Wednesday, January 9, 2013

Improving Doctors’ Schedules for Better Throughput and Access

Improving scheduling can have a major impact on patient flow efficiencies, throughput, access, and patient experience. Physicians and healthcare executives, burdened by myriad new healthcare requirements, are feeling increased pressure to improve operational effectiveness and should not overlook this opportunity.

To understand the size of this opportunity, consider a few examples for a primary care doctor in a traditional practice:
  1. Leaving one hour of appointments per week unfilled costs $10,000+ per year in missed revenue.
  2. Running an average of 30 minutes late per day costs $3,000+ per year in staffing costs.
  3. Losing just one patient costs $1600+ per year in lost revenue, and 87% of patients say that wait time is a significant factor affecting their overall visit experience.
That is a lot of money to leave on the table, and the stakes have never been higher. Achieving core operational efficiencies and sustainable improvements in workflow is key to patient and physician retention, and clinic profitability.

Two common scheduling mistakes:

Focusing only on productivity and access:  Physician organizations are focused – and should be – on improving throughput and access. However, if this is done without understanding the root causes of delays and inefficiencies in the patient flow process, it can backfire. For example, when asked to add another patient, physicians rarely add time. Instead, they typically double-book appointments. This causes them to run further behind, which, in turn, leads to unhappy patients, greater physician and staff stress, and longer days (with more overtime pay). Exhausted by an unsustainable pace, the reaction is often to reduce – rather than increase – the amount of template time available. The net result is actually reduced productivity and access.

Scheduling appointments with insufficient data:  Physician schedules are typically set up in 10, 15 or 20-minute increments, but visits are scheduled with insufficient information to know the actual time needed for the appointment. Many clinics establish increments for short and long appointment “types” (often based simply on the average or mode). Other clinics give all patients the same time (e.g., 20 minutes) regardless of the reason for the visit. In either case, when appointments are set without full knowledge of the specific reason for each visit and actual provider time needed, the results are the same: a large number of “scheduling outliers” (appointments scheduled with either too little or too much time). These outliers (often >70% of the appointments) create an uneven flow during the day. Consider, for example, if five patients in a row require five more minutes than scheduled. The doctor is already 25 minutes behind half way through their morning! Conversely, if patients need less time than scheduled, doctors start to double book to fill perceived extra time. Both scenarios create inefficiencies, and fuel the ongoing tension between providers and schedulers (receptionists or call centers). These so-called “scheduling errors” are not the fault of the scheduling staff, but the scheduling process itself.

Two surefire ways to improve scheduling and operational efficiency:

Measure and analyze patient flow:  There is a surprising lack of understanding of the patient flow process. Understanding starts with measuring the visit cycle time in more detail, including the time it takes to perform each step in the visit process (e.g., check in, rooming, provider exam, etc.) and the time the patient waits between each step. The data then needs to be analyzed for issues and anomalies, and delays and bottlenecks. For example, if patients arrive an average of 4 minutes early and it takes 9 minutes to complete check-in and rooming, the doctor is 5 minutes behind schedule by the time they enter the exam room. Once the problem is understood, adjustments can be made. Alternatively, suppose it takes 9 minutes on average to room patients for one doctor and 3 minutes for another. What are the reasons for the variation? Is it that the first assistant is inefficient or that the second one is not performing all the rooming tasks, leaving them for the provider to do? Or is it something else? The analysis and ensuing discussion will help eliminate delays, optimize each team member’s role, and streamline the visit process.

Schedule visits according to the expected exam duration:  By measuring patient flow, you now have the actual provider face-to-face time with the patient, and the ability to analyze actual vs. scheduled exam duration by reason for visit. Detailed analysis of this data will typically reveal two things. First, the actual duration of exams frequently doesn’t match the scheduled 15 or 20 minute appointments. For example, the average diabetes visit might be scheduled for 15 minutes, but the providers’ time in the exam room is typically around 10 minutes for a stable diabetic patient, and around 20 minutes for an unstable diabetic patient. Second, the providers’ actual exam duration by reason for visit is generally consistent. Choosing a scheduling increment that enables appointments to be scheduled around the bimodal distribution, and scheduling based on the specific reason for the visit and expected exam duration, will result in fewer scheduling outliers and a more even flow throughout the day. This requires that schedulers have the right tools and education to appropriately schedule, but with greater clarity on the amount of time actually needed, this becomes more manageable.

Running on time is achievable. When doctors run on time, they are more efficient – and patients, doctors, and staff have a better experience. Understanding and optimizing physician scheduling and patient flow is the key to sustainable improvements in throughput, access and satisfaction.

Bonnie Cech, CEO and Founder

This post is cross-posted from Washington Healthcare News, February 2013.
You can download this article as a PDF.

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