Pediatric Hematology / Oncology Clinic

Final Report for Analysis of Operations

April 13, 1995

Program and Operations AnalysisProject Team

Cristina BermudezKatherine Horvath

Julie PinskySeth Roseman

TABLE OF CONTENTS

Introduction and Background 1Project Background 1Goals of Project 1Expected Outcome 1

Methods 2Data Collection 2Problems with Data Collection 2Staff Survey 3

Project Findings 3Efficiency Concerns 3Definition of Appointment Time 5Admittance on a First Come First Serve Basis 8Appointment Time is not Determined by Patient Processes 9

Conclusions and Recommendations 10Regarding Appointment Time and Scheduling 10Comprehensive Cancer Center 11

1.0 Introduction and Background

1.1 Project Background

Current patient flow through the pediatric hematology/oncology clinicis not optimal. Patient flow is not corresponding with thepredetermined schedule. This is leading to problems such as largequeues and clinic inefficiencies, both of which effect the patient’sservice quality. Clinic staff have a desire at this point in time to reviewpolicies and procedures followed and determine what improvementscould be made to help alleviate current problems.

1.2 Purpose of Project

The purpose of this project is to analyze patient flow for the pediatrichematology/oncology clinic and make recommendations forimprovement based upon the investigation. The recommendationswill be for the current system, and will also serve as a reference for theplanning of the Comprehensive Cancer Center. The expected outcomeof this project is to improve the level of service quality for the patientthrough possible changes in procedures, policies, the system, stafflevels, or equipment.

1.3 Goals of Project

The five main goals of this project are to:

•Analyze patient flow through the clinic• Develop a flowchart of the clinic processes•Analyze service times, wait times, and patient scheduling• Determine any remaining causes of clinic inefficiencies•Make recommendations for improvements

1.4 Expected Outcome of Project

From the data collected, we expect to determine the patient flowthrough the clinic. We will learn exactly where a patient goes, theexpected duration for different components of care, and generally whattime of day different treatments occur. Coding the patients by “patienttype” will help us to differentiate different processes and flows expectedfor the various patient types.

We also expect to analyze our findings and adapt them to the clinic’sneeds. Possible recommendations could include increasing availableclinic space, revamping the patient or staff scheduling system, oraltering current processes to change patient flow. The conclusions we

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draw will hopefully give the clinic a basis for forecasting their needs inthe new Comprehensive Cancer Center.

2.0 Methods

The methods used in this investigation involve using data collection sheets,see Appendix A, which track the time a patient arrived, was served at, and lefteach phase of treatment. Medical staff in every area the patient encounterswere asked to complete these data sheets. This data was collected for fiveweeks to properly account for patient scheduling fluctuations. After datacollection, the project team analyzed the data to formulate recommendations.A project schedule of the investigation can be found in Appendix B.

2.1 Data Collection

Data collection ran for five weeks. Patients received data sheets at thefront desk, along with a brief explanation of the project. They thencarried the forms with them throughout their visit to the pediatrichematology/oncology clinic. At each step of care, health care providersfilled in the time the patient arrived, the time the patient left, and anycomments about the care. Providers were coded by type of employee,and services such as blood draw, vital sign check, radiology, andchemotherapy and infusion treatment are accounted for separately.Animal-shaped clip boards were provided by the project team for thesurveys in an effort to make data collection more enjoyable forchildren in the clinic.

2.2 Problems with Data Collection

Problems with data collection stem from the data sheet. Sometimesthe data sheets are incomplete, with crucial information missing. Inorder to effectively analyze patient flow, and determine the actualvolume of patients at each phase of care, the forms need to be filledout.

There are inconsistencies with the data collected. Different health careproviders fill the forms out in different manners. For example, duringchemotherapy and infusion treatments, some nurses consider eachhourly patient check as a “provider encounter,” and others consider it apart of the “treatment process.” Also, provider codes are inconsistent.An example of this occurs with the blood lab. Sometimes providersfrom the blood lab fill in their provider code as “12,” yet other timesthey write “lab on second floor.” Proper analysis requires us tostandardize this verbatim, to establish norms of care.

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2.3 Staff Survey

Additionally, a staff survey, found in Appendix C, was conducted. Staffwere asked to fill out a questionnaire revealing their feelings aboutefficiency and quality of care provided by the clinic. They were asked toidentify perceived problems and processes currently working well.Staff were also asked to make any recommendations for increasedefficiency in the clinic.

3.0 Project Findings

3.1 Efficiency Concerns

While a patient can normally expect a small amount of waiting timebetween each phase of care, excessive waiting is unacceptable.Excessive waiting causes patients to become dissatisfied with their care,and less motivated to arrive at their appointments in a timely manner.If the patient feels regardless of when he/she arrives, the waiting timewill be excessive, then he/she is less likely to arrive at the appointmenttime.

During our investigation of the pediatric hematology/oncology clinic,we found that average patient waited 41% of the total time he/she wasat the clinic. While service time accounted for 59% of the patient’slength of stay, the waiting time remains excessive.

SERVICE VS. WAIT TIME AS APERCENTAGE OF LENGTH OF

WAITSERVICE 41%

59%

3

Breaking the total waiting time down into waiting times for eachspecific health care provider revealed discrepancies between thedifferent health care provider types. The provider types included:

• Attending MD• Fellow• Clinic nurse• Nurse practitioner• Other (including medical assistant, social worker, etc.)

WAIT TIME SERVICE TIME

While the attending MD, nurse practitioner and other revealed theservice time to be greater than the amount of waiting time, the clinicnurse showed a large amount of waiting time. This could possibly bedue to improper data sheet completion. For the first week of the study,different clinic nurses were filling the data sheet out differently,impacting both the treatment duration and their provider rncounterswith patients. While treatment is taking place, clinic nurses usuallycheck on a patient once an hour, every hour, for about five minutes.Because a patient is receiving care, and is not merely waiting for thenurse to reappear, we requested that these provider encounters beconsidered part of the overall treatment process, and be recorded assuch. Until all employees understood the data sheet completion

SERVICE AND WAIT TIMESPER PROVIDER

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4

process, some clinic nurses characterized treatment check-ups asprovider encounters. Although we reassigned these encounters astreatment process time, a few of them may have been missed; thusaltering the proportion of service and waiting time for the clinicnurses.

Additionally, it is also important to note the frequency of providerencounters that each provider type equals. The percentage of totalprovider encounters that each provider type accounts for issummarized below.

Provider Type: Percent of Total ProviderEncounters

Attending MD 32%Fellow 11%Clinic nurse 30%Nurse practitioner 11%Other 16%

Finally, blood draw efficiency must be analyzed. Blood draw serviceand waiting times differ between the second floor blood lab and withinthe pediatric hematology/oncology clinic. Patients who have theirblood drawn in the clinic, are patients who all have a line in place.Patients who have their blood drawn in the second floor lab, are thosewho must have their blood drawn in the normal manner with aneedle. Investigation revealed that both the service and waiting timesin the second floor lab were greater than those in the clinic. Thisimpacts overall waiting time and patient length of stay. However, it isimportant to note that 38% of the blood draws are performed in the lab,while 62% are performed in the clinic.

3.2 Definition of Appointment Time Varies

The appointment time is being defined differently by the patients andthe health care providers. According to the health care providers, thetime the patient is supposed to see the health care provider back in anexamining room is the appointment time. This calls for patients toadjust accordingly to arrive before the appointment time early enoughto take care of blood draw and paperwork. The patients, however, arearriving at varying times before and after the scheduled appointmenttime. In order to define what the patient views appointment time as,further analysis must be done.

Comparing the patient check-in time and the scheduled appointmenttime reveals that patients are not arriving at the scheduled

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appointment time, thus patients do not feel that check-in time equalappointment time.

Looking at the difference in check-in time and appointment time, mostpatients are arriving from one half hour early to one hour later thanthe scheduled appointment time. This does not allow for blood draw,vital signs and paperwork to be completed before the first health careprovider encounter occurs. This greatly differs from the health careproviders’ definition of appointment time.

CHECK-IN TIME ANDAPPOINTMENT TIME FOR ALL

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TIME DIFFERENCE (HH:MM, NEGATIVEMEANS PATIENT WAS EARLY)

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Looking at the patient waiting time from check-in to the first medicalprocess shows that most patients wait zero to twenty minutes beforebeing initially seen. This is again important when analyzing if patientsare defining appointment time in the same manner as health careproviders.

Comparing the patient appointment time to the first providerencounter clearly shows that appointment times are not correlating tofirst provider encounters. Most patients are waiting zero to one hourbefore seeing the first provider.

ALL PATIENT WAIT (CHECK-INTO FIRST PROCESS)

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3.3 Admittance on a First Come First Serve Basis

The clinic schedules patients according to the provider and the patienttype. Most often a patient schedules his/her appointment during checkout of their previous appointment with the receptionist, Sharon. Atthis time the patient is given the day and time of their nextappointment.

Currently, the clinic is allowing patients to be seen inside the clinic ona first come first serve basis. In other words, the patient is seen as soonafter their arrival as possible regardless of their appointment time.During the 5 weeks of data collection it was observed that patients arebeing seen up to 4 hours before their actual appointment time.

By scheduling patient appointments the clinic agrees a type of contract.The inferred clinic liability of this contract is that a patient who arriveson time for their scheduled appointment should be seen at theirappointment time.

Patients seen before their appointment time cause an average of 3other patients who had arrive on time for their appointments to bedelayed. This occurred 80% of the days observed in our study. Theresult is that an average of 2.4 appointment contracts are violated daily

APPOINTMENT TIME VS. FIRSTPROVIDER ENCOUNTER

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by the clinic. Remember, that these are situations in which theappointment time could have been kept.

One opportunity for improvement of the clinic is to admit patientsaccording to their appointment time. In this manner the clinic willcondition return patients to arrive on time by only admitting patientsat their scheduled time, not first come first serve.

The clinic follows this first come first serve methodology partly becauseit is hard to predict if the next patient will arrive on time. If the clinicinsists on continuing this policy it is advised that they only allowpatients to be seen early that arrive before 10:00 a.m. In the datacollected it was observed that the clinic could accept additional patientsearly in the morning without disrupting later patients. It was thepatients arriving at midday for appointment times in the afternoonthat were causing problems.

3.4 Appointment Time is not Determined by Patient Processes

Patients visiting the clinic undergo processes before they see theircorresponding MD. or nurse. Common processes include recording ofvital signs and blood draw. Within the blood draw process their is adistinction. If the patient has a line the blood is drawn within theclinic. If the patient does not have a line the blood is drawn at the lab.The average time to draw blood (7 mm. 28 sec.) in the clinic is almosthaff of the time of the lab (15 mm. and 17 sec.).

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For this reason, a patient which will have his/her blood drawn in thelab should be told to arrive at a different time than a patient havinghis/her blood drawn in the clinic. The number of late patients can bereduced by implementing a “clinic check in” time to account for allpatient processes.

Another process that has great variability is treatment.stay of a patient undergoing treatment is bimodal.

The length of

Currently, the clinic is cramped for space in which to providetreatment. As much as possible patients undergoing treatment shouldbe divided among Monday and Tuesday appointments. This willsubdue overcrowding.

3.5 Patient Flow

Along with noting clinic problems, the patient flow through the clinicwas established. The patient flow includes provider encounters,treatment processes, as well as ilustrating mean waiting and servicetimes for wach phase of care. This patient flow can be found inAppendix D.

4.0 Conclusions and Recommendations

4.1 Conclusions Regarding Appointment Time and Scheduling

LENGTH OF STAY FROM APPTTIME FOR PATIENTS WITH

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Currently, the definition of patient arrival time is ambiguous. It is notobvious whether arrival time should be the appointment time, or atime previous to the appointment time. To standardize this, arrivaltime and appointment time should be considered the same. Workingbackwards from the patient’s first encounter with the scheduled directcare provider, the patient’s needs should be identified. All patienttraits and activities including: blood draw type and location, treatmentprocess, and patient type can be used to determine the neccessary preptime to allow for a patient to complete processes before seeing thescheduled health care provider. Subtracting this determined time fromthe time of the patient’s scheduled first encounter will reveal theappropriate appointment time to give the patient.

Furthermore, the patients should be served in their scheduled order.Currently, the patients are conditioned to arrive early in the morningand late in the afternoon. Once the patients realize that even if theyarrive early they will be seen in their appropriate slot, they will bemore apt to come on time; which would make the entire schedulingsystem more accurate.

4.2 Recommendations Involving the Comprehensive Cancer Center

The recommendations discussed in the previous section should beimplemented in the Comprehensive Cancer Center to insure lessvariability in arrival time. Also, amendments to the schedulingsystem should be made if process times change significantly. Forexample, if the blood lab continues to be in Taubman, while thepediatric hemotology/oncology clinic has moved to theComprehensive Cancer Center, the time to get to the blood lab and backwill increase. Additionally, we recommend that a blood lab is put inthe Cancer Center to decrease this travel time and the total length ofthe patients’ stay.

It is currently necessary to administer treatment in the Infusion roomand the Play room. We understand in the Comprehensive CancerCenter a large infusion room has been planned, along with a playroomthat will be placed in a different location. The proximity between theplayroom and infusion room will not make it possible to utilize theplay room as a place to administer treatment. Thus, the total spacewhere treatment can be administered will decrease. Optimally, werecommend that the floor space within the Comprehensive CancerCenter be reallocated to move the play room and infusion roomtogether, so both can be used to administer treatment. If this is notpossible, we recommend that part of the infusion room be designatedas playroom area, so that children receiving treatment can also play.

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This is important to ensure the setting is more conducive to a pediatricenvironment.

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Appendix A

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Appendix C

Pedric 5-(emato(ogy/Oiico(ogy StaffSurvey

As part of our patient flow analysis of the pediatric hematology/oncology clinic,, we areinterested in staff perceived problems and concerns with current operations. We appreciateyou taking the time to fill this survey out. Please return this to Sharon at the front desk.Thank you.

Provider Type: (i.e. attending M.D., nurse practitioner)

1. What do you perceive to be the largest problem with patient flow through the clinic?

2. What types of problems, if any, hinder your daily tasks? Please be specific.

3. Do you feel that you have enough room space allocated for daily tasks?If not, where is the spatial inadequacy? (Please Circle) 1 2 3 4 5

Not Enough Adequate More ThanEnough

4. Do you feel that the current patient scheduling is effective in maintaining an optimalpatient flow? (Please Circle) 1 2 3 4 5Not Effective Adequate Very Effective

5. Do you feel that the clinic runs efficiently? (Please Circle) i 2 3 4 5Why or why not? Not Efficient Adequate Very Efficient

6. Where do you think improvements could be made in the clinic to increase the quality ofservice to the patient?

7. Do you have any questions or concerns with the data collection sheets the student team iscurrently using?

Appendix D