Systematic Determination of
Clinic Space Requirements
UMANG DOSI
April 25, 2000
BME 273 - Senior Design
Department of Biomedical Engineering
Vanderbilt University School of Engineering
ABSTRACT
Vanderbilt University Medical Center (VUMC) has been growing in size, capacity,
human resources, and most of all, patient demand since if was established in 1925. As the new
Vanderbilt Children's Hospital is being designed and built, increasing amounts of space will
become available as the pediatrics clinics scattered throughout TVC and Medical Center East
move into their new locations. The leaders of VMG and TVC feel that each clinic should have a
mandate that requires them to assess their clinic efficiency and space utilization along with the
assessment of their business plan. The objective of this project was to design a tool that would
systematically assess current and future utilization of space and resource needs. A systematic
survey design effort was organized in order to create a comprehensive workbook capable of
asking any and all pertinent questions. This project involved an iterative process that began with
a need and an equation and ended in a product that will be used throughout TVC and VUMC.
The equation provided the framework for the project of creating this tool, and input gained from
interviews and observations with TVC staff helped to develop the questions asked in the
workbook.
During the development of the workbook, several pilot studies were done in
Pediatrics, Urology, Paint Control, Ophthalmology and Nephrology clinic. Clinics of varying
size, capacity and specialties were chosen to assess the flexbility of the clinic. After meeting
with clinicians, managers, and the key stakeholders of the project, it has been concluded that the
workbook is a comprehensive tool that addresses all aspects of a clinical event in order to
systematically assess the current and future needs for the use of space and resources. It is easy to
use, and it will bring about the results desired by all levels of the Vanderbilt University Medical
Center.
1
INTRODUCTION
Vanderbilt University Medical Center (VUMC) has been growing in size, capacity,
human resources, and most of all, patient demand since if was established in 1925. This
continuous growth demands a constant re-evaluation of clinic space and patient demands. The
staff and patients very often feel that inefficient use of space and resources leads to adverse
effects in all outpatient clinics. Patient satisfaction is continuously decreasing as the amount of
time they wait in a waiting room increases. Healthcare providers and front desk staff are also
increasingly impatient with the system when they feel over-capacitated while working long hours
and overtime. Finally, physicians feel as if they are not reaching the maximum capacity that can
be accomplished in their practice.
These contradicting opinions and feelings must be dealt with in a scientific manner in
order to remain fair and objective.
The VUMC infrastructure is highly interwoven and
complicated in nature due to the large numbers of resources it involves. In the past, due to the
lack of a formal understanding of all resource capacities, The Vanderbilt Clinic (TVC) and the
Vanderbilt Medical Group (VMG) have justified these nodes of dissatisfaction and inefficiency
by declaring the problem to be due to insufficient space allocations throughout the clinic4.
However, several detailed studies have begun to show that while the majority of physical
capacities of the clinic remain under-utilized, there is the need to assess the process of providing
healthcare throughout TVC. Vanderbilt's Quality Education and Measurement Department has
conducted numerous studies that indicate that it is necessary to gather data on the process flow
characteristics and the exact nature of both human and clinical resource utilization before
determining where inefficiencies lie within the system. Dr. Quinn, Director, has successfully
2
established a method in which scientific data can be gathered in the form of room utilization
studies, resource studies, and front desk studies in order to assess the process flow of healthcare
through the clinics. Although her work does not stop there, this type of work is very lengthy and
highly labor-intensive. It calls for data collectors to sit down with clinicians and clinic managers
to learn the specifics of their particular process, which is a certain inefficiency in itself when the
clinicians could probably answer these questions themselves without the interpretive efforts of
the data collectors.
As the new Vanderbilt Children's Hospital is being designed and built, increasing
amounts of space will become available as the pediatrics clinics scattered throughout TVC and
Medical Center East move into their new locations. Not only will the executives in charge of
TVC and VMG need to decide the amount of space allocated in these new facilities, but they will
also have to decide how the newly vacated space needs to be redesigned and allocated. As it
stands today, based on the setup within the VUMC infrastructure, clinicians and managers hold
no accountability in the matter of efficient use of clinic space because they do not have to pay for
its use. The leaders of VMG and TVC feel that each clinic should have a mandate that requires
them to assess their clinic efficiency and space utilization along with the assessment of their
business plan. Their goal is to create a standard workbook that can be filled out in order to
gather this data in a systematic and scientific way. There is a need to delicately balance the
needs of the patients and human resources while maintaining a sense of pragmatism and reality
to efficiently operate the clinics at VUMC4.
The objective of this project was to design a tool that would systematically assess current
and future utilization of space and resource needs. A systematic survey design effort was
3
organized in order to create a comprehensive workbook capable of asking all the pertinent
questions necessary to answer the following four major questions:
1. What is the current process and how are resources being utilized? Can a more
efficient process be designed without additional resources?
2. If an efficient process currently exists, what additional resources are needed (people,
space, equipment, etc.)
3. How much growth is expected?
4. Is there a possibility of sharing resources in another area or clinic to maximize the use
of these resources?
This workbook will help to assess the utilization of current and future space and resource
needs. In the near future, as clinics move to other locations, there will be an opportunity to
thoughtfully rearrange operations to improve efficiency and provide for additional growth. This
workbook will not only allow clinicians to understand their clinic processes fully, but it will also
provide a systematic method to evaluate future options for space allocation.
Several clinics were used in order to assess the utility of this workbook including
Pediatrics, Urology, Pain Control, Ophthalmology and Nephrology. The development of this
workbook was deemed possible and timely due to the Vanderbilt Quality Education and
Measurement department's assessment that the operation of all outpatient clinics are similar
enough to gain viable data by asking them all the same questions.
While collecting data with a systematic method will be an important first step, the real
benefits will be realized when the clinics and managers of clinics realize the efficiencies and
inefficiencies that exist in their processes. The redesign efforts that will be guided by the data
collected will have more purpose and less supposition backing the projects, and the challenge of
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process redesign will be made easier by the fact that there is a visible picture of the change and
development the clinic will go through.
The Vanderbilt Clinic is 504,834 square foot facility in Nashville, TN. It is made up of
95 clinics ranging from primary care to specialty and subspecialty clinics. The average size of a
single 6,000 square feet5. Each clinic is in charge of setting its own schedules. Each clinic has a
waiting room, exam rooms, a reception area, offices and/or desk space for attendings and nurses.
When the administrators in the Space and Facilities department begins to plan out a clinic space,
they plan for 3 exam rooms and one office per physician in that clinic. Each exam room is about
80 sq. feet in size, and each office is about 100 sq.feet .n size6. Depending on the need, size and
space allocation for the clinic, there may be a procedure room, a conference room, an education
room, a place for resident-attending consultations, as well as an area for quick lab work.
There are a total of 374 exam rooms in TVC. There could be anywhere from 4 to 35
exam rooms in the clinic depending on current space allocation and patient demand. Generally,
each clinic is supported by a clinic manager, support staff including PSCs (patient service
coordinators), technicians, nurses (LPNs, RNs, nurse practitioners), residents and fellows and
finally, attending physicians.
Some clinics may incorporate educators, social workers,
psychologists; etc. depending on the type or practice and the need for these types of outside
support staffs. TVC sees 650,000 patients a year in the clinic with a variety of insurance carriers,
both HMO and fee-for-service. About 28% of their patients are on TN Care, 22% Medicare,
47% commercial insurance and 3% are uninsured 4.
If there is overlap, or the clinic space is shared by two specialties, then the clinic sessions
are either split by half-days or scheduled for different days of the week. Most clinic sessions last
5
from 8am - 5pm. The last appointments for the day are usually scheduled for no later than 3:30.
Exam times can be staggered by every 15 minutes or every half hour.
Although each part of the staff has some primary functions, in reality these functions
begin to run together and overlap. It is a fact that over 700 staff members in TVC are trained to
check patients in4.
Many agree that this high number is a waste of human resources and
efficiency. It also leads to higher rates of errors in check-in and registration that costs a great
deal in insurance money at the end. The primary functions of a PSC are to check patients in and
out, schedule appointments and answer the phone. Sometimes the physician's own secretary
does the appointment scheduling from a completely different space oftentimes located where the
doctor's office is in a separate building. The technicians float and make sure that the equipment
is prepared, the lab work gets to the lab, the rooms are stocked with gowns and medical
instruments. The LPN and the RNs have similar positions, but since RNs are more highly
educated, they are usually in charge of doing any type of blood work, procedures that must be
done, and generally doing a preliminary workup of the patient. He or she is charge of answering
questions coming in via phone calls. The LPN is usually in charge taking the patient back to the
exam room and taking vital signs. They are usually in charge of filing medical records and
making sure that the records are in the right place as they are needed. Although this may seem
like a simplified view of the breakdown of tasks, there is quite a bit of overlap in these positions,
and due to patient volume, these people support the running of the clinic to the greatest extent.
Finally, attending physicians and residents are, of course, seeing patients. The resident usually
does the exam and then he or she will confer with the attending. After that, depending on the
situation, the attending physician, themselves, may also conduct an examination of the patients.
6
METHODS
This project involved an iterative process that began with a need and an equation and
ended in a product that will be used throughout TVC and VUMC. Over the past few years, the
need to develop a tool to systematically determine space allocation has been felt by the leaders of
TVC and VMG. During the last year, an equation was developed that provided the framework
for the project of creating this tool. Subsequent interviews & observations of TVC staff ensued.
The input obtained from both questions and answers were evaluated to determine the format of
the workbook and develop the questions asked in the workbook.
The methods have involved several steps that are outlined below:
1. The equation to determine clinic space needs had been developed, and the need for a
systematic method of space/resource evaluation was needed.
2. I flowcharted the healthcare process of Pediatrics Suite D by observation and interviewing
staff.
3. I met with clinic managers and administrators to gain an overall perspective of the clinic.
4. The questions to be asked were broken down into five categories: Process, People,
Equipment, Growth and Overlap.
5. Telecommunication became a single category.
6. I began to develop questions based on interviews and the data needed to fit the equation.
7. I worked with clinic managers to assess whether the questions were going in the right
direction.
7
8. As the workbook developed, I met with people of all capacities (nurses, technicians, PSC’s)
and asked them to tell me if the types of questions being asked were easily understood and
answerable.
9. I met with the key stakeholders of the project to present the workbook and gain feedback.
Key stakeholders included executives of VMG, Space and Facilities Planning, Constructive
Administration and Strategic Development.
10. While assessing their comments, I re-evaluated their lists of demands and wishes and
compared them to the objectives of the project as well as the timeline I was working with.
11. It was decided that the workbook needed to be divided into two parts: Part 1 incorporates all
data collection in order to determine if the clinic is currently using its space and resources
efficiently. If it is seen that this is the case, then Part 2 will walk the clinician through the
process in order to determine where new space or resources are needed.
12. Each part was then broken down into the components of the equation and the individual
categories were developed to match the formula.
13. Work developed as I started to pilot the workbook in several clinics including the Pain
Control Center, Urology, Pediatrics, Ophthalmology and Nephrology.
14. I worked with clinic managers and staff to fill out the workbook in order to understand what
information was easily obtained and what needed to be clarified.
15. I gathered data from different clinics and started to analyze the utility of the workbook in
determining space/resource needs.
16. A flowchart of the ideal clinical event process existed from a workshop Dr. Quinn conducted
during the early part of this year. Using it as a guide, I used Flowcharter 7 to create a
template that can be filled out by those who fill out the workbook. With the help of Dr.
8
Quinn and Frances Sanders, I refined the flow chart template to show the real process that a
patient goes through from check-in to check-out.
17. The final touches were put onto the workbook as instructions were clarified and the
workbook was formatted to its current look.
18. Final comments came from the clinic manager of Urology and the Assistant COO of VMG to
ensure that demands from several levels of the clinic had been met.
Equations:
There is a rational way to determine a clinic's space needs. One can determine who and
what requires space, how much space is required by each person, task or piece of equipment.
Patient volume and an adjustment for growth and overlap must also be taken into account. It is
possible to reduce the total amount by determining how much space can be used for multiple
tasks by multiple resources. Finally, the mathematically rigorous equation simplifies itself to the
following:
(1)
Clinical Space Needs = (Resources and Tasks) • (Space Required) • (Growth Adjustment) - Overlap
Each component in parentheses is a vector of elements; each element corresponds to a person,
piece of equipment, or task that requires space. The clinic's space needs are calculated by taking
the dot product of the three vectors and subtracting Overlap.1
The workbook has been developed around the framework provided by this equation.
While no mathematical calculations can be made with the data collected, evaluating the input
provided through the answers to the questions can make a very accurate assessment.
1
For the purposes of VUMC, the Overlap component effectively equals 0 in this equation since none of the clinics
overlap in space. Each specialty has its own space allocated.
9
Furthermore, calculating the room utilization rate can open the door to a whole new
analysis of the efficient use of space. Using the following equation, one can determine what the
rate of utilization is. Utilization rate can be defined as “the percentage of time a resource is
being used1. It can be calculated using the equation given below:
(2)
Utilizatio n Rate 
( P )(T p )
( R )(Tt )
P = Avg. # Pts / Day
x 100
Tp = Avg. Exam time / pt. (hr)
R = Total number exam rooms
Tt = Total Time clinic open/ day
The data behind these variables can be collected from the workbook and used to asses the room
utilziation rate. It is true that one does not get the whole story behind the way exam rooms are
utilized in the clinic without conducting a lengthy and labor-intensive survey. But the use of this
equation combined with the other questions asked in the workbook give a very comprehensive
answer that can be used to accurately assess the clinic’s situation.
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RESULTS and DISCUSSION
Throughout its development, the workbook was presented to different parts of the staff of
the following five clinics: Nephrology, Ophthalmology, Urology, Pediatrics and Pain Control.
The purpose in giving this workbook to clinics varying in size, patient population, and specialty
was to determine the flexibility of the workbook in accurately assessing the differing clinics.
The final version of the workbook is shown in Appendix A. The results from the various clinics
helped to develop the four components of Part One of this workbook.
The Nephrology clinic helped in determining the importance of finding the overlap
between positions as well as the breakdown of the tasks done by a person in a certain positions.
Figure 1 shows the breakdown of a PSC before and after workbook assessment. In Figure 1.a.,
one can see that she spent almost equal amounts of time doing several tasks such as answering
the phone, check in, computer work and paperwork. It was seen that the nurse was doing most
of these same tasks as well. By filling out the workbook and the chart asking for overlapping
responsibilities, the clinic manager was able to visualize what her staff was doing in a day. The
tasks were reassigned so that the PSC's job focused only on three main roles as seen in Figure
1.b.: taking phone calls, working on the computer and updating charts. Now, the PSC could
concentrate on her job, and she did not feel overcapacitated by trying to accomplish too many
tasks at once.
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NEPHROLOGY - PSC & AA Activities
(Pre-Workbook Assessment)
Figure 1.a
Call Bd
2%
Alert Sheet
1%
Urines, Assisting Nurse
4%
Charts
2%
Check In
12%
Business Conversation
11%
Check Out
3%
Quick Labs
8%
Computer
13%
Phone
25%
Copying
1%
Errands
5%
Faxing
2%
Mail
1%
Paperwork & Labs
8%
MD's ofc
2%
NEPHROLOGY - PSC & AA Activities
(Post-Workbook Assessment)
Figure 1.b
Business
conversation
4%
Window/Pt
2%
Charts
20%
Phone
38%
Computer
12%
Copying
1%
Dictation
2%
Paperwork &
Labs
9%
MD office
2%
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Mail
1%
Faxing
3%
Errands
3%
E-mail
3%
Once it had been determined that the workbook worked towards an accurate assessment
of resource utilization, I moved on to test space needs. The Pain Control Clinic (PCC) was used
to pilot the workbook in order to determine if a complete picture of the clinic process could be
determined. It was in great need of this space assessment at the time, and I interviewed the
receptionists (PSC), the office manager and the head nurse to see if the questions being asked
were comprehensive enough to be of use. More importantly, I was interested in making sure that
the questions were stated in an easy enough format that was not too confusing for busy clinicians
and manager to go through, understand, and fill out.
The pilot study in PCC was especially helpful in that it cleared up many uncertainties
about what information was important and what information was extraneous for the purposes of
the workbook. The workbook was in a rough format of the one show in Appendix A, but it still
allowed me to sort through the information gathered to come to some definite conclusions.
Table 1 shows the comprehensive analysis that was done in order to determine what the needs of
the PCC were.
Table 1
Resources
• 2 Attending MDs
• 2 Nurses
• 2 PSCs
• 1 Office Admin
Avg. # pts. seen / day: 26
Avg. exam time / pt: 0.467 hrs
# Exam Rooms: 6
Total clinic time: 8 hrs
Utilization Rate: 25.28%
Space
• 6 Exam Rooms
• 1 Conference Room
• Office Space
Conclusion:
PCC has adequate exam rooms for
the number of physicians. It does
need additional and separate space
for patient recovery after procedures.
13
The size of the Pain Control Clinic was small enough to be able to examine the
interactions between patients, support staff and attending physicians. Extensive empirical data
from the studies that Dr. Quinn has conducted suggest that an attending physician can be most
productive and efficient with three exam rooms. In the case of the PCC, there are two doctors
and six exam rooms, which suggests that they should be running efficiently and cost-effectively.
But then one must question the relatively low utilization rate of 25.8%. Their answers questions
in the workbook guided me to a possible reason. It was seen that the average exam time for a
patient is 26 minutes. Therefore patients are scheduled for 30-minute intervals. It was also seen
that there was a great deal of exam room utilization accounted for when it was being taken up by
patients in recovery from procedures that are done frequently in the clinic. It was also seen that
attendings went to Radiology to do procedures for an average of 6-7 hours a week during normal
clinic hours when patients were already scheduled. The conference room was being used for
multiple reasons including waiting room overflow, storage charts, doctor-patient conferences,
and even, on rare occasions, as a seventh exam room. It was determined that the bottleneck was
not due to the check-in procedure or anywhere in the front-desk area. Inefficiencies were
determined in the utility of exam rooms. Conclusions were drawn that the Pain Control Clinic is
in need of at least two recovery rooms (1 per attending physician). That way, the patients who
are taking anywhere from 30 minutes to 3 hours to recover will not be tying up an exam room
that could be used to see patients.
It was also determined that physicians should not be
scheduled to see patients during the times they may anticipate a need to go to Radiology to do a
procedure.
There are many factors involved in determining the future growth of the clinic. One way
to measure the growth is to tally the number of new patients and return patients being seen in one
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day. An example of this is given in Figure 2. This data come from the pilot study done in
Ophthalmology. There are many doctors, so the number of patients scheduled at each 15-minute
interval
is
relatively
Doctors' Template (Tuesday)
higher. The black part
12
of each bar shows the
number of new patients
portion of the bar shows
the number of return
patients. If one looks at
the general
trend of
Number of Patients
being seen. The yellow
10
8
Return
New
6
4
2
black vs. yellow over a
0
0
17
:0
0
16
:3
0
16
:0
0
15
:3
0
15
:0
0
14
:3
0
14
:0
0
13
:3
0
13
:0
0
12
:3
0
12
:0
0
11
:3
0
11
:0
0
10
:3
30
10
:0
00
9:
30
9:
00
8:
30
8:
7:
period of 5 days, one
7:
00
0
Time
can begin to assess the
growth of the clinic. But this cannot be the only way to determine growth. In the case of this
clinic, most patients come for an eyesight check-up and they only return once a year, or they may
not return at all. It would be more effective in the case of a clinic that has chronic patients in
need of constant care and examination. Therefore, other data had to be collected to get a better
picture of the growth of a clinic. The workbook asks the clinician or manager to provide data on
the patients seen over the last six months in order to get a better picture of the patient population.
Along these same lines, it is important to note whether or not the clinic is referral based as well
as the types (age groups) of the patients coming into the clinic. The more extensive this data is,
the better our ability is to judge the growth of the clinic. The clinicians are also asked to give a
15
predictive statement of where they see the clinic in the next three years. They are asked to think
in terms of the patient population and if they know of any environmental or social changes that
may impact the need for their specialty (i.e. growth of Williamson County will require more
PCPs, rise in Hepatitis C will increase need for more Hepatologists, etc.).
Finally, a Patient Wait Time study was conducted in the Adult Primary Care Center. The
results are show in Figure 3. It is an interesting look at the clinical event. One can see how early
a patient arrives for their appointment and then compare it to the time they are actually seen by
the physician. Finally, the time for the whole visit can be calculated based on arrival and
checkout time. This also allows us to see how much time a patient waits before actually being
seen by the physician. After this data was collected an additional data point was introduced, but
I was unable to do a pilot study to see how it turned out. The additional data point was to chart
when the patient is actually taken into the exam room. This information was added to be
compared to the appointment time. It would also get around the fact that the room utilization
studies that were conducted by Dr. Quinn and her associates are very precise and also very labor
intensive. The aim of this part of the workbook was to design an easier method of gathering the
same information without loosing a great deal of accuracy.
The data gathered here must be incorporated into the questions that are asked to
understand the entire situation, but the numbers present the average clinical event nicely.
16
Cost Analysis
The development of this workbook did not cost a great deal of money. The only thing to
be considered was the time spent by clinic mangers and physicans in answering questions.
A
great deal of maintainence is not required although the first few actual trials will ultimately lead
to a few adjustments here and there.
Although no actual cost analysis is required in the workbook, it has been seen that the
workbook will allow clinicians to determine how to use the space they’ve been allocated better
and more efficiently. At this point in time, Vanderbilt is beginning to go through a redesign
effort. According to VMG Chief Operating Officer, David Posch, there is scattered data on what
it costs to run a clinic because of the VUMC infrastructure and the fact that funds are very
intermingled between the medical school, TVC and the hospital.
By having clinics fill out the workbook, the leaders of TVC will be able to assess how
well these practices are using space. By effectively re-allocating the space in the future, VUMC
will begin to save money and increase patient satisfaction. A market analysis shows that
650,000 patients are seen at TVC. Many of them are from Davidson county, but they come from
around the country as well. Many Vanderbilt clinics are specialty clinics that serve patients no
other clinic in the are can serve. Cost analysis shows that cost of running a clinic will be about
$700 per visit. By doing a redesign based on the data collected from the workbook, a benefit
analysis shows that Vanderbilt will save many millions of dollars in human resource salaries.
With a more efficient process, TVC will be able to see more patients while continuing to grow.
17
CONCLUSIONS
The three major components of Part 1 of the workbook ask questions and evoke answers
that can be used to determine the efficiency of a clinic. Part 2 walks the clinics through the
clinical even in the form a flowchart. This system is useful in showing the clinicians all of the
steps that staff and patients go through during one clinical event.
The workbook is a comprehensive tool that addresses all aspects of a clinical event in
order to systematically assess the current and future needs for the use of space and resources. It
is easy to use, and it will bring about the results desired by all levels of the Vanderbilt University
Medical Center.
RECOMMENDATIONS
Based on the flexibility and utility of the workbook, I recommend that every clinic be
required to fill this out as part of their yearly clinic assessment. I also propose that the clinics
who initially fill out the workbook for the purposes of assessing their current and future space
needs be examined with extra care in order to work out details that may be lacking. It is
important when the clinic progresses to Part 2 of the workbook, that they understand the way the
flowchart is set up so that they may take full advantage of viewing their process. The flowchart
will probably need a bit of fine-tuning since it has not been through a pilot study, but the greatest
need is to make sure it is flexible enough to capture the actual process for each clinic.
18
REFERENCES
Written References:
1. Hawkins, Susan. "Metropolitan Primary Care Clinic, Indianapolis, USA". Harvard School of
Public Health. 1997.
2. Hutton, David; et al. “The Vanderbilt Clinic Adult Primary Care Center, Suite 2 Process
Simulation Model and Analysis for Improvement". Standford University. March 13, 1998.
Interview References:
2. Ron Hill, Vice President Strategic Development, March 13,2000.
3. David Posch, Chief Operating Officer, Vanderbilt Medical Group. April 11, 2000.
4. Cyril Stewart, Associate Director, Construction Adminsitration, Space & Facilities Planning,
March 2, 2000.
ACKNOWLEDGEMENTS
I would like to thank many people for their help, advice, and interest in this project. First and
foremost, I would like to thank Dr. Quinn without whom this entire project would not have been
possible. A mere "thank you" will never be enough. Timothy Quinn for lending his practical
expertise; Frances Sanders for her help with Flowcharter and my poster board; Layle Kenyon for
her invaluable insights and patience through all of my questions; the nurses and staff members of
the clinics I did my pilot study in; Mohona Ausderau for going above and beyond the call of duty
and meeting with me on her busiest days; Mr. Posch, Dr. Seddon, and Mr. Hill for their
enthusiasm and timely efforts to provide answers to my most random questions; Cyril Stewart who provided me with floor plans and more information than I knew what to do with. Finally, I
would like to thank Dr. Paul King and Paul Clayton for their advice and encouragement
throughout this past year.
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APPENDIX A
SPACE
DETERMINATION
WORKBOOK
A systematic approach to determining clinic
efficiency and space needs.
Center for Clinical Improvement
Vanderbilt University Medical Center
April 25, 2000
20
INTRODUCTION
The purpose of this workbook is to help you assess the utilization of your current space
and resources, as well as to anticipate future space and resource needs. In the near future, as
some clinics move to other locations such as the Children's Hospital, the Musculoskeletal
Institue and the Wilkerson Center, we will have the opportunity to thoughtfully rearrange our
operations to improve efficiency and provide additional room for growth. The completion of this
workbook will not only allow you to understand your clinic processes more fully, but will
provide a systematic method to evaluate future options for space allocation.
Part 1 will walk you through the data collection needed to determine your current
efficiency. Based on the analysis of these data, we will help you decide if Part 2 will help you
assess whether or not changes would benefit current and future processes of care for your
patients, and how to make these changes.
There are four questions embedded in this workbook:
1. What is the current process and how are resources being utilized?
Can a more efficient process be designed without additional
resources?
2. If an efficient process currently exists, what additional resources
are needed (people, space, equipment, etc.)?
3. How much growth is expected?
4. Is there a possibility of sharing resources with another area or
clinic to maximize use of these resources?
The mathematically rigorous definition follows:
Clinic Space Needs = (Resources/Tasks) · (Space Required) · (Growth
Adjustment) - Overlap
Part 1 of the workbook will allow you to collect data pertinent to the four components of
this equation. This project will take several days to complete. It is important that you and your
colleagues take the time to accurately collect and report data, as it will help to assess your current
utilization of space and resources in order to further determine your clinic needs.
21
PART 1
DATA COLLECTION
22
RESOURCES AND TASKS
CURRENT HUMAN RESOURCES
Please indicate the number of individuals working in the clinic:
____ Attending physician
____ Resident physician
_______Secretary ____ Technician
____ RN
____ Receptionist (PSC)
____ LPN
____ Other
Do you foresee the need to increase or decrease these resources? If so, who, how many, & why?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
TASKS
In the space below, please answer the following questions:
1. What are the day-to-day activities performed by each of the following people? (i.e. NOT job
description but actual work done)
2. Also indicate the physical space needed by each position (i.e. desk, exam room, office; etc.)
3. Feel free to substitute positions listed but unrepresented in your clinic with unlisted staff
positions to account for their tasks and space needs.
a. Receptionist (PSC)
Day-to-Day Activities
Space Needs
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
23
b. Secretary
Day-to-Day Activities
Space Needs
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
c. Technician
Day-to-Day Activities
Space Needs
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
d. LPN
Day-to-Day Activities
Space Needs
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
e. RN
Day-to-Day Activities
Space Needs
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
24
f. Resident physicians:
Day-to-Day Activities
Space Needs
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
g. Attending physicians:
Day-to-Day Activities
Space Needs
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
h. Off-site resources / Education and Consultation:
Day-to-Day Activities
Space Needs
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
________________________________________________
________________________________
OVERLAPPING RESPONSIBILITIES
In the following table, please list all activities carried out by more than one type of resources.
Follow the example given in the first row of the table. Not all columns must be filled in. The
activity may only overlap two positions, or it may overlap more than 4 positions.
25
Which of the above positions’ activities overlap with each other (i.e. two positions answering
phone, or pulling medical record charts).
Please fill in the chart with all overlapping activities, and feel free to add rows as needed.
Activity
(EX.) Pulling Charts
Overlapping Responsibilities
PSC
LPN
26
Tech
COMMUNICATION and PHONES
 Since phone traffic can consume a significant amount of resources, please fill out the phone
log on the following page for a 3-day period. Record all phone calls taken or made during
this time.
 Please make a separate copy of the phone log for each person who used the phone for the
working of the clinic (i.e . Receptionist, Nurse; etc.). Mark the name of the person and their
title at the top of the log.
 Mark I for incoming and O for outgoing calls.
 Please indicate what was done to respond to the phone call in the Action column.
 ALL PATIENT DATA WILL REMAIN CONFIDENTIAL
After you have collected the phone logs, please answer the following questions:
1.
What is the total number of phone calls that came into your practice/clinic each day for
the following reasons?
2.
What is the total number of phone calls taken by each individual position each day for the
following reasons?
Clinical Questions:
Rx Refills:
Day 1 _____ Day 2 _____ Day 3 _____
Day 1 _____ Day 2 _____ Day 3 _____
Receptionist _____
Receptionist _____
Secretary _____
Secretary _____
Nurse _____ Other _____
Nurse _____ Other _____
Test Results:
General Information:
Day 1 _____ Day 2 _____ Day 3 _____
Day 1 _____ Day 2 _____ Day 3 _____
Receptionist _____
Receptionist _____
Secretary _____
Secretary _____
Nurse _____ Other _____
Nurse _____ Other _____
Ordering Tests:
Other:
Day 1 _____ Day 2 _____ Day 3 _____
Day 1 _____ Day 2 _____ Day 3 _____
Receptionist _____
Receptionist _____
Secretary _____
Nurse _____ Other _____
Secretary _____
Nurse _____ Other _____
Comments:
27
PHONE CALL LOG
Name: ____________________
Patient Last Name
Time Called
Position: ___________________ Date:__________
I/O
Reason for Call
28
Action
SPACE REQUIREMENTS
ROOM UTILIZATION
Please indicate the number of rooms you have of each type listed below:
_____ Exam
_____ Procedures
_____ Education / Consultation
______Office _____ Medical Records
_____ Conference
_____ Other
1.
Are your exam rooms used for purposes other than seeing patients? Y
2.
If yes, for what purposes? How much time (hrs) per day?
N
______________________________________________________________________________
3. If you have conference rooms, are they used for purposes other than meetings?
Y
N
3a. If yes, for what purposes How much time (hrs) per day?
_____________________________________________________________________________
EQUIPMENT
1.
What type of specialized equipment does your practice need that takes up floor space or
requires a special room?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
2. What percent of your patients need equipment that will take up additional space? ______
3. Do your patients regularly need X-Rays or Lab tests during a visit?
3a. If Yes, percent requiring X-Rays during a regular visit? ______
3b. Percent requiring lab tests during regular visit? ______
PROCEDURES
29
Y
N
Note: If you DO NOT have a procedure room, please go to question 5. on page 12.
1. Please fill out the following table with a list of procedures conducted in your clinic/practice/.
Indicate what equipment is necessary to carry out the procedure, where the procedure takes
place, and who is doing the procedure. Follow the example in the first row.
Procedure
(EX) Laser Eye
Surgery
How
Who?
Often?
(day/week)
8 / day
Attendin
g
Tech
Equipment
needed
Laser
If you have more procedures, please insert copies of this chart as needed.
30
Space Needed
(Where?)
Procedure
(Laser) room
1.
If you do not have a procedure room, where do you perform procedures?
____________________________________________________________________________
2.
Do your patients require a recovery period from procedures?
Y
N
3.
What percent of patients regularly require space for recovery each day? __________
4.
Where does the recovery time take place?
______________________________________________________________________________
MEDICAL RECORDS
1.
Where are your patients’ charts stored (shadow charts)?
______________________________________________________________________________
____________________________________________________________________________
2.
Who is responsible for pulling and re-filing the charts each day ? (can be multiple people)
______________________________________________________________________________
______________________________________________________________________________
3.
Who updates the information in the charts, i.e. the problem lists, medications, etc.
(can list multiple people).
______________________________________________________________________________
____________________________________________________________________________
4.
What other issues does your practice have related to medical records, documentation, etc?
______________________________________________________________________________
______________________________________________________________________________
31
FLOOR PLAN
 Please provide a current floor plan for your area (see example). If you do not have one, Space
and Facilities can provide one. Please call 322-4962 for your clinic floor plan.
 Please mark any discrepancies (i.e. exam room used as office or storage).
 Next, flow out and number the path that the patients take in your area.
For example, patients register at front desk (1), sit in waiting room (2), get called for VS in subwaiting area (3), go to an exam room (4), go to procedure room (5), check out (6).
EXAMPLE:
32
GROWTH ADJUSTMENT
PATIENT POPULATION
1. Is your clinic referral-based only? Y
N
2. Estimate the percentages of patients that fall within the following age groups.
_____ 0-10
_____10-18
_____19-25
_____55-65
______65-75 _____76+
_____26-35
_____36-45
_____46-55
CLINIC CAPACITY
 Please provide the clinic template. Indicate how you divide up exam rooms per doctors'
session per day and week and how many patients each physician sees. (See example in
Appendix A)
1. Please provide data on the physicians' scheduled sessions and number of patients seen per
session for the last 6 months.
2. During the course of their regular clinic time, do the attending physicians leave the clinic
area to perform procedures or consult in other areas?
Y
N
2a. If so, what is the average length of time (hrs.) spent away from clinic for this purpose?
_______ hours/day
3. What special needs do your patients have that would impact space or resource needs? (i.e.
patients have wheelchairs, are predominantly older persons, children who come with family, etc.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
4. Please provide the patient no-show rate per physician for the last year. __________
5. Please provide data on patient population growth for the past 3 years.
33
6.
If you know of any environmental or social changes that will impact your specialty,
please give a brief descriptive forecast for the next 3 years (i.e. growth of Williamson
County will require more PCPs, rise in Hepatitis C will increase need for more
Hepatologists, etc.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
THROUGHPUT
Throughput is the amount of time it takes patients to be seen on your specialty/area. Knowing
how that time is spent is important in order to assess where efficiency gains might be made.
There are several ways to capture these data:
 Please fill out the following log instead of your normal check-in log for the next 3-day
period. To accomplish this you can:
1. Give the patients the Patient’s Data Collection Form to fill out and have them turn it in to
you. Then you can enter the data in the log. (This form can be tailored specifically for your
area).
2. You can keep track of the log without patient assistance.
3. It is okay to do both depending on the day's activity or the patients' abilities to fill out the
forms.
 Please indicate whether the patient is new or returning by writing N for new or R for
returning in the N/R column.

ALL PATIENT DATA WILL REMAIN CONFIDENTIAL
34
35
PATIENT TIME STUDY
The purpose of this study is to assess patient wait times.
 Please do not put your name anywhere on this form.
 Please give your completed form to the receptionist on your way out.
 Feel free to tell us anything about your visit that may be helpful to us. You may use the back
of this form.
All information will remain confidential.
Thank you! We sincerely appreciate your time and effort 
Name of Clinic: _________________________
Doctor: ____________________
Date: _____/_____/_____
To be filled in by staff:
Type of Visit: (Circle One)
Arrival Time: (patient signs in at front desk):
_____:_____
Appointment Time: (actual time pt. scheduled)
_____:_____
Registration Time: (time of Epic registration)
_____:_____
New Appointment
Return Visit
Add-On
Procedure only
To be filled out by patient:
To be filled out by nurse OR patient:
In room time (time first escorted to exam room)
Procedure
Time In
Time Out
_____:_____
X-Ray
___:___
___:___
Physician time (time first seen by physician)
Lab
___:___
___:___
_____:_____
Other:
___:___
___:___
Check-out time (Time returned to receptionist)
_____:_____
36
Part 2
PROCESS ANALYSIS
37
SPACE TEMPLATE FLOW CHART
On the following pages is a “generic” flowchart of scheduling, registration, check-in,
clinical event and check out. . Please review this flowchart and edit to fit your own
practice/clinic. In the space allocated, please designate who does the tasks and where that person
is located.
Describe your process for a new patient visit as well as return patient visit. If procedures
are done, please indicate where in the process they would occur (during the office visit, after
checkout in another area, etc.)
38
APPENDIX A:
Sample Clinic Template (including no. patients seen)
MONDAY a.m.
TUESDAY a.m.
Dr. A
Dr. B
Dr. C
25
25
20
Dr. D
Dr. E
Dr. F
Dr. G
TOTAL
70
TOTAL
25
25
25
6
81
WED. a.m
Dr. H
Dr. I
Dr. J
Dr. C
10
40
20
20
TOTAL
90
WED. p.m
THURS. a.m.
Dr. K
Dr. G
Dr. J
Dr. L
Dr. A
TOTAL
20
6
20
20
25
91
Dr. A
Dr. E
Dr. C
20
15
15
TOTAL
50
MONDAY p.m.
TUESDAY p.m.
Dr. A
Dr. I
Dr. H
Dr. M
22
35
15
20
Dr. N
Dr. E
Dr. L
Dr. K
25
20
25
20
Dr. C
Dr. E
Dr. H
20
20
15
Dr. C
Dr. J
Dr. A
Dr. K
TOTAL
92
TOTAL
90
TOTAL
55
TOTAL
77
TOTAL
80
TOTAL
159
TOTAL
171
TOTAL
145
TOTAL
168
TOTAL
140
39
THURS. p.m.
FRIDAY a.m.
20
15
22
20
FRIDAY p.m.
Dr. E
Dr. C
Dr. D
Dr. N
Dr. O
10
20
20
25
15
REMINDER
Did you remember to provide the following documents?






Phone Log (for each resource) for 3 days
A template of each physician’s sessions and patients
Patient no-show rate
6 months of patient schedule and physician session data
Patient Visit Log for 3 days
Floor Plan
40