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
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
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.