To: Kathryn Angell, Chief Administrator, University Health

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To: Kathryn Angell, Chief Administrator, University Health Powered By Docstoc
					To: Kathryn Angell, Chief Administrator, University Health Services Clinic
Date: July 8, 1980
From: Consultant A, PMII
Re: Proposal to Improve Performance at University Health Services Clinic

After reviewing the data you have given me, I decided on the following measures to
ensure the UHS Walk In Clinic runs more efficiently while at the same time providing a
pleasant experience for patients. The switch to the triage system has succeeded in
decreasing the overall wait time, however there is room for improvement. I recommend
concentrating efforts to improve services in three critical areas (please refer to attached
flow chart):

1. The Moment of Truth (MOT) when patients first arrive at the clinic. This is critical
   because the first moments when patients arrive are the most important for making
   their visit feel reasonable. Patients now wait 19 minutes to see a triage nurse. It is
   possible with minimal resources to improve the quality of this initial wait time. For
   example, the receptionist can request the patient’s records while the patient is filling
   out the AVF in the waiting area, both giving the patient something to do while
   waiting and speeding up the record retrieval process. The waiting room should be
   pleasant, with current magazines regarding health and chairs comfortably spaced.

2. The problem of physicians being occupied with regular patients during assigned walk
   in clinic hours. With the switch to the triage system, physicians are seeing 48% of
   patients who enter the clinic. Meanwhile, more than a third of physicians are 100%
   occupied with pre-set “appointments”, creating an unbalanced utilization of staff and
   a bottleneck for patients waiting for physicians. If physicians are freed up to really
   serve the purposes of the walk in clinic, then overall processing time will decrease. I
   recommend you approach this problem from a few angles:
    Physicians should be confronted to determine root of the problem. If the problem
       lies with their inability to meet demands for individual appointments, then the
       issue must be dealt with using the support of Sholem Postel, MD, the chief
       administrator of professional services.
    Clinic must be advertised as walk in only, to deter users from requesting specific
       providers. Implement with brochures, signs, online resources, and verbally by
       nurses and physicians.
    If the problem persists, consider a no-request policy during peak hours.

3. The percent of patients seen exclusively by a nurse practitioner. It was expected with
   the change to a triage system that NPs would see more patients through the process,
   however NPs now see fewer patients. As of now, patients waiting to see a NP only
   wait 7 minutes after seeing the triage nurse. Total processing time will decrease if
   more patients are seen through the system without the need to see a MD. This would
   also alleviate some of the stress from physicians being occupied with regular patients.
   To implement this, triage nurses need to be well trained in assessing patients and if in
   doubt, send patients to an NP first. I also recommend following through with the
   expansion of nurse practitioners’ ability to treat a wider variety of problem.
Current Process Flow Chart for UHS Walk In Clinic Triage System:
   Patient enters walk in      Triage nurse meets with      Patient waits to see NP or        Patient sees NP            Patient sees MD             Visit is Complete
           clinic                      patient                        MD                      28% of patients            48% of patients          average of 37.5 min. wait
   Wait time: 19.7 minutes     Triage: 3.5 min.
 1. Patient fills out AVF                                                                 Emergency: Patient sees    Emergency: Patient sees
 Form                                                                                     NP or MD immediately       NP or MD immediately
 2 min.
                               Triage nurse determines
 2. Receptionist reviews       whether patient sees a NP    Wait time for NP: 6.7 min.    Treat. by NP: 32.8 min.
 AVF, requests                 or MD.                       A. Patient record put in NP   Patient sees NP
 Patient’s record                                           pile
 8.5 min                                                                                                             Patient referred to MD 5%
                                                                                                                     of patients seen by NP are
 3. Clerk matches AVF                                                                                                referred to MD
 to record, places record
 in “triage pile”                                           Wait time for MD: 25.2 min.                              Treat. by MD: 19.4 min.
 5 min.                                                     B. Patient record put in MD                              Patient sees MD              Patient visit is complete

                                                            C. Patient record put in                                 Patient sees MD
                                                            NP/MD pile to compensate
                                                            for NP overload

                                                            Wait time for MD: 33.8 min.                              Treat. by MD: 19.4 min.
                               24% of patients request to   D. Patient record put in                                 Patient sees requested MD
                               see a specific NP or MD      specified MD pile                                        MDs occupied with
                                                                                                                     regular patients take 40%
                                                                                                                     of available MD capacity.

                                                                                                                     Confront physicians and
                                                                                                                     strongly discourage from
 Wait time in beginning        Triage nurses send more      Increase number of patients   Increase the variety of    setting informal
 can be improved by            patients to NP when in       waiting to see NP to          patients treatable by an   appointments with regular
 creating a better waiting     doubt.                       decrease wait time for MD     NP through expanding       patients during walk in
 room atmosphere and                                                                      guidelines.                hours in order to free up
 requesting records while                                                                                            MD capacity to see true
 patient is filling out AVF.                                                                                         walk in patients.

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