| | |UHS: Walk-in Clinic | |Post-Triage Analysis | | | | | | |
University Health Services (UHS) walk-in clinic was reorganized from a first-come first-seen to a triage-modified first-come first-seen system due to complaints about waiting times, and perceived and real inefficiencies. The post-triage system demonstrated limited improvement over the pre-triage system. An evaluation of waiting times (Exhibit 5) to be seen by MDs or nurse practitioners (NPs) did not demonstrate improvement for either the unassigned patients or for the patients requesting treatment by a specific MD. Over seven minutes were added for the triage process.
As the attached post-triage flow diagram illustrates, there are four significant bottlenecks that constrict daily activity with high cycle times. System Capacity (using an eight hour day) at these bottlenecks are: the cycle time 53. 2 minutes can see 8. 960 patients per day; cycle time 44. 6 minutes can see 10. 76 patients per day; cycle time 39. 5 minutes can see 12. 152 patients per day; and cycle time 66. 6 minutes can see 7. 027 patients per day. Contributing to these bottlenecks are systemic processes, variable patient demand, resulting in supply-demand mismatch.
An analysis of the supply and demand effectiveness for meeting capacity for both the MD and NP is as follows: on average, the clinic sees 143 patients per day with MDs accounting for 67% and NPs accounting for 33% of patients. Twenty-two MDs contribute 150 hours per week and eleven NPs contribute 173 hours per week. The current hourly case load consist of MD’s treating on average 3. 1 patient per hours and the NP’s seeing on average 1. 8 patients per hour. UHS has adequate staff and space to meet the current patient population; however, there is a discrepancy in MDs and NPs workload indicating that the NP’s productivity is constrained.
The clinic concept has been altered by treating physicians who are utilizing the walk-in clinic as an extension of their regular clinic through the use of “walk in appointments”. This alteration of the walk-in concept resulted in 3 major issues that impaired patient flow: 1) the availability of MDs to see true walk-in patients is reduced by 34% (exhibit 10, [sic] 3. 4%), 2) the availability of MDs to see patients that the NPs need help with is reduced, and 3) walk-in appointments may be loading patients at the beginning of clinic and immediately after lunch possibly contributing to supply-demand mismatches (Fig. ). Additionally, the walk-in appointment system may increase variability in arrival patterns of patients, variability in type and level of services needed, variability in service rates, and variability in capacity. As a result, rendering of services have suffered, as have patient satisfaction due to increased wait times. Variability can be reduced by allowing “walk-in appointments” on low volume days and at low census times (e. g. 4pm -6p M-F and Saturday mornings or between 12n-1p or after 4p Wed – Fri, see Figs. and 2). MD schedules could be rearranged so that MDs with more walk-in appointments are scheduled for clinic duty at the same time as physicians who have fewer of these appointments resulting in increased MD availability and reduced supply-demand mismatches. In addition, limiting the number of walk-in appointments per day to no more than 25% of total patient volume (~ 35 per day) and weighting walk-in appointments to lower volume days (e. g. Wed – Fri) could decrease variability throughout the day and week.
In general, implementing changes that limit the times, frequency, and days patients can request a particular physician will ensure both patients and physicians know when these services are available. UHS would not benefit from completely disallowing patient-physician requests as this could result in a 33% decrease in the annual number of visits or a decrease in revenue by $3,244,814. By implementing a schedule that promotes efficient utilization of resources, physicians and patients can be incentivized to adhere to the schedule while not detracting from the clinic’s mission to be available for acute care walk-in clients.
Shifting workload from the MDs to the NPs would be both desirable and cost effective. This would require changes in current operations. One recommendation is to take a 1. 3 FTE from the MD staff (average cost $58,500) and fill that 1. 3 FTE with a NP (average annual cost $27,300), for a savings of $31,200. Concomitantly, the NP scope of practice associated with core treatment privileges would need to be expanded (Exhibit 8), reducing the requirement for NP-MD consultation. When combined, an increase in NP FTEs coupled with an expanded scope of practice should decrease wait time and facilitate patient flow without sacrificing quality of care.
Productivity is critical to the success of the clinic therefore NP contracts should address productivity measures, and if necessary, require minimum patient quotas (daily or weekly). Implementation of these changes should reduce bottlenecks, decrease variability among provider options, and allow more patients to be seen in a timely manner. The recommendations to Ms. Angell are to alter the current method for triaging and treating patients at UHS clinic. The current process has impacted progression of patients through the facility creating bottlenecks at multiple stages of the treatment process.
Guidelines should be established for productivity levels of triage nurses, nurse practitioners, and physicians. To reduce stress to the first bottleneck, the in-processing phase needs better control patient arrival patterns that could be adjusted by limiting the times, frequency, and days patients can request a particular physician. Scheduling will need to be managed to ensure both patients and physicians know when these services are available. This change will allow the triage nurse to distribute the patients according to the clinic guidelines and reduce the “request for specific MD/NP” bottleneck.
We also recommend that current guidelines be revised to facilitate shifting the patient load more equally to nurse practitioners. We also recommend that one triage nurse be replaced by a floating NP triage nurse. The NP triage nurse could address minor concerns (doctors’ notes, prescription refill, etc. ), reducing a step in the process flow diagram for these minor concerns, and create a second exit strategy. In addition, the triage NP could enhance the triage process by distributing patients more efficiently, thus decreasing mismatch of patients with roviders that cannot complete care. The final bottleneck is linked to the providers. Currently the physicians are adequately productive based on 150 hours they are required to work per week, however NP capacity is being wasted potentially due to waiting for MDs to see inappropriately triaged patients and due to the narrow scope of patients that NPs can care for. Decreasing the physicians’ patient load to approximately 50% will require an adjustment in their current FTEs. Based on physician data, some physicians (e. g. , Dr. Auckland and Dr. Lobito) are not meeting average quota.
Physician contracts may need to be reviewed and productivity measures identified. Finally, by attempting to manage this process we will need to increase our NP productivity which will require an additional 1 to 2 FTEs. By increasing the NPs current patient load from 33% to 50-60%, the volume should shift and decrease the bottleneck strain. In summary, Ms. Angell has several opportunities to address productivity, bottlenecks, and patient satisfaction. It may take several renditions to find the best working mix, but these recommendations represent an overview of the most urgent without major operational disruptions.