1. 1 FY’02 ASA Presentation Occupational Medical Service, DS “Medical Care in a Timely Fashion” Presented by: James Schmitt Team Members: Alpha Bailey James Burger Robert Ostrowski (Team Leader) James Schmitt Office of Research Services, NIH 18 November 2002

2. 2 Table of Contents Introduction ……………. …………………………………………………. ASA Template …………………………….……………………………….. Customer Perspective……………………….……………………………… Customer Segmentation …………………….………………………………….. Customer Satisfaction……………………….………………………………….. Internal Business Process Perspective……………………………………… Process Map……………….…………………………………………………….. Conclusions from Discrete Services Deployment Flowcharts…………………… Process Measures………………………………………………………………… Learning and Growth Perspective…………………………………………… Conclusions from Turnover, Sick Leave, Awards, EEO/ER/ADR Data………… Analysis of Readiness Conclusions……………………………………………… Financial Perspective………………………………………………………… Unit Cost………………………………………………………………………….. Asset Utilization………………………………………………………………….. Conclusions and Recommendations…………………………………………. Conclusions from FY02 ASA..…………………………………………………… Recommendations…………………………………………………………………

3. 3 Introduction

4. 4 Occupational Medical Service (OMS) The OMS mission is to provide: Work-related medical care Preplacement medical evaluations Occupational injuries and illnesses Surveillance for health hazards at the worksite Return to work evaluations Care for personal medical emergencies Health promotion activities

5. 5 OMS Quality Improvement (QI) Efforts 1991 - QI training is part of OMS orientation 1992 - Each employee completes a QI project 1992 - Cross-functional QI Teams formed Customer satisfaction surveys Computer application development Review of the preplacement evaluation process Review of clinic hours Review of services available for occupational injuries 1992 - External audit of the OMS QI program

6. 6 OMS QI Efforts (cont.) Customer Satisfaction Surveys prior to the ASA External customer (employee) surveys April 1995, November 1995, April 1996, May 1997, April 1999, March 2001 External customer (supervisor) survey October 1997 Internal customer (OMS) surveys August 1995, June 1996

7. 7 ASA Template

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10. 10 “Care in a Timely Fashion” Our team elected to examine more closely the timeliness of clinical care provided in the OMS Building 10 clinic for: Routine work-related visits (both with and without appointments) Personal medial emergencies Personal urgent medical problems

11. 11 Customer Perspective Customer Segmentation

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13. 13 Customer Segmentation (cont.) NIH occupational injury/illness data FY’02 23%Clinical Center employees 18% Office of the Director employees 7% DES 6% ORS, non-DES 5% OD, non-ORS 17% Contractors 11% NCI 6% NIAID 31% Other 22 ICs and the FDA

14. 14 Customer Perspective Customer Satisfaction

15. 15 External Customer Survey Is based upon the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) criteria for outpatient medical care Employees’ top 5 priorities 1. Competent, safe medical care 2. Care in a timely fashion 3. Effective communications with staff 4. Clean, organized environment 5. Respect and caring

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17. 17 Customer Satisfaction (cont.) Percent of OMS customers that ‘agreed’ or ‘strongly agreed’ that medical care was provided in a timely fashion (wait < 15 min.) 1995, April 96.5 % of 361 1995, November 97.5% of 332 1996, Aprilnot surveyed 1997, Maynot surveyed 1999, April 99.4% of 314 2001, February 98.0% of 100

18. 18 Internal Business Process Perspective

19. 19 Block Diagram of Service Group Service Group and discrete service are one and the same: A more meaningful high-level view is provided on the next page

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21. 21 Deployment Flowchart

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23. 23 The OMS triage nurse plays a pivotal role in the operation of the Building 10 clinic. The triage nurse is responsible for determining: whether the request for service falls within OMS’ scope of services, the relative urgency of the visit, and the level of care required. Conclusions from OMS Discrete Services Deployment Flowchart

24. 24 Process Measures

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26. 26 Visits With Appointments Prior surveys set 15 minutes as a reasonable time a customer with an appointment may wait to be evaluated by an OMS provider. This survey redefined a reasonable wait as 5 minutes. The average wait in this survey was 7.5 minutes The average was skewed by the time taken for preplacement medical evaluations and related laboratory visits.

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28. 28 Visits Without Appointments Triage The expected wait to be evaluated by the OMS triage nurse is less than 1 minute for emergencies and 5 minutes or less for all other visits. The actual waiting time to be evaluated by the triage nurse was 0 minutes for emergencies and 5 minutes for all other visits.

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30. 30 Visits Without Appointments Next Available Appointment Ideally, a visitor with a medical emergency will receive an appointment within 2 minutes. The median wait time for an appointment was 9 minutes. The most frequent reported wait was 0 minutes. Ideally, a visitor with an urgent medical problem will receive an appointment within an hour. The median wait time for an appointment was 20 minutes.

31. 31 Visits Without Appointments Next Available Appointment (cont.) Ideally, a visitor with a routine medical need will be offered an appointment within 3 hours. The median wait time for an appointment was 20 minutes.

32. 32 Learning and Growth Perspective

33. 33 Annual bonus program for OMS employees. Awards based upon the employee’s Performance and Significant contributions that significantly enhanced the quality of OMS services, or made OMS a more enjoyable worksite 100% received a performance-based bonus. 30% received a bonus for a significant contribution. Conclusions from Awards Data

34. 34 What is the correct mix of skills and abilities to work in OMS? 1. Customer service mentality - “people skills” 2. Communication skills 3. Common sense 4. Commitment to being part of a team 5. Technical skills (e.g., clinical competency, experience with OWCP, etc.,) Analysis of Readiness Conclusions

35. 35 Implications of the wrong mix of skills, abilities or tools to carry out OMS’ mission? Longer waits, less efficient, and possibly, less competent care. Compromise OMS’ role in providing a safe and healthy work environment. In many instances this may only be an inconvenience. However, in some situations workers’ lives may be jeopardized (i.e., care for chest pain, asthma, anaphylaxis, exposures to HIV-1 and herpes B virus.) Analysis of Readiness Conclusions

36. 36 Financial Perspective

37. 37 The units for OMS are the number of patient visits recorded. Consultations, medical reviews, presentations, and other services that do not involve direct patient care were not included. Costs for the OMS contract include the following: Contract staff costs Computer application developer NIH personnel costs IT expenses Supplies and materials Unit Cost Measures

38. 38 Unit Cost Measures (cont.) FY’02FY’03 Total Costs$2,494,988$2,542,318 Total Visits34,88135,927 Cost/Visit$71.53$70.76

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41. 41 OMS has 28.48 FTE Asset utilization = 90% The 10% shortfall is the anticipated consequence of staffing OMS so that there are always clinicians available to attend to medical emergencies and requests for urgent care This percentage would be higher, if the OMS triage nurses routinely declined employee requests for immediate care for non-emergent medical complaints Asset Utilization Measures

42. 42 Conclusions and Recommendations

43. 43 Conclusions from ASA FY02 1. OMS has a well established QI program. 2. Customer satisfaction for each of their 5 top priorities has been exceptionally high for the last 7 years. 3. The increased average wait for appointments was largely due to the time required to construct a clinical record for workers receiving preplacement exams and language barriers. 4. The triage system is working.

44. 44 Conclusions from ASA FY02 (cont.) 5. The OMS triage nurse routinely accommodates employees’ desire to be seen immediately for routine services. 6. The mechanism for capturing “appointment time” for emergency medical care in this study was faulty. 7. OMS staff increasingly rely on a customized software application for the operation of the Building 10 clinic.

45. 45 Repeat the study within the next two years and broaden the types of visits examined (e.g., return visits for occupational injuries, international travel, surveillance program visits). Request that individuals receiving a preplacement medical evaluation report to OMS 20 minutes before their scheduled evaluation. Recommendations