The Use of TOC in a Medical Appointment Scheduling System

Transcription

1 The Use of TOC in a Medical Appointment Scheduling System Presented By: James F. Cox III PhD and Timothy M. Robinson MD Date: June TOCICO. All rights reserved. 1

2 Benefits of attending this session Attendees will benefit from understanding: 1. SOG: The appointment scheduling problem and its solution. 2. The major causes of poor organizational performance in a medical practice. 3. The application of several TOC tools to a medical practice through various examples in an actual medical practice. 2

3 Presentation organization Case background / results SOG : The appointment scheduling problem and its solution The 5 question change sequence TOC tools used and examples in the medical practice Summary Questions (as a group and on breaks) 3

4 Case background Family practice is the gatekeeper to healthcare. First point of contact for the patient. Jack of all trades. Provides referrals for complex ailments. Patients are not going to providers. Decreased demand: Trends are an increase in no-shows and in no appointments slotted. 4

5 Case background Family practice clinic Location, population 1, and unemployment 2 Small southern town, pop : 16,920 (2010) from 17,310 (2000). Hispanic population increased to 16% (2010). Census counts 90,912 people in county (2% increase) Unemployment rate: 6% (2007); 14.5% (2009); 12% (2012) 1 Source: Welker, Steve. County's population grows, city's shrinks, Morganton News Herald, Published: March 03, Source: US Bureau of Labor Statistics 5

6 Case background Family practice clinic (con t) Patient base characteristics > 55,000 patients; 13,000+ seen in last 3 year (active patients). Pre-implementation 12.5 providers (8 MDs, 5 PAs, 1 NP). Today 11.5 providers (8 MDs, 4 PAs, 1 NP). structured in 6 pods (2 providers / pod); 1 MD does research; 1 PA does occupational medicine. In-house lab, X-ray, Total employment = 70. 6

7 Case results Financials Revenue earned (%) 100% 104% 109% 124% Net ordinary income 100% 156% Other indicators No shows % high high July Dec. lower lower No appt slotted % high high July Dec. lower lower Idle Time Initial Now Per month 1900 minutes 555 minutes 7

8 Case results % increase 2010 to 2011 Number Revenue earned Non-TOC providers 8 11 TOC providers 4 25 TOC provider Slots/day Added Provider Provider Provider Provider

9 Case results Appt. type TOC practice Competitor 1 Competitor 2 Est. pt HME 1 wk 4 wks 3-6 wks New pt HME 3-4 wks 8 wks 3-6 wks Est. pt acute same day w/in 24 hrs w/in 24 hrs New pt acute same day hrs w/in 72 hrs 9

10 SOG: Process for constructing breakthrough solutions 1. Identify a giant, not a choopchick Identify the enormity of the area not addressed by the giant. 3. Get on the giant s shoulders. 4. Identify the conceptual difference between the reality that was improved so dramatically by the giant, and the area untouched. 5. Identify the wrong assumption. 6. Conduct the full analysis to determine the core problem, solution, etc.

11 Where are we? We used various TOC tools to reduce duration and variability in patient appts. Let s now look at the literature both academic and practitioner to identify the types of schedules used by providers. 11

12 Background: Types of schedules (A & P literature) N 2 1 N 2 1 N 2 1 N 2 1 Session 1 Session 2 Individual block (stream) / fixed interval Session 1 Session 2 Individual block (stream) / fixed interval w an initial block Session 1 Session 2 Multiple block (wave) / fixed interval Session 1 Session 2 Multiple block (wave) / fixed interval w an initial block 12

13 Xyz provider appointment schedules N 2 1 POD A Session 1 Lunch Session 2 Review Paperwork N Provider 1 (MD) Variable block (wave) / variable interval 2 Session 1 Lunch Session 2 Review 1 29 slots N 2 1 N Paperwork Provider 2 (MD) Individual block (stream) / fixed interval POD B Session 1 Lunch Session 2 Review Session 1 Lunch Session 2 Review 24 slots 24 slots Paperwork Provider 3 (MD) Variable block (wave) / variable interval 29 slots Paperwork Provider 2 (PA) Variable block (Wave) / variable interval Legend HME RC/acute Work-in 13

14 UDEs identified by presenters Goal-related problems Revenue fees are down. Profits are low or non-existent. Healthcare provided isn t as good as desired. Market-related problems Practice has a high percentage of unfilled appointment slots particularly during the lull (summer) season. Patients are frequently no shows for appointments. Process-related problems Patients are frequently waiting to see the provider. The provider is frequently idle based on the flow. 14

15 What to change to? Effects of these injections on the appt. durations Insert additional appt. slots to absorb idle time. Idle time exists in most appt. slots. Appt. duration is reduced. Appt. variability is reduced. Strat inj. Achieve immediate improvement towards becoming an ever-flourishing practice. Opns inj. Implement the five-focusing steps. Staff inj. Identify the biggest problem blocking patientprovider flow. Opns Inj. Implement BM in scheduling, check-in / check out, CMA/nurse, provider. Opns Inj. Implement DBR for (new) appointment scheduling. Acct Inj. Use throughput accounting for evaluating improvement opportunities. Sales inj. Remind pts of importance of meeting appts or cancelling ahead of time. Use large appt. reminder card for refrigerator, two phone calls, , etc. HR inj. Redefine each person s job description / responsibilities based on TOC. Eliminate the engines of disharmony. Replace with engines of harmony. 15 Mkting inj. Schedule Obama physicals in the lull seasons for new and existing pts. Gov t paid. Provide more acute appts. in winter.

16 What to change to? The TOC solution to appointment scheduling A new appt schedule structure with more appt slots exists. Idle time is aggregated. Inj. Additional appt. slots are inserted in the schedule. Inj. BM is used to provide a continuous flow of pts in / out of exam rooms. Current appt durations have provider idle time. Inj. Provider treats one patient after the other regardless of appt. time. Current (new) appointment schedule is used. Inj. The practice Implements the TOC tools and Processes of On-Going Improvement. 16

17 TOC tools used in the medical practice 1. Thinking es What is the practice s core problem? What is each person s biggest problem blocking achieving the goal of being an ever-flourishing practice? 2. The change sequence Why change? What to change? What to change to? How to cause the change? How to sustain the change? 3. Engines of harmony How do we change from engines of disharmony? 4. Five-focusing steps What is the constraint and where should it be? 5. Drum-buffer-rope How do we apply DBR in an appointment system? 6. Buffer management What is blocking long- & short-term patient flow? 7. Throughput accounting How do we evaluate improvement opportunities? 8. Marketing: Mafia offer What is an irrefutable offer to the market? How do we manage seasonality in a medical practice? 9. Sales How do we close the deal to ensure making the appointment? 17

18 One Process Of Ongoing Improvement WHY CHANGE? What to Change? What to Change to? How to sustain the change? How to cause the Change? 18

19 Why Change: Different perspectives Owner Provider Patient Employee Government Insurance company Core problem 19

20 One Process Of Ongoing Improvement Why Change? WHAT TO CHANGE? What to Change to? How to Sustain the Change? How to Cause the Change? 20

21 What to change? Different perspectives Owner Provider Patient Employee Government Insurance company Core problem 21

22 What to change? What (or who) is the problem? Traditional finger-pointing games Owners Providers Patients Employees Governments Insurance companies The spinner 22

23 What to change? Owners perspective TOC implementation: Owners filled out questionnaire Ask owners: What is the goal of the organization? Answer: To provide excellent health care to the community at a profit. What is blocking your practice from achieving that goal? Answer: Our people. (not enough, too many, not motivated, not qualified, etc.) Assessment: Must fix our functional problems (in operations, marketing, sales, human resources, accounting, strategy) to fix these problems. 23

24 What to change? The patient-provider. Define the present flow of patients. Room 3 Room 3 Room 2 Room 2 Sick patient WC 1 Check-in WC 2 Vitals Room 1 WC 3 MD/PA Room 1 WC 5 Check-out Well patient Lab Tests? No WC 4 Tests Yes Yes 24

25 What to change? A pod Define the present flow of patients. Room 3 Room 3 Sick patient WC 1 Check-in WC 2 Vitals Room 2 Room 1 WC 3 MD/PA Room 2 Room 1 WC 5 Check-out Well patient Lab Tests? No WC 4 Tests Yes Yes Room 3 Room 3 Sick patient WC 1 Check-in WC 2 Vitals Room 2 Room 1 WC 3 MD/PA Room 2 Room 1 WC 5 Check-out Well patient Yes Lab Tests? Yes 25 No WC 4 Tests

26 What to change? Provider & assistant flow-related UDEs POD 1 Provider 1: Provider has idle time, not used for pt care. Assistant 1: CMA works through lunch and late to service all patients. Provider 2: Decreased pt flow / volume leads to decreased income. Assistant 2: Pod lacks teamwork. POD 2 Provider 1: Waiting on pts to fill out paperwork, obtain X-rays or labs. Assistant 1: There is not enough time to do paperwork or keep up with the CMA schedule. Provider 2: CMA has too much work for her to keep up. Assistant 2: CMA schedules female pts (70-80% of pts) for mammograms. 26

27 One Process Of Ongoing Improvement Why Change? What to Change? WHAT TO CHANGE TO? How to Sustain the Change? How to Cause the Change? 27

28 What to change to? Throughput accounting applications to UDEs / injections to personal clouds 1. One provider had only two exam rooms Refurbish office to 3 rd exam room for one MD. (-$5000) 2. One provider had almost 80% female patients (most needing mammograms scheduled by her assistant). Provider took paperwork home each night. Give radiology lab listing of pts needing mammograms. (no $) 3. Congestion at the vital stations for physicals; physicians waited while patients were in queue at eye chart. Purchase eye chart to reduce MD waits on physicals. (-$50) 4. Physician time used for non-medical tasks. Offloading non-medical paperwork from MD, such as normal labs, pap smears and mammograms, completing prior authorization forms, diabetic supplies, etc. Results: Added an ave. of 4 slots / provider appt. schedule (+$400/provider/day) More importantly, patients, providers & staff less stress. 28

29 What to change to? Eliminate Engines of Disharmony. Build Engines of Harmony Source: Cox III, James F., Lynn H. Boyd, Timothy T. Sullivan, Richard A. Reid, and Brad Cartier, 2012, The Theory of Constraints International Certification Organization Dictionary, Second Edition, page 50, URL = 29 engines of disharmony Processes in an organization that cause problems in achieving the organization s goal. These include: Many people not knowing (i.e., cannot clearly verbalize) how what they are doing is essential to the organization. Most people not knowing how what many of their colleagues are doing is essential, or at least contributes, to the organization. Organizational Conflicts People operating under conflicts such as conflicting policies or conflicts in resource allocation. Inertia Many people required to perform tasks for which the reason no longer exists. Individual Conflicts Gaps between responsibility and authority. engines of harmony Processes in an organization that support the achievement of the organization s goal. These include: Each person knowing exactly how he or she contributes to the organization and knowing that the contribution will be recognized. Each person knowing exactly how others contribute to the organization and knowing that their contributions will be recognized. Aligning all rules with the goal and strategy of the company. Systematically identifying and removing gaps between responsibility and authority. Putting in place a constraint-focused continuous improvement program and culture.

30 What to change to? Applying the Five Focusing Steps to the Patient / Provider Process 1. IDENTIFY the system's constraint(s). 2. Decide how to EXPLOIT the system's constraint(s). 3. SUBORDINATE everything else to the above decision. 4. ELEVATE the system's constraint(s). 5. WARNING!!!! If in the previous steps a constraint has been broken, go back to step 1, but do not allow INERTIA to cause a system's constraint. 30

31 What to change to? Define the TOC flow of patients. Time buffer Room 3 Space buffer Room 3 Stock buffer Sick patient WC 1 Check-in WC 2 Vitals Room 2 Room 1 WC 3 MD/PA Room 2 Room 1 WC 5 Check-out Well patient Lab Tests? No WC 4 Tests Use of exam rooms in maintaining high utilization of the provider and flow of patients. Yes Yes WC 4 Tests 31

32 What to change to? Pod TOC flow diagram Room 3 Room 3 Sick patients WC 1 C H E C K - I N P R O C E S S WC 2 Vitals WC 2 Vitals Room 2 Room 1 WC 4 Tests Room 3 Room 2 Room 1 WC 3 MD/PA Yes Lab Tests? Yes WC 3 MD/PA Room 2 Room 1 No WC 4 Tests Room 3 Room 2 Room 1 WC 1 C H E C K - O U T P R O C E S S Well patients 32

33 What to change to? Eliminate the Engines of Disharmony. Build the Engines of Harmony. How do you move a practice having engines of disharmony to one operating with engines of harmony? engines of disharmony engines of harmony 1. Provide a clear definition of the goal: An ever-flourishing practice 2. Document the patient / provider flow. 3. Have each person discuss his / her role (traditionally to do the best job they can at their particular station; TOC maintain flow to/from provider and buffer provider from interruptions.). Source: Cox III, James F., Lynn H. Boyd, Timothy T. Sullivan, Richard A. Reid, and Brad Cartier, 2012, The Theory of Constraints International Certification Organization Dictionary, Second Edition, page 50, URL =

34 What to change to? Eliminate the Engines of Disharmony. Build the Engines of Harmony (con t) Source: Cox III, James F., Lynn H. Boyd, Timothy T. Sullivan, Richard A. Reid, and Brad Cartier, 2012, The Theory of Constraints International Certification Organization Dictionary, Second Edition, page 50, URL = Discuss the five focusing steps and how to implement them. (con t) 1. IDENTIFY the system's constraint(s). The constraint should be the provider with a small buffer to ensure high utilization. 2. Decide how to EXPLOIT the system's constraint(s). Off-load the provider of all unnecessary tasks and interruptions. The CMA is the constraint in many flows, off-load her as well. 3. SUBORDINATE everything else to the above decision. Have a discussion of what the TOC role is for each person. Document this TOC role with a new job description. Submit to owners/staff for review / approval. This becomes the new mode of operation. 4. Elevate the system s constraint. CMA is the constraint as flow increases. Hire one CMA to assist in patient-physician flow for each pod. 5. WARNING!!!! If in the previous steps a constraint has been broken, go back to step 1, but do not allow INERTIA to cause a system's constraint. If in step 4, the constraint is broken. Hiring another assistant per pod places the constraint at the provider. This is the logical and strategic place for the constraint.

35 What to change to? Eliminate the Engines of Disharmony Build the Engines of Harmony (con t) engines of disharmony engines of harmony 5. Implement buffer management to identify problems in the flow from Scheduling to Check-in to Nurse / Certified Medical Assistant to Provider to Check-out and exit the system. 6. Use the cloud to: Align responsibility and authority. Address problems identified in the patient-provider flow by buffer management. 7. Immerse the staff by focusing their attention on identifying and solving day-to-day flow problems. 8. Provider focuses on current patient only (only emergency interruptions) thus increasing the quality of patient heath care. Source: Cox III, James F., Lynn H. Boyd, Timothy T. Sullivan, Richard A. Reid, and Brad Cartier, 2012, The Theory of Constraints International Certification Organization Dictionary, Second Edition, page 50, URL = 35

36 What to change to? TOC Buffer Management Practice Flow Diagram Scheduler role: Proactively fills R Y G zones with call-ins, walk-ins and patients w appts. 3-4 days away Next 12 hours schedule Check-in Check-out Maintains pt. appt sequence Sick patients Next 15 minutes schedule WC 1 C H E C K - I N P R O C E S S WC 1 C H E C K - I N P R O C E S S WC 2-1 Vitals WC 2-2 Vitals WC 2-3 Vitals WC 2-4 Vitals Pod 1 Pod 2 Room 3 Room 2 Room 1 WC 4 Tests Room 3 Room 2 Room 1 Room 3 Room 2 Room 1 WC 4 Tests Room 3 Room 2 Room 1 WC 3 MD/PA-1 Yes Lab Tests? Yes WC 3 MD/PA-2 WC 3 MD/PA-3 Yes Lab Tests? Yes WC 3-4 MD/PA Room 3 Room 2 Room 1 No WC 4 Tests Room 3 Room 2 Room 1 Room 3 Room 2 Room 1 No WC 4 Tests Room 3 Room 2 Room 1 WC 1 C H E C K - O U T P R O C E S S WC 1 C H E C K - O U T P R O C E S S Well patients 36

37 What to change to? Buffer reports and purposes Scheduler buffer report (next 12 hours) Fill in the rolling buffer schedule in priority sequence (R-Y-G) by pulling call-ins, walk-ins, and patients scheduled a few days out into empty slots in the schedule. Record problems in red region. Check-in / check out buffer report (next 15 minutes) Check red region (next five minutes) of rolling buffer to determine whether patient is in office but not yet checked ( immediately) in or a potential no show. Record problems in red region. CMA / nurse buffer report Check to ensure exam rooms are continually full / empty to ensure uninterrupted flow of patients to / from the provider. Record problems in red region. Provider buffer report Record all interruptions, causes and duration or blockage of patient ing (full kitting-everything that is needed is there.). 37

38 One Process Of Ongoing Improvement Why Change? What to Change? What to Change to? How to Sustain the Change? HOW TO CAUSE THE CHANGE? 38

39 How to cause the change? Who will champion the cause? A brick wall separates decisions made in each function in a medical practice. This is my turf! This is my turf! Medicine Business $$$ BUT the patient-provider must be managed. 39

40 How to cause the change? Problem identified by business mgr UDE Partners/providers lack agreement /priorities on how to achieve the goal / objectives of the practice. The goals of xyz are high-quality medicine and profitability. My goal (and role) as business mgr is to manage the finances and communicate the mission and strategy of BPC. My biggest UDE blocking me from achieving this goal is the inconsistency and changing importances (priorities) of objectives and actions in the practice. This is displayed as a lack of agreement from partners and providers in priorities and actions. The end results of this lack of agreement is that we spend lots of resources fixing, changing and responding to minority interests (firefighting). This causes delays and we lose sight of the main mission. To reduce conflicts in the practice I put up with this situation. 40

41 One Process Of Ongoing Improvement Why Change? What to Change? HOW TO SUSTAIN THE CHANGE? What to Change to? How to Cause the Change? 41

42 Summary Attendees will benefit from understanding: 1. SOG: The appointment scheduling problem and its solution. 2. The major causes of poor organizational performance in a medical practice. 3. The application of several TOC tools to a medical practice through various examples in an actual medical practice. 42

43 The End and the Beginning Being a provider should be like what you dreamed about as a child. 43

44 Presenters Biographical sketch James F. Cox III, Ph.D., TOCICO certified, CFPIM, CIRM, JONAH s JONAH, Professor Emeritus, was the Robert O. Arnold Professor of Business at the University of Georgia. Prior to an academic career of over 30 years, he held positions in industry and the military. He taught Jonah workshops and numerous TOC workshops and programs. Dr. Cox s research has centered on TOC for over twenty-five years. He recently co-edited (with John Schleier) the TOC Handbook. He has written three books on TOC and has authored/coauthored over 90 articles in top academic and practitioner journals. He was the coeditor of the APICS Dictionary (five editions with John Blackstone) and more recently coeditor (with Lynn Boyd) of the TOCICO Dictionary., 2 nd edition. Dr. Cox, an APICS member for over 30 years, held numerous chapter, regional, and national offices (BODs for 4 years, E & R Foundation BODs 9 years including 4 as president). He also served on the TOCICO Board of Directors and as its first director of certification. He has spoken at over 50 APICS and other professional organization chapter meetings, several regional seminars and several international conferences on TOC. He has received the APICS Voluntary Service Award and the TOCICO Lifetime Achievement Award for his contributions to the field. 44

45 Presenters Biographical Sketch Timothy M. Robinson, MD Auburn University BS Zoology, Magna Cum Laude 1993 The Medical College of Georgia 1998 Anderson Area Medical Center Family Practice Residency 2001 Currently a partner in a 13 provider primary care medical practice (Burke Primary Care, LLC) in Morganton, NC 45