Improving Productivity and Efficiency in Outpatient Clinics
Executive Summary
Aim
A literature review was carried out to determine what evidence was available
internationally that could help to inform methods of increased productivity and
efficiency in outpatient clinics in the UK.
Objectives
The four main questions were:
1. What can be done in the primary care or community setting to reduce
pressure on outpatient clinics?
2. What can be done to decrease the numbers of new and return appointments
to the outpatient clinics?
3. How can outpatient appointments be used more effectively?; and
4. How can efficiency be improved by reducing variation and overall demand and
what are the resultant effects on savings and cost containment?
Literature Search
A literature search was carried out and of the 178 papers identified, 22 met the
inclusion criteria. The search focused on international evidence and excluded
papers referring exclusively to the UK setting as it was considered that this literature
was already well known.
Objective 1: Reducing pressure on outpatient clinics
This question aimed to identify how the demand on outpatient services could be
transformed in terms of, for example, how people think about these services, their
location, their movement towards primary care and by supporting self-care.
Research which addresses this is discussed below:
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Outreach clinics
Outreach clinics are clinics in the community rather than in the hospital. A recent
systematic review explored the international evidence.
The key findings were:

Research exploring the use of outreach clinics tended to describe urban, nondisadvantaged areas although the groups which are most likely to benefit from
such clinics are disadvantaged groups and those living in rural areas.

Such clinics had the potential to improve access to specialist services,
improve liaison between specialists and primary carers, and to benefit from
the fact that patients tended to find such clinics less stressful and more
familiar.

At present the research does not suggest that there were increased
efficiencies as a result of these services.
Objective Two: Reducing new and return appointments

One study aimed to improve efficiency by actively pre-assessing patient
charts and pre-specifying management plans before scheduled outpatient
visits. Investigations could be ordered in advance and visits cancelled if
unnecessary. This was successful and weekly clinic attendance fell by 40%.
Urgent referrals could be seen in the same week while maintaining low
waiting times for routine referrals.

None of the papers identified in the search explored reducing inpatient
referrals by other methods: such as working with general practitioners to
reduce unnecessary attendance or providing greater education for self care to
patients when they are inpatients.
Objective Three: Utilising outpatient appointments more effectively
A number of approaches were discussed in the literature to use outpatient
appointments more effectively.

Group medical appointments: Patients were given education about their
condition as a group and then seen in a shorter individual session. The
approach reduced waiting times, increased hourly profit (US system) and
resulted in greater patient satisfaction.
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
Electronic Medical Record: Electronic medical records have been used to
increase communication between health sectors. Overall it would seem that
they are used differently in different settings and their potential is not yet being
realised. While they may improve the system process they create new
challenges as they are not always easy to use.

Reminders: Several methods were tested to decrease the number of patients
who failed to attend including text, telephone and letter reminders and all of
these were successful.

Electronic Consultation: A review of electronic consultation was carried out.
The results showed that it could be practiced in a large number of medical
specialities and had application in primary consultation, second opinion
consultation, telediagnosis and administrative roles (eg e-referral). However
much of the literature is descriptive or anecdotal and hence the results are
inconclusive. At present they do not replace face to face consultations but
augment them. It is possible that this system could be used to triage patients
and also so that investigations could be ordered in advance of an
appointment.

Quick diagnosis clinics: In this Spanish study, patients with severe diseases
who would otherwise have been admitted to hospital were assessed in
outpatients and then, if there were no contraindications, they were treated as
outpatients even for illnesses for which they would usually require admittance.
An estimated 4,563 bed days a year were saved, the mean cost was
hospitalisation was significantly reduced and overall satisfaction for this
approach was high.
Objective 4: How can efficiency be improved and what are the
resultant effects on savings and cost containment?
The papers identified in this area largely described theoretical modelling, lean
management and six sigma approaches to improve the efficiency of the outpatient
clinic. Using these approaches in conjunction with analysing how a clinic works or
working with relevant members of staff showed:

Modelling was used to reduce queues, estimate ‘failed to attend’ patients and
plan accordingly, find bottlenecks in the system, improve flow of patients
between areas, improve appointment systems, test different scenarios,
reduce length of stay, estimate capacity and so on.
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
These approaches reduced waiting times in clinics, reduced non-attendance,
allowed more people to be seen, allowed physicians to spend more time with
patients and increased satisfaction.

Such methods have the advantage of allowing new approaches to be tested
without disruption to current services and the ability to alter one variable and
see the implication of this.

A risk assessment approach was also used in a sexually transmitted infection
clinic which assessed patients in terms of their risk of infection and gave them
suitable tests depending on this likelihood. The authors stated that this had
significant cost and time savings.

None of the papers identified described variation reduction or methods of
reducing overall demand
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1. Introduction
This paper reviews evidence on ways of increasing productivity and efficiency in
outpatient clinics. The main questions it aims to address are (i) what can be done in
the primary care or the community setting to reduce pressure on outpatient clinics,
(ii) what can be done to decrease the numbers of new and return appointments to
the outpatient clinics, (iii) how can outpatient appointments be used more effectively;
and (iv) how can efficiency be improved by reducing variation and overall demand,
and what are the resultant effects on savings and cost containment. The project
team considered that the UK evidence in this area was already well-known within the
government and therefore this review focuses on international evidence.
2. Literature Search
A full literature search was carried out and the details of the search terms and
methods can be made available on request. The initial results of the search were
scanned by the national lead for primary care, community and outpatients, and as a
result the search terms were refined and the search repeated. This second search
identified 178 papers and presentations. The abstracts of these were accessed and
assessed for inclusion and at this stage 104 papers were excluded. The remaining
seventy-four papers were read in full and a further fifty-two of these were excluded
on the grounds of relevance, inappropriate methodology or referring only to the UK
setting. The present review summarises the remaining twenty-two papers with
reference to the four main questions above.
3. Literature Review
3.1 What can be done in primary care or the community setting to reduce
pressure on outpatient clinics
This question aimed to understand how demand for outpatient clinics could be
transformed by, for example, how people think about these services, their location,
their movement towards primary care and by supporting self-care. Only one paper
was found which was relevant to this area, which was a Cochrane review of outreach
clinics.
Outreach Clinics
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A Cochrane review published in 2012 examined the cost and benefits of outreach in
different specialities and countries including the UK .(1) Of the 73 papers found,
nine met the inclusion criteria and the majority of these described non disadvantage
populations in developed countries and were set in urban areas. The main types of
settings were (1) specialist clinics in urban primary care settings instead of hospital
outpatient departments (2) specialist clinics in rural community primary health
centres or hospitals where there was no resident specialist, and (3) sub-specialist
clinics in major regional centres where there was only a resident ‘general’ specialist
service. This meant that outreach services served a range of urban, rural and
remote populations of varying degrees of health, healthcare and socioeconomic
disadvantage. The authors stated that the aims and potential benefits of these
services were (i) to improve access to specialist services, (ii) to improve liaison
between specialists and primary carers, and (iii) to benefit from consultation in
primary care settings such as the fact that patients tended to find them less stressful
and more familiar.
The authors also explored potential costs related to the additional cost of service
provision, the cost of the travelling specialist, and the opportunity cost of taking them
out of their setting. The review quoted a UK systematic review [Powell, 2002] which
included one randomised control trial (RCT) and one other study that controlled for
case mix. This concluded that outreach clinics lead to improved communication
between GPs and specialists and better access and improved patient access but
had increased costs and was a less efficient use of specialists’ time. This review
stated that, in the UK, the decision to provide specialist outreach services was made
because it was felt to be more convenient for patients and that this convenience was
considered to be worth the extra cost. The review authors stated that there had been
little analyses of the quality of care compared with hospital clinics, nor of the
implications for equity of access. They believed that in different countries, where
there were fewer specialists and greater rural population, it was likely that costs and
benefits would differ. The authors also commented that there were risks for people
who were mentally ill, homeless and so on and that these groups would have
different service needs.
This review undertook a descriptive overview of all studies of specialist outreach
clinics including those which did not meet the inclusion criteria to estimate their
effects on access to specialist care, quality and appropriateness of care, health
outcomes, patient and provider satisfaction, use of services and costs and to assess
the influence of different contexts and styles of service delivery on their outcomes.
The review identified 73 specialist outreach interventions in 14 countries and a wide
range of settings was represented, from specialists visiting urban general practice
near major hospitals to small aircraft or four wheel drive vehicles to visit remote parts
of Africa, Australia and Canada. These had been established to improve access,
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foster collaboration and improve efficiency and appropriateness of health care
service use. Virtually all disciplines were represented. Overall the good quality
studies were done in UK, Europe, USA and urban Australia and focused on urban
non disadvantaged groups, whereas the studies in rural Australia, rural Canada,
Africa, South America and the Middle East were descriptive. In the latter case there
may be a greater opportunity to benefit but the quality of the studies made it difficult
to draw conclusions. The quality of studies was significantly higher in evaluations of
outreach to non-disadvantaged populations and in the areas where the potential to
benefit was marginal. In summary: neither the included nor excluded UK studies
suggested that outreach in urban non disadvantaged settings provided any
significant benefit in health improvement or the effectiveness of healthcare delivery
although they may have benefits in terms of patient experience. In addition these
clinics were more costly. Some studies found that specialists found them
inconvenient and it did not lead to the improved communication that they had hoped.
As most studies took place in urban, non-disadvantaged groups, it was not possible
to draw conclusion for more disadvantage patients or those in rural areas both of
whom may have been expected to benefit from such clinics
Overall the authors concluded that the benefits of simple outreach models in urban
non-disadvantaged populations seemed small and were often more expensive
although they had the potential to improve both access and communication. There
was a need for good comparative studies of outreach in rural and disadvantaged
settings where outreach might confer most benefit to access and health outcomes.
Based on this Cochrane review the evidence does not exist to support the theory
that outreach clinics transform demand on outpatient clinics or that they are more
effective or efficient.
3.2
Reducing new and return appointments
If reductions could be made in inappropriate visits or return appointment to outpatient
clinics then this could reduce pressure on these services as well as increased patient
satisfaction. Only one study identified in the literature review addressed this
question directly (3). The authors stated that previous research has shown that
patients are reviewed unnecessarily in outpatient clinics and outpatient attendance
does not reduce hospital readmissions. Moreover inappropriate visits reduce access
by increasing waiting times. The aim of this approach was to use the outpatient
clinic more efficiently by exploring unnecessary attendance and improving efficiency
by actively pre-assessing patient charts and pre specifying management plans
before scheduled outpatient visits. All charts were reviewed by a senior clinician
two weeks before the clinic and a brief, written management plan was made. This
meant that investigations could be ordered in advance so that they would be
available on time and clinic visits cancelled if unnecessary, or postponed if the
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required investigation would not be available in time. Pre-screening for a clinic took
about three hours. Over six months 768 patients were scheduled for review in the
medical outpatient department, following pre screening, in only 458 of cases was
review necessary. Weekly clinic attendance fell by 40% from 32.8 patients to 19.1
patients (p<0.05). This meant that urgent referrals could be seen in the same week
while maintaining low waiting times for routine referrals. One of the premises of this
study was that Senior House Officers would ask for patients to be reviewed who
could have been discharged because they thought it would do no harm, whereas it
caused anxiety and time for patients, created opportunity costs, and made this way
of seeing patients appear to be standard care. However SHOs do need to see
patients for training purposes and patients cannot always be seen by senior
clinicians so this method were SHOs make decisions and these are reviewed by .
senior clinicians helps to assess whether a further appointment was necessary. In
addition by ordering investigations in advance the clinic time could be maximised.
Waiting times did not reduce as a result of this approach, but these had already been
good. This clinic also had an aggressive discharge policy, a waiting time of only
three weeks and open door access. The authors considered that there may be even
greater implications for other clinics.
In terms of the review question, regarding the potential for reducing new and return
appointments, this study does suggest that one method is by reviewing patient
charts in advance of clinics. However this is only one study and no papers identified
in the search explored reducing inpatient referrals by other purposes, such as
working with general practitioners to reduce unnecessary attendance or providing
greater education for self care to patients.
3.3
Utilising outpatient appointments more effectively
Productivity and efficiency could also be improved by using outpatient appointments
more effectively. The literature search identified several papers that were relevant to
this area. They broadly consisted of group medical appointments, electronic records
in one form or other, and a reminder system to reduce the number of patients failing
to attend. One paper also described a method to use outpatient clinics in order to
reduce inpatient numbers. These studies are outlined below.
Group medical appointments
Group medical appointments generally refer to those appointments which are divided
into two: the first part being an education session done with patients as a group, and
the second part being an individual session, which can be shorter and more focused
as information has been given at the group stage. The advantages of this approach
are that groups can be taken by a nurse or other clinician, the group appointment
gives patients the opportunity to talk to people with similar illnesses and share
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experiences, and the consultant can spend less time with each patient individually
but that this time is more specific to them, rather than repeating the same general
information to each patient. Studies have demonstrated improved quality of care,
and, as a result of improved education, fewer emergency department and speciality
visits. However other studies have shown that these clinics are not always
economically viable. Three papers were identified in this review which explored the
efficiency of group medical appointments.
A US study published in 2010 tested the group medical appointment approach in a
dermatology clinic to see if there were cost savings and if this approach was
economically viable in other areas including plastic surgery, gastroenterology,
orthopaedic surgery and dental departments, all of which had adopted this approach
in this clinic. (4) Patients first had a group appointment where they were shown a film
or presentation about their conditions, a nurse then provided education related to the
manifestation of their condition and discussed common management strategies.
Patients were then seen by a physician individually with more time consuming
procedures scheduled for a later date. More patients were seen at a higher profit
rating per hour. All individual and departmental group appointments were
significantly more profitable per hour than their comparators who didn’t have this
approach. Moreover the approach was particularly efficient within dermatology
where significantly more patients per hour and profit were made. The paper gives
detailed breakdown on how profit was calculated but this is specific to the US system
and is not replicated here. The authors conclude that there is a great deal of
potential here for improved access due to shorter waiting times and greater costeffectiveness.
Another study published in 2011which tested group education sessions in a slightly
different way took place at a pain clinic in Western Australia (5). The hypothesis for
the research was to look at a system change from traditional medical consultation to
inter-professional group education coupled with patient request for pain medication.
Patients completed a triage questionnaire assessed by clinicians then those with
persistent pain were offered self-training educative pain sessions if they met the
criteria. The outcome measures were – number of patients who then requested
individual appointments, wait times, unit cost per new patient referred, recurrent
health care utilization, patient satisfaction, Global Perceived Impression of Change
and utilized pain management strategies. Following this session 48% of attendees
requested individual outpatient appointments, wait times reduced from 105.6 to 16.1
weeks at one unit and 37.3 to 15.2 weeks at the second, and costs reduced from
$1,805 Australian dollars to $541. In addition at follow up patients scored their
satisfaction more positively, felt that they had changed their practice more and used
more pain management strategies. This suggests that in some areas it is possible
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that some patients can be seen only in a group setting and do not necessarily
require individual appointments.
A third paper tested the feasibility of having group medical appointments in an
outpatient speciality care clinic for Chronic Obstructive Pulmonary Disorder run by a
nurse practitioner in the USA and concluded that this was feasible and may
represent an efficient use of resources, but as only six patients were included and
the research was qualitative it would need to be followed up before conclusions
could be drawn.(6)
Overall it would seem that group medical appointments have the potential to improve
outpatient efficiency and effectiveness.
Electronic Medical Record
Electronic Medical Record (EMR) systems may include clinical notes,
problem/medication lists and test results and can provide information about chronic
conditions and prior use which might reduce redundant and inappropriate screening,
diagnosis and medications. They can also generate care suggestions and
automated reminders, improve adherence to evidence based guidelines, increase
efficiency and improve communication between departments or sectors.
This literature search identified two papers, both referring to the US setting, which
explored the use of EMR. The first of these, published in 2011 estimated the
relationship between electronic medical record use and efficiency of use and
provider productivity during visits to US office based physicians. (7) This is a
particularly useful study because the sample size is so large – 62, 710 patient visits
to 2625 physicians. The study was carried out because despite the perceived
advantages of electronic medical records, clinicians could be slow to adopt them.
Data were obtained on demographics, clinical notes, prescription orders and
laboratory and imaging results. Efficiency was measured as utilization of
examinations, laboratory tests, radiology procedures, health education, non
medication treatments and medications. Productivity was measured as total services
provided per 20 minute period. Survey weighted regressions estimated association
of EMR use with services provided. Overall EMR use was associated with higher
probability of any examination, any laboratory test, any health education, and fewer
laboratory tests overall. During pre / post surgery visits it was associated with fewer
radiology procedures. It was not associated with utilization of non-medical
treatments and medications, or visit duration. During routine visits for chronic
problems it was associated with more diagnostic / screening services provided per
twenty-minute period. Overall electronic record use had mixed associations with
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efficiency of utilization and provider productivity during visits to US office based
physicians. The relationship between EMR and utilization differed by types of
service and by major reason for visit It had a strong relationship with diagnostic /
screening services during visits for a new problem and chronic care but little or no
association with interventions / medications during visits for pre post surgery and
preventive care. It was associated with higher use of any examination, any
laboratory test and any health education and with lower use of lab tests and
radiology procedures during some visits.
The author states that EMR use differed by type of service and major reason for visit.
It had a strong relationship with diagnostic / screening services during visits for new
problems and chronic care and little or no association with interventions /
medications during visits for pre / post surgery and preventive care. The findings are
consistent with studies that found that EMR increased the provision of specific tests
and counselling. However there is no conclusive evidence that EMR reduced the
number of laboratory tests and radiology procedures. EMR use was also associated
with higher visit intensity and productivity especially during routine visits for chronic
problems. Previous research has shown little relationship between EMR use and
provision of specific quality indicators. This may be due to poor implementation,
ineffective training or resistance to change. It may result in net cost savings and
improve the productivity of provider time during visits and so it may allow more
services within a tighter time period. Limitations of this survey are that data are self
reported there may be differences between patients with EMR than other patients
and that the study was based on cross-sectional analysis meaning that causality is
unproven. The study did not quantify cost savings nor did it consider the
appropriateness of services offered.
Another study in the US setting looked at perceived efficiency impacts following
electronic health record implementation.(8) This was introduced to help to improve
efficiency in care delivery as a result of growing demand for services and
increasingly complex patient population in community health centres (CHC). The
objective of this study was to explore EHR users’ perspectives about the EHR
implementation process and impact in a CHC network. Data were collected through
semi-structured interviews with thirty-nine key informants. Results were that while it
was perceived as improving the efficiency of several clinic processes it also created
new challenges in general system interface issues. This led to more training and IT
support being arranged. The authors also felt that this system may not be
successful with some patient groups. They concluded that it can cause both barriers
as well as efficiencies because of these problems. However it is important to
highlight this was a qualitative study which explored staff members perception of
efficiencies and these were not tested to see if the perceptions related to practice.
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It is likely that there are many studies which test perceptions and use of EMR. The
two papers discussed in the above paragraph explore different aspects of EMR:
efficiency and user perception, and they are both inconclusive. However it makes
intuitive sense that if used and implemented properly there is potential for improved
effectiveness and efficiency of service as well as communication between
specialities. If more conclusive information on EMRs is required a specific review of
this area should be carried out.
Electronic Consultation
As well as electronic medical records, electronic consultation also has the potential
to improve efficiency in outpatient services. A structured review of 185 articles about
the delivery of e-mail based telemedicine was carried out. (11) This was useful both
for remote areas and to save clinical time. The results show that it could be
practiced in a large number of medical specialities and has application in primary
consultation, second opinion consultation, telediagnosis and administrative roles (eg
e-referral) where attached digital camera images were used for telediagnosis.
Diagnostic accuracy of these images was the predominant topic of research and
results showed email as a valid measure of delivering these medical services.
However the authors of this review stated that much of the literature is descriptive or
anecdotal and hence suffers from inconclusive results. At present electronic
consultations do not replace face to face consultation but augment them. It is
possible that this system could be used to triage and one study suggested it could
reduce outpatient clinics by 75% - 25% of cases [Baldwin, L 2003] by identifying
which results were negative or could easily be managed in primary care. Further
reductions could be made by ordering investigations in advance by e-mails. There
was some reluctance to use this because of the difficulty of reimbursement and of
storing information.
Reminders
Patients who do not attend clinics can cause system inefficiencies as clinicians tend
to respond by overbooking which can lead to bottle necks in the system. Several
methods have been used to decrease the number of patients who failed to attend
including text, telephone and letter reminders and this has been done in various
different clinics. (9;10) In the first two of these studies, text reminders were sent to
patients and in the third, timely reminders were sent by letter. All of these
approaches decreased the number of ‘failed to attends’ significantly.
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This section showed that there are a number of ways in which outpatient
appointments can be used more effectively. From the above evidence the most
promising is the group medical appointment, but it also seems that electronic
consultation and electronic medical records have the potential to improve
communication and ensure appropriate investigations are carried out. It also shows
that reminder systems are easy ways to decrease the number of failed to attend.
Quick diagnosis clinics
One study was identified which related to using outpatient clinics more effectively to
reduce inpatient admissions. This was a Spanish study published in 2011which
investigated the use of quick diagnosis units (QDU) for the evaluation of suspected
severe diseases in an attempt to use organisational change to improve efficiency
and resource allocation and reduce inappropriate hospitalization (2). The authors
aimed to evaluate 1000 consecutive patients using the quick diagnosis unit and
ascertain the degree of satisfaction among the patients as well as the costs of this
model compared to conventional practices. Patients evaluated in the QDU typically
met the criteria that they had potentially severe diseases that would normally require
hospital admission for diagnosis, their general condition allowed for outpatient
treatment and they did not have physical or psychological disabilities that would
make travelling to the hospital several times difficult. Patients who would have been
admitted for a diagnostic workup if this unit did not exist were considered ‘hospital
admission avoided.
As a result of this approach, the authors stated that an estimated 12.5 beds each
day were avoided which was 4,563 a year (this was calculated by multiplying
average bed days for patients with the number of patients who were assessed as
avoiding admittance because of the QDU), the mean cost per process for a
conventional hospitalization was 3,416.13 Euros whereas it was 735.65 in the quick
diagnosis unit. Forty-one percent of patients would have been candidates for
conventional hospitalisation and patients expressed a high degree of satisfaction
with their care. The results highlighted (i) overall satisfaction with QDU was high (ii)
repeated travel to hospital was not a major difficulty for the patients and (iii) if further
diagnostic tests were required patients would prefer the QDU model over admission.
The authors concluded that inappropriate hospitalisation is expensive and happens
because of inadequate outpatient services and that in Spain patients can be in
hospital for several days awaiting results of diagnostic tests for potentially severe
diseases when treatment could have already begun if the diagnosis was made
quicker. In terms of limitations, the authors felt that in using these resources for
diagnosing mild disorders it may delay the diagnosis of severe diseases. The key to
the QDU success was prioritisation of specialized consultancy and diagnostic tests.
The results have already resulted in policy changes; patients are increasingly being
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referred directly from the emergency department or primary health care centres to
the QDU in lieu of hospitalisation producing savings in hospital beds and costs. The
authors believed that this model could be used in the UK and other countries;
quoting a 2001 study which stated that 28% of UK hospital admissions were
inappropriate. This approach has the potential for cost effectiveness of care, for
reduced admissions and for higher patient satisfaction.
The above papers give some insight into how outpatient clinics can be used more
effectively by using group appointments in appropriate cases, by exploring how
electronic records and electronic consultations can be used more effectively and by
reducing the number of patients who do not attend. In addition one paper identified
how outpatient clinics can be used in situations were previously patients were
admitted as inpatients.
3.4 Improve efficiency, variation reduction, potential savings and
containing costs, reducing overall demand
This question covers a range of areas and these are discussed in turn:



Improving efficiency, potential savings and containing costs: to some extent
these have been covered in the previous section specifically in outpatient
demand and reconfiguration of service.
Variation reduction: no papers were found on this.
Reducing overall demand : the search did not cover anything specifically on
this. This is a large topic which would require a review of health interventions
and so on if it were to be addressed fully.
However a number of studies have described attempts to improve efficiency using
modelling approaches which usually involve some kind of mathematical model or
computer simulation of clinics or involve a team working to uncover inefficiencies in a
system. Such methods have the advantage of allowing new approaches to be tested
without disruption to current services and the ability to alter one variable to see what
the implication of this could be. This section describes various types of modelling
and management approaches which have taken place with the aim of improving the
way that clinics are organised so that they are more efficient.
Modelling: Flow
Modelling was used in a study in order to improve flow in a preoperative assessment
clinic in the Netherlands. (12) The clinic sought to demonstrate how the
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involvement of essential employees combined with mathematical techniques to
support the decision-making process, resulted in a decreased length of patient stay.
This outpatient clinic had a mixture of walk in patients and those with appointments.
Queuing theory was used to model the initial set up of the clinic and later to model
possible alternative designs. This model had inputs of: patient arrival time and
expected time with clinic employees and the performance measures calculated were
patient length of stay and employee utilization rate. A group then met to see if the
original design was successful or needed to be adapted. By using the model it was
possible to reschedule appointments and reallocate tasks in a more efficient way.
This resulted in a shorter time for the anaesthesiologist to decide on approving the
patient for surgery. As a result, despite a sharply increased number of patients
attending the clinic, the length of stay of patients in the outpatient clinic remained
unchanged. The authors stated that the major advantage of mathematical modelling
is the opportunity to analyse the system while having no impact on the system itself
and meant that different possibilities could be assessed in theory without constant
disruption.
A study in the Netherlands also modelled patient flow. The authors considered that
long waiting times were a problem often encountered at preoperative assessment
clinics. Using a multifactor approach the appointment system was designed to run
more efficiently and effectively and decrease waiting times. Over a three week
period, flow times were measured. These were used to calculate the procedure time
of the nurse and physician and the patient’s waiting time. Patients were also asked
to complete a patient experience questionnaire. Previously a standard fifteen minute
appointment was allocated. In the new system patients were given a questionnaire
in the waiting room, based on this patients were given appointment times of twenty
or thirty minutes and specific spaces were reserved for walk in appointments.
Rather than patients being unallocated and physicians taking them in turn,
physicians were given particularly patients at the start of the day. Waiting times and
patient experience were compared after the implementation of the new appointment
system. It was found that waiting times were decreased and patients experience
both with waiting and overall was improved. It was also found that if there were
increased punctuality on both the parts of the physician and patient this would further
improve.
A computer simulation was also developed to detect fundamental flaws in clinic
flow.(16) The authors developed a discrete-event simulation as a cost-effective way
to diagnose inefficiency and create and test strategies for improvement. They went
through each of the simulation creation steps, including information gathering,
process mapping, data collection model creation and results. This showed that
bottlenecks were present in the medication administration and check out steps of the
clinic process and in waiting for prescriptions. There were work queues throughout
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the clinic and by the end of the day some patients had not completed their
appointment as they were caught in the queue. The simulation predicted that
matching resources to excessive demand at appropriate times for these bottleneck
steps would reduce patients’ mean time in the system. Different scenarios were
tested including increasing length of work days, reassigning staff, different amount of
resources and so on. The average size of the checkout queue decreased from 36 to
7 patients and the average time from 90 to 30 minutes. The authors concluded that
there could be other factors in the real world operation of a clinic which this does not
address but considered the simulation to be a good tool to help to see what
problems there were and to redesign accordingly. Another important result of this
model is that it found that for all patients to complete their visits during the allotted
clinic hours with the allotted clinic resources was mathematically impossible.
Modelling: Six sigma
The six sigma approach is business management strategy originally designed by
Motorola but now used in many sectors. It seeks to improve the quality of process
outputs by identifying and removing the causes of errors and reducing variability. It
combines expert views with statistical methods and quality management with the aim
of reducing costs and improving profits.
Two papers used the six sigma approach in order to use outpatient clinics more
effectively. The first of these was a US paper which aimed to do this by better coordinating patient flow without decreasing time with physicians.(13) There were long
waiting times in this clinic which caused dissatisfied patients and then dissatisfied
clinicians. Clinicians also became frustrated at not being able to manage the clinic
effectively due to high no show rates. A six sigma project was begun to address this.
A team was set up which consisted of a nurse, practical nurse, clerical staff, nurse
practitioner, resident physician and faculty physician. They looked at how the patient
moved through the clinic, when they checked in and checked out and so on and held
a brainstorming session to assess problems. They analysed this and found some
variations, for example that more experienced physicians had shorter appointment
times and less variation in times. They also found an inadequacy in the check in
process which caused a bottleneck in processing charts by staff; who were
interrupted by the telephone, walk in etc. In addition there were not enough
available examination rooms. A number of changes were implemented to improve
these factors and ongoing measurement was made over the year. Overall patient
waiting time and time spent going through the outpatient process decreased
significantly whereas time spent with a physician remained the same.
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A second study also in the US setting applied the Six Sigma tools of change
acceleration process to improve patient access in an outpatient clinic in a hospitalbased residency training programme. (14) The authors stated that their search in
Medline found no other previous study in English that integrated all three aspects of
clinic operations, i.e. financial productivity, organisation efficiency and resident and
student education using the six sigma tools of management.
The problem in this area was that it was hard to get appointments, the clinic was
slow and it was difficult to schedule follow up. Residents were also concerned about
cancelled clinics, rearranged schedules, competing priorities and work hour
restrictions. Two clinics were compared, one after six sigma, the other continuing as
normal. Wait times for the new obstetrics clinic (the case) decreased from 38 to 8
days and the time the patient spent in the clinic decreased from 3.2 to 1.5 hours.
More initial and return appointments could be arranged and the clinics’ revenue
improved. There were no changes in the control clinic during the same time period.
Another paper aimed to organise a clinic more effectively by using modelling to
estimate which patients were likely not to show and then to plan for this
accordingly(15). The modelling showed that those who were most likely to be ‘no
shows’ were younger, single patients and those with fewer costs covered by
Veterans Associations. Also those living nearer the clinic had higher incidence of no
show as did those with appointments made further in past and who attended less
regularly, those with depression and those with drug dependencies. The authors
developed a logistic regression model using electronic medical records to estimate
patients’ ‘no show’ probabilities and then used these estimates to create a clinic
schedule that maximised the clinic capacity utilization while maintaining short patient
waiting times and clinic overtime costs, using three years of appointment information.
This allowed more patients to be seen each day and improved efficiency. The
authors stated that estimates suggest that ‘no shows’ wasted 25.4% of scheduled
time in family medicine and cost 14% of anticipated daily revenue. This is
traditionally addressed by overbooking but this means patients wait around a great
deal and often leads to the clinic going overtime. This approach therefore allows the
clinics to be used more effectively.
Modelling: capacity
A clinic in the Netherlands used computer simulation to reduce patient length of stay.
(17) Models were developed for analysing the capacity needed in appointmentbased hospital facilities using a simple analytic queuing model to understand what
capacity would be required to meet the norm of seeing all new patients within 2
weeks. A simulation model was used which could handle daily variations in demand
and capacity scheduling and also it calculated what was needed to get rid of the
backlog. The analytic model was successful at providing a quick insight into the
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extra capacity needed for the neurology department. The added value was that it
allowed the possibility of taking into account variations in demand for different
weekdays and a realistic schedule for doctors’ consultations. This model was
applied to another clinic and shown to be generally applicable.
Lean Management
Lean management is a model developed by Japanese car makers that is based on
continuous elimination of waste and variability in a process.(18) It does this by
approaching problems in a systematic way as they occur. This approach is called ‘
‘do today’s work today.’ In health care the aim is to deliver high-quality care, safety
and timely access. One response to this is to avoid long waiting times which have a
detrimental impact on quality of care and patient care and some clinics have adopted
open or advanced access to address this. The full paper discusses this in relation to
health-care systems and can be accessed if this is of interest.
The lean management approach was tested out in a children’s cystic fibrosis clinic to
see if it could make the system more efficient and use resources more
effectively(19). The authors wished to decrease the time a patient spends alone in
an examination room without altering the time that the providers spend caring for
patients. The application of lean methods was used to see whether reducing
variation could significantly decrease lead time. They started by mapping the flow of
patients from arrival to discharge, patients papers were time stamped at each stage,
the time they were in treatment rooms was collected as was the time they were in
contact with a provider. It was found some things which slowed the clinic down.
These included: empty rooms not used, full rooms subject to interruption, another
sibling being present, patient waiting for results and left alone during this time,
waiting for a clean room and waiting as a result of research data collection.
Changes were made where obvious ones were possible (quick hits) for example,
sign on room to say it was full, patient chart on door so that next clinician knew that
patient was alone and ready to be seen, visits for research purposes treated
separately, check in speeded up, patients reminded two day before their
appointment and told which test results they should bring. Clinicians each used to
see one patient at time which meant that there were empty periods for some
clinicians while waited for patient to get to them. As this was most likely to happen
earlier in the day, the system was rearranged so that it was frontloaded. All of these
changes were implemented on the same day with no cost. Baseline analysis
revealed only 19.3% of patient visits were completed in 60 minutes or less with mean
and median visits of 84 and 81 minutes respectively. After the lean system had been
implemented 41.5% of patient visits were completed in 60 minutes or less and both
mean and median visit times decreased by 10 minutes per visit. This lead to an
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increase in revenue for the hospital and this was achieved with no additional
administrative costs.
New appointment system
As patient non attendance in outpatient clinics is closely linked to longer waiting
times for appointments, the authors of a US study developed a new scheduling
system that reduced waiting times from more than 4 months to less than 3
weeks.(20) The new system was that instead of new patients requesting
appointments and being scheduled over the next available weeks or months and
clinics being overbooked to minimise the effects of cancellation, appointments
became available each Monday at 8.30 and were filled on a first come, first served
basis. Once these were filled, other patients were asked to call back the following
Monday. Those who did not receive an appointment after calling three times were
scheduled in. As a result of this approach non attendance was significantly reduced
(64% v 31% at 18 months, p<0.0001) and proportion of patients who returned for at
least one follow up visit did not differ between the two methods. The authors then
compared attendance using rapid access v traditional system. The rapid access
system resulted in a 50% reduction in non attendance over 18 months.
Demographics, diagnoses and likelihood of scheduling follow up visits were the
same between the two groups.
Risk assessment
An approach to determining patient’ treatment based on their risk factors was
assessed in a sexually transmitted infection (STI) outpatient clinic in the
Netherlands.(21) This was not a method of triage but rather was about tailoring
services based on risk factors. Visitors were classified as high or low risk for STI
and prioritised accordingly. They were then assigned to standard and short
screening protocols respectively. In total 14 391 visitors (64%) received standard
screening and 8 056 received short screening. They were then both screened for
the main STIs but only the high risk group was screened for the less prevalent STIs
whereas the low risk group had minimal counselling, no physical examination and
collected their own samples. The prevalence of the main STIs in both groups was
18.1% and 7.6% respectively and this resulted in good sensitivity at 74% but lower
specificity at 42%. The authors concluded that this prioritizing system was effective
in differentiating between visitors at high and low risk for STI contributing to provision
of tailored STI services increased efficiency and improved client access. However
they did not address the fact that it is likely that some of those in the low risk group
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had STIs which were not identified as they were not tested. This could mean that
early intervention would not be possible and may also lead to false reassurance and
the subsequent spread of STIs. It would have been more appropriate to have tested
the prioritisation decision first for accuracy before putting this into practice. If this
approach was refined, however, it may be work with other outpatient clinics in the UK
setting.
Supply and demand matching
This paper explored whether supply and demand could be better matched in order to
reduce delays to outpatient speciality care without increasing capacity.(22) The
authors stated that to deal with the uncertainty in the distribution of demand, a clinic
needs to forecast fluctuations in demand and plan supply accordingly. It must also
be able to respond flexibly to react to fluctuations. This paper was a systematic
review of interventions applied by 18 clinics using the model of ‘advanced access,’
and a statistical analysis of the effects of the interventions on their delays. The clinics
applied different combinations of interventions aimed at the way they match supply
and demand. In advance of this, no clinic applied interventions to shape demand
(e.g. shifting demand to weeks when this was low) nor did they use historical data to
anticipate demand. After the interventions, fourteen clinics showed significant
improvements, two had improvements and two others did not improve. On average
access reduced from 47 to 21days.
The results indicated that improving the way that supply and demand were matched
could solve delays. However the clinics had also made significant efficiency gains by
reducing demand and improving the way that supply was organised,
The reasons for delays were a mix of factors interacting with each other which meant
that a bundle of interventions should be implemented tailored to each clinic. The
results of the study suggest that delays can be solved by reorganising things to
match supply and demand but whether this will remain after the end of the study
when people are less supported / highly motivated is uncertain. Other delays and
system failures could be introduced. However the implication of this review is that
delays may not be a capacity problem but a system problem.
Although no evidence was found specifically in reducing variation and reducing
overall demand it is clear that there are a number of modelling approaches which
can help outpatient clinics operate more efficiently to maximise their capacity and
address potential problems. Modelling has the advantages of being able to explore
a number of variables and altering one of these to assess impact and also to
minimise any disruption in clinics as changes can be tried out in theory in the first
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instance. It is clear that there is great potential for modelling approaches and that
this will also be relevant to the UK system.
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