Academic clinics share best practices
Short wait times, efficient scheduling key
Ambulatory care accounts for more than half of U.S. health expenditures and could account for half of average hospital revenue by the year 2000, making it central to the future delivery of quality health care, the way the University HealthSystem Consortium sees it. It's a complex arena, with a tangle of topics that need to be addressed: balancing patient care, education, and research; improving access and service with limited resources; and meeting the increasingly high expectations of both payers and patients.
To start addressing those topics and to provide ambulatory benchmarks, the Oak Brook, IL-based UHC sponsored an ambulatory clinics benchmarking project with 38 of its academic medical center members. Tools for the project included a benchmarking survey, patient satisfaction and referring physician satisfaction surveys, site visits, and telephone interviews, says Danielle Carrier, program director in operations improvement at UHC. Performance indicators focused on five key areas: access, patient throughput, utilization, efficiency, and satisfaction.
Key observations from the survey data include:
o Average time intervals for a nonurgent appointment ranged from six to 14 days for new patients and four to 11 days for returning patients.
o On average, patients in primary care clinics wait less time than patients in specialty clinics. The average time spent waiting was 29 to 53 minutes for a new patient and 27 to 46 minutes for a returning patient.
o Across clinic types, clinics have approximately two exam rooms per physician FTE, and two to three patients are seen per exam room session.
Healthcare Benchmarks asked three of the facilities identified as better performers in the project to share some of their results and best practices.
At University of Massachusetts Memorial Health Care, UMass Campus, in Worcester, MA, the primary care internal medicine and orthopedics clinics excelled in each of the main performance measures but are still finding ways to improve, says May Chin, administrative director for ambulatory services. By adjusting provider and clinic hours, the clinics reduced their time interval to next appointment from more than three weeks to within two weeks. Physicians were organized into teams with clusters of support staff and residents so that patients see the same provider or team on subsequent visits.
The primary care clinics also established a call center that uses a triage system to appropriately handle 1,500 to 2,000 calls a day, Chin says. The new phone system will soon be installed using automated call distribution with personalized messages for each clinic so patients are reassured their call will be answered. The clinics had accepted a 15% abandonment rate on calls; now that number is down to 10% and is expected to drop below 5% with the new phone system. Before, some patients got stuck on hold or transferred around the office or left a message that was never returned. Now, those problems are minimized.
The family medicine clinic at the University of Wisconsin Hospital and Clinics in Madison revised its service standards, increased communication with providers, and improved scheduling as part of the UHC project, says Mark Hamilton, vice president of ambulatory services. Service standards include a pledge to see patients promptly (signs to that effect will soon be posted for patients to see) and to make appointments available for new patients within 14 days. Data on such issues as appointment availability and cancellations are given to providers regularly so they can adjust accordingly. Certain times of the day are set aside in the schedule for physicals and procedures, and slots are also set aside for urgent care and short office visits.
Peggy Soehnlein, clinic manager, says quality improvement groups that tackle such issues as appointment no-shows have made all the difference. One group discovered that most no-shows happened early in the morning. Surveys found social issues in the mostly urban, low-income patient population were keeping patients away and that 76 individuals accounted for 80% of the no-shows. The clinic now calls all patients to remind them of appointments and make sure they know about the availability of cab rides. Health check fairs are offered four times a year in the clinic from 4 p.m. to 8 p.m. with balloons and face painting to entice the children. So far, no-shows have decreased by 3%, and more children are getting well-checks.
At the University of Kentucky Medical Center in Lexington, the internal medicine group sees new patients within five working days and returning patients the same day or the next day, says Kathleen Greene, clinic manager. Internal standards say patients must spend less than 15 minutes in the waiting room; most wait between one and four minutes. How do they do that? For one thing, one of the younger physicians is kept available every day to see same-day call-in patients. For another, the computerized scheduling system has appointments set up every 15 minutes except for the last 15 minutes of every hour. That gives the physicians control over their schedules so they can either add in an urgent patient or make up time lost earlier in the hour with other patients. If patients are more than 10 minutes late, they are treated as walk-ins. "It was painful at first, but now we don't have nearly as many late patients," Greene says.
Clinic staff had input into the physical layout of the office, which operates on two hallways with central nursing stations. The call center is located just a few steps away from medical records, which saves time. Also, the physicians have their academic offices in the clinic, so it's easier to find them and harder to lose charts between buildings.
The clinic also issues monthly report cards that identify each physician by name and report on number of patients seen per day, number of no-shows, average wait time, patient satisfaction, and number of clinics cancelled by the physician.
[For more information on the UHC ambulatory benchmarking project, contact Danielle Carrier, program director, operations improvement, University HealthSystems Consortium, 2001 Spring Road, Suite 700, Oak Brook, IL 60523-1890. Telephone: (630) 954-3794. Web site: www.uhc.edu.]
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