CASE STUDY
CLIENT: Hunterdon Medical Center Flemington, NJ
Integral resource utilization study executed for family practice wishing to eliminate their waiting room. Most practices are satisfied minimizing patient waiting before a scheduled appointment, but Hunterdon Medical Center hoped to eliminate their waiting room completely. While developing a workflow that focused on patients’ forward progress through the system, resource allocation and utilization became the catalysts of success. EXECUTIVE SUMMARY Array’s work began with a current state mapping and visioning session to determine
SERVICE: Transformation
how the staff at the Hunterdon Medical Center work, and how they hoped to operate in
METHOD: Resource Utilization
the future. After these exercises, we collected data for two weeks, giving the team an idea of where bottlenecks occurred in the system. Providers expected resident appointments lasted longer due to the teaching involved,
Challenge
causing increased waiting times. However, data showed that attending physicians’
Providers were unsure why patient waiting times were so high in their practice and desired to make improvements by altering flow and adjusting resource allocations to match their daily appointment schedule.
appointments actually delayed appointments more often. Root cause analysis revealed that when attending physicians stepped out of the room to retrieve a patient’s paperwork for, they were called on for other small tasks that ultimately added time to their patient’s appointment. A multi-disciplinary team developed a new patient flow that focused on patient movement through the system. In the ideal state, patients arrive and check-in before a nurse takes them for a vitals assessment. Then, they move to an exam room, where they might receive immunizations before their physician comes in. As the team
Solution
designed the new process and put the transformation plan in place, we encouraged
Array designed a new process based on current state mapping and data collection, which revealed unexpected provider appointment durations. Using a simulation model, we were able to show the team which resources need to be in place to eliminate patient waiting before a scheduled appointment.
the staff to focus on ensuring all necessary resources were available for all staff, with the intention of eliminating the need for physicians to leave the exam room. Array developed a simulation model to help determine how many exam rooms, assessment spaces and check-in positions were necessary to sustain the new process with minimal patient waiting time. Staff provided feedback throughout the model creation, quickly recognizing it as a credible representation of their system. This allowed them to use the model as a decision-making tool to quantify the number of resources needed to support their new process.
PROJECT HIGHLIGHTS
2
PROPOSED CHECK-IN KIOSKS
12
RESOURCE QUANTITY COMBINATIONS TESTED
10
%
TARGET VOLUME INCREASE
Client Profile HUNTERDON MEDICAL CENTER FLEMINGTON, NJ Hunterdon Medical Center’s Family Practice Residency Program is one of the oldest and most respected in the nation. Hunterdon Medical Center, the Hunterdon Healthcare flagship hospital, treats more than 8,600 inpatients annually, including 33,000 emergency department visits, and more than 292,000 outpatient visits per year. The 178-bed teaching hospital provides a full range of preventive, diagnostic and therapeutic inpatient and outpatient hospital and community health services. http://www.hunterdonhealthcare.org
CURRENT STATE Across the country, service industries are implementing self-service kiosks at a growing rate. The healthcare industry is also starting to bring this technology into their facilities. While kiosks seem to be the obvious choice for check-in, there is still the need for personal interaction in many cases. Hunterdon Medical Center was interested in incorporating self-service kiosks alongside traditional check-in at their family practice, but wanted to explore the best possible solutions for combining kiosks with traditional registration. Currently, Hunterdon uses traditional check-in at their family practice. In the current state map (Figure 1), we see that patients check-in at a desk, wait, and then move to an exam room, where a nurse takes vitals before the exam. Array focused on the check-in process for this study, specifically, how many patients arrive each hour throughout the day, how long it takes new patients and existing patients to check-in, and how much time there is between patient arrivals.
Current State Map
Future hope is for online scheduling
Most not mailed back
20% of patients are non English speakers (Spanish)
New patient packet mailed
Confirmation call by PSR
Get info Make appointment Demographic Insurance With PSR Input info Give directions
If quick appointment Registration process soon to be kiosk
Arrival • • • • • • • •
Method RESOURCE UTILIZATION A resource is anything that aids the movement of work through a system. Organizations hope to optimize their resources’ utilization because they typically have an associated cost, which decreases with higher utilization. After determining ways to maximize throughput and implement flow, we can ensure full resource utilization without creating non-value-adding process steps.
Primary Care / Family Practice April 10th 2015
Patient Portal Appointment request
IP & OP EHR not connected
Greeted by PSR ID Insurance card Review demo sheet Collect mailed forms Collect copay Med review form 3-4 minutes for returning patients
No privacy, no space
Waiting •
Average 30 minutes
Weight in • •
Scale in hall Written on encounter form
Tracker boards
Exam room Vitals • • •
• • •
Queue starts at sessions beginning
• • • •
RN, LPN, CMA, MA Other vitals Temp , BP, heart rate, pulse, height, pain assessment Review Med rec Review pre-visit planning Confirm other health maintenance items Chief complaint Can take up to 10 min to room a patient All real time documentation Routing slip in sleave outside door
History not entered into HER before seeing MD
• • • •
Exam Teaching Inconsistent real time documentation Later years order tests, care plan
Care Plan not always generated real time
Labs/ EKG
MD Visit • Exam • Teaching • Inconsistent real time documentation • Care plan • Order tests in EHR • MD enters return visit request. Write on routing slip
Resident MD Visit Video Monitored
Nurse paperwork Pre-visit planning sheet Fee voucher Routing slip
Order communication not consistent
Check out • • •
Wrap Up • • • •
In exam room Review plan Review results Enter return visit order
Faculty / RMD • • •
Discuss plan Present Review read films
•
Get AVS Schedule next visit Scripts (clinical referral, diagnostic studies etc.) May meet with Managed Care Rep.
Managed Care Rep • • • •
See Reena Insurance pre-check Pre Auth Medication pre auth
RMD Complete visit
RMD / Faculty Patient visit
Figure 1: Current state process map for family practice patient flow.
FUTURE STATE As we explored the possibilities for the future state with the team, Array learned of their desire to include self-service kiosks for check-in. The addition of kiosks to the practice would allow patients more options for check-in and provide staff the opportunity to focus on more critical tasks. Of course, the team also wanted to provide high-quality service to their population not interested in using a kiosk, and to new patients who need additional assistance with scanning documents. DATA ANALYSIS To understand the interaction between self-service kiosks and registrars, Array proposed using a simulation model. The model would represent the system, taking into account a number of assumptions regarding the use of each resource by the expected patient population. Array created data forms to collect information about the duration of each step in a patient appointment. Since the specific micro-steps related to the check-in process were not currently collected by the health record system at Hunterdon, we used this manual data collection form two weeks for all patients who arrived at the practice.
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The extended data collection period allowed Array to gather enough process duration data to create a statistical curve that could predict the duration of each step in the simulation model. These curves allow the model to represent the actual system, while accounting for the variation that the practice experiences. SIMULATION Array built the simulation model to answer specific questions around resource utilization and patient waiting times. It incorporates the collected patient data and uses predictive analytics to apply process times that fit within the curve for each step. For this problem, it was only necessary to model the check-in, vitals and assessment steps. Focusing on these three steps allowed for swift analysis of 12 potential resource combination scenarios. We made a number of assumptions about the way patients will interact with the kiosks and registrars when both are available for the check-in process. These assumptions also incorporated real data about the number of new patients, who Hunterdon expected to always interact with a registrar while checking in for their first appointment. Incorporating these assumptions into the model and adjusting them
Transformation Our core mission is the same as that of our clients: improve the quality of our work, increase our efficiency, and motivate our staff to reach for success. At Array, we are establishing a culture of continuous improvement at all levels of our organization. We seek to empower team members to be agents for good change. We begin all endeavors by considering process before exploring solutions. Our team can guide your organization through pre-design, ensuring clear goal-setting; target outcomes; process analysis and design; and decision support. Our Lean-led approach to project definition provides a clear path to the right project before you begin to design.
throughout the model-design process helped the users understand which variables would impact patient waiting times.
HOW CAN WE ENSURE EFFECTIVE RESOURCE UTILIZATION?
RESULTS After distilling the results from the model, Array presented them to the team at Hunterdon. We shared the resource combinations that led to the best results with the users in a concise format, like the one in Figure 3. These tables allowed the users to see how adding and subtracting resources impacted patient waiting times. Involving these content experts throughout the model-building process led to a high-level of confidence in the model outputs, allowing users to utilize the results to support their decisions.
TOOLS USED:
Current Operating Procedures with Projected Volumes 2 Kiosks
2 Registrars
4 Assessment Providers
Every aspect of the healthcare industry relies on resources, including staff, equipment and space. It’s imperative that organizations utilize their resources effectively. Our skilled and experienced consulting team can help your organization develop a strategy for utilization optimization, ensuring that every resource is providing the highest value while improving process flow.
PTs Waiting for Check In
PTs Waiting for Assessment
>0 min
5.6%
6.4%
>2.5 min
0.9%
1.1%
>5 min
0.6%
0.9%
>7.5 min
0.3 %
0.6%
>10 min
0.1%
0.3%
>12.5 min
.01%
0.4%
>15 min
0%
0.4%
>17.5 min
0%
0.3%
0%
0.4%
>20 min
Adjacency Diagram, Capacity & Utilization Assessment, Consensus, Process Mapping, Simulation Modeling
24,600 Patients Seen over 1 Year .1% = 25
.5% = 123
1% = 246
5% = 1230
Figure 3: Simulation results showing waiting times for patients with given resource allocations.
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Discovering Your Healthcare Solutions Together We are innovators who specialize in the areas your system seeks out to leverage its valuable operational and facility resources. Array Advisors has the expertise and skills to reach beyond your milestones and provide you the decision support you need.
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