1

FY’02 ASA Presentation

Occupational Medical Service, DS“Medical Care in a Timely Fashion”

Presented by: James Schmitt

Team Members: Alpha BaileyJames BurgerRobert Ostrowski (Team Leader)James Schmitt

Office of Research Services, NIH

18 November 2002

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Table of ContentsIntroduction ……………. ………………………………………………….ASA Template …………………………….………………………………..

Customer Perspective……………………….………………………………Customer Segmentation …………………….…………………………………..Customer Satisfaction……………………….…………………………………..

Internal Business Process Perspective………………………………………Process Map……………….……………………………………………………..Conclusions from Discrete Services Deployment Flowcharts……………………Process Measures…………………………………………………………………

Learning and Growth Perspective……………………………………………Conclusions from Turnover, Sick Leave, Awards, EEO/ER/ADR Data…………Analysis of Readiness Conclusions………………………………………………

Financial Perspective…………………………………………………………Unit Cost…………………………………………………………………………..Asset Utilization…………………………………………………………………..

Conclusions and Recommendations………………………………………….Conclusions from FY02 ASA..……………………………………………………Recommendations…………………………………………………………………

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Introduction

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Occupational Medical Service (OMS)

The OMS mission is to provide:

• Work-related medical care• Preplacement medical evaluations• Occupational injuries and illnesses• Surveillance for health hazards at the worksite• Return to work evaluations

• Care for personal medical emergencies

• Health promotion activities

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OMS Quality Improvement (QI) Efforts

• 1991 - QI training is part of OMS orientation

• 1992 - Each employee completes a QI project

• 1992 - Cross-functional QI Teams formed• Customer satisfaction surveys• Computer application development• Review of the preplacement evaluation process• Review of clinic hours• Review of services available for occupational

injuries

• 1992 - External audit of the OMS QI program

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OMS QI Efforts (cont.)

• Customer Satisfaction Surveys prior to the ASA

• External customer (employee) surveys• April 1995, November 1995, April 1996,

May 1997, April 1999, March 2001

• External customer (supervisor) survey• October 1997

• Internal customer (OMS) surveys• August 1995, June 1996

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ASA Template

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ASA Template - 2002

Customer Value Proposition

Team Leader

Provide occupational medical services

Discrete Services

Service Group

Customer Intimacy Sustain

Provide work-related, emergent and urgent medical care in a timely manner

DS1: Provide occupational medical services

Product Leadership Harvest

Robert Ostrowski

Operational Excellence Growth

Service Strategy

Team Members

Alpha Bailey, James Burger, Robert Ostrowski, James Schmitt

Customer Perspective

X

X

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Maintain Safe Working Environment - Provide Occupational Medical Service (OMS)

Customer PerspectivePerformance Objective Performance Measure

Increase unders tanding of customer base

Customer segmentation of Discrete Services

Increase customer satisfaction

Customer satisfaction ratings from the ORS Customer Scorecard for each Discrete Service

Medical care in a timely fashion

Time in OMS prior to being evaluated by an OMS health care provider, with or without an appointment

Internal Business Process PerspectivePerformance Objective Performance Measure

Increase unders tanding of processes .

Complete process maps of Service Group/Discrete Services

Identify methods to measure processes .

Identify and report on process measures for Discrete Services

Meet or exceed goals for the timeliness of service

Patients should be seen within 15 minutes of their scheduled appointments . Patients with unscheduled vis its should be seen: within 2 minutes for medical emergency medical care; within 2 hours for urgent medical care; and within 2 work days for routine medical care

Learning and Growth PerspectivePerformance Objective Performance Measure

Enhance quality of work life for employees in ORS.

TurnoverSick Leave UsageContacts /Complaints with EEO/ER/ADRAwards/Recognition

Maintain & enhance competencies for the future organization.

Analysis of Readiness Index

Financial PerspectivePerformance Objective Performance Measure

Minimize unit cost at a defined service level.

Change in Unit Cost for each Discrete Service

Maximize utilization of assets .

Actual assets utilized/planned asset utilization for each Discrete Service

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“Care in a Timely Fashion”

• Our team elected to examine more closely the timeliness of clinical care provided in the OMS Building 10 clinic for:

• Routine work-related visits (both with and without appointments)

• Personal medial emergencies

• Personal urgent medical problems

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Customer Perspective

Customer Segmentation

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23%

17%

11%7%

6%

6%

5%

4%

3%

2%

2%

2%

12%

CC

Contractors

NCI

DES

ORS (excluding DES)

NIAID

OD (excuding ORS)

NHLBI

NIMH

NINDS

NICHD

NLM

18 Other ICs + FDA

NIH Injury / Illness Data FY'02 (n = 1345)

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Customer Segmentation (cont.)

• NIH occupational injury/illness data FY’02

• 23% Clinical Center employees

• 18% Office of the Director employees• 7% DES• 6% ORS, non-DES• 5% OD, non-ORS

• 17% Contractors

• 11% NCI

• 6% NIAID

• 31% Other 22 ICs and the FDA

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Customer Perspective

Customer Satisfaction

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External Customer Survey

• Is based upon the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) criteria for outpatient medical care

• Employees’ top 5 priorities

1. Competent, safe medical care

2. Care in a timely fashion

3. Effective communications with staff

4. Clean, organized environment

5. Respect and caring

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0

1

2

3

4

Competent, safemedical care

Care in a timely fashion

Effective communicationswith staff

Clean, organizedenvironment

Respect andcaring

OMS Customer Satisfaction Survey ResultsApril 1995 and March 2001

1995 (n=361)

2001 (n=100)

4 = Strongly Agree, 3 = Agree, 2 = Disagree, 1 = Strongly Disagree

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Customer Satisfaction (cont.)

• Percent of OMS customers that ‘agreed’ or ‘strongly agreed’ that medical care was provided in a timely fashion (wait < 15 min.)

• 1995, April 96.5 % of 361

• 1995, November 97.5% of 332

• 1996, April not surveyed

• 1997, May not surveyed

• 1999, April 99.4% of 314

• 2001, February 98.0% of 100

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Internal BusinessProcess Perspective

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Block Diagram of Service Group• Service Group and discrete service are one and the

same:

• A more meaningful high-level view is provided on the next page

Provide OccupationalMedical Services

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Patient Arrives Checks InEvaluated byHealth Care

Provider

Returns toWorkplace

Maintain Safe Working EnvironmentProvide Occupational Medical Services

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Deployment Flowchart

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Occupational Medical Service Care in a Timely Fashion Process MapFriday, November 01, 2002

PatientOMS

AdministrativeStaff

OMS TriageNurse

OMS ClinicianPersonal Health CareProvider, Hospital orUrgent Care Facility

Arrives atOMS andrequests

evaluation

Was there ascheduled

appointment ?

Updateadministrativedata and notify

OMS clinician ofthe patient’s

arrival

Updatesadministrative

data and notifiesthe triage nurse

Evaluates thepatient at OMS

clinic

Does therequest fall

within the OMSscope of

services ?

Is the needEmergent,Urgent orRoutine ?

Schedule anappointment

Schedule anappointment

PerformEvaluation

Discharge toPatient’s HealthCare Provider

PerformEvaluation

PerformEvaluation

Yes

No

No

Yes

EmergentUrgent

Routine

PerformEvaluation

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• The OMS triage nurse plays a pivotal role in the operation of the Building 10 clinic.

• The triage nurse is responsible for determining:

• whether the request for service falls within OMS’ scope of services,

• the relative urgency of the visit, and • the level of care required.

Conclusions from OMS Discrete Services Deployment Flowchart

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Process Measures

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OMS Survey Data - Visits With Appointments, March 2002

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

Min

ute

s

Acceptable Wait For Evaluation Actual Wait For Evaluation

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Visits With Appointments

• Prior surveys set 15 minutes as a reasonable time a customer with an appointment may wait to be evaluated by an OMS provider.

• This survey redefined a reasonable wait as 5 minutes.• The average wait in this survey was 7.5 minutes• The average was skewed by the time taken for

preplacement medical evaluations and related laboratory visits.

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OMS Survey Data - Visits Without Appointments - Triage, October 2002

0

5 5 5

0

5 5 5

0

1

2

3

4

5

6

(n=31) Emergency (n=44) Urgent (n=22) Routine (n=84) TriageOnly

Min

ute

s

Ideal Median Time to Triage Actual Median Time to Triage

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Visits Without AppointmentsTriage

• The expected wait to be evaluated by the OMS triage nurse is less than 1 minute for emergencies and 5 minutes or less for all other visits.

• The actual waiting time to be evaluated by the triage nurse was 0 minutes for emergencies and 5 minutes for all other visits.

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OMS Survey Data - Visits Without Appointments - Appointment, October 2002

0

20

40

60

80

100

120

140

160

180

200

(n=31) Emergency (n=44) Urgent (n=22) Routine

Min

ute

s

Ideal Median Time to Appointment Actual Median Time to Appointment

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Visits Without AppointmentsNext Available Appointment

• Ideally, a visitor with a medical emergency will receive an appointment within 2 minutes. • The median wait time for an appointment was 9

minutes. The most frequent reported wait was 0 minutes.

• Ideally, a visitor with an urgent medical problem will receive an appointment within an hour.• The median wait time for an appointment was 20

minutes.

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Visits Without AppointmentsNext Available Appointment

(cont.)

• Ideally, a visitor with a routine medical need will be offered an appointment within 3 hours.• The median wait time for an appointment was 20

minutes.

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Learning and Growth Perspective

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• Annual bonus program for OMS employees.

• Awards based upon the employee’s• Performance and• Significant contributions that significantly

• enhanced the quality of OMS services, or • made OMS a more enjoyable worksite

• 100% received a performance-based bonus.

• 30% received a bonus for a significant contribution.

Conclusions from Awards Data

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What is the correct mix of skills and abilities to work in OMS?

1. Customer service mentality - “people skills”

2. Communication skills

3. Common sense

4. Commitment to being part of a team

5. Technical skills (e.g., clinical competency, experience with OWCP, etc.,)

Analysis of Readiness Conclusions

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• Implications of the wrong mix of skills, abilities or tools to carry out OMS’ mission?• Longer waits, less efficient, and possibly, less

competent care.

• Compromise OMS’ role in providing a safe and healthy work environment.

• In many instances this may only be an inconvenience. However, in some situations workers’ lives may be jeopardized (i.e., care for chest pain, asthma, anaphylaxis, exposures to HIV-1 and herpes B virus.)

Analysis of Readiness Conclusions

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Financial Perspective

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• The units for OMS are the number of patient visits recorded.• Consultations, medical reviews, presentations,

and other services that do not involve direct patient care were not included.

• Costs for the OMS contract include the following:• Contract staff costs• Computer application developer• NIH personnel costs• IT expenses• Supplies and materials

Unit Cost Measures

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Unit Cost Measures (cont.)

FY’02 FY’03

Total Costs $2,494,988 $2,542,318

Total Visits 34,881 35,927

Cost/Visit $71.53 $70.76

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Change in Total Cost Unit

$71.53

$70.76

$70.20

$70.40

$70.60

$70.80

$71.00

$71.20

$71.40

$71.60

FY'02 FY'03

Un

it C

ost

Per P

ati

en

t C

on

tact

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OMS Asset (Staff) Utilization

0

47155

5239

0

10000

20000

30000

40000

50000

60000

1

28.48 FTEs

Hou

rs W

ork

ed

Productive Hours Nonproductive Hours

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• OMS has 28.48 FTE• Asset utilization = 90%

• The 10% shortfall is the anticipated consequence of staffing OMS so that there are always clinicians available to attend to medical emergencies and requests for urgent care

• This percentage would be higher, if the OMS triage nurses routinely declined employee requests for immediate care for non-emergent medical complaints

Asset Utilization Measures

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Conclusions and Recommendations

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Conclusions from ASA FY02

1. OMS has a well established QI program.

2. Customer satisfaction for each of their 5 top priorities has been exceptionally high for the last 7 years.

3. The increased average wait for appointments was largely due to the time required to construct a clinical record for workers receiving preplacement exams and language barriers.

4. The triage system is working.

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Conclusions from ASA FY02 (cont.)

5. The OMS triage nurse routinely accommodates employees’ desire to be seen immediately for routine services.

6. The mechanism for capturing “appointment time” for emergency medical care in this study was faulty.

7. OMS staff increasingly rely on a customized software application for the operation of the Building 10 clinic.

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• Repeat the study within the next two years and broaden the types of visits examined (e.g., return visits for occupational injuries, international travel, surveillance program visits).

• Request that individuals receiving a preplacement medical evaluation report to OMS 20 minutes before their scheduled evaluation.

Recommendations