in the Eye Plastics and Neuro-Ophthalmology Eye Clinics ...

1 :MargaretPennington,ClinicSupervisorCoor dinatorElizabethOthmanKelloggEyeCenterUn iversityofMichiganMedicalCenterMay1992 Consultants:JamesArmistead, :EyePlasticsAveragePatientVisitTimes12 Table2: neuro -OphthalmologyAveragePatient VisitTimes12 Figure1:EyePlasticsPercentageofTotalPati entWaitingTime13 Figure2: neuro -OphthalmologyPercentageofT otalPatientWaitingTime13 Figure3:EyePlasticsPercentageofPatientsP erEncounter14 Figure4: neuro -OphthalmologyPercentageofP atientsPerEncounter15 Table3:StaffPhysicianTimeUtilization17 Figure5:StaffPhysicianTimeUtilization18 FlowCharts19 Simulation19 Figure6 :EyePlasticsSimulationStaffMemberUtiliza tion22 Table5: neuro -OphthalmologySimulationStaf fMemberUtilization22 Table6:EyePlasticsSimulationAveragePatie ntVisitTimes23 Table7: neuro OphthalmologySimulationAveragePatientVis itTimes23 Figure8:AverageTotalPatientTime, :ClinicoverlapComparedto Normal 31 AdditionalGraphicalAnalysis32 ConclusionsandRecommendations41 Schedules42 EyePlasticsMorningClinic42 EyePlasticsAfternoonClinic43 neuro -OphthalmologyMorningClinic44 neuro -OphthalmologyAfternoonClinic45 FridayAfternoonShortProcedureClinic46 Appendices49 ,andtimeisscarceforthestaffphysician, , ,returnpatientswerefoundtotakesignifican tlylesstimethannewpatientsfortotalproced uretime,totalwaittime, ,thestaffphysician,ingeneral, , , , , ,throughouttheclinic, ,whohasashorterproceduretime,throughthec linicfaster, , , , ,thereisnocliniconFridayafternoon,theref ore, ,andtotalwaittime, , ,theheadstaffphysicianfortheEyePlasticsc linic,contactedElizabethOthman,SeniorCli nicalSystemsAnalystoftheManagementSystem sDepartmentoftheUniversityofMichiganHosp itals, ,DirectorofManagementSystemsoftheUnivers ityofMichiganHospitalsandAdjunctassistan tProfessor.

2 IndustrialandOperationsEngineering,Unive rsityofMichigan,AnnArbor,whointurncontac tedstudentconsultantsJamesArmisteadII,Br ianBurk,DavidChan, ,onevisualfieldroom,aclericalstaffrecept ion/workarea, ,clericalstaff, , :fortheEyePlasticsclinic, ,fortheNeuro-Ophthalmologyclinic, ,CherylCaudill, ,andLatishaField, , , , , , , , , , , , :Thepurposeofthisprojectistostudytheprob lemsexperiencedattheclinic, , , , , ,conductedbyMargaretPennington,wasobserv ed, , ,(showninAppendixA), ,totalvisittimes,staffphysicianencounter times,residentphysicianencountertimes,te chnicianencountertimes, , ,asimulationprogramminglanguage, ,tofindtheoptimumintegrationbetweennewan dreturnpatients, , : whichstaffphysicianclinicwasvisited patientidentificationstamp patientappointmenttime timethepatientarrived patientcheck-in/outtime whetherthepatientwasaneworarevisitAndfor eachofuptofivepatient/staffencounters: staffmemberattending timetheprocedurestarted/ended proceduresperformedThedatacollectedwas,i nsomeareas, ,separatedbetweentheEyePlasticsandNeuro- Ophthalmologyclinics, , ,and,ingeneral, : averagewaittimeperpatient averagelengthofstayperpatient averageproceduretimeperpatient averagelengthofprocedureperstaffmember probabilityofwhichstaffmemberattendspere ncounter probabilityofwhichprocedurewillbeperform edperstaffmemberperencounter , , :thenumberofexamroomsavailable,numberoft echnicians,numberofreceptionists, , ,andtheprogramwasoverseenbyMediniSingh,A ssociateProfessor,IndustrialandOperation sEngineering,TheUniversityofMichigan.

3 Allnewpatients,allreturnvisitpatients, , , ,afterthesecondencounter, sthird,fourth, ,beforeapatientisabletomoveinthesystem, ,theymust seize seize anexaminationroomand seize ,technicians, ,technicians,residentphysicians,andstaff physicians, , , , ,suchasvisualfieldsanddilations, ,ifseveralnewpatientsarescheduledatonce, , ,suchasdilationsorvisualfields, ,suchastimetowhatfortheeyestodilateandti metowaitforthevisualfieldroom, , thrownout whenaveragingtimesintheanalysis, , ,itdoesnottakeintoaccountansweringphones , , , sform, , , ,andtimeisscarceforthestaffphysician, :Aftertheinitialobservationsoftheclinic, ,onanaverage, , ,totalwaittime,totaltime,andpercentofUni versityofMichiganMedicalCenterPage11 ManagementSystemstimespentwaitingareshow nforeachindividualdoctor, ,returnpatientswerefoundtotakesignifican tlylesstimethannewpatientsfortotalproced uretime,totalwaittime,andtotaltimeinthec linic(seeTablesI&2).

4 Thiswastrueforeachclinic, , ,onthewhole, (refertoTables1&2).Table1:EyePlasticsAve ragePatientVisitTimesPhysicianTotalTotal WaitTotalClinic% (PatientType)ProcedureTimeTimeSpentTime( minutes)(minutes)Waiting(minutes)Elner(n ew) (new) (return). (return) (PatientType)ProcedureTimeTimeSpentTime( minutes)(minutes)Waiting(minutes)Cornbla th(new) (new) (return) (return) (return) (new)(new)(return)IICornblathTrobeCornbl athTrobe(new)(new)(return)(return)Thetim estudyalsoshowedthepercentageofpatientst hatrequiredaspecificnumberofprocedures(s eeFigures3&4).Itisassumedthatthegreatert henumberofproceduresapatientreceives, NewDReturnUniversityofMichiganMedicalCen terManagementSystemsPage14 EyePlasticsPercentageofPatientsPerEncoun terc-i100908070605040-30-20- 10-0 12345 EncounterNumberc ) ,thestaffphysician,ingeneral, , , , :StaffPhysicianTimeUtilizationStaffClini cActualPhysicianUtilization(%)Utilizatio n(%) :ClinicUtilization=Th/(END-APP)TE=totalt imeofencountersbythestaffphysicianduring oneclinicEND=Endtimeoflaststaffphysician /patientencounteroftheclinicAPP=Firstsch eduledappointmenttimeoftheclinicZdenotes sumofActualUtilization=ZTh/(END-FE)TE=to taltimeofencountersbythestaffphysiciandu ringoneclinicEND=Endtimeoflaststaffphysi cian/patientencounteroftheclinicFE= +LiNelson+TrobeFinerStaffPhysicianFlowCh arts:Theflowcharts,containedinAppendixB, ,observations.

5 Thefindingsfromthesimulationprogramsareb asedonsimulationrunsusingtworeceptionist s,twotechnicians, ,relatingtotheEyePlasticsclinic, ,Figure7,relatingtoNeuro-OphthalmologyCl inic, , ,)0003-Iw0 (Black)3 Technicians(White)CombinedReturnVisitSim u1ationType200crC-Q1000 (Black)3 Technicians(White)ReturnVisitCombinedNew PatientSimulationTypeTable4 , ,seenbelow, :EyePlasticsSimulationAveragePatientVisi tTimesPatientTypeTotalTotalWaitTotalClin ic%ofTimeProcedureTimeTimeSpentTime(minu tes)(minutes)Waiting(minutes) : neuro -OphthalmologySimulationAveragePat ientVisitTimesPatientTypeTotalTotalWaitT otalClinic%ofTimeProcedureTimeTimeSpentT ime(minutes)(minutes)Waiting(minutes) ) (Black)TotalServiceTime(White) TotalLengthofStay(Black)TotalServiceTime (White) , (resultsfromtimestudy,seeFigures11and12) . , , normal inpatienttotallengthofstay, normal normal inpatienttotallengthofstay, normal Normal (White)8 Rooms(Grey)4 Rooms(Black)Neuro200100 0 (black)ReturnVisit(grey) (blackReturnVisit(grey) (inMinutes)UniversityofMichiganMedicalCe nterManagementSystemsDTotalWaitTimeSTota lProcedureTimePage39U) (new)(new)(return)(return)StaffPhysician (PatientType) neuro -OphthalmologyAverageP atientVisitTimes(inMinutes) I.

6 DTotalWaitTime1 TotalProcedureTimeCornblathTrobeCornblat hTrobe(new)(new)(return)(return) , , ,abacklogofpatientsiscreated, , , ,afterthestaffphysicianisdoneprocessingt hefirstreturnvisitpatient, ,throughouttheclinic, ,whohasashorterproceduretime,throughthec linicfaster, , ,forexample, :8:00 NEW:_____DB:PHONE:_____ADDRESS: REF:_____DX:_____8:00 NEW:_____DB:.PHONE:_____ADDRESS: REF:_____DX:_____8:00 RETURN:_____8:00 RETURN:_____8:45 RETURN:_____9:15 RETURN:_____9:30 :_____ADDRESS: REF:_____DX:_____9:30 RETURN:_____9:45 RETURN:_____10:00 RETURN:_____10:15 RETURN:_____10:30 NEW:_____DB:_____PHONE:_____ADDRESS:____ _REF:_____DX:_____10:45 RETURN:_____11:00 RETURN:_____UniversityofMichiganMedicalC enterPage42 ManagementSystemsEyePlasticsAfternoonCli nic:1:00 NEW:_____DB:_____PHONE_____ADDRESS:_____ REF:_____DX:_____1:00 NEW:_____DB:_____PHONE:_____ADDRESS:____ _REF:_____DX:_____1:00 RETURN:_____1:00 RETURN:_____1:45 RETURN:_____2:15 RETURN:_____2:30 NEW:_____DB:_____PHONE:_____ADDRESS:____ _REF:_____DX:_____2:30 RETURN:_____2:45 RETURN:_____3:00 RETURN:_____3:15 RETURN:_____3:30 NEW:_____DB:_____PHONE:_____ADDRESS:____ _REF:_____DX:_____3:45 RETURN:_____4:00 RETURN.

7 _____UniversityofMichiganMedicalCenterPa ge43 ManagementSystemsNeuro-OphthalmologyMorn ingClinic:8:00 NEW:_____PHONE:_____ADDRESS: REF:_____DX:_____8:00 NEW:_____DB:PHONE:_____ADDRESS: REF:_____DX:_____8:00 RETURN:_____8:00 RETURN:_____8:45 RETURN:_____9:00 NEW:_____DB:PHONE:_____ADDRESS: REF:_____DX:_____9:30 RETURN:_____9:30 NEW:_____PHONE:_____ADDRESS:_____REF:___ __DX:_____10:00 RETURN:_____10:15 NEW:_____DB:_____PHONE:_____ADDRESS:____ _REF:_____DX:_____10:30 NEW:_____DB:_____PHONE:_____ADDRESS:____ _REF:DX:UniversityofMichiganMedicalCente rPage44 ManagementSystemsNeuro-OphthalmologyAfte rnoonClinic:1:00 NEW:_____DB:PHONE:_____ADDRESS: REF:_____DX:_____1:00 NEW:_____DB:PHONE:_____ADDRESS: REF:_____DX:_____1:00 RETURN:_____1:00 RETURN:_____1:45 RETURN:_____2:00 NEW:_____DB:PHONE_____ADDRESS: REF:_____DX:_____2:30 RETURN:_____2:30 NEW:_____DB:PHONE:_____ADDRESS: REF:_____DX:_____3:00 RETURN:_____3:15 NEW:_____DBPHONE:_____ADDRESS: REF:_____DX:_____330 NEW:_____DB:PHONE:_____ADDRESS: REF:DX:UniversityofMichiganMedicalCenter Page45 ManagementSystemsFridayAfternoonShortPro cedureClinic:1:00 RETURN:_____1:00 :_____1:45 RETURN:_____2:15 RETURN:_____2:30 RETURN:_____2:45 RETURN:_____3:00 RETURN:_____3:00 RETURN:_____4:00 RETURN:_____4:15 , , ,amarksuchasan L ,ontheaverage, , , ,thereisnocliniconFridayafternoon,theref ore, ,beingatanunpopulartime,couldberotatedbe tweenand!

8 , , ,italsodisruptsthestaffphysician,theresi dentphysicians,orthetechnicianswhentheym ustbeasked,afterthefact, ,andtotalwaittime, ,therecommendationsdescribedabove,usinga standardizedschedule,beginningeachclinic withtwonewpatientsandtworeturnvisits,giv ingreturnvisitpatientspriorityovernewpat ients,developingalistofUniversityofMichi ganMedicalCenterPage47 ManagementSystemsshortandlongcommonproce duresforreturnvisitpatients,usingacolorc odingsystemtodifferentiatebetweennewandr eturnvisitpatients,havingveryshortreturn visitproceduresgroupedtogetherinoneclini c,havingthestaffphysicianswritedownthepr oceduresperformed,andmakingthestaffphysi ciansawareofthetimespentwiththepatientsd uringtheencounters, ,thetotaltimeintheclinicperpatientwillde creaseonthewhole, :EyePlasticsandNeuro-OphthalmologyClinic s ataCollectionFormDr:AppointmentTime:____ _ArrivalTime:_____PatientType:NewPatient ReturnVisitRegistration:StartTime:_____E ndTime:_____CheckOut:StartTime:_____EndT ime:_____1stEncounterDoctorStartTime:___ __EndTime:_____EJResidentDilation:Histor y:EyeExam:DTechnicianVisualField:Humphre y1 JGoldmanOthertask:_____2ndEncounterDocto rStartTime:_____EndTime:_____ResidentDil ation:History:EyeExam:LJTechnicianVisual Field:HumphreyGoldmanOthertask:_____3rdE ncounterDoctorStartTime:_____EndTime:___ __ResidentDilation:History:L1 EyeExam:TechnicianVisualField:LJHumphrey DGoldmanOthertask:_____4thEncounterDocto rStartTime:_____EndTime:_____UResidentDi lation:UHistory:UEyeExam:UUTechnicianVis ualField:UHumphreyUGoldmanOthertask:5thE ncounterUDoctorStartTime:_____EndTime:__ ___UResidentDilation: UHistory:UEyeExam:UlUTechnicianVisualFie ld:lUHumphreyUGoldmanOthertask:_____YesN oIIiir.

9 <{Physicianz44%%YesAvailable?Available?YesY YesGetHistoryNoNo4 CenNNoPhysicianA??YessAvlable?K lable?Available?YesesYes0 NoResidentNoPhysicianAvailable?YesnDilaffo4 JDropsppTInSTAWIOJIJTDN euro-Ophthalmology_____ClinicCDDilationWait0 StaffResidentNoPhysicianAvailable?_*lableWaitYesYesfExarnineEyes<alF>.. [FieldNoNoesExaminationI_____StaffPhysic ian< **EYEPLASTICS COMBINEDSIMULATION**COMPILERDIRECTIVES** TECHEQU1,SRESEQU2,SSTAFFEQU3,SINTEGER&TI ME,&TEKS,&RED,&RECPT,&DAYSREAL&TTECH,&TS TAFF,&TSERVICE,&TSYSTEM,&TRECPT,&TRES**C ONTROLSTATEMENTS**WTECH1 FUNCTIONRN3, ,16+(24*FRN4)/.850,9/1,6+(10*FRN4) , ,20+(12*FRN6)/1,15+(8*FRN6)ENCOUNT1 FUNCTIONRN9, ,1 , ,E2 ,32+(16*FRN7)/1,4+(4*FRN7)Advbasedonproc edureWRES2 FUNCTIONRN13,E3 ,11+(20*FRN8)/.550,2+(FRN8) ,10+(10*FRN8)WSTAFF2 FUNCTIONRN15,E22 ,12+(l0*FRN16)/1,8+(5*FRN16)ENCOUNT2 FUNCTIONRN9, ,l/.690,2 , , ,0/l,20+(10*FRN21) ,El3rdenctrisw/tech1,7+(6*FRN22) ,E23 ,15+(10*FRN14)/1,10+(9*FRN14) ,E23 ,5 (8*FRN16)/1,8+(8*FRN16) , ,1/.]}

10 Ll0,2 , ,E24 ,8+(8*FRN16)/1,5+(8*FRN16) ,Dl4 ,3 WSTAFF5 FUNCTIONRN15,E15thenctrisw/staffphysicia n1,8+(8*FRN26) ,D15 ,3**NWTECH1 FUNCTIONRN3, ,18+(8*FRN4)/.910,17+(6*FRN4) ,18+(10*FRN4) , ,20+(12*FRN6) ,20+(10*FRN6) , ,1 , ,E1 ,18+(10*FRN7)AdvbasedonprocedureNWRES2 FUNCTIONRN1O,E3 ,21+(9*FRN11)/.580,8+(6*FRN11) ,21+(8*FRN11) ,E32 ,22+(7*FRN12)/.330,16t(6*FRN12) ,15+(9*FRN12) , ,1/.600,2 , , ,O/l,20+(10*FRN15)Receivedilationaridadv ancetimeNWTECH3 FUNCTIONRN16,E13 ,15+(12*FRN17) ,El3 ,17+(14*FRN18) ,E23 ,12+(14*FRN21) ,13+(ll*FRN21) , ,1/.300,2 , , ,10+(24*FRN25)NWSTAFF4 FUNCTIONRN26,El4thenctrisw/staffphysicia n1,13+(12*FRN27) ,D24 ,2 ,3 NWSTAFF5 FUNCTIONRN3O,El5thenctrisw/staffphysicia n1,1l+(18*FRN29) ,D15 ,2 ROOMSTORAGE8 NonvariablestoragesVFROOMSTORAGE1 STAFFSTORAGE1**PROGRAMBEGINS**GENERATE28 ,5,,60,,5 PLGeneratestreamofpatientsTESTLE240,AC1, PROCESSN opatientsafterfourhoursTERMINATE0 DeathtoXACT!