Casestudy powerpoint

Doctor, Your Patient Is Waiting - Process Wait Time at Bayside Clinic

Abstract

Bayside Family Practice has been growing, but patient dissatisfaction has been growing as

well. Patient satisfaction is essential for outpatient clinics to retain and grow patient volumes.

Bayside needs to analyze existing Electronic Medical Record (EMR) data to pinpoint process

inefficiencies and develop recommendations for process improvement to eliminate

bottlenecks. This case illustrates a non-value-add identification problem typical in many

medical practices and also in many other settings. The case demonstrates the challenge of

analyzing an existing data set to identify trends used to derive data-supported

recommendations. Although the problem occurs in the healthcare domain, the problem and

associated skills are not healthcare dependent.

Learning Outcomes

By the end of this case study, the student should be able to:

 Analyze a data set to identify trends, support or not support contentions, and draw

conclusions to support recommendations

 Apply learning in process analysis to identify process inefficiencies

 Apply critical thinking skills to formulate a comprehensive, data-supported

recommendation to a real-world operational problem

Case

Introduction

Bayside Family Practice is a full-service doctor’s office with ten board-certified physicians

specializing in general family practice. The practice has expanded over the last two years to

attract new patients and increase volumes. There are currently ten primary care physicians,

four medical assistants, two front desk receptionists, and two billing/collections specialists

employed in the clinic.

While the practice has enjoyed high patient satisfaction outcomes over the years, recently,

patient satisfaction has decreased as measured through the Clinician & Group Consumer

Assessment of Healthcare Providers and Systems survey (CG-CAHPS). This survey is a part

of the Agency for Healthcare Research and Quality (AHRQ) program that studies and reports

healthcare patient experience. AHRQ provides surveys for healthcare providers to measure

patients’ evaluations of their health care experiences (About CAHPS, 2021). The CG-

CAHPS survey specifically includes questions concerning “providers and staff in primary

and specialty care settings” (CAHPS Clinician & Group Survey, 2019). The Chief of

Clinical Operations, Dr. James Millwood, has trended patient satisfaction survey data over

the last two years and noticed some troubling trends as patient volumes have risen (refer to

Table 1). Additional patient comments have indicated that patients’ most frequent concerns

center on how long they wait before and during their visits. This trend is concerning to Dr.

Millwood because he is aware of several studies demonstrating that the time patients spend

waiting is negatively associated with patient satisfaction (Xie & Or, 2017). Since patient

satisfaction is critical to retaining and increasing the utilization of the clinic, he has decided

that he needs to focus on aspects of the patient visit that contribute to patient wait times.

Table 1: CG-CAHPS Score Summery (Prior & Current Years)

Category Prior Year Current Year

Access to Clinic 80% (90th Percentile) 76% (75th Percentile)

Provider Communication 95% (90th Percentile) 96% (90th Percentile)

Staff Performance 89% (90th Percentile) 83% (75th Percentile)

Use of Information for Care Coordination 83% (90th Percentile) 86% (90th Percentile)

Patient’s Rating of Provider 90% (90th Percentile) 86% (75th Percentile)

Dr. Millwood performs some research and turns up evidence in other studies showing that

while patient satisfaction decreases with longer wait times, satisfaction increases when paired

with more extended time spent with the physician (Anderson, Camacho, and Balkrishnan,

2007). He now considers the two main data points he believes he will need for this project:

the time patients spend waiting and the time physicians spend with patients.

Typical Clinic Patient Flow

The clinic is open from 8 am - 5 pm on Mondays through Fridays and has a front desk area

with a lobby where two full-time employees work each day of the week. These employees are

responsible for checking in patients, answering the phone, and checking patients out. In

addition, both employees perform other duties as needed.

There are eight exam rooms available. Typically, four physicians work in the clinic each day,

with the physicians rotating different days of the week. In addition, four medical assistants

(MA) are on staff daily, with each MA supporting one physician. Patients first approach the

front desk and check-in. Once checked in, the patients are asked to take a seat in the lobby

until they are called back for their appointment. The MAs are responsible for taking patients

back to an exam room from the lobby, taking and recording vital signs, performing

medication verification, and taking an initial history of new patient issues, problems, and

concerns as part of a process known as “arriving” the patient.

The MA hands the patient off to the physician who provides patient care in the exam room.

When the physician finishes with the patient, the physician communicates follow-up orders

and instructions to the MA. The MA is responsible for returning to the exam room to begin

the follow-up and checkout process. First, patients have the opportunity to ask questions, and

the MA communicates any follow-up instructions, prescriptions, or anything else the

physician requests. Then the MA walks the patient to the front counter back to the front desk

for checkout.

Back at the front desk, the MA communicates the necessary follow-up information to the

person performing checkout functions. The front desk employee checks the patient out and

schedules any follow-up appointments or tests as required.

Clinic Staffing The clinic has ten physicians on staff rotating various days of the week and four MAs hired,

each working Monday through Friday. The current practice is to allow each physician to have

two exam rooms when working, resulting in a limit of four physicians seeing patients at any

given time. Based on an equitable allotment of days, each physician has an opportunity to

see patients two days per week. Unfortunately, the schedule rarely works out as planned.

Physicians switch days and sometimes show up when not scheduled. Several physicians have

expressed concern to Dr. Millwood that two days a week do not provide enough patient

schedule time to build their individual practices. They have also expressed concern that clinic

capacity is not fully utilized. Figure 1 provides a sample of the physician room schedule.

Figure 1: Physician & Exam Room Schedule: January 4 through January 8

Clinic capacity is defined as the total number of patients that can be seen on a given day. At

Bayside, a room is considered to be fully utilized when at least 20 patients are seen per day.

This value has been set by Dr. Millwood considering room turnaround time (cleaning

between patients) and lunch hours.

So far, Dr. Millwod has explained the physical exam room limitation and MA labor limitation

that constrain him from offering more patient schedule time to each physician above their two

days per week. He has not been able to craft a good answer for the clinic capacity question

since no one, at the moment, knows the actual clinic utilization. While he has been able to

push the problem “down the road” in the past, at least two of the physicians have been more

vocal lately, expressing their displeasure.

Electronic Medical Record Data and Process Measurements

The clinic utilizes an Electronic Medical Record (EMR) system. An EMR system is a

software application where physicians electronically document medical history, diagnoses,

medications, immunization dates, allergies, lab results, and notes. In addition, the system

captures timestamp audit data to indicate when staff or physicians complete various functions

within the system. These timestamps help calculate time lengths for multiple steps of the

patient experience process.

EMR systems have provided many benefits to clinical practices. The systems allow

physicians to collect and share information electronically, which offers many advantages over

paper records. One critical benefit to clinical practices is improved communication between

the physician and support staff (Dunn, 2007). EMRs reduce miscommunications and should

ensure that all relevant data is collected. However, as with most computer systems, the

information is only as good as the inputs to the system. Studies have demonstrated that a high

degree of physician and staff willing participation and rules and procedures are necessary for

EMR data to be complete and accurate (Liu, Zowghi, & Talaei-Khoei, 2019). Dr. Millwood

realizes that the physicians and staff need to be using the EMR system consistently and

effectively for the timestamp data to be accurate enough to analyze.

Dr. Millwood worked with an IT analyst to pull data from the Electronic Medical Record

(EMR) system. First, they collected timestamp data from the system for when physicians and

MAs performed different functions in the EMR that represent various milestones in each

patient’s visit (refer to Table 2). Then, using the differences between the multiple timestamps,

the team calculated measurements representing separate components of the patient visit. The

nine process measurements are defined in Table 3.

Table 2: EMR Function Timestamps and Process Measurements

EMR Function Timestamp (Milestones)

Measurements

Begin Check-In

End Check-In When coupled with the “First Contact with Receptionist” timestamp, the difference can represent the length of the Check-In Process.

Patient Roomed When coupled with the “End Check-In” timestamp, the difference can represent the length of time the patient waits in the lobby.

MA Leaves Exam Room When coupled with the “Patient Roomed” timestamp, the difference can represent the length of time the MA spends with the patient.

Physician Enters Exam Room When coupled with the “MA Leaves Exam Room” timestamp, the difference can represent the length of time the patient waits in the exam room.

Physician Leaves Exam Room

(Visit Ends)

When coupled with the “Physician Enters Exam Room” timestamp, the difference can represent the physician’s length of time with the patient.

Follow-up & Check-out Begin When coupled with the “Physician Leaves Exam Room” timestamp, the difference can represent the length of time the patient waits prior to the checkout process.

Check-Out Ends When coupled with the “Follow-up and Check-Out Begins” timestamp, the difference can represent the length of time of the patient checkout process

Table 3: Patient Visit Process Measurements

Difference between EMR Function Timestamp (Milestones)

Process Measurement

End Check-In and Begin Check-In Check-In Duration

Patient Roomed and End Check-In Wait from Check-In To Room

MA Leaves Exam Room and Patient Roomed MA Patient Care Duration

Physician Enters Exam Room and MA Leaves Exam Room

Wait from MA to Physician

Physician Leaves Exam Room and Physician Enters Exam Room

Physician Patient Care Duration

Physician Leaves Exam Room and Follow-Up and Check-Out Process Begins

Wait Until Check-Out

Check-Out Ends and Follow-Up and Check-Out Process Begins

Follow-Up & Check-Out Duration

Data Description

The Microsoft Excel spreadsheet provided with this case study contains the data you need for

your analysis. The dataset has three main sections giving information about over 4000 patient

appointments. The first section includes the first three columns of data and contains the

physician’s name, the appointment date, and the length of the scheduled appointment. The

second section of data includes the EMR timestamp data. Finally, the last section of data

contains the length of different segments of patient visits, including the following data

elements:

 Check-In Duration – duration in minutes of the check-in process

 Wait from Check-In To Room – duration in minutes of patient wait time from the

point of check in to the time the patient arrives in an exam room

 MA Patient Care Duration – duration in minutes of the length of time the MA spends

with the patient

 Wait from MA to Physician – duration in minutes of patient wait time from the point

of the MA leaving the exam room to the time the physician enters the exam room

 Physician-Patient Care Duration – duration in minutes of the length of time the

physician spends with the patient

 Wait Until Check Out - duration in minutes of patient wait time from the point of the

physician leaving the exam room to the time the MA begins the follow-up and

checkout process.

 Check Out Duration – duration in minutes of patient wait time from the point of the

physician leaves the exam room to the time the checkout process begins

While reviewing the data, Dr. Millwood noticed that there were several data records with

missing data values in various variables (you can identify these issues in the case dataset).

Missing values can pose significant problems when analyzing data (Kang, 2013). The most

concerning problem in Dr. Millwood’s study is the potential for the missing data to reduce

the representativeness of the sample and potentially lead to incorrect conclusions.

Clinic Stakeholders Physicians

Dr. Millwood seeks to recruit the best family practice physicians to the practice.

Accomplishing this goal requires him to provide physicians some flexibility concerning the

scheduling of patients. Each physician is required to be available for 20 appointments per

day. However, there is no policy concerning the appointment scheduling strategy. For

example, some physicians prefer to schedule patients every 15 minutes for the first 5 hours of

the day and then have the afternoon free for other activities. Other physicians prefer to space

the appointments out throughout the day and have free time between each appointment.

In the past, Dr. Millwood experimented with standardized patient scheduling expectations for

all physicians, but several physicians left the practice. While compensation is an important

satisfaction consideration, Dr. Millwood has realized that physician satisfaction with

nonfinancial aspects of the clinic is equally important in keeping physicians at the practice.

Focus on physician satisfaction is essential since the relative cost for physicians to change

practices is low, making it reasonably easy for physicians to move from one practice to

another to seek higher satisfaction.

Medical Assistants

Medical Assistants have been quite vocal in the last year concerning challenges in keeping up

with the workload. They have expressed concern that even with new staff, there are times

when they cannot keep up with the work required for each patient. The MAs have indicated

specific times when workloads are less likely to be completed in the allotted time. The most

common criteria have been when patients are scheduled 15 minutes apart. The MAs indicate

that there is not enough time between patients to transition from one patient to another

without causing schedule delays. The transition requires cleaning the leaving patient room,

getting the entering patient room ready, pulling up the entering patient data, and retrieving the

entering patient from the lobby.

Dr. Millwood is sensitive to the MA concerns because it has been challenging to recruit and

retain employees to fill these positions. There is a great deal of competition for MAs in the

local market. According to the US Bureau of Labor Statistics, the average pay for an MA is

$17.23 per hour, placing the job in direct competition with many other equally paying but

less intensive jobs that do not require certification. Bayside has difficulty outcompeting larger

physician practices on pay and benefits, so MA job satisfaction is also critical to Dr.

Millwood.

Challenge

Dr. Millwood believes that the data he has collected provides insight into possible solutions

for the practice. He needs to investigate the following.

 What are the average wait times for patients in the clinic across the patient experience

(i.e., are there specific process steps where wait times are higher, indicating a

bottleneck)?

 What is the average time physicians and MAs spend with patients delivering care?

 Do average patient wait times differ by physician or MA?

 Does evidence exist to support the MA’s contention that scheduling patients 15

minutes apart contributes to longer patient wait times?

Dr. Millwood needs to obtain information from the data to formulate a plan to address the

potential conflicting elements of the physician, medical assistant, and patient satisfaction.

You are on Dr. Millwood’s team and must analyze the data provided with this case study to

provide a recommendation. Your analysis of the data will help you formulate answers to the

following discussion questions.

Discussion Questions

1. Identify the average value-added process step times and the non-value added process step

times. Value-added process steps are those steps where the patient receives some value,

while non-value added process steps are steps where patients are waiting and not

receiving any value. Identify and discuss areas of the patient process about which Dr.

Millwood should be concerned based on your findings from your data analysis. Include

any discussion about specific physicians that are of concern.

2. Using the data, determine the validity of the medical assistants’ concerns regarding

patient scheduling cadence and workload. Discuss your conclusions supported with

evidence from the data.

3. Process bottlenecks are constraints that slow the throughput of patients as they move

through their clinic visits. Considering your answers to the questions above, formulate a

recommendation for Dr. Millwood to address any process bottlenecks and non-value-

added activities you have identified in your data analysis. Your solution recommendation

should also address any concerns you may have identified concerning medical assistant

workloads. Address each of the three stakeholder satisfaction impacts in your

suggestions. Finally, support your proposal with evidence.

4. Dr. Millwood needs to develop a solution concerning clinic capacity and the physician’s

requests to see more patients. Consider the current clinic capacity constraints from both a

physical space and labor perspective. Develop a solution that will work within each of

these constraints. If your solution does not fall within the constraints (i.e., you

recommend hiring more labor or propose a physical space modification solution), you

must justify any increased capital or operating costs. This problem requires an

understanding of clinic capacity and current utilization rates. Calculate these values and

use them in your analysis, and include supporting evidence for your recommendation.

References

About CAHPS. (2021, June). Retrieved July 22, 2021, from

https://www.ahrq.gov/cahps/about-cahps/index.html

Anderson, R. T., Camacho, F. T., & Balkrishnan, R. (2007). Willing to wait?: The influence

of patient wait time on satisfaction with primary care. BMC Health Services Research, 7:31,

doi:10.1186/1472-6963-7-31.

CAHPS Clinician & Group Survey. (2019, March). Retrieved July 22, 2021, from

https://www.ahrq.gov/cahps/surveys-guidance/cg/index.html

Dunn, M.J. (2007). Benefits of electronic medical records outweigh every challenge.

Wisconsin Medical Journal, 106, 159-160.

Kang, H. (2013). The prevention and handling of the missing data. Korean Journal of

Anesthesiology, 5, 402-406.

Liu, C., Zowghi, D, & Talaei-Khoei, A. (2019). An empirical study of the antecedents of data

completeness in electronic medical records. International Journal of Information

Management, 50, 155-10.

Xie, Z., & Or, C. (2017). Associations Between Waiting Times, Service Times, and Patient

Satisfaction in an Endocrinology Outpatient Department: A Time Study and Questionnaire

Survey. The Journal of Health Care Organization, Provision, and Financing, 54, 1-10.