Case Study
Background
You have been brought in to manage a portfolio of several specialty clinics in a large multi-physician group practice in an academic medical center. The clinics reside in a multi-clinic facility that houses primary care and specialty practice as well as a satellite laboratory and radiology and pharmacy services. The practice provides the following centralized services for each of its clinics: registration, payer interface, and billing. The CEO of the practice has asked you to initially devote your attention to Clinic X to improve its efficiency and patient satisfaction.
Access Process
A primary care physician, patient or family member calls the receptionist at Clinic X for appointment. If the receptionist is in the middle of helping a patient in person, the caller is asked to hold. The receptionist then asks the caller, “How may I help you?” If the caller is requesting an appointment within the next month, the appointment date and time is made and given verbally to the caller. If the caller asks additional questions, the receptionist provides answers. The caller is then given the toll free pre-registration phone number and asked to preregister before the date of the scheduled appointment. If the requested appointment is beyond a 30 day period, the caller’s name and address are put in a “future file” because physician availability is given only one month in advance. Every month, the receptionist reviews the future file and schedules an appointment for each person on the list, and a confirmation is automatically mailed to the caller.
When a patient preregisters, the financial office is automatically notified and performs the necessary insurance checks and authorizations for the appropriate insurance plan. If the patient does not preregister, when the patient arrives in the clinic on the day of the appointment and checks in with the specialty clinic receptionist, she is asked to first go to the central registration area to register. Any obvious problems with authorization are corrected before patient returns to the specialty clinic waiting room.
Receptionist’s Point of View
The receptionist has determined the best way to not inconvenience the caller is to keep her on the phone as short an amount of time as possible. The receptionist also expresses frustration with the fact that there are too many things to do at once.
Physician’s Point of View
The physician thinks too much of his time is spent on paperwork and chasing down authorizations. The physician senses that appointments are always running behind and that patients are frustrated, no matter how nice he is to them.
Patient’s Point of View
Patients are frustrated when asked to wait in a long line to register, which makes them late for their appointments, and when future appointments are scheduled without their input. As a result of this later factor, and work of childcare conflicts, patient often do not show up for these scheduled appointments.
Office Nurse’s Point of View
The office nurse feels that he is playing catch up all day long and explaining delays. The office nurse also wishes there was more time for teaching.
Billing Office’s Point of View
The billing office thinks some care is given that is not reimbursed because of inaccurate or incomplete insurance or demographic information or that care id denied authorization after the fact.
Data
On the Picker Institute website (pickerinstitute.org), you will find the following patient expectations and dimensions of care for adults and children in their outpatient experiences with a hospital or clinic outpatient appointment:
- Respect for patient s’ values, preferences, and expressed needs
- Coordination and integration of care
- Information and education
- Physical comfort
- Emotional support and alleviation of fear and anxiety
- Involvement of family and friends
- Transition and continuity
- Access to care
Your last quarter’s worth of performance data for clinic is
Overall satisfaction with visit | 82% |
Staff courteous and helpful | 90% |
Waiting room time | 64% |
Examination room wait time is less than 15 minutes | 63% |
Patient no-show rate | 20% |
Patient cancellation rate | 11% |
Provider cancellation rate | 10% |
Preregistration rate | 16% |
Average number of patient visits per day | 16 |
Range of patient visits per day | 10-23 |
Instructions –
- Decide which problem your group wants to focus on as your first priority. Describe the problem and why you chose this problem
- State the goal for this improvement effort
- Identify the fundamental knowledge that is required on the team to solve this problem. Define the people you will invite to participate on the team and the fundamental knowledge they bring to the team.
- Document the current process (as is described in the case) using a process flow chart.
- Identify your customers and their expectations.
- Explore and prioritize root causes of the problem by doing the following:
- Brainstorm root causes and document the causes on a fish bone diagram
- Describe how you would collect data about how frequently root causes contribute to the problem.
- From the points mentioned below select and explain the ones that apply to improving your process. Be sure to take into account what you have learned from your work in question 1-6
- Eliminate waste (e.g., things that are not used, unnecessary duplication)
- Improve workflow (e.g. minimize handoffs, move steps in the process closer together, find and remove bottlenecks, do tasks in parallel, adjust to high and low volumes)
- Manage time (reduce steps and waiting times)
- Manage variation (create standard work)
- Design systems to avoid mistakes (use reminders)
- Incorporating what you learned in above steps, improve the process and document the improved process with a process flow chart or work flow diagram.
- Decide what you will measure to monitor the voice of the process and briefly how you would collect the data
- Briefly explain your change effort using PDCA cycle.
Source
Kelly, D.L. (2011). Applying Quality Management in HealthCare. AUPHA.
Expert Solution Preview
1. The problem that the group wants to focus on as their first priority is the waiting room time as it was rated the lowest in the last quarter’s worth of performance data for the clinic. Patients are frustrated with having to wait in a long line to register, which makes them late for their appointments.
2. The goal for this improvement effort is to reduce waiting room time for patients by 50% in the next quarter.
3. The fundamental knowledge required on the team to solve this problem includes knowledge of process improvement methodologies, customer service, healthcare operations, and data analysis. The team will consist of the clinic’s receptionist, nurse, physician, and billing office representative. The receptionist brings knowledge of patient scheduling and check-in procedures, the nurse brings knowledge of patient triage and care, the physician brings knowledge of patient care and diagnosis, and the billing office representative brings knowledge of insurance policies and billing procedures.
4. The current process (as described in the case) will be documented using a process flow chart. This will include steps such as the patient calling the receptionist for an appointment, preregistration, central registration, and checking in with the specialty clinic receptionist.
5. The customers are the patients who visit the clinic. Their expectations include respect for their values and preferences, coordination and integration of care, information and education, physical comfort, emotional support, involvement of family and friends, transition and continuity of care, and access to care.
6a. Root causes of the problem may include scheduling too many patients at the same time, inefficient check-in procedures, lack of staff, and patients not preregistering.
6b. Data can be collected by tracking wait times for patients in the waiting room, number of patients seen per day, and patient satisfaction surveys.
7. To improve the process, the team will eliminate waste by streamlining check-in procedures and improving workflow by minimizing handoffs and finding and removing bottlenecks. Managing time by reducing steps and waiting times and managing variation by creating standard work will also be essential.
8. The improved process will be documented with a process flow chart or work flow diagram that reflects the changes made to streamline check-in procedures and reduce waiting room time.
9. To monitor the voice of the process, the team will measure wait times for patients in the waiting room and patient satisfaction with improvements made. Data will be collected by patient satisfaction surveys and tracking wait times.
10. The change effort will be explained using the PDCA cycle (Plan, Do, Check, Act). The team will first plan the changes to be made, then implement those changes, check their effectiveness by monitoring wait times and patient satisfaction, and act on areas in need of improvement. The cycle will continue until the goal of reducing waiting room time by 50% is achieved.
