CLIENT:
Hunterdon Medical Center CASE STUDY
Flemington, NJ
Integral resource utilization study executed for family practice wishing to eliminate their waiting room. Most practices are satisfied minimizing patient waiting before a scheduled appointment, but Hunterdon Medical Center hoped to eliminate their waiting room completely. While developing a workflow that focused on patients’ forward progress through the system, resource allocation and utilization became the catalysts of success.
CHALLENGE
EXECUTIVE SUMMARY
Providers were unsure why patient waiting
Array’s work began with a current state mapping and visioning session to determine
times were so high in their practice and
how the staff at the Hunterdon Medical Center work, and how they hoped to operate
desired to make improvements by altering
in the future. After these exercises, we collected data for two weeks, giving the team
flow and adjusting resource allocations to
an idea of where bottlenecks occurred in the system.
match their daily appointment schedule.
Providers expected resident appointments lasted longer due to the teaching involved, causing increased waiting times. However, data showed that attending physicians’ appointments actually delayed appointments more often. Root cause
SOLUTION
analysis revealed that when attending physicians stepped out of the room to retrieve
Resource Utilization
added time to their patient’s appointment.
Array designed a new process based
A multi-disciplinary team developed a new patient flow that focused on patient
on current state mapping and data
movement through the system. In the ideal state, patients arrive and check-in before
collection, which revealed unexpected
a nurse takes them for a vitals assessment. Then, they move to an exam room, where
provider appointment durations. Using a
they might receive immunizations before their physician comes in. As the team
simulation model, we were able to show
designed the new process and put the transformation plan in place, we encouraged
the team which resources need to be in
the staff to focus on ensuring all necessary resources were available for all staff, with
place to eliminate patient waiting before a
the intention of eliminating the need for physicians to leave the exam room.
scheduled appointment.
Array developed a simulation model to help determine how many exam rooms,
a patient’s paperwork for, they were called on for other small tasks that ultimately
assessment spaces and check-in positions were necessary to sustain the new process with minimal patient waiting time. Staff provided feedback throughout the model creation, quickly recognizing it as a credible representation of their system. This allowed them to use the model as a decision-making tool to quantify the number of resources needed to support their new process.
PROJECT HIGHLIGHTS
2
Proposed Check-in Kiosks
12
Resource Quantity Combinations Tested
10%
Target Volume Increase
CLIENT PROFILE Hunterdon Medical Center Flemington, NJ
Current State Across the country, service industries are implementing self-service kiosks at a growing rate. The healthcare industry is also starting to bring this technology into their facilities. While kiosks seem to be the obvious choice for check-in, there is still
Hunterdon Medical Center’s Family
the need for personal interaction in many cases. Hunterdon Medical Center was
Practice Residency Program is one of the
interested in incorporating self-service kiosks alongside traditional check-in at their
oldest and most respected in the nation.
family practice, but wanted to explore the best possible solutions for combining
Hunterdon Medical Center, the Hunterdon
kiosks with traditional registration.
Healthcare flagship hospital, treats more
Currently, Hunterdon uses traditional check-in at their family practice. In the current
than 8,600 inpatients annually, including
state map (Figure 1), we see that patients check-in at a desk, wait, and then move
33,000 emergency department visits,
to an exam room, where a nurse takes vitals before the exam. Array focused on the
and more than 292,000 outpatient visits
check-in process for this study, specifically, how many patients arrive each hour
per year. The 178-bed teaching hospital
throughout the day, how long it takes new patients and existing patients to check-in,
provides a full range of preventive,
and how much time there is between patient arrivals.
diagnostic and therapeutic inpatient and outpatient hospital and community health
Current State Map
services.
20% of patients are non English speakers (Spanish)
www.hunterdonhealthcare.org
Arriva l
• • •
Greeted by PSR ID Insurance card Review demo sheet Collect mailed forms Collect copay Med review form 3-4 minutes for returning patients
No privacy, no space
W a iting •
Average 30 minutes
W eight in • •
Scale in hall Written on encounter form
Tracker boards
E xa m room Vita ls • • •
• • •
Queue starts at sessions beginning
• • • •
RN, LPN, CMA, MA Other vitals Temp , BP, heart rate, pulse, height, pain assessment Review Med rec Review pre-visit planning Confirm other health maintenance items Chief complaint Can take up to 10 min to room a patient All real time documentation Routing slip in sleave outside door
History not entered into HER before seeing MD
Nurse paperwork Pre-visit planning sheet Fee voucher Routing slip
Order communication not consistent
• • • •
Exam Teaching Inc ons is tent rea l tim e doc um enta tion Later years order tests, care plan
Care Plan not always generated real time
Labs/ EKG
M D Vis it • Exam • Teaching • Inc ons is tent rea l tim e doc um enta tion • Care plan • Order tests in EHR • MD enters return visit request. Write on routing slip
Resident MD Visit Video Monitored
Resource Utilization
Get info Make appointment Demographic Insurance With PSR Input info Give directions
If quick appointment
• • • • •
Primary Care / Family Practice April 10th 2015
Patient Portal Appointment request
New patient packet mailed
Confirmation call by PSR
Registration process soon to be kiosk
TOOL
Future hope is for online scheduling
Most not mailed back IP & OP EHR not connected
C hec k out • • •
W ra p U p • • • •
In exam room Review plan Review results Enter return visit order
Faculty / RMD • • •
Discuss plan Present Review read films
•
Get AVS Schedule next visit Scripts (clinical referral, diagnostic studies etc.) May meet with Managed Care Rep.
Managed Care Rep • • • •
See Reena Insurance pre-check Pre Auth Medication pre auth
RMD Complete visit
RMD / Faculty Patient visit
Figure 1: Current state process map for family practice patient flow.
A resource is anything that aids the movement of work through a system. Organizations hope to optimize their
Future State
resources’ utilization because they
As we explored the possibilities for the future state with the team, Array learned
typically have an associated cost, which
of their desire to include self-service kiosks for check-in. The addition of kiosks to
decreases with higher utilization. After
the practice would allow patients more options for check-in and provide staff the
determining ways to maximize throughput
opportunity to focus on more critical tasks. Of course, the team also wanted to
and implement flow, we can ensure full
provide high-quality service to their population not interested in using a kiosk, and to
resource utilization without creating non-
new patients who need additional assistance with scanning documents.
value-adding process steps.
Data Analysis To understand the interaction between self-service kiosks and registrars, Array proposed using a simulation model. The model would represent the system, taking into account a number of assumptions regarding the use of each resource by the expected patient population. Array created data forms to collect information about the duration of each step in a patient appointment. Since the specific micro-steps related to the check-in process were not currently collected by the health record system at Hunterdon, we used this manual data collection form two weeks for all patients who arrived at the practice. The
Page 2 | Case Study
extended data collection period allowed Array to gather enough process duration data to create a statistical curve that could predict the duration of each step in the
TRANSFORMATION
simulation model. These curves allow the model to represent the actual system,
Our core mission is the same as that of
while accounting for the variation that the practice experiences.
our clients: improve the quality of our work, increase our efficiency, and motivate
Simulation
our staff to reach for success. At Array, we
Array built the simulation model to answer specific questions around resource
are establishing a culture of continuous
utilization and patient waiting times. It incorporates the collected patient data and uses predictive analytics to apply process times that fit within the curve for each
improvement at all levels of our organization. We seek to empower team
step. For this problem, it was only necessary to model the check-in, vitals and
members to be agents for good change.
assessment steps. Focusing on these three steps allowed for swift analysis of 12
We begin all endeavors by considering
potential resource combination scenarios.
process before exploring solutions. Our
We made a number of assumptions about the way patients will interact with the
team can guide your organization through
kiosks and registrars when both are available for the check-in process. These assumptions also incorporated real data about the number of new patients, who Hunterdon expected to always interact with a registrar while checking in for their first appointment. Incorporating these assumptions into the model and adjusting them throughout the model-design process helped the users understand which
pre-design, ensuring clear goal-setting; target outcomes; process analysis and design; and decision support. Our Lean-led approach to project definition provides a clear path to the right project
variables would impact patient waiting times.
before you begin to design.
Results
How can we ensure effective resource utilization?
After distilling the results from the model, Array presented them to the team at Hunterdon. We shared the resource combinations that led to the best results with the users in a concise format, like the one in Figure 3. These tables allowed the users to see how adding and subtracting resources impacted patient waiting times. Involving these content experts throughout the model-building process led to a high-level of confidence in the model outputs, allowing users to utilize the results to support their decisions.
Every aspect of the healthcare industry relies on resources, including staff, equipment and space. It’s imperative that organizations utilize their resources effectively. Our skilled and experienced consulting team can help your organization develop a strategy for utilization optimization, ensuring that
Current Operating Procedures with Projected Volumes 2 Kiosks
2 Registrars
4 Assessment Providers
every resource is providing the highest
PTs Waiting for Check In
PTs Waiting for Assessment
>0 min
5.6%
6.4%
>2.5 min
0.9%
1.1%
>5 min
0.6%
0.9%
>7.5 min
0.3 %
0.6%
>10 min
0.1%
0.3%
>12.5 min
.01%
0.4%
>15 min
0%
0.4%
>17.5 min
0%
0.3%
0%
0.4%
>20 min
value while improving process flow.
Tools used: Adjacency Diagram, Capacity & Utilization Assessment, Consensus, Process Mapping, Simulation Modeling
24,600 Patients Seen over 1 Year .1% = 25
.5% = 123
1% = 246
5% = 1230
Figure 3: Simulation results showing waiting times for patients with given resource allocations.
Cast Study | Page 3
DISCOVERING YOUR HEALTHCARE SOLUTIONS TOGETHER We are innovators who specialize in the areas your system seeks out to leverage its valuable operational and facility resources. Array Advisors has the expertise and skills to reach beyond your milestones and provide you the decision support you need.
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Published: MAY 2016