supplemental material to support the team s findings, conclusions, and recommendations. Background The University of Michigan Turner Geriatrics Center, located in East Ann Arbor Medical Campus, is open Monday through Friday 8:00 AM to 5:00 PM. The Geriatrics Center opened in May of 1997, and is specifically designed for geriatrics research and teaching clinical programs. The University of Michigan Turner Geriatrics Center includes a Primary Care Clinic and a Specialty Care Clinic. The project focuses on the Primary Care Clinic. Within the Primary Care Clinic, patients can be seen by a Fellow/Resident and Attending in what is considered to be the Teaching Clinic, or by an Attending alone in what is considered to be the Private Clinic. Approximately 32,000 appointments are made with the Primary Care Clinic each year. Of the 1

32,000 appointments made each year, approximately 7,800 are cancelled. The Primary Care Clinic currently employs 2 Residents, 5 Fellows, and 20 Attendings. Residents serve in the Primary Care Clinic for two weeks. Fellows serve in the Primary Care Clinic for one year. Attendings are permanent employees within the Primary Care Clinic. Current Process The team identified three categories of patients: New Patient, Returning Patient (Regular), and Returning Patient (Hospital Discharge). Each type of patient is processed uniquely during their visit. The team identified three Primary Care Providers: Residents, Fellows, and Attendings. The current clinic processes employed within the Teaching Clinic are defined by patient category according to the following high level flow charts shown in Figures 1 3. Figure 1: New Patient Figure 2: Returning Patient (Regular) Figure 3: Returning Patient (Hospital Discharge) 2

The process begins when a patient checks in at the main desk in the lobby. Patients can arrive early, on-time, or late for their scheduled appointment. As a patient is checked in, paperwork is printed in the Medical Assistant Office, and Primary Care Providers are alerted of the arrival via a monitor mounted in the Staff Room. The patient waits in the lobby until they are called by the Medical Assistant. The Medical Assistant measures the patient s height, weight, and blood pressure, and reviews their medication list. The Resident/Fellow meets with the patient and assess the patient s needs. The Resident/Fellow confers with the Attending regarding the patient diagnosis. Once the Resident/Fellow and the Attending have agreed on a diagnosis, they return to the patient to finish the consultation. If a patient requires procedures, they are completed before the patient checks out. Procedures are performed by Medical Assistants or Registered Nurses. Social Work is required for New Patients and Returning Patients (Hospital Discharge). Social Work is only required for Returning Patients (Regular) when the Primary Care Provider request it. The need for Social Work is determined during the patient s visit. The patient checks out at one of two check out stations. Checking out includes reviewing a patient s billing paperwork and scheduling any future appointments that may be required. Key Issues The following problems are perceived to be issues contributing to unsatisfactory clinic flow. The team will review the problems and determine how they contributing to unsatisfactory clinic flow. Late Arrival: Patients and Primary Care Providers Inadequate Equipment for Medical Assistant Appointment Lack of Communication Between Clinic Staff Primary Care Provider Interaction Procedures Being Performed by Staff Other Than Medical Assistants and Registered Nurses Delay Accumulation Previous Study In 2007, a time study entitled Turner Geriatric Clinic Time and Motion Study was conducted by an unknown party hired by the University of Michigan Turner Geriatrics Center to assess the general flow of the clinic and identify areas of non value-added time that occur during a patients visit. The study did not address how Primary Care Providers use their time while they are in the clinic. Project Objectives The primary objectives of the project are as follows: Analyze General Clinic Flow Analyze the general clinic flow from the perspective of the patient 3

Identify areas of non value-added time Develop recommendations to minimize areas of non value-added time Analyze Primary Care Provider Time Utilization Analyze the general clinic flow from the perspective of the Primary Care Provider Provide quantitative feedback that can be used to evaluate the Fellows and Attendings Develop a time study that can be reused by clinic staff Assess General Clinic Flow biannually Provide quantitative measure to evaluate Fellow Time Management and Attending Time Utilization Project Scope The scope of the project encompasses the analysis of the general flow of the Primary Care Clinic at The University of Michigan Turner Geriatrics Center. The Specialty Care Clinic is outside the scope of the project. The project focuses on the Teaching Clinic, in which appointments are made with a Resident/Fellow and Attending. Appointments made within the Private Clinic are outside the scope of the project. While the team was observing the Attendings, data from the Private Clinic was collected unintentionally. This data will be used to assess Attending Time Utilization. The project includes the evaluation of the Fellows and Attendings. Evaluation of the Residents is outside the scope of the project. The team will compare the results of studies performed within the Primary Care Clinic to those derived in 2007, outlined in the Turner Geriatric Clinic Time and Motion Study. Support Provided The Clinic Manager and Coordinator have facilitated all clinic access. The Clinic Manager has acted as a liaison between the team and the Medical Director and Operations Board. The Coordinator has acted as a liaison between the team and the Clinic Manager, and helped the team develop methodology for assessing the process. The Clinic Manager has provided the following resources: Current Primary Care Provider Schedule Paperwork carried with the patients during their visit The Coordinator has provided the following resources: Turner Geriatric Clinic Time and Motion Study Appointment scheduling and arrival times for 2009 2010 Appointment arrival times for patients observed during the data collection period 4

Methodology The team collected qualitative and quantitative data that was used to analyze the general flow of the Primary Care Clinic at The University of Michigan Turner Geriatrics Center and assess Primary Care Provider Time Utilization. The team analyzed the collected data to develop recommendations to minimize areas of non value-added time that occur during a patient s visit, provide quantitative feedback that can be used to evaluate the Fellows and Attendings and, present a time study that can be reused by the clinic staff biannually to analyze the Primary Care Clinic. Tasks were performed by the team according to the following schedule: Met with Client ------------------------------------------------------------- Tuesdays, 9 AM as Required Met with Coordinator -------------------------------------------------- Wednesdays, 9 AM as Required Met with Team ----------------------------------------------------------------------------------As Required Collected Data Conducted Interviews --------------------------------------------------------------- October 5 October 8 Observed General Clinic Flow ---------------------------------------------------- October 6 October 8 Conducted Time Study from Patient s Perspective ------------------------ October 11 November 3 Conducted Time Study from Primary Care Provider s Perspective ---- October 26 November 11 Observed Social Work ------------------------------------------------------------------------ November 17 Presented Proposal to Operations Work Group ---------------------------------------------- October 21 Analyzed Data ---------------------------------------------------------------- October 15 November 29 Formulated Recommendations -------------------------------------------- November 29 December 7 Presented Recommendations to Operations Work Group --------------------------------- December 7 Interviews The team conducted interviews with the Patient Services Associate, Check-In and Check-Out Clerks, Medical Assistants, Registered Nurses, Residents, Fellows, Attendings, and Social Workers. Interviews were collected formally over a period of three days, and informally throughout the data collection process as questions arose. The purpose of conducting interviews was to determine if the actual process of a patient s visit deviates from the ideal process of a patient s visit, define staff duties, and gather insight on why non value-added time occurs during a patient s visit. General Clinic Flow Observation The team spent three days observing each aspect of the process involved in a patient s visit. Observation allowed the team to determine an optimal way to design a time study to assess Patient Wait Time and Primary Care Provider Time Utilization. Data was collected for three patients, one Fellow, and one Attending. Each team member spent 15 hours observing. 5

Time Study The time study focused on the general flow of the Primary Care Clinic from the perspective of the patient and the Primary Care Provider. The time study was conducted over a period of six weeks. Patient Perspective The team studied Patient Wait Time in three phases over a period of four weeks. The collected data was used to identify areas of non value-added time that occur during a patient s visit. During the first phase, team members collected data from 20 patients using a macro-enabled Excel program specifically designed to track patient movement. A sample of the data collected can be found within the Appendix. Each team member spent approximately ten hours observing clinic flow over a period of five days. Using data from the first phase, the team was able to create a Data Collection Sheet to be filled out by the clinic staff during a patient s visit. A copy of the Data Collection Sheet can be found in the Appendix. During the second phase, the team collected data using the macro-enabled Excel program while the clinic staff simultaneously filled out the Data Collection Sheet. The team collected the same data as the clinic staff to ensure that data collected using the Data Collection Sheet was accurate. Data collected using the Data Collection Sheet was compared to the data collected using the macro-enabled Excel program to ensure validity. The team used the t-test method to assess the validity of the data, and found the data collected using the data collection sheets to be valid and appropriate to use in analysis. The Data Collection Sheet was revised by the team multiple times to reduce user error. During the third phase, the clinic staff filled out a Data Collection Sheet for each patient without simultaneous data collection by team members using the macro-enabled Excel program. The Data Collection Sheet was distributed with a stopwatch clipboard to ensure consistent times were recorded throughout the data collection process. The Check-In Clerk recorded Patient Type, Appointment Time, and Check-In start and end times. The Check-In Clerk handed the Data Collection Sheet to a Medical Assistant along with other paperwork that always follows a patient throughout the visit. Medical Assistants recorded the time the patient was called and how long it took to take vitals. The Medical Assistants would leave the Data Collection Sheet on a shelf in the staff room for the Residents/Fellows to pick up. Residents/Fellows recorded how long they were in the room with the patient. If Social Work was required, the Social Worker recorded how long the appointment lasted and where the consultation took place. The last staff member to see the patient would hand in the Data Collection Sheet to the Check-Out Clerk. The Check-Out Clerk recorded the Check-Out start and end times. The Check-Out Clerks were responsible for collecting all data collection sheets. The data collection sheets were picked up by the team weekly, and the stopwatch clipboards were returned to the Check-In Clerk for reuse. 6

Each team member spent approximately 30 hours observing in the clinic during phases two and three of the time study. Data from 202 patients was collected. Only data from 124 patients was usable due to data collection error. Only 60% of the Data Collection Sheets were filled out correctly by the clinic staff members. Primary Care Provider Perspective The team collected data by observing the activities of the Residents, Fellows, and Attendings to analyze the general clinic flow from the perspective of the Primary Care Provider. The team used a macro-enabled Excel program specifically designed to track Primary Provider Care movement. A sample of the data collected can be found within the Appendix. The team recorded when the Primary Care Provider arrived, how long they interacted with a patient, how long they interacted with each other, and any other miscellaneous activity that occurred. Data was collected for three Residents, three Fellows, and six Attendings. The data allowed the team to make qualitative assessments about the general flow of the clinic. The specific data collected for the Fellows and Attendings regarding time utilization was used for individual evaluation. Data Analysis The team performed extensive data analysis using Excel and Minitab. Results from the data analysis were used to make recommendations on how to improve the general flow of the clinic, evaluate Fellows and Attendings, and provide a repeatable time study tool. Data Comparison The team compared data described in the Turner Geriatric Clinic Time and Motion Study and the current study. The detail of this comparison can be found in the Appendix. The comparison addresses the following questions: How much time is attributed to each step of a patient s visit? Where does wait time occur during a patient s visit? How often do patients arrive late? Formulate Recommendations The team formulated recommendations using input from the Clinic Manager and the Coordinator. Time Study The time study focused on the general flow of the Primary Care Clinic from the perspective of the patient and the Primary Care Provider. Patient Perspective The team identified three categories of patients: New Patient, Returning Patient (Regular), and Returning Patient (Hospital Discharge). The team was unable to collect data for Returning 7

Patients (Hospital Discharge). Supplemental data collected from the patient s perspective can be found in the Appendix. Service Time versus Wait Time In the case of a New Patient, service time includes the following activities: Check-In Social Work Medical Assistant Appointment Resident/Fellow Appointment Resident/Fellow and Attending Appointment Check-Out In the case of a Returning Patient (Regular), service time includes the following activities: Check-In Medical Assistant Appointment Resident/Fellow Appointment Resident/Fellow and Attending Appointment Check-Out Wait time occurs between each service time during the patient s visit. Findings Figure 4 displays the average service time versus wait time for New Patients. Figure 5 displays the average service time versus wait time for Returning Patients (Regular). Service time is shown in dark grey; wait time is shown in light grey. Times are measured in hours : minutes. The team observed that wait time occurs due to patient s arriving early, Primary Care Providers arriving late, a lack of communication between Clinic Staff Members, Resident/Fellow and Attending interaction, delay accumulation, and other miscellaneous factors. The team outlined the following findings for wait time occurring in between service times: Check-In Wait time occurs before Check-In when there is a queue in lobby. Wait time occurs after Check-In when the patient waits in the lobby to be called by the Social Worker. Social Work Appointment Wait time occurs before the Social Work Appointment when the patient waits in the lobby to be called by the Social Worker. The patient waits in the lobby if an exam room is not available. Medical Assistant Appointment 8

Wait time occurs before the Medical Assistant Appointment when the patient waits in the lobby to be called by the Medical Assistant. The patient waits in the lobby if an exam room is not available. Resident/Fellow Appointment Wait time occurs before the Resident/Fellow Appointment when the patient waits in the lobby or the exam room to be seen by the Resident/Fellow. The patient waits in the lobby if an exam room is not available. The patient waits in an exam room if an exam room is available. Resident/Fellow and Attending Appointment Wait time occurs before the Resident/Fellow and Attending Appointment when the patient waits in the exam room to be seen by the Resident/Fellow and Attending. The patient waits in an exam room while the Resident/Fellow consults with the Attending. Wait time occurs after the Resident/Fellow and Attending Appointment if procedures are required. The patient waits in the exam room until a Medical Assistant or Registered Nurse performs procedures that are required. Check-Out Wait time occurs before Check-Out when there is a queue at both Check-Out stations. The patient waits in the lobby until they are called by the Check-Out clerk. Figure 4: New Patient Service Time versus Wait Time (Source: IOE 481 Team Observation, Size: 6, Dates: October 20 th November 9 th ) 9

Figure 5: Returning Patient (Regular) Service Time versus Wait Time (Source: IOE 481 Team Observation, Size: 35, Dates: October 20 th November 9 th ) Conclusions Wait time attributed to patient s arriving early, Resident/Fellow and Attending interaction, and some miscellaneous factors cannot be controlled by the clinic. Wait time attributed to Primary Care Providers arriving late, a lack of communication between Clinic Staff Members, delay accumulation, and some miscellaneous factors can be controlled by the clinic. The team outlined the following conclusions for wait time occurring in between service times: Check-In Wait occurs very rarely before Check-In, and does not have a significant impact upon the general flow of the clinic. Wait should only occur after Check-In if a patient arrives early for their scheduled appointment. Social Work Appointment Wait time occurs before the Social Work Appointment when the patient waits in the lobby to be called by the Social Worker due to the Social Workers not being effectively notified that the patient has arrived. Medical Assistant Appointment Wait time occurs if a patient is in the bathroom or if the equipment used by the Medical Assistants is being used. There does not appear to be a shortage of Medical Assistants scheduled to work during clinic. Resident/Fellow Appointment Wait time occurs before the Resident/Fellow Appointment due to the Resident/Fellow not being effectively notified that the patient is ready or when the Resident/Fellow is backed up. Resident/Fellow and Attending Appointment Wait time that occurs before the Resident/Fellow and Attending Appointment is inevitable. 10

Wait time occurs after the Resident/Fellow and Attending Appointment if procedures are required due to the Medical Assistant / Registered Nurse not being effectively notified that the patient is ready. Check-Out The patient s paperwork is often not ready immediately after their appointment ends. Patients often disappear before checking out. Recommendations The team recommends the clinic take actions to make wait time that cannot be controlled by the clinic as productive as possible, and reduce the wait time that can be controlled by the clinic. The team outlined the following recommendations for wait time occurring in between service times: Patient Arrival Check-In No recommendation. Social Work Establish an effective notification system for Social Workers. Medical Assistant Appointment Add a private station in the lobby containing equipment the Medical Assistants need to check the patient, reducing wait time and patient travel time. Resident/Fellow Appointment Establish an effective notification system for Residents/Fellows. Medical Assistants / Registered Nurses performed required procedures while patient is waiting for the Resident/Fellow and Attending appointment. Resident/Fellow and Attending Appointment Escort patients to Check-Out. Check-Out No recommendation. Patients can arrive early, on-time, or late. A patient is considered to be on-time if they show up within 5 minutes of their appointment. 11

Findings Patient Number Percentage Patient Arrive Early (> 5min) 54 52% Patient Arrive On Time 26 25% Patient Arrive Late (< 5 min) 23 22% Table 1: Patient Arrivals (Source: IOE481 team observation, Size: 103, Date: October 20 th November 9 th ) Figure 6: Patient Arrivals 16 15 14 12 10 8 6 4 2 0 6 1 1 3 0 10 2 Early 4 4 9 6 8 11 9 7 6 Late 0 0 0 1 (Source: IOE481 Observation by Team, Size = 103, October 20 November 9) Conclusions Early arrivals increase wait time from the perspective of the patient. Late arrivals contribute to clinic delay. Recommendations The team recommends that patients are told to arrive 5 minutes before their appointment time. This would ensure they have enough time to Check-In, even if there is a queue. 12

Primary Care Provider Perspective Medical Assistant Appointment All patients are scheduled to spend 10 minutes with the Medical Assistant. Findings The average appointment times with Medical Assistant are shown in Table 2. Conclusions Average Time (Hour: Minute) New Patient Teaching Clinic 0:11 Return Patient Teaching Clinic 0:08 Table 2: Average Medical Assistance Appointment Time (Source: IOE 481 Team Observation, Size: 114, Dates: October 20 th November 9 th ) The average Medical Assistant appointment time is less than or close to the scheduled appointment time. Recommendations The Medical Assistant appointment does not affect the general clinic flow. The team recommends no changes be made to the Medical Assistant appointment time. Primary Care Provider Appointment Time New Patients are scheduled 80 minutes to meet with the Primary Care Provider. Returning Patients are scheduled 40 minutes to meet with the Primary Care Provider. This appointment time includes the Resident/Fellow Appointment, the Resident/Fellow and Attending Consultation, and the Resident/Fellow and Attending Appointment. Findings The average appointment times with Primary Care Provider are shown in Table 3. Patient Average Time (Hour: Minute) New 1:14 Return 0:45 Table 3: Primary Care Provider Appointment Time (Source: IOE 481 Team Observation, Size: 114, Dates: October 20 th November 9 th ) 13

Conclusions The average Primary Care Provider appointment time is less than or close to the scheduled appointment time. Recommendations The Primary Care Provider appointment does not affect the general clinic flow. The team recommends no changes be made to the Primary Care Provider appointment time. Resident/Fellow and Attending Consultation The main assumption by the clinic staff at the beginning of the study was that bottlenecks occurred when the Resident/Fellow and Attending consultation occurred. Findings The Resident/Fellow and Attending Consultation data is shown in Table 4. Total Patient Visits 22 Patient Visits Delayed 5 Average Minutes Delayed 6.4 Average Minutes Delayed (Overall) 1.5 Percentage of Patient Visits Delayed 22.7% Table 4: Resident/Fellow and Attending Consultation (Source: IOE 481 Team Observation, Sample Size: 22, Dates: October 26 th November 3 rd ) Conclusions The average delay caused by the Resident/Fellow and Attending Consultation does not significantly affect the general clinic flow. Recommendations Delay from patient perspective is inevitable. The team recommends the clinic use this time to perform procedures if required. Primary Care Provider Lateness One of the initial qualitative observations was physicians arriving to the clinic later than their scheduled time. 14

Lateness (min) Findings The percentages of late arrivals by Primary Care Providers are shown in Table 5. Percentage Overall Lateness 47.4% Attendings 62.5% Fellows 60% Residents 16.7% Table 5: Percentage Late Based on Doctor Type (Source: IOE 481 Team Observation, Sample Size: 8 Attendings, 5 Fellows, 6 Residents, Dates: October 26 th November 11 th ) The average lateness in minute of the Primary Care Providers is shown in Figure 7. 40 35 Figure 7: Average Lateness 30 25 20 15 10 5 0 Attendings Fellows Residents Primary Care Provider (Source: IOE 481 Team Observation, Sample Size: 8 Attendings, 5 Fellows, 6 Residents, Dates: October 26 th November 11 th ) Lateness categorized by each Primary Care Provider can be found in the Appendix. Conclusions Primary Care Providers often arrive late, causing delay at the start of the clinic. 15

Delay (minutes) Recommendations The team recommends there be some type of accountability system established for Primary Care Providers. Delay Accumulation Delay accumulated throughout the day occurs due to patient and Primary Care Provider lateness and unexpected backups. Findings Delay accumulates between the first and second halves of the clinic. The team took the difference between when the resident or fellow entered the exam room and the patient s appointment time, which gave a delay data point for each patient. The average delay during the physician data collection was 23 minutes. The data is reflected in Figure 8. 35 30 Figure 8: Delay Accumulation 25 20 15 10 5 0 Morning Clinic Afternoon (Source: IOE 481 Team Observation, Size : 40 Patient visits, Dates: October 26 th November 11 th ) Conclusions Delay accumulates 12.8 minutes in the morning and 28.7 minutes in the afternoon. Recommendations The team recommends the clinic instate a 30 minute break between the morning and afternoon clinic. 16

Repeatability of Time Study The team has three recommendations for a repeatable time study to be used by the clinic staff. Use Observation Sheet This suggestion is what the team used for data collection throughout this project. Patient observation sheets would be distributed with other documentation at the check-in desk and medical staff would record their time whenever they are handed the observation sheet. The medical provider observation sheet would be put on each exam room door and whenever a medical provider enters or leaves the room, they could simply record the time. This method would be cost effective for the geriatrics clinic because there is no extra money required for doing so. Based on the team s experience however, medical staff usually forgot to record data because of their already overwhelming amount of paperwork. There would be many incomplete observation sheets which would lead unreliable results or inaccurate results that may not be beneficial to the geriatrics clinic. The team found that 40% of Data Collection Sheets were either incomplete or incorrect, and there were relatively small sample sizes of data collected. Hire Another Team This suggestion is also what the team used for data collection during the project. Using observation sheets created too much incomplete data. A hired team would follow patients and medical providers and record their time throughout each process. This method would be more accurate than just using observation sheets and would also help reduce medical staff workload. However, human error may exist with this method and also would cost money to hire a team to do the study. Install RFID System This suggestion would provide the most accurate data for geriatrics center. Radio Frequency Identification (RFID) technology is somewhat similar with bar-code technology, but RFID uses radio frequency to communicate with computer devices. RFID readers would be installed in the staff room, the hallways, and in exam rooms. Medical providers would be given their own RFID tags and patients would be given one upon entry into the clinic. The RFID readers would recognize a nearby RFID tag and record the time. This data would be transferred to a computer database for further analysis. No one would need to record data. The medical providers would just need to bring their own RFID tag and the computer would collect data automatically. This method could record exact time and provide reliable and abundant feedback to the geriatrics clinic. Installing the system and developing the software would be expensive however. The cost of 50 RFID tags and 10 RFID readers would be in the range of $5000 (www.rfidjournal.com). Expected Impact The project will result in the following changes: 17

Improve general flow of the clinic Minimize areas of non value-added time that occur during a patient s visit The project will provide the following tools: A time study that can be used biannually by clinic staff members to analyze clinic flow and assess patient wait time and Resident/Fellow and Attending time utilization Quantitative feedback of Fellows regarding time management Quantitative feedback of Attendings regarding time utilization 18

Table of Contents Appendix A: Time Study Patient Perspective Data Collection Sample... 1 Appendix B: Time Study Primary Care Provider Perspective Data Collection Sample... 2 Appendix C: Data Collection Sheet.... 3 Appendix D: Data Comparison.. 4 Table 1: Service Time Comparison for New Patient. 4 Table 2: Service Time Comparison for Return Patient.. 5 Table 3: Wait Time Comparison for New Patient. 6 Table 4: Wait Time Comparison for Return Patient.. 7 Figure 1: Patient Arrival Distribution Comparison... 8 Appendix E: Actual Patient Flow....... 9 Figure 1: New Patient...,,... 9 Figure 2: Returning Patient (Regular),,... 10 Figure 3: Returning Patient (Hospital Discharge),,.... 11 Appendix F: Ideal Patient Flow....... 12 Figure 1: New Patient... 12 Figure 2: Returning Patient (Regular),,... 13 Figure 3: Returning Patient (Hospital Discharge),,.... 13 Appendix G: Time Study Patient Perspective..... 14 Table 1: Patient Demographics....... 14 Table 2: Average Total Time for New Patient Teaching and Private Clinics.. 14 Figure 1: Time Distribution for Clinic Visit New Patient.... 14 Table 3: Average Total Time for New Patient Teaching Clinic... 14 Table 4: Average Total Time for New Patient Private Clinic.. 15 Table 5: Average Service Time for Teaching Clinic New Patient... 15

Figure 2: Service Time Distribution for Teaching Clinic New Patient.... 15 Table 6: Average Waiting Time for Teaching Clinic New Patient.. 16 Figure 3: Waiting Time Distribution for Teaching Clinic New Patient... 16 Figure 4: Cumulative Time Graph for Teaching Clinic New Patient... 17 Table 7: Average Service Time for Private Clinic New Patient... 17 Figure 5: Service Time Distribution for Private Clinic New Patient.... 18 Table 8: Average Waiting Time for Private Clinic New Patient...... 18 Figure 6: Waiting Time Distribution for Private Clinic New Patient... 19 Figure 7: Cumulative Time Graph for Private Clinic New Patient... 19 Table 9: Average Time for Return Patient Teaching and Private Clinic.. 20 Table 10: Average Time for Return Patient Teaching Clinic... 20 Table 11: Average Time for Return Patient Private Clinic... 20 Table 12: Average Service Time for Teaching Clinic Return Patient.. 20 Figure 8: Service Time Distribution for Teaching Clinic Return Patient. 21 Table 13: Average Waiting Time for Teaching Clinic Return Patient. 21 Figure 9: Waiting Time Distribution for Teaching Clinic Return Patient 22 Figure 10: Cumulative Time Graph for Teaching Clinic Return Patient.. 22 Table 14: Average Service Time for Private Clinic Return Patient.. 23 Figure 11: Service Time Distribution for Private Clinic Return Patient.. 23 Table 15: Average Waiting Time for Private Clinic Return Patient 24 Figure 12: Waiting Time Distribution for Private Clinic Return Patient. 24 Figure 13: Cumulative Time Graph for Private Clinic Return Patient. 25 Figure 14: Clinic Visit Time Distribution New Patient.... 25 Figure 15: Clinic Visit Time Distribution Returning Patient... 26 Appendix H: Time Study Primary Care Provider Perspective......... 27

Figure 1: Resident Time Distribution........ 27 Figure 2: Fellow Time Distribution........ 27 Figure 3: Attending Time Distribution........... 28 Figure 4: Time Distribution by Primary Care Provider.......... 28 Table 1: Primary Care Provider Interaction Delay Data........ 29 Figure 5: Primary Care Provider Lateness.......... 29 Figure 6: Average Lateness by Primary Care Provider......... 30 Table 2: Percentage Late Based on Doctor Type........ 30 Table 3: Percentage Late Based on Doctor Type and Individual Doctor........ 31 Figure 9: Average Delay Based on Morning and Afternoon Appointment Times. 31 Figure 10: Average Delay Based on Hourly Appointment Time Intervals. 32

Appendix A: Time Study Patient Perspective Data Collection Sample Team Collection Student Name Observation Date Visitor Type Appointment Time Start End Check-in 8:17:35 AM 8:19:38 AM (Early/On time/late) Time spend during Check in Remarks? Appointments with MA 8:21:37 AM 8:23:21 AM Time spend during Vitals MA presents in Exam room Time spend during MA in Room Social Work (yes/no) (Where?) Remarks? Time spend for social work Patient In Exam Room (Room Number) 8:23:31 AM MD/Fellow/Resident Enter 8:44:24 AM 9:07:08 AM time spend for exam (if Fellow/Re with Attendings) time spend attendings with F/R Patient Out Exam Room Entire time spend in exam room Social Work (yes/no) (Where?) Time spend during social work 9:07:42 AM Check-Out 9:11:48 AM 9:13:53 AM Time during check out Remarks? Visitor Type Total Time Spend In Clinic Total Time Spend for Waiting Check-in - Appointment MA MA - MA in Exam Room MA - Social Work Previous process - in Exam Room Waiting In Exam Room Waiting In Exam Room Waiting In Exam Room Waiting In Exam Room Exam room - Social Work Returning Patient 8:00 AM 1=New JUN YOUNG CHOI 11-Oct Patient 1 Early 0:02:03 0:01:44 0:00:00 0:00:00 0:22:44 0:00:00 0:44:11 0:00:00 0:02:05 Patient 1 2 0:56:18 0:27:42 0:01:59 0:00:00 0:00:00 0:00:00 0:00:00 0:00:00 0:00:00 0:00:00 0:00:00 2=Return New Number Patient Type Appointment Time Start Time End Time Check in 7:58 AM 7:59 AM Call from MA 7:59 AM 8:00 AM MA intake in Exam Room 8:00 AM 8:06 AM Patient in Exam Room (if MA intake is taken in Exam Physicians in Exam Room If Attending only 8:12 8:37 AM If Fellow only If Resident only If Group If Residents/Fellows meet with attendings in staff If Residents/Fellows visit patients with attendings Social Work? (if yes, please record the time and place) Check-Out 8:46 AM 8:47 AM Total Time for clinic visit Check-in Call from MA MA intake Total MA Time If Attending If Fellow If Resident If Group Meeting in consult room After consult Social work Check-out 1 Returning 7:55 AM 0:49 0:01 0:01 0:06 0:07 0:25 0:00 0:00 0:00 0:00 0:00 0:00 0:01 Staff Collection In Exam Room Social Work - Check out 0:21:27 0:04:06 Invalid 1

Appendix B: Time Study Primary Care Provider Perspective Data Collection Sample 2

Appendix C: Data Collection Sheet *Geriatrics Center Time Study Sheet Patient Sticker Patient Type (Please circle one of section) New Patient Returning Patient Appointment Time Start Time End Time Check-In Call from MA MA intake in Exam room Patient in Exam Room (if MA intake is taken in Exam room, please leave it blank) Physicians in Exam Room (Please record the name in following catagories) If Attending only: If Fellow only: If Group: If Residents/Fellows meet with attendings in staff room, please record the time. If Residents/Fellows visit patients with attendings after staff room meeting, please record the time. Social Work? Yes No (If yes, Please record the time and place) Check-Out Remarks? *Please submit this time collection sheet and clipboard together at check-out area. If you have any questions, please contact Brian Atkinson. Thank you for your cooperation. 3

Appendix D: Data Comparison This section provides a data comparison between the 2007 and 2010 patient flow analysis of The University of Michigan Turner Geriatrics Center. The report addresses the following questions: How much time is attributed to each step of a patient s visit? Where does wait time occur during a patient s visit? How often do patients arrive late? New Patients and Returning Patients (Regular) are examined. Table 1: Service Time Comparison for New Patient The table shows the service time comparison for new patients between the 2007 and 2010 study. This service time is from the patient s perspective and the total service time in 2007 was 2 hours and 2 minutes versus 1 hour and 57 minutes in the 2010 study. The time difference is minimal between 2007 and 2010. 4

Table 2: Service Time Comparison for Return Patient The table shows the service time comparison for return patients between 2007 and 2010. The total service time in 2007 was 1 hour and 5 minutes and 57 minutes in 2010. Similar to the new patient service time comparison, there is a small difference between 2007 and 2010. 5

Table 3: Wait Time Comparison for New Patient The table shows the wait time comparison for new patients between 2007 and 2010. The total wait time was 69 minutes in 2007 and 72 minutes in 2010. There is no significant change in wait time from the patient s perspective. 6

Table 4: Wait Time Comparison for Return Patient The table shows the wait time comparison for return patients between 2007 and 2010. The total wait time was 54 minutes in 2007 and 45 minutes in 2010. The total wait time from the patient s perspective has decreased slightly but not significantly. 7

Figure 1: Patient Arrival Distribution Comparison According to the 2007 report, only 9% of patients arrived late for their appointment time but the 2010 study shows that 22% of patients arrived late. The sample size in the 2007 study was 327 patients and the 2010 study sample size was 114 patients. 8