+

DA Patient Flow Project – What have we achieved?Dr Andy CO Cheng (Assoc Cons) Dr Ben NM Lam (Cons)WISER HKEH

+Acknowledgement

All involved / affected staff in HKEH Administrative Appointment Finance / Shroff Medical MRO Nursing Optometry OT appointment

+ Morning DA (SOPD)

+Define

+Project Charter Scope

Morning DA old cases

Aim Streamline patients’ flow in HKEH Reduce patients’ “in-hospital” time

Overcrowding – conflicts Infection control issues Patients’ safety / hospital responsibility

Methods TOCLSS (Theory Of Constraints, Lean, Six Sigma)

+Team Project Sponsor:

Dr Stanley Chi (DHCE)

Project Leader: Dr Ben Lam (Cons)

Facilitator: Dr Theresa Li (CM,

Cons)

Members: Dr Andy Cheng (Assoc

Cons) Ms Phyllis Yim (WM, OPS) Ms Eva Lui (FO i/c) Ms June Kwok (DM,

Optom) Mr Keith Lee (HM) Mr Ryan Fung (AHM) Mr Tony Lam (PSO / PRO)

Special thanks: Dr L Wong (RS) Dr N Chan (Resident)

+Measure

+ Current state flowchart

Pharmacy

Registration

VA

Investigation Doctor’s consultation room

MP

Treatment

Appt booking

OT booking

Shroff

Average time in HKEH = 1:35:00 (0:45:00 – 2:36:00)Average number of stations = 6 (range 4 – 8) *% patients <90 minutes = 43%

+ Current state (selected variables + exclude outliers)

Inventory Waiting time Process time

No. Mean Range No. Mean Range No. Mean Range

Registration 37 380 - 118

34 0:15:47 0:01:15 – 0:31:34 37 0:00:210:00:08 – 0:00:40

VA 36 56 0 - 99 35 0:42:04 0:00:18 – 1:10:20 35 0:03:390:01:58 – 0:12:00

Consultation

- Total 49 7 0 - 24 35 0:36:12 0:00:05 – 1:33:30 36 0:06:150:01:00 – 0:25:45

- (No MP) 18 0:23:41 0:00:05 – 0:52:40 18 0:05:110:01:00 – 0:25:45

- (With MP) 17 0:49:28 0:19:01 – 1:33:30 18 0:07:200:01:00 – 0:10:55

Treatment 22 3 0 - 10 23 0:03:25 0:00:05 – 0:11:20 25 0:01:160:00:17 – 0:06:40

Appointment 26 31 0 - 62 24 0:08:48 0:00:04 – 0:20:26 30 0:00:530:00:09 – 0:03:09

Pharmacy 14 14 1 - 25 15 0:08:26 0:01:30 – 0:28:55

+

+Analyze

+Possible reasons (selected)

Unnecessary stations

Unnecessary / overdoing investigations (over-processing)

Unpredictable workload

Huge patient load

Clinic design for patient flow

+Waiting time for VA

+Waiting time for doctors consultation

+Waiting time for Appointment booking

+

Improve

+What have we done for the bottleneck (TOC) - VA? Leveling

Quota for VA / no VA for each time slot DA FU checklist

Decide what investigations to be done next visit before seeing doctor

Major change of work pattern in many parties!

TL clinic

Add 1 ECA

VA only if necessary

Change of optometrist break time (prn)

+What have we done for the bottleneck (TOC) - VA?

Enhanced IT system for appointment booking Allow checkbox for investigations next visit

+Other improvements

OT appointment counter help booking next appointment Less one station for patients

OT appointment staff take up PM DSC admission Free up one more appointment staff at 11 am

+Other improvements

MP allergy data entry into record Risk management

Drug payment Kiosk (Finance) Less one station for patients Nursing / ECA staff help promote Utilization rate now 18.9%

+ Current state flowchart

Pharmacy

Registration

VA

Investigation Doctor’s consultation room

MP

Treatment

Appt booking

OT booking

Shroff

•Exclude rebook cases

+Barriers

Change of workflow!!

Staff acceptance

More work initially

Results not immediately seen

Results not easily seen

+Results for in-premises time

Pre-Change Post-change p-valu

e

Diff

Mean total time in HKEH

1:35:00(0:45:00 – 2:36:00)

1:19:00(0:23:00 – 2:22:00)

0.66 20%

% less than 90 minutes

43% 64% 0.04 21%

Stations (excluding pharmacy)

6 (4 – 8)

4.4 (3 – 7)

0.01 27%

Total number of old cases booked

615 597

+Results for in-premises time

+Results for VA

Pre-Change(n=36)

Post-change(n=21)

p-valu

e

Difference

VA inventory 56(0 – 99)

25(0 – 48)

<0.01

(?) 55%

VA waiting time 0:42:04(0:00:18 – 1:10:20)

0:14:15(0:00:00 – 0:31:00)

<0.01

(?) 66%

VA process time 0:03:39(0:01:58 – 0:12:00)

0:05:20(0:03:00 – 0:13:00)

0.15 46%

+Results for VA

+Results for doctors consultation

Pre-Change(n=49)

Post-change(n=39)

p-valu

e

Dr consultation inventory

7(0 – 24)

6(1 – 12)

0.09

Dr consultation waiting time

0:36:12(0:00:05 – 1:33:30)

0:39:08(0:03:00 – 1:16:00)

0.26

Dr consultation process time

0:06:15(0:01:00 – 0:25:45)

0:06:40(0:02:00 – 0:33:00)

0.53

+Results for doctors consultation

+Results for other stations

Pre-Change(n=33 / 28)

Post-change(n=38)

p-valu

e

Diff

Registration process time

0:00:21(0:00:08 – 0:00:40)

0:00:27(0:00:15 – 0:01:52)

0.08

Appointment inventory

31(0 – 62)

3.82(0 – 14)

<0.01

Appointment waiting time

0:08:48(0:00:04 – 0:20:26)

0:01:17(0:00:00 – 0:03:36)

<0.01

Appointment process time

0:00:53(0:00:09 – 0:03:09)

0:00:18(0:00:09 – 0:01:05)

<0.01

+Results for other stations

+How do our patients react?

No. of complains received / month

Optometry Department in DA

DA waiting time Total

Jan 2009 to Jun 2011 3.7 2.1 5.8

Jul 2011 to Dec 2011 0.8 0.3 1.1

* Including both written and verbal complaints to PRO

Complaints reduced by 81%

** Appreciations by patients

+Control

+Monitoring

Yearly review Waiting time / in-premises time Complaints

DA total quota

Breakdown of systems No stat VA Incorrect transfer / data entry of DA FU checklist VA measurement in children Stat trial lens

+Challenges

Expect more and more patients

New / expanding services e.g. Lucentis injection

Manpower – down 3 doctors

+

Thank you