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Staff at the Virginia Mason Center for Women’s Health in Seattle thought they knew why patient wait times were long and access to providers was difficult. The reasons appeared to be simple: Patients arrived late, there weren’t enough exam rooms, and the center needed more staff.
Imagine their surprise when research not only proved those notions false, but gave them the tools to cut wait times in half, improve access for general physicals by more than 60%, boost provider productivity by a quarter, and raise patient satisfaction scores.
"We had a multifaceted problem," says Marnee Iseman, MHA, section manager of general internal medicine and the Center for Women’s Health at the Virginia Mason Medical Center in Seattle. "It took 47 days to get a routine physical, 26 days to get an appointment for a non-urgent medical problem, a minute to answer the phone, and 101¼2 minutes from the time a patients arrived to when they saw a provider."
But Iseman was given an opportunity to address those problems when the Center became one of 23 organizations participating in a study on patient access and flow by the Institute for Health Care Improvement in Boston. Participants were given 10 months to reduce their wait times by 50% or more using rapid cycle improvement, a quality improvement methodology that uses a "plan, do, study, act" model.
Over the course of nine months, Iseman and her staff conducted 25 short experiments. The resulting changes cut the time for an appointment for a physical to 10 days and for a non-urgent medical appointment to two days. Phones are now answered within four rings, or 24 seconds, and patients rarely wait longer than five minutes from when they arrive to when they see their providers.
Iseman says that one key to the success of her project was that those who would have to change their behavior were the ones gathering data. "We just couldn’t get the data we wanted from anywhere like the finance department, so we asked the people doing the work to do the research. It was a slam-dunk. You can’t debate data if you are the one providing it. By the time we suggested changes, they already knew there was a problem and were ready to hear about solutions."
The other element of success was the short cycle times used for the experiments. "If you study something for 15 months, by the time you get your results, the situation has changed, and you are back to square one," says Iseman. "This way, you study something for a couple days, make a change, and you see the results. It also means that a small practice can do this. You don’t need a lot of support staff to do a three-day study."
The most important change for patients was improving access. Iseman says she didn’t differentiate between types of appointments: She knew that if access was improved for general physicals, it would also improve for other types of appointments.
"It sounds silly, but we started by writing a philosophy of access that says if you are in the office, you will be seeing patients." In a tertiary care facility, this is often more of an issue than in another type of practice. There are often administrative meetings or research projects that demand the time of the practitioners. But Iseman says by stating the obvious, they became more focused on their primary mission.
Next, she analyzed the demand for appointments how many were same day, how many were follow-up, and how many were other routing matters.
As part of the analysis, Iseman looked at how much time each type of appointment took. When she started the project in mid-1995, 40 minutes were allocated for general physicals. "We found if physicians reviewed the chart before a physical, they could cut six minutes off the time needed for the exam. All of a sudden, you have 25% more access."
She also had providers look at their schedules twice a day to see how much time they had available and how it was filled. The staff found that although the center recently increased the number of hours devoted to seeing patients, the appointment length was increased, too. "If you are seeing five patients rather than 10 in a given time, you are not being productive," Iseman says.
The research also highlighted a problem with how physicians dealt with no-shows. "Some practices look at that and say that’s where same day access will come. Some practices double-book and figure it will all wash out at the end of the day." But Iseman says that if your physician schedules 32 hours and has a 5% no-show rate, then that person is only at 95% of a productivity goal. "Instead, we tell them to go to 105%, and out of that will come your no-show rate."
Another problem with schedules was that office assistants try to protect the schedules of their providers. "They close out time so they can play catch-up.’" But that impacts both access and the provider’s paycheck. "We had the providers talk to the staff about this. We felt that managers wouldn’t have been as effective delivering that message."
To combat telephone delays, Iseman started by writing a commitment to telephone service. "Whether we like it or not, patients consider access on the phone the same as access in person. If a physician doesn’t return a phone call, then we are creating demand by encouraging that patient to call back again. The commitment is that the first person who handles the call has to handle all the needs. This eliminates the call back. If you can’t answer a question, then you find the person who can help. If that person is busy, then you tell the caller who will call them back and when."
A study of incoming calls showed that about 6% of incoming calls are from patients wanting test results. Staff discovered a way to head off those calls. "When the patients left, we would tell them the results would be available in a couple of days. We asked if we could phone them and if they had a machine or voice mail, could we leave a detailed message. We documented the answer and called as soon as the test results were ready."
This process took a third as long as writing a letter, says Iseman. "Usually, they are primed about what results will be and mean, but 7% of the time they need more information from a nurse, and 7% still want a letter."
Finally, she started using the Erlang calculation. This is a mathematical function that shows how to staff according to your needs. For instance, if you get 100 calls between 8 and 8:30 a.m. on Monday mornings with an average talk time of 30 seconds and you want to answer the phone in 24 seconds or less, the Erlang formula will tell you how many people you need answering your phones during that time to achieve that response level. "Before we did this, we staffed to the average. That doesn’t work. You can’t ever meet your goals if you don’t staff to the peak time."
Iseman says any telephone company representative should be able to provide you with information on the Erlang calculation.
Because the wait time in the lobby was already short, it was not viewed as the most important change. "Most of our complaints were about access and the telephone problems," says Iseman. But the center still tackled the issue of the 101¼2 minutes wait time.
Iseman conducted a series of short experiments. Each patient had a piece of paper on the chart. When the patient arrived, the time was noted. When the patient was called from the waiting room, the time was noted; and when the patient saw the provider, the time was noted.
"We had this bias that the reason for delays was that patients arrived late." But the paper noting arrival times actually showed that 93% of patients arrived 15 minutes or more early. "We took away the trump card," Iseman says.
Next, Iseman suggested that rather than hand off the patient from the receptionist to someone else, the receptionist should just escort the patient directly to an exam room. "If you eliminate the notion that certain providers own certain exam rooms, you can cut out the excuse that there is no exam room available." Staff also stopped "gauging" patients not calling them out of the waiting room until their appointment time, even if they arrived early.
The staff make a big discovery: If they didn’t explain to providers about their experiments, physicians would not change their behavior and wait time would continue to be long but in the exam room instead of the lobby.
There have been considerable payoffs from Iseman’s efforts. "We have 23% greater productivity today than we did a year ago. Our patient satisfaction information shows that our patients appreciate the changes, and our physicians are making more money."
An additional benefit was reaped. Prior to the study, the center was angling for another full-time provider. "But when we looked at the items pilfering the schedule, it equaled 1.5 clinical full-time equivalents that we were squandering over the course of the day."
Iseman says any practice can make the same kinds of strides if they follow her advice. "Be clear on your current process flow. If you get into rapid cycle improvement and you test something every week, the volume of ideas that will surface on how to do things better will overwhelm you. If you are not focused on something specific, you get off on tangents. Saying you want better access isn’t enough. You have to be numerical. How much do you want to improve access? You need that concrete number to test yourself against."
• Marnee Iseman, MHA, Section Manager, General Internal Medicine & Center for Women’s Health. Virginia Mason Medical Center, Seattle. Telephone: (206) 223-8863.
• Institute for Healthcare Improvement, Boston. Telephone: (617) 754-4800.