Joslin Diabetes Center
Affiliated Programs Annual Meeting
Exam Room Utilization:
Simple Analysis for Constructive Discussion
Sarah O’Neill
Ambulatory Director
Beth Israel Deaconess Medical Center
Oct. 25, 2011
Background
Beth Israel Deaconess
Medical Center


Tertiary Care Teaching Hospital
631 licensed beds



429 medical/surgical beds
77 critical care beds
60 OB/GYN beds
Background
BIDMC Ambulatory Services

625,000 outpatient visits annually



15% Primary Care
85% Specialty Care
350,000 (56%) of outpatient visits


Med/Surg office practice
BIDMC owned facilities
Background
Academic Medical Center



Faculty physicians part of separate partner
organization
Faculty physician schedules complex –
Clinical, Teaching, Research
MD Trainee education integrated into outpatient
practice


83 Fellows
257 Residents and Interns
Context




Medical office practice growing on average
4% a year
2007 three year strategic development – MD
recruitment in many ambulatory areas
Market analysis indicated optimal location in
Boston
GME credentialing required expanded
outpatient experience
Context



Space tight on campus
Increased need for additional space for on
campus off practice
Cost of significant renovations prohibitive
The Goal


Understand utilization – are we truly using
what we have
Develop standard and fair measure to inform
decision making
Decision Making to Date


Based on room reservation schedules
Anecdotal reports of actual practice sessions



Ad hoc site visits range from overflowing to empty
Little detail beyond # of planned physician
recruits
Failed efforts to assess use based on patient
time in room
Beginning the Conversation

Initial analyses reviewed


Weekday use
Reservation use
Weekday Use


Request for more space based on peak
usage
Is usage even across the week?
Ambulatory Services FY 06 Office Practice
Annual Scheduled Hours by Day of Week
% of Weekday Capacity
Scheduled Hours (incl. factor for room turnover)
Exam Room Weekday Capacity in Hours (at 85% util.; adj. for Holidays and Peak Factor)
Annual Hours
120,000
100,000
80,000
74%
72%
69%
67%
60,000
53%
40,000
20,000
0
Monday
Tuesday
Wednesday
Thursday
Friday
Ambulatory Services FY 06 Office Practice
Annual Scheduled MORNING Hours by Day of Week
% of Weekday Capacity
Scheduled Morning Hours (incl. factor for room turnover)
Exam Room Weekday Capacity in Hours (at 85% util.; adj. for Holidays and Peak Factor)
60,000
Annual Hours
50,000
87%
94%
87%
88%
40,000
86%
30,000
20,000
10,000
0
Monday
Tuesday
Wednesday
Thursday
Friday
Ambulatory Services FY 06 Office Practice
Annual Scheduled AFTERNOON Hours by Day of Week
% of Weekday Capacity
Annual Scheduled Hours
Exam Room Weekday Capacity in Hours (at 85% util.; adj. for Holidays and Peak Factor)
60,000
Annual Hours
50,000
40,000
63%
67%
73%
56%
30,000
41%
20,000
10,000
0
Monday
Tuesday
Wednesday
Thursday
Friday
Weekday Use

Helped identify unused capacity – reduced
the anecdotal “noise”

Data for analysis not readily available


Analysis at the appointment level – huge amount
of data
Limited ability to dig in to detail by service or
provider
Reservation Use


Exam room “reserved” for regular weekly
session
Reserved session = 4 hours
Use of Reserved Hours
red bold = >92% or 48 weeks worked
green bold = < 85% or 44 weeks worked
Utilization of Reserved Exam Room Time
practice location
Annualized
Reserved Hours
FY 07 Total
Actual SCHED
Hours
% of time in the
year reserved
hours open
% of time in the
year reserved
hours used
Equivalent weeks
worked out of
52/yr
Weeks Open
Shapiro 5b
12,450
13,082
-5%
105%
55
(3)
Shapiro 8a
16,000
16,154
-1%
101%
53
(1)
Annualized60,050
Shapiro 2c
11,300
Reserved
Shapiro 7b
19,300
Shapiro
8b
32,400
Hours
(50 weeks)
53,069
12%
88%
46
6
9,608
15%
85%
44
8
14,845
23%
77%
40
12
20,520
37%
63%
33
19
Shapiro 6,1
Rabb 1
8,650
5,374
38%
62%
32
20
Shapiro 2a
4,400
2,310
48%
53%
27
25
Shapiro 3a
6,400
3,277
49%
51%
27
25
8,223
55%
45%
23
29
191,053
24%
76%
39
13
4,638
-11%
111%
58
(6)
2,841
4%
96%
50
2
Shapiro 7c
LMOB 7
LMOB 5a
Actual 18,400
252,400
Scheduled4,175
Hours 2,950
LMOB 5
5,500
4,982
9%
91%
47
5
LMOB 4
8,050
7,051
12%
88%
46
6
LMOB 3a
2,750
2,329
15%
85%
44
8
5,450
red bold = >92% or
48 weeks3,619
worked
LMOB 6
3,800
2,283
green bold = < 85% or 44 weeks worked
LMOB 3b
4,000
1,332
Range
15%
105%
LMOB 2a
3,000
445
34%
66%
35
17
40%
60%
31
21
67%
33%
17
35
85%
15%
8
44
65,250
30%
70%
37
15
LMOB 1
45,969
Reservation Use
Helpful
 Highlights wide variation



Clinical contract oversight – length of sessions, cancellations,
make ups, etc.
Ongoing review of space available for others to reserve
Reinforced existing space still available
Long term usefulness
 Evaluates reserved time only
 More provider use of reserved time versus space use
 Depends on managers providing schedules
 Based on a snapshot in time (schedules change)
Finding a Simpler Metric

Use more readily available data





Not dependent on practice management
Evaluates 12 months – level seasonal and
academic variation
From scheduling system – existing data extract
Available at clinic and provider level
Analyses exam room versus provider use
Premise of Metric


Physician schedule reliable - needs to reflect
real average time needed for each visit type
Begin generously



Scheduled versus kept activity
All visits – within session or add on
Based on weekday use – any extended hours
improves metric
Exam Room Availability

Assume room available 8 hours, M-F




Two 4 hours sessions
250 days a year (less 10 holidays)
One room available 2,000 hours/year
For each practice suite - include all clinics/
providers (MDs, NPs, etc.) using exam room
space in that location
Calculation at Practice Level
% Utilization =
Annual Scheduled Hours
# exam rooms x 2,000 hrs
PROVIDER TIME IN ROOM
Practice Location
Available Exam Rooms
Total Actual Scheduled Visits
% of time exam room
used by provider (b,e)
Shapiro 2c
9
24,997
51%
Shapiro 8b
18
28,602
53%
Shapiro 9
21
32,375
54%
Shapiro 7a
8
9,698
48%
Shapiro 6,1
60
114,498
44%
Shapiro 3b
14
24,826
34%
13
19,546
36%
10
14,802
31%
6
6,125
20%
3
3,135
26%
205
372,204
44%
LMOB 4
7
11,970
45%
LMOB 1
3
4,240
50%
LMOB 8b
4
7,986
38%
LMOB 7
5
7,715
40%
LMOB 8a
5
10,138
33%
LMOB 0B
9
10,679
33%
LMOB 5
7
8,851
25%
LMOB 3b
3
2,860
24%
LMOB 6
6
5,489
18%
LMOB 2a,b
2
1,351
13%
67
95,139
29%
Shapiro 7c
Shapiro 2a
Shapiro 5a
Shapiro 3a
TOTAL EAST
TOTAL WEST
% Time Provider in Room
Range 13% - 54%
Calculation at Practice Level
% Utilization =
Annual Scheduled Hours + Room turnover
# exam rooms x 2,000 hrs
PROVIDER “PLUS” TIME IN ROOM


Simple standard/ average factor
Based on variety of observations
Practice Location
Available Exam
Rooms
Total Actual Scheduled Visits
% of time exam
room used by
provider (b,e)
Average Minutes/
Visit
Exam Room Utilization
Shapiro 2c
9
24,997
51%
37
86%
Shapiro 8b
18
28,602
53%
52
69%
Shapiro 9
21
32,375
54%
52
67%
Shapiro 7a
8
9,698
48%
61
61%
Shapiro 6,1
60
114,498
44%
38
60%
% Time Provider in Room
Range 13% - 54%
Shapiro 3b
14
24,826
34%
36
53%
Shapiro 7c
13
19,546
36%
39
49%
Shapiro 2a
10
14,802
31%
35
43%
Shapiro 5a
6
6,125
20%
33
38%
Shapiro 3a
3
3,135
26%
42
37%
205
372,204
44%
LMOB 4
7
11,970
45%
44
63%
LMOB 1
3
4,240
50%
53
62%
TOTAL EAST
Provider plus turnover time
Range 18% - 99%
62%
LMOB 8b
4
7,986
38%
33
55%
LMOB 7
5
7,715
40%
41
53%
LMOB 8a
5
10,138
33%
30
50%
LMOB 0B
9
10,679
33%
43
42%
LMOB 5
7
8,851
25%
39
41%
LMOB 3b
3
2,860
24%
40
32%
LMOB 6
6
5,489
18%
33
25%
LMOB 2a,b
2
1,351
13%
31
18%
67
95,139
29%
TOTAL WEST
42%
The New Metric

Adding turnover time helped





Appropriately adjust for shorter visit, higher room
turnover time needed
Shift focus to relative variation versus absolute %
The relative outcomes passed the “smell” test
– fit known practice experience
Discussion turned to use of existing space
Increased interest in ways to use space more
efficiently
Why the Range?

Review of space model



Offices integrated into practice
Practice suite separate from offices
Optimal practice size


Small (5 or less) suites less flexible
10 to 12 exam rooms with proper support space
most efficient


Critical for specialties balancing OR/ procedure and
office visit time
Physician clinical commitment oversight
Options for maximizing Space








Move support functions out of exam rooms
Limit physicians to 2 rooms per session
Start and end sessions on time
Shared space use
Schedule meetings outside of practice hours
Rearrange commitments so full session used
Shift session to offsite facilities
Extend hours – evenings and weekends
Further Analysis at MD Level
KEPT Visits
Throughput
Unigue Patients/ PANEL
(Based on scheduled activity)
at 50
weeks/
year (h);
Visits/
RESERVED
ROOM
Avg.
Weeks
Worked
per
RESERVE
D ROOM
at avg.
weeks
worked;
Visits/
RESERVE
D ROOM
Provider
Total
Kept
% Not
Kept
New to
Clinic (b)
% New (b)
Panel Last
12 Mos
Panel/
RESERVED
ROOM
Avg.
Visits/
Patient
Annual
visits/
RESERVE
D ROOM
Provider 9
314
21%
192
61%
221
221
1.4
314
6.3
55
6
Provider 8
418
16%
242
58%
260
173
1.6
279
5.6
44
6
Provider 6
737
21%
218
30%
361
120
2.0
246
4.9
35
7
Provider 3
316
20%
77
24%
240
240
1.3
316
6.3
32
10
Provider 7
358
24%
108
30%
214
107
1.7
179
3.6
27
7
Provider 2
1,373
13%
138
10%
695
116
2.0
229
4.6
22
10
Provider 5
858
20%
140
16%
342
68
2.5
172
3.4
21
8
Provider 1
1,719
15%
233
14%
1,178
168
1.5
246
4.9
18
14
Provider 4
237
22%
27
11%
172
86
1.4
119
2.4
14
8
6,330
18%
1,375
18%
3,683
1.7
119
2.4
25
5
Total
Outcome from use of new metric


Generated a broad guideline to begin to filter/
prioritize space requests
Eventually moved to kept rather than
scheduled hours
Utilization Guideline
Current guidelines using KEPT VISITS as base
>60%
50% TO 60%
Optimal space
Approaching
utilization maximum use usage that
request space
adjusts for peaks
and or
and allows for
implement
urgent add on
decompression
sessions without
opportunities
difficulty.
40% TO 50%
< 40%
Reasonable
use but with
potential for
growth or
sharing
underused
sessions
Under use consider
consolidation
with other
services
Exam Room Utilization
Practice
Exam
Rooms
FY 08
FY 09
FY 10
Shapiro 7b
14
60%
61%
61%
cannot add sessions
Shapiro 2c
17
49%
51%
54%
limited ability to add
Shapiro 8a
18
56%
56%
53%
Shapiro 8b
22
57%
61%
51%
Shapiro 9
21
43%
43%
52%
Shapiro 3b
13
46%
46%
48%
Shapiro 7a
8
53%
53%
47%
Rabb 1
9
39%
43%
43%
Shapiro 2b
4
13%
39%
47%
Shapiro 2a
10
43%
39%
40%
234
46%
48%
48%
LMOB 8a
5
48%
60%
60%
LMOB 1
5
47%
49%
48%
LMOB 7
6
43%
44%
49%
LMOB 4
9
49%
52%
55%
Deac 1
5
8%
11%
49%
LMOB 8b
4
44%
51%
55%
LMOB 5
4
35%
35%
38%
B/P Span 3
6
40%
40%
37%
LMOB 6
5
25%
34%
32%
LMOB 3a
5
21%
19%
19%
73
41%
43%
46%
room for growth
limited ability to add
room for growth
Outcome –
Improved use of existing space



Simplified/standardized use of scheduling
templates
Reduced cancellations due to competing
commitments in research and teaching
Encouraged creative options for existing
space



Better sharing across divisions
Office/exam room for more full time clinicians
Minimized/delayed the need for renovations
Outcome –
Improved use of existing space

Annual Volume increased by 64,000 visits

14 exam rooms added during that time
Questions?