efficiency in office practice barbara s. boushon, rn, bsn mark murray and associates
TRANSCRIPT
Efficiency In Office Practice
Barbara S. Boushon, RN, BSNMark Murray and Associates
Office Efficiency (work flows)
The right person doing the right task at the right timeBarrier-freePatient-centeredPredictable, standardizedBased on systems, not peopleBased on team structure
Capacity: The Link Between Access and
Efficiency
Increased capacity leads to improved accessImproved access leads to more efficient office processesMore efficient processes increase capacity
Cycle Time MeasurementCheck in MA to Room Check outMD LeavesMD Enters
Process•Greet
•Check in/registration
•Get chart
•Prepare information
•Vital signs
•Interview
•Prepare information
•Greet interview
•Exam
•Closure
•Prepare information
•Closure
Over-arching•Information transfer
•Communication, pre, during, post visit
•Synchronize patient, provider, information, equipment
•Standardize rooms
•Choreography
Measurement- cycle time
Audit
The MetricsLead Time = start to end
The sum of the cycle times + delaysFor the whole process
The visitThe referralMedical record retrieval
Each segment of the process = cycle time
Appointment booking, reminder, registration, greeting, waiting room, rooming, vital signs, value added vs non-value added time
System:Group of processes working together to achieve aim
Process:Group of tasks working in an orderly fashion to achieve an aim
Tasks:A specific job or piece of work
Tools:Workflow analysis/work task analysis
Terms
Flow Through the Office
Check-in to Nurse
Nurse to Room
Dr. in to Dr. out
Check-out to leave
Lead Time
How Processes Support Flow
Check-in to Nurse
Nurse to Room
Dr. in to Dr. out
Check-out to leave
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Check-in to Nurse
GreetRegisterRouting slipUpdate informationObtain directions to clinic nurseObtain chartGo to clinicWait
RN/MA/LPN to Exam Room
GreetGather chartReview/update preventative health informationEducate/treat for prevention as indicatedGo to clinic room, vitals Wait
Doctor In to Doctor Out
GreetOpen chart/computerHistoryExamAssessmentEducationPlanDocumentation
Check Out to Leave
Review ordersPharmacy education?Nurse education?Send for more lab/XR?Set up referrals?Set up next appointment?
How Processes Support Flow
Check-in to Nurse
Nurse to Room
Dr. in to Dr. out
Check-out to leave
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Lead Time ExampleCycle Time
0
10
20
30
40
50
60
70
Week Ending
Min
ute
s
Average Goal
AM HUDLE
Align Patients, Providers, Staff
Decreased Appointment Types
Real Time Work
Separated Tasks Lab in Exam Room
How do we decrease the
waiting in the office….
And keep the value added time?
FrameworksHigh Leverage ChangesChange Concepts
Medical Office Efficiency High Leverage Changes
Balance Capacity and DemandSynchronize Patient, Provider, and InformationPredict and Anticipate Patients NeedsOptimize Rooms and EquipmentManage Constraints
Balance Capacity and Demand
Predict daily demand for non-appointment services
Understand the components of demand for services:-documentation-medication refills-lab review- messages-referrals-forms management
What is the matching process? Batch vs. one piece flow
Match the demand to the correct resource For all non-appointment services
Synchronize Patient, Provider, and Information
Start on time and stay on time Identify and maximize the value stream Synchronize Patient Synchronize Provider Synchronize information
Registration process Closure of last visit Chart check Rooming criteria
Document, do work in real time
I n fo rm a tio n
R o o m
P a tie n t
P ro v id e r
S yn c h r o n izatio n T im e fo r O ffic e V is it
E q u ip m e n t
10:00 10:30 11:00
Staff
Synchronization “Truisms”
The whole process can only go as fast as the slowest stepIf the process starts 15 minutes “late” each session (AM and PM), a full time clinic can “waste” 400+ appointments per year.Must work “backwards” from sync time to make sure everything is ready on time.
Predict and Anticipate Patient Needs
Practice level approach:Plan for seasonal demand changes
Flu season, Vacation season, Snowbird season
Plan for the unexpected but predictable daily demands
Admissions, procedures, consults, information needs
Understand and standardize common proceduresAlign expertise of care teams with patient needs; plan the visit
Predict and Anticipate Patient Needs
Visit level approachCommunication is harder than you think“Huddle” – dialogue among team intended to get everyone “on the same page”
Stand up meeting of less than 5 minutesUsed to plan clinic session; prior to procedure; at a “hand off”Promotes familiarity, shared expectations
Communication Overview
14% of each 40 hour work week is wasted in miscommunicationOver 50% of errors in VA’s Root Cause Analysis traced back to miscommunicationCommunication basics
Familiarity of staff – call each other by nameListen to understand, not to plan next comebackCommunicate what you see and knowExplicitly ask everyone for input
Optimize Rooms and Equipment
Adequate number of roomsOptimize Rooms
Open roomingFully stocked roomsStandardize layout, supplies
Move equipment to the patientOptimize SpaceSignals for equipment
Identify and Manage Constraints
Person constraint for non-appointment work Maximize the care team: “what is the work?” Put inspection step in front of the constraint All work to highest level of skill, expertise, and licensure Standard Protocols
Process constraint No idle time Separate phone flow, patients flow, and paper flow Continuous flow
Specific processes
Identify the Constraint
Constraint= the rate limiting step (Theory of Constraints-TOC)
Who is the person (role) in front of whom most waiting occurs?What is the process in front of which most waiting occurs?
Maximize the ConstraintPut resources around the constraint to optimize their outputEven if other steps work below their maximal capacityAllow no down-time for the constraint
Change Concepts from Industry
Identify value, then eliminate waste
Improve the flow of workOptimize the work environmentManage variation
Identify Value (from customer view), then add
value ……Patients say:
“Treat me with respect”“Be friendly and caring”“Give me a long-term healthcare relationship”“Make your services convenient”
(Education, skill, and training are assumed)
Focus Group
…and Eliminate Waste (Lean Thinking)
EliminateThings that aren’t usedMultiple entryOverkillIntermediaries
Sample
Improve the Flow of WorkSynchronizeMinimize hand-offsMove steps closer togetherAutomateDo tasks in parallelPractice continuous flowUse pull systems
Optimize the Work Environment
Improve access to informationTrainCross-trainReduce set-up time
Manage Variation
StandardizeCreate contingency plansManage peak demand
ReferencesVA Delays ManualThe Improvement Guide: A
Practical Approach to Enhancing Organizational Performance.
G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey-Bass Publishers., San Francisco, 1996,
Chapter 7 and Chapter 13