Patient Flow In Waiting Room
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Healthcare clinics are under a great deal of pressure to reduce costs and improve quality of service. In recent years, healthcare organizations have concentrated on preventive medicine practices and have tried to reduce the length of time that patients stay in a hospital. Outpatient services have gradually become an essential component of healthcare. Organizations that cannot make their outpatient component cost-effective are finding themselves financially burdened in this ever-changing industry (Caldwell, 2005).
Patient waiting times and waiting-room congestion in outpatient settings are two challenges facing the healthcare industry. Survey results indicate that excessive waiting time is often the major reason for patients' dissatisfaction with outpatient services. Waiting times of 10 to 15 minutes are considered reasonable.
Outpatient clinics are in essence queuing systems. These systems embody a unique set of conditions that must be considered when examining the appointment making procedure. Patient flow is simplified when scheduled patients arrive punctually and a single doctor serves them within predefined processing times. The flow gets more complicated when multiple doctors are involved or patients arrive late. Other factors that may complicate the flow are no-shows, walk-ins, and emergencies. In addition, doctors are sometimes delayed or interrupted throughout the course of the day by events not directly related to medical consultation.
The flow of an established patient in the waiting room is the subject of this process analysis. The process begins when the patient walks in the door. If the receptionist is not helping another patient, she greets the patient that has just walked in. The patient waits in line to check in with the receptionist (he or she enters the Arrival Queue). Once the patient reaches the desk, the receptionist asks if he/she has an appointment. If the patient does have an appointment, the receptionist "arrives" the patient, which consists of checking the patient into the computer system. Then, the receptionist checks the patient's demographics, which takes approximately two (2) minutes. Next, the receptionist asks if the patient has insurance. If the patient does have insurance, the receptionist collects their co-pay and asks them to take a seat and wait for their name to be called. If the patient does not have insurance, they are asked to fill out an eligibility waiver form (this takes five minutes), then asked to sit down. At this point, the patient enters the Waiting Queue, which acts as a buffer for the next stage of the patient flow: the medical consultation or examination itself.
This is the end of the patient flow in the waiting room process.
Returning to the first decision point, if the patient does not have an appointment, the receptionist collects the patient's information and establishes the reason for his or her visit. This takes about five minutes. Then, the receptionist contacts the nurse, which takes five minutes or more. The nurse takes at least five minutes to decide if the patient needs to be seen in the office. If the patient does not need to be seen in the office (immediately), then they are re-scheduled, sent to the Emergency Room, or sent to Urgent Care. If the patient does need to be seen in the office immediately, then the doctor's availability is checked (this takes at least five minutes). If the doctor is not available, then the patient is sent to the Emergency Room or Urgent Care. If the doctor is available, then the receptionist "arrives" the patient and the flow continues as described above.
The cycle time is the average time it takes to complete a unit. In this case, the patient is considered the unit. Because this process involves the interaction of human beings and not machines, the flow of patients in a waiting room is not "paced". This means that the timed movement of patients through the process and the cycle time are not fixed. As a result of this, when one patient takes longer to process, the Arrival Queue becomes a bottleneck. Patients begin to stack up behind one another while they wait for the other patients to be processed. This is point in the process that needs improvement. By fixing the time it takes to process each patient and removing or reordering certain steps, the cycle time could be reduced and the bottleneck eliminated.
Work Process Improvement
As stated earlier, the cost for health care is rising for both employers and employees; therefore, both employers and employees are seeking for medical groups that provide systems of very well coordinated care. Coordinating care creates significant advantages for patient by delivering high-quality care efficiently, so that patients get the most for their health care dollars. When services are integrated and carefully designed across the stream of care, this thoughtfulness up front eliminates duplication of processes and inappropriate services. Patients, employers and medical groups benefit in terms of better health and streamlined costs associated with the care.
Survey after survey suggest that the biggest frustrations for patients are:
1. Appointment access
2. Phone Access
3. Getting information about their test results
4. Understanding how to use medical group systems (referrals, eligibility, business department, etc.)
With a structured Work Process Improvement process, our organization developed several objectives to integrate services that lead to efficiency, they are:
1. Security for the patient
2. Bette working relations in the entire care chain
3. Higher competence through the care chain
4. Documentation and communication improvements
5. Quality through the entire care chain
6. Enhance physician and staff satisfaction
7. Reduce variation in ambulatory care process through a patient focused approach to care.
Care Teams in an integrated approach to cost based medical care that aids in the reduction of efficiencies, stream lines the various queues, improves documentation, increases quality of care, improve negotiating power of the medical group versus insurers.
In Care Team model the flow is as follows:
When the patient arrives, the CTM Welcome asks the patient if they have an appointment and checks to see if they are on time. If patient has an appointment and is on time, the CTMW welcomes the patient and brings up the patients information in CIS (IDX) and arrives the patient. If the patient in not new, the CTMW checks the Financial Status Category (FSC) to see if the patient's insurance is current. The next step is to collect the copay, provides a receipt to the patient and asks the patient to have a seat.
If the patient is missing insurance information the CTMW (Greeter) will provide a courtesy phone to the patient to contact the eligibility department. If the patient cannot pay the copay at the time of services they complete a 10-day copay agreement and still keep their appointment. The standard medical receptionist answers phones, takes messages, makes appointments and prepares charts, which as stated earlier takes the focus away from focusing on the patient. The CTM Welcome's responsibility is solely the patient.
Other systems have been put in place to take the load of the CTMW. As stated earlier, the greeter has the capability to put the patient through to the eligibility department and thus does not have to contact the insurance companies directly and go through a lengthy routine to verify patient eligibility.
Either patients or pharmacies are constantly calling the medical office for refill requests or authorizations. We have put in place a Pharmacy Support Center staffed by nurses and pharmacists. The physicians have signed off on medication protocols that allow the support center to automatically refill chronic medications.
In the old flow, the receptionists prepped the charts for the next day. In the new flow, Health Information Services (medical records department) prepares the chart and makes sure all four documents (elements) are present. The elements include the dictation cover sheet, the snapshot (which is a printed summary of the patients medical chart), the superbill and patient information labels.
One integral part of the new flow is that the doctors have two medical assistants. The new title is Care Team Member 2 and they are split up to two positions, Care Team Room and Care Team Phone. The clinician, the two medical assistants and the greeter make up a "Care Unit". Several care units make up a "Care Team". As stated earlier the care team (units) work together to provide continuity of care to the patient in a way that increase care quality and efficiency. The care team members switch weekly from phone duty to room duty. This way they get to know the patients well and have a good understanding of the unit's needs and capabilities. The role of the care team phone is make appointments and take messages for patients that call in. They, after a while, will know their patients well and be able to anticipate their needs as well and the doctors.
In the above scenario, the CT welcome arrived an established patient. If a new patient calls in, the CTM Phone will take the call and register the new patient by entering the patient demographic in IDX, generating a new medical record number and scheduling a "NEW" appointment. When the CTM phone completes this transaction with the patient, she then forwards the new patient to eligibility to verify insurance coverage. When the "NEW" appointment is made, the patient is automatically scheduled for orientation with a Patient Liaison. The Patient Liaison is a patient advocate and will assist the new patient with a site orientation, explain the pharmacy support process, the referral process, after hours access, hospital affiliations and etc. He, or she, acts as a patient advocate, helping the patient with complaints or billing concerns.
In a climate of rising expenses and declining reimbursement, how an organization uses the nursing staff can make or break a practice. It is becoming clear that a multidisciplinary, coordinated approach to patient care achieves better results, especially with complex organizations. Appropriate distribution and delegation of tasks to trained individuals working together in a coordinated way allows the physician to spend more time on complex decision making. Repetitive or time-consuming tasks, such prepping medical records, paper charts, care coordination or regulation of routine medications need not be done solely by a physician. A team approach requires that you define individual roles and responsibilities and that you follow clear and consistent processes with every patient. Good teamwork reduces many of the workflow delays and bottlenecks that are so common in practice today.
Chase, R., Jacobs, R., Aquilano, N. (2004). Operations Management for Competitive Advantage. McGraw-Hill Companies Boston.