Efficiency In Office
Practice
Barbara S. Boushon, RN, BSN
Mark Murray and Associates
Office Efficiency (work flows)
The right person doing the right task at
the right time
Barrier-free
Patient-centered
Predictable, standardized
Based on systems, not people
Based on team structure
Capacity: The Link Between
Access and Efficiency
Increased capacity leads to improved
access
Improved access leads to more efficient
office processes
More efficient processes increase
capacity
Cycle Time Measurement
Check in
MA to Room
MD Enters
MD Leaves
Check out
Process
•Greet
•Vital signs
•Greet interview •Prepare information
•Check in/registration•Interview
•Exam
•Closure
•Get chart
•Prepare information•Closure
•Prepare information
Over-arching
•Information transfer
•Communication, pre, during, post visit
•Synchronize patient, provider, information, equipment
•Standardize rooms
•Choreography
Measurement- cycle time
Audit
The Metrics
Lead Time = start to end
The sum of the cycle times + delays
For the whole process
The visit
The referral
Medical record retrieval
Each segment of the process = cycle time
Appointment booking, reminder, registration, greeting,
waiting room, rooming, vital signs, value added vs nonvalue added time
Terms
System:
Group of processes working together to achieve aim
Process:
Group of tasks working in an orderly fashion to
achieve an aim
Tasks:
A specific job or piece of work
Tools:
Workflow analysis/work task analysis
Flow Through the Office
Check-in to Nurse
Dr. in to Dr. out
Nurse to Room
Lead Time
Check-out to leave
How Processes Support Flow
1
1
Process
Process
Nurse to Room
1
Process
Process
1
Process
Process
Dr. in to Dr. out
Check-in to Nurse
1
1
Check-out to leave
1
1
1
Process
Process
Process
Check-in to Nurse
Greet
Register
Routing slip
Update information
Obtain directions to clinic nurse
Obtain chart
Go to clinic
Wait
RN/MA/LPN to Exam Room
Greet
Gather chart
Review/update preventative health
information
Educate/treat for prevention as
indicated
Go to clinic room, vitals
Wait
Doctor In to Doctor Out
Greet
Open chart/computer
History
Exam
Assessment
Education
Plan
Documentation
Check Out to Leave
Review orders
Pharmacy education?
Nurse education?
Send for more lab/XR?
Set up referrals?
Set up next appointment?
How Processes Support Flow
1
1
Process
Process
Process
Process
Process
Process
Check-out to leave
Nurse to Room
1
1
Dr. in to Dr. out
Check-in to Nurse
1
1
1
1
1
Process
Process
Process
6/
5/
1
6/ 999
12
/1
6/ 999
19
/1
99
6/
26 9
/1
99
9
7/
3/
19
7/
9
10 9
/1
99
7/
17 9
/1
99
7/
24 9
/1
99
7/
31 9
/1
9
8/ 99
7/
1
8/ 999
14
/1
99
8/
21 9
/1
8/ 999
28
/1
99
9
9/
4/
1
9/ 999
11
/1
9/ 999
18
/1
99
9/
25 9
/1
9
10 99
/2
/1
10 999
/9
/
10 199
9
/1
6/
19
10
/ 2 99
3/
10 199
/3
9
0/
19
11 99
/6
/
11 199
9
/1
3/
19
99
Minutes
Lead Time Example
Cycle Time
Average
50
40
30
20
10
Separated Tasks
Goal
70
60
AM HUDLE
Align Patients, Providers, Staff
Decreased Appointment Types
Real Time Work
Lab in Exam Room
0
Week Ending
How do we decrease the
waiting in the office….
And keep the value added time?
Frameworks
High Leverage Changes
 Change Concepts

Medical Office Efficiency High
Leverage Changes
Balance Capacity and Demand
Synchronize Patient, Provider, and
Information
Predict and Anticipate Patients Needs
Optimize Rooms and Equipment
Manage Constraints
Balance Capacity and Demand

Predict daily demand for non-appointment services
 Understand
the components of demand for services:
-documentation
-medication refills
-lab review
- messages
-referrals
-forms management

What is the matching process?
 Batch

vs. one piece flow
Match the demand to the correct resource
 For
all non-appointment services
Synchronize Patient, Provider,
and Information





Start on time and stay on time
Identify and maximize the value stream
Synchronize Patient
Synchronize Provider
Synchronize information





Registration process
Closure of last visit
Chart check
Rooming criteria
Document, do work in real time
Synchronization Time for Office Visit
Equipment
Patient
Room
10:00
10:30
11:00
Staff
Information
Provider
Synchronization “Truisms”
The whole process can only go as fast as the
slowest step
If the process starts 15 minutes “late” each
session (AM and PM), a full time clinic can
“waste” 400+ appointments per year.
Must work “backwards” from sync time to
make sure everything is ready on time.
Predict and Anticipate Patient Needs
Practice level approach:
Plan for seasonal demand changes
Flu season, Vacation season, Snowbird season
Plan for the unexpected but predictable daily
demands
Admissions, procedures, consults, information needs
Understand and standardize common
procedures
Align expertise of care teams with patient
needs; plan the visit
Predict and Anticipate Patient Needs
Visit level approach
Communication is harder than you think
“Huddle” – dialogue among team intended to
get everyone “on the same page”
Stand up meeting of less than 5 minutes
Used to plan clinic session; prior to procedure; at
a “hand off”
Promotes familiarity, shared expectations
Communication Overview
14% of each 40 hour work week is wasted in
miscommunication
Over 50% of errors in VA’s Root Cause
Analysis traced back to miscommunication
Communication basics
Familiarity of staff – call each other by name
Listen to understand, not to plan next comeback
Communicate what you see and know
Explicitly ask everyone for input
Optimize Rooms and Equipment
Adequate number of rooms
 Optimize Rooms

Open rooming
 Fully stocked rooms
 Standardize layout, supplies

Move equipment to the patient
 Optimize Space
 Signals for equipment

Identify and Manage Constraints

Person constraint for non-appointment work
 Maximize
the care team: “what is the work?”
 Put inspection step in front of the constraint
 All work to highest level of skill, expertise, and licensure
 Standard Protocols

Process constraint
 No
idle time
 Separate phone flow, patients flow, and paper flow
 Continuous flow

Specific processes
Identify the Constraint
Constraint= the rate limiting step
(Theory of Constraints-TOC)
Who is the person (role) in front of
whom most waiting occurs?
What is the process in front of which
most waiting occurs?
Maximize the Constraint
Put resources around the constraint to
optimize their output
Even if other steps work below their
maximal capacity
Allow no down-time for the constraint
Change Concepts from Industry
Identify value, then eliminate waste
 Improve the flow of work
 Optimize the work environment
 Manage variation

Identify Value (from customer
view), then add value ……
Patients say:
“Treat me with respect”
“Be friendly and caring”
“Give me a long-term healthcare
relationship”
“Make your services convenient”
(Education, skill, and training are assumed)
Focus Group
…and Eliminate Waste (Lean
Thinking)
Eliminate
Things that aren’t used
Multiple entry
Overkill
Intermediaries
Sample
Improve the Flow of Work
Synchronize
Minimize hand-offs
Move steps closer together
Automate
Do tasks in parallel
Practice continuous flow
Use pull systems
Optimize the Work Environment
Improve access to information
Train
Cross-train
Reduce set-up time
Manage Variation
Standardize
Create contingency plans
Manage peak demand
References


VA Delays Manual
The Improvement Guide: A Practical
Approach to Enhancing Organizational
Performance.
G. Langley, K. Nolan, T. Nolan, C.
Norman, L. Provost. Jossey-Bass
Publishers., San Francisco, 1996,
Chapter 7 and Chapter 13