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Efficiency In Office Practice Barbara S. Boushon, RN, BSN Mark Murray and Associates.

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Presentation on theme: "Efficiency In Office Practice Barbara S. Boushon, RN, BSN Mark Murray and Associates."— Presentation transcript:

1 Efficiency In Office Practice Barbara S. Boushon, RN, BSN Mark Murray and Associates

2 Office Efficiency (work flows) The right person doing the right task at the right time Barrier-free Patient-centered Predictable, standardized Based on systems, not people Based on team structure

3 Capacity: The Link Between Access and Efficiency Increased capacity leads to improved access Improved access leads to more efficient office processes More efficient processes increase capacity


5 Cycle Time Measurement Check inMA to RoomCheck 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

6 The Metrics Lead Time = start to end The sum of the cycle times + delays For the whole process The visit The referral Medical 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

7 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

8 Flow Through the Office Check-in to Nurse Nurse to Room Dr. in to Dr. out Check-out to leave Lead Time

9 How Processes Support Flow Check-in to Nurse Nurse to Room Dr. in to Dr. out Check-out to leave

10 Check-in to Nurse Greet Register Routing slip Update information Obtain directions to clinic nurse Obtain chart Go to clinic Wait

11 RN/MA/LPN to Exam Room Greet Gather chart Review/update preventative health information Educate/treat for prevention as indicated Go to clinic room, vitals Wait

12 Doctor In to Doctor Out Greet Open chart/computer History Exam Assessment Education Plan Documentation

13 Check Out to Leave Review orders Pharmacy education? Nurse education? Send for more lab/XR? Set up referrals? Set up next appointment?

14 How Processes Support Flow Check-in to Nurse Nurse to Room Dr. in to Dr. out Check-out to leave

15 Lead Time Example

16 How do we decrease the waiting in the office…. And keep the value added time?

17 Frameworks High Leverage Changes Change Concepts

18 Medical Office Efficiency High Leverage Changes Balance Capacity and Demand Synchronize Patient, Provider, and Information Predict and Anticipate Patients Needs Optimize Rooms and Equipment Manage Constraints

19 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

20 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

21 10:0010:3011:00 Staff

22 Synchronization Truisms The whole process can only go as fast as the slowest step If 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.

23 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 procedures Align expertise of care teams with patient needs; plan the visit

24 Predict and Anticipate Patient Needs Visit level approach Communication is harder than you think Huddle – dialogue among team intended to get everyone on the same page Stand up meeting of less than 5 minutes Used to plan clinic session; prior to procedure; at a hand off Promotes familiarity, shared expectations

25 Communication Overview 14% of each 40 hour work week is wasted in miscommunication Over 50% of errors in VAs Root Cause Analysis traced back to miscommunication Communication basics Familiarity of staff – call each other by name Listen to understand, not to plan next comeback Communicate what you see and know Explicitly ask everyone for input

26 Optimize Rooms and Equipment Adequate number of rooms Optimize Rooms Open rooming Fully stocked rooms Standardize layout, supplies Move equipment to the patient Optimize Space Signals for equipment

27 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

28 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?

29 Maximize the Constraint Put resources around the constraint to optimize their output Even if other steps work below their maximal capacity Allow no down-time for the constraint

30 Change Concepts from Industry Identify value, then eliminate waste Improve the flow of work Optimize the work environment Manage variation

31 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

32 …and Eliminate Waste (Lean Thinking) Eliminate Things that arent used Multiple entry Overkill Intermediaries Sample

33 Improve the Flow of Work Synchronize Minimize hand-offs Move steps closer together Automate Do tasks in parallel Practice continuous flow Use pull systems

34 Optimize the Work Environment Improve access to information Train Cross-train Reduce set-up time

35 Manage Variation Standardize Create contingency plans Manage peak demand

36 References VA Delays Manual The 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

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