1. Lean Six Sigma Black Belt Project Improving Throughput to Provider
Neurology Outpatient Clinic Visits
July 22, 2017
Sue Warshal

2. Throughput to Provider in Room
Overview
Healthcare System
Managing more than 850,000 patient visits annually at 3 hospitals and 27 ambulatory care (outpatient) facilities
Neurology Outpatient
8,233 completed patient visits
Neurology Outpatient
Event
Date
Sample Size
Total Throughput
Throughput to Provider in Room
1st Time Study – Conducted by Process Improvement (PI) Team
July 2016
31 patient visits 82 40
Rapid Process Improvement – Led by PI Team
26 initiatives identified
2nd and 3rd Time Study – Conducted by Neurology Staff
August 2016
November 2016
21 patient visits
22 patient visits 94 92 58 57
EPIC Data Analysis
2016
5,638 patient visits
1,831 on-time visits
102 46 43

3. Define – Voice of the Customer
Wait list
Scheduling from October 2016 referrals
3,236 New Patients
918 Recall Patients
Limited Schedule releases
Patient Surveys
Long waiting list for initial appointment
Long appointments
Extensive wait to see Provider
(simulated) Patient Satisfaction Score vs. Wait Time
Staff Surveys / RPI
Reduce Door to Doctor Time

4. Define – SMART Goal
Broad Goal: Improve patient throughput for Neurology clinic visits.
Specific: Identify inputs that significantly affect the variability in time between when the patient enters the waiting room to when the patient has first interaction with the provider. Alter processes that would provide meaningful decreases in throughput times.
Measurable: Shadow staff and providers to understand process steps. Analyze EPIC data for on-time patients, to identify statistical significant input variables. Identify throughput goal by evaluating effect on patients/healthcare system. Compare improvement in throughput to baseline of 43 minutes on average.
Attainable: EPIC data is available for analysis. Throughput goal will be attained by evaluating throughput needed to accommodate demand of services.
Relevant: There is on average a two week waiting list for Neurology appointments. Improving throughput will decrease the probability of patients seeking services elsewhere, will improve patient satisfaction, and will increase revenue for the department.
Time-Based: Shadowing and current data will be analyzed within three months. Processes improvement changes will be implemented and analyzed for another three months.
SMART Goal: Within six months, will shadow staff and use EPIC data to identify inputs that meaningfully influence variability in Throughput to Provider for Neurology patients arriving on-time for their clinic visits. Will reduce throughput to 35 mins/average and eliminate upper 22% of variance within three months of implemented improvements. This will eliminate clinic waiting lists and improve patient satisfaction.

5. Define – Neurology Appointment Flowchart

6. Define – Throughput Times (minutes)
Current Throughput to Provider = 43 minutes

7. Define – Throughput Goal (simulated)
Average Throughput Goal: 35 minutes
Clinic Capacity: Total current minutes = 8,233 x 43 = 354,019
To accommodate 10,000 patients per year / capacity = 35 minutes on average
Upper Limit Goal: 59 minutes = eliminating current upper 22%

8. Measure – Cause and Effect Diagram

9. Measure – Variation in Scheduling

10. Measure – Variation in Appointment Type

11. Measure – Variation in Provider
(Only B.W. & J.H-C)

12. Check-In – Voice of the Customer
Providers

13. Analyze – Shadowing Analysis
Scheduling
Students
Waitlists / Released schedules
General vs Specialty Clinic availability
Double Booking
Hour of Day
Registration
Confirming information
Intake Form
Medical Assistant
6+ within an hour
Nurse
By-pass nursing (med check)
Provider
Employee (NP) vs Medical Group (MD)
Provider Wait
On-Time
Review charts
Discharge notes

14. Analyze – Student influence
NP ( ), Resident ( ) vs MD

15. Analyze – Scheduling Appointment Availability
75% General on Wait/Recall Lists (estimate)
Number of Scheduled Patients

16. Analyze – Scheduling Double Booking Hour of Day 44 times during year
43 days (17%)
16 providers (67%)
Significant (p=0.005) throughput difference before vs after double booked appointments
Fridays
No students
Less patients

17. Improve - Recommendations

18. Improve – Baseline vs Post Changes (simulation)
Accurate patient status within EMR
NP’s complete discharge notes in patient room
Intake form shorter and direct input into EMR
NP reviews all referrals
Schedules available 3 months out
No double booking
Printers at each registration station
Student identification with EMR
General Session slots increased to 75%
MD mtg twice per week; Friday AM slots available
“Catch-up” appts scheduled once per session
NP available for initial “catch-up” appointments

19. Improve – Throughput Change (simulated)
Baseline Throughput: 43 minutes
Average Throughput Goal: 35 minutes; upper limit goal of 59 minutes
Post Implementation: 33 minutes

20. Improve – Variance Change (simulated)

21. Control – Monthly Dashboard (simulation)