Pediatric Hematology / Oncology Clinic

Pediatric Hematology / Oncology Clinic Final Report for Analysis of Operations April 13, 1995 Program and Operations Analysis Project Team Cristina Bermudez Katherine Horvath Julie Pinsky Seth Roseman

Introduction and Background 1 Project Background 1 Conclusions and Recommendations 10 Comprehensive Cancer Center 11 Regarding Appointment Time and Scheduling 10 Admittance on a First Come First Serve Basis 8 Efficiency Concerns 3 Appointment Time is not Determined by Patient Processes 9 Definition of Appointment Time 5 Project Findings 3 Staff Survey 3 Data Collection 2 Methods 2 Problems with Data Collection 2 Expected Outcome 1 Goals of Project 1 TABLE OF CONTENTS

1.0 Introduction and Background 1.1 Project Background Current patient flow through the pediatric hematology/oncology clinic is not optimal. Patient flow is not corresponding with the predetermined schedule. This is leading to problems such as large queues and clinic inefficiencies, both of which effect the patient s service quality. Clinic staff have a desire at this point in time to review policies and procedures followed and determine what improvements could be made to help alleviate current problems. 1.2 Purpose of Project The purpose of this project is to analyze patient flow for the pediatric hematology/oncology clinic and make recommendations for improvement based upon the investigation. The recommendations will be for the current system, and will also serve as a reference for the planning of the Comprehensive Cancer Center. The expected outcome of this project is to improve the level of service quality for the patient through possible changes in procedures, policies, the system, staff levels, or equipment. 1.3 Goals of Project The five main goals of this project are to: Analyze patient flow through the clinic Develop a flowchart of the clinic processes Analyze service times, wait times, and patient scheduling Determine any remaining causes of clinic inefficiencies Make recommendations for improvements 1.4 Expected Outcome of Project From the data collected, we expect to determine the patient flow through the clinic. We will learn exactly where a patient goes, the expected duration for different components of care, and generally what time of day different treatments occur. Coding the patients by patient type will help us to differentiate different processes and flows expected for the various patient types. We also expect to analyze our findings and adapt them to the clinic s needs. Possible recommendations could include increasing available clinic space, revamping the patient or staff scheduling system, or altering current processes to change patient flow. The conclusions we 1

draw will hopefully give the clinic a basis for forecasting their needs in the new Comprehensive Cancer Center. 2.0 Methods The methods used in this investigation involve using data collection sheets, see Appendix A, which track the time a patient arrived, was served at, and left each phase of treatment. Medical staff in every area the patient encounters were asked to complete these data sheets. This data was collected for five weeks to properly account for patient scheduling fluctuations. After data collection, the project team analyzed the data to formulate recommendations. A project schedule of the investigation can be found in Appendix B. 2.1 Data Collection Data collection ran for five weeks. Patients received data sheets at the front desk, along with a brief explanation of the project. They then carried the forms with them throughout their visit to the pediatric hematology/oncology clinic. At each step of care, health care providers filled in the time the patient arrived, the time the patient left, and any comments about the care. Providers were coded by type of employee, and services such as blood draw, vital sign check, radiology, and chemotherapy and infusion treatment are accounted for separately. Animal-shaped clip boards were provided by the project team for the surveys in an effort to make data collection more enjoyable for children in the clinic. 2.2 Problems with Data Collection Problems with data collection stem from the data sheet. Sometimes the data sheets are incomplete, with crucial information missing. In order to effectively analyze patient flow, and determine the actual volume of patients at each phase of care, the forms need to be filled out. There are inconsistencies with the data collected. Different health care providers fill the forms out in different manners. For example, during chemotherapy and infusion treatments, some nurses consider each hourly patient check as a provider encounter, and others consider it a part of the treatment process. Also, provider codes are inconsistent. An example of this occurs with the blood lab. Sometimes providers from the blood lab fill in their provider code as 12, yet other times they write lab on second floor. Proper analysis requires us to standardize this verbatim, to establish norms of care. 2

Additionally, a staff survey, found in Appendix C, was conducted. Staff were asked to fill out a questionnaire revealing their feelings about 3 59% WAIT SERVICE 41% SERVICE VS. WAIT TIME AS A PERCENTAGE OF LENGTH OF During our investigation of the pediatric hematology/oncology clinic, length of stay, the waiting time remains excessive. we found that average patient waited 41% of the total time he/she was at the clinic. While service time accounted for 59% of the patient s will be excessive, then he/she is less likely to arrive at the appointment If the patient feels regardless of when he/she arrives, the waiting time and less motivated to arrive at their appointments in a timely manner. Excessive waiting causes patients to become dissatisfied with their care, between each phase of care, excessive waiting is unacceptable. time. While a patient can normally expect a small amount of waiting time 3.1 Efficiency Concerns 3.0 Project Findings efficiency in the clinic. identify perceived problems and processes currently working well. efficiency and quality of care provided by the clinic. They were asked to Staff were also asked to make any recommendations for increased 2.3 Staff Survey

Breaking the total waiting time down into waiting times for each specific health care provider revealed discrepancies between the different health care provider types. The provider types included: Attending MD Fellow Clinic nurse Nurse practitioner Other (including medical assistant, social worker, etc.) SERVICE AND WAIT TIMES PER PROVIDER WAIT TIME SERVICE TIME U zw I-() 0:43:12 0:36:00 0:28:48 0:21:36 0:14:24 0:07:12 0:00:00 ATTEN DING MD FELLO W CLINIC NURSE OTHER NURSE PRACT loner PROVIDER TYPE While the attending MD, nurse practitioner and other revealed the service time to be greater than the amount of waiting time, the clinic nurse showed a large amount of waiting time. This could possibly be due to improper data sheet completion. For the first week of the study, different clinic nurses were filling the data sheet out differently, impacting both the treatment duration and their provider rncounters with patients. While treatment is taking place, clinic nurses usually check on a patient once an hour, every hour, for about five minutes. Because a patient is receiving care, and is not merely waiting for the nurse to reappear, we requested that these provider encounters be considered part of the overall treatment process, and be recorded as such. Until all employees understood the data sheet completion 4

nurses. altering the proportion of service and waiting time for the clinic 5 time reveals that patients are not arriving at the scheduled Comparing the patient check-in time and the scheduled appointment adjust accordingly to arrive before the appointment time early enough further analysis must be done. time. In order to define what the patient views appointment time as, arriving at varying times before and after the scheduled appointment to take care of blood draw and paperwork. The patients, however, are examining room is the appointment time. This calls for patients to time the patient is supposed to see the health care provider back in an The appointment time is being defined differently by the patients and the health care providers. According to the health care providers, the 3.2 Definition of Appointment Time Varies impacts overall waiting time and patient length of stay. However, it is while 62% are performed in the clinic. important to note that 38% of the blood draws are performed in the lab, in the second floor lab were greater than those in the clinic. This needle. Investigation revealed that both the service and waiting times blood drawn in the clinic, are patients who all have a line in place. Patients who have their blood drawn in the second floor lab, are those who must have their blood drawn in the normal manner with a the pediatric hematology/oncology clinic. Patients who have their and waiting times differ between the second floor blood lab and within Finally, blood draw efficiency must be analyzed. Blood draw service Nurse practitioner 11% Clinic nurse 30% Fellow 11% Attending MD 32% Provider Type: Percent of Total Provider Encounters Other 16% summarized below. provider encounters that each provider type accounts for is Additionally, it is also important to note the frequency of provider encounters that each provider type equals. The percentage of total provider encounters. Although we reassigned these encounters as treatment process time, a few of them may have been missed; thus process, some clinic nurses characterized treatment check-ups as

appointment time, thus patients do not feel that check-in time equal appointment time. CHECK-IN TIME AND APPOINTMENT TIME FOR ALL DAYS LI 60 Z 40 jz 20 D z0-0 o o o;o co 0 0 0 TIME OF DAY CHECK-IN TIME APPOINTMENT TIME Looking at the difference in check-in time and appointment time, most patients are arriving from one half hour early to one hour later than the scheduled appointment time. This does not allow for blood draw, vital signs and paperwork to be completed before the first health care provider encounter occurs. This greatly differs from the health care providers definition of appointment time. CHECK-IN TIME VS. APPOINTMENT TIME 60 Ii- 50 I. 30 20 Z 10 0 0 0 0 00 0 0 0 0 0 0 0 ocococ 00000 I I I I TIME DIFFERENCE (HH:MM, NEGATIVE MEANS PATIENT WAS EARLY) 6

providers. are defining appointment time in the same manner as health care being initially seen. This is again important when analyzing if patients 7 before seeing the first provider. first provider encounters. Most patients are waiting zero to one hour encounter clearly shows that appointment times are not correlating to Comparing the patient appointment time to the first provider WAIT TIME (HH:MM) 00 00 0 00 00 00 C ) Z 10 D 20 EJJ LU 40 rr Z 50 U) 0 coo o o I 30 40.00% o _. 60 80.00% 60.00% 20.00% 80 100.00% 70 0.00% TO FIRST PROCESS) ALL PATIENT WAIT (CHECK-IN Looking at the patient waiting time from check-in to the first medical process shows that most patients wait zero to twenty minutes before

PROVIDER ENCOUNTER APPOINTMENT TIME VS. FIRST 8 result is that an average of 2.4 appointment contracts are violated daily delayed. This occurred 80% of the days observed in our study. The Patients seen before their appointment time cause an average of 3 other patients who had arrive on time for their appointments to be The inferred clinic liability of this contract is that a patient who arrives on time for their scheduled appointment should be seen at their appointment time. being seen up to 4 hours before their actual appointment time. During the 5 weeks of data collection it was observed that patients are after their arrival as possible regardless of their appointment time. a first come first serve basis. In other words, the patient is seen as soon By scheduling patient appointments the clinic agrees a type of contract. Currently, the clinic is allowing patients to be seen inside the clinic on appointment. out of their previous appointment with the receptionist, Sharon. At type. Most often a patient schedules his/her appointment during check The clinic schedules patients according to the provider and the patient this time the patient is given the day and time of their next 3.3 Admittance on a First Come First Serve Basis WAIT TIME (HH:MM) cy) CJC J 0 C) 0 0 i- - CJ Ci 0C0)0CQ) 5 0 l 15 20 10 z 25 o oo 0 00000000 0.00% 10.00% 70.00% 50.00% 40.00% 30.00% 20.00% 0 30 35 40 100.00% 90.00% 80.00% 60.00%

9 Location Lab Clinic 1 -J 0:00:00 a) 0) 0z I 4) 1424 Service Time 0.. Wait Time 0 0:21:36 Blood Draw and Wait Time haff of the time of the lab (15 mm. and 17 sec.). The average time to draw blood (7 mm. 28 sec.) in the clinic is almost clinic. If the patient does not have a line the blood is drawn at the lab. distinction. If the patient has a line the blood is drawn within the vital signs and blood draw. Within the blood draw process their is a corresponding MD. or nurse. Common processes include recording of Patients visiting the clinic undergo processes before they see their 3.4 Appointment Time is not Determined by Patient Processes patients arriving at midday for appointment times in the afternoon early in the morning without disrupting later patients. It was the patients to be seen early that arrive before 10:00 a.m. In the data that were causing problems. insists on continuing this policy it is advised that they only allow it is hard to predict if the next patient will arrive on time. If the clinic The clinic follows this first come first serve methodology partly because collected it was observed that the clinic could accept additional patients according to their appointment time. In this manner the clinic will condition return patients to arrive on time by only admitting patients at their scheduled time, not first come first serve. One opportunity for improvement of the clinic is to admit patients appointment time could have been kept. by the clinic. Remember, that these are situations in which the

reduced by implementing a clinic check in time to account for all patient processes. 10 4.1 Conclusions Regarding Appointment Time and Scheduling 4.0 Conclusions and Recommendations treatment processes, as well as ilustrating mean waiting and service Appendix D. times for wach phase of care. This patient flow can be found in was established. The patient flow includes provider encounters, Along with noting clinic problems, the patient flow through the clinic 3.5 Patient Flow be divided among Monday and Tuesday appointments. This will subdue overcrowding. treatment. As much as possible patients undergoing treatment should Currently, the clinic is cramped for space in which to provide 0 0 C) 0 C J C) jf) CD r CD 0) 000 99 000 00 00 00 00 4 1 7 6 5 3 2 0 0.00% 40.00% 20.00% 80.00% 9 8 100.00% 60.00% TREATMENT TIME FOR PATIENTS WITH LENGTH OF STAY FROM APPT stay of a patient undergoing treatment is bimodal. Another process that has great variability is treatment. The length of his/her blood drawn in the clinic. The number of late patients can be lab should be told to arrive at a different time than a patient having For this reason, a patient which will have his/her blood drawn in the

time previous to the appointment time. To standardize this, arrival time and appointment time should be considered the same. Working 11 as playroom area, so that children receiving treatment can also play. Center a large infusion room has been planned, along with a playroom Center be reallocated to move the play room and infusion room together, so both can be used to administer treatment. If this is not It is currently necessary to administer treatment in the Infusion room possible, we recommend that part of the infusion room be designated and the Play room. We understand in the Comprehensive Cancer that will be placed in a different location. The proximity between the playroom and infusion room will not make it possible to utilize the play room as a place to administer treatment. Thus, the total space where treatment can be administered will decrease. Optimally, we recommend that the floor space within the Comprehensive Cancer The recommendations discussed in the previous section should be the patients stay. the Cancer Center to decrease this travel time and the total length of system should be made if process times change significantly. For example, if the blood lab continues to be in Taubman, while the will increase. Additionally, we recommend that a blood lab is put in Comprehensive Cancer Center, the time to get to the blood lab and back implemented in the Comprehensive Cancer Center to insure less variability in arrival time. Also, amendments to the scheduling pediatric hemotology/oncology clinic has moved to the 4.2 Recommendations Involving the Comprehensive Cancer Center arrive early they will be seen in their appropriate slot, they will be Furthermore, the patients should be served in their scheduled order. and late in the afternoon. Once the patients realize that even if they Currently, the patients are conditioned to arrive early in the morning more apt to come on time; which would make the entire scheduling system more accurate. appropriate appointment time to give the patient. process, and patient type can be used to determine the neccessary prep traits and activities including: blood draw type and location, treatment care provider, the patient s needs should be identified. All patient time to allow for a patient to complete processes before seeing the the time of the patient s scheduled first encounter will reveal the backwards from the patient s first encounter with the scheduled direct scheduled health care provider. Subtracting this determined time from obvious whether arrival time should be the appointment time, or a Currently, the definition of patient arrival time is ambiguous. It is not

environment. 12 This is important to ensure the setting is more conducive to a pediatric

Appendix A

-Th Provider Process Time Time comments # Begin End Vital Signs B1o6dDraw:: ProvidéIncotmnter #1... Próvidt.EncoÜnter #2x: Provider.tjcounLer#3. Provider Encounter #4 ProvidérEncoinifer#5.::..:: : Other..:. :::.. : I xovider Treatment Process Time Use hme clodc accompanng data sheet Key on Check In Deflnitiot cf unteraiy lace t face Back Phannacy Order Sent j meeting between prcvder and patient Infusion Room Treatment Start Any sepirabon f two or more Playroom Treatment End minutes is anct1er encounter

Appendix B

23-Jan 30-Jan 6-Feb 13-Feb 20-Feb 27-Feb 6-Mar 13-Mar 20-Mar 27-Mar 3-Apr 10-Apr 17-Apr 24-Apr.iTh Appendix C: Detailed Project Schedule Gantt Chart: Week Activities: 23-Jan 30-Jan 6-Feb 13-Feb 20-Feb 27-Feb 6-Mar 13-Mar 20-Mar 27-Mar 3-Apr 10-Apr 17-Apr 24-Apr Proposal Approval Clinic Orientation * Data Sheet Development : Data Sheet Training : * Data Collection Analysis : * * Formulate * Recommendations Presentation * * Spring Break

Appendix C

you taking the time to fill this survey out. Please return this to Sharon at the front desk. Thank you. interested in staff perceived problems and concerns with current operations. We appreciate As part of our patient flow analysis of the pediatric hematology/oncology clinic,, we are 7. Do you have any questions or concerns with the data collection sheets the student team is currently using? 6. Where do you think improvements could be made in the clinic to increase the quality of service to the patient? Why or why not? Not Efficient Adequate Very Efficient 5. Do you feel that the clinic runs efficiently? (Please Circle) i 2 3 4 5 Not Effective Adequate Very Effective patient flow? (Please Circle) 1 2 3 4 5 4. Do you feel that the current patient scheduling is effective in maintaining an optimal Enough Not Enough Adequate More Than If not, where is the spatial inadequacy? (Please Circle) 1 2 3 4 5 3. Do you feel that you have enough room space allocated for daily tasks? 2. What types of problems, if any, hinder your daily tasks? Please be specific. 1. What do you perceive to be the largest problem with patient flow through the clinic? Provider Type: (i.e. attending M.D., nurse practitioner) Pedric 5-(emato(ogy/Oiico(ogy StaffSurvey

Appendix D