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Measurement
Mike Davies, MD FACPMark Murray and Associates
• Review importance of measurement
• Review what to measure
• Review how to measure it
• Tools
• Interpretation of measures
Importance of Measurement
• What is our aim?
• What will we change?
• How will we know a change is an improvement?
A im to re d u c e d e la y
O rg a nize a te a m
M e a s ure *
No
M a k e c ha ng e sto pro c e s s
R e -m e a s ureIm pro ve d?
I m b e d c h a n g e inc u ltu re
Yes
“Kinds” of Data
• Judgment– Research– Performance appraisal – “do something TO you”
• Improvement– Process improvement efforts– “do something WITH you”
Key Metrics
• Primary Care
• Delay• Demand• Supply• Panel Size • Continuity• No show• Lead time
Backlog SupplyActivity
Demand
Lead Time
Delay
DelayA
B
How to “See”
Universe from which demand comes
Solution A for Delay
Demand
Supply
Solution B for Delay
Demand
Supply
Perfect Flow
Demand
Supply
Delay
How long do patients wait?
Delay
• Third next available appointment (time to open space)
• Future open capacity (amount of open space)
• Actual Waiting (“A” to “B”)
A
B
C
Three Ways to Measure Delay
D
Monday Tuesday W ednesday Thursday Friday
8:00 AAAA AAAA AAAA AAAA AAAA
8:20 BBBB BBBB BBBB BBBB
8:40 C C C C C C C C C C C C C C C C C C C C
9:00 D D D D D D D D D D D D D D D D D D D D
9:20 EEEE EEEE EEEE EEEE EEEE
9:40 F F F F F F F F F F F F F F F F
10:00 G G G G G G G G G G G G G G G G G G G G
10:20 HHHH HHHH HHHH HHHH HHHH
10:40 IIII IIII IIII IIII IIII
11:00 JJJJ JJJJ JJJJ JJJJ JJJJ
11:00 KKKK KKKK KKKK KKKK KKKK
11:20 LL LL LL LL LL LL LL LL
11:40 MMMM MMMM MMMM MMMM MMMM
1:00 NNNN NNNN NNNN NNNN NNNN
1:20 O O O O O O O O O O O O O O O O
1:40 PPPP PPPP PPPP PPPP PPPP
2:00 Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q
2:20 R R R R R R R R R R R R R R R R R R R R
2:40 SSSS SSSS SSSS
3:00 T T T T T T T T T T T T T T T T T T T T
3:20 UUUU UUUU UUUU UUUU UUUU
3:40 VVVV VVVV VVVV VVVV VVVV
4:00 W W W W W W W W W W W W W W W W W W W W
Days to 3rd Next Available
107
93
103
77
21 24 24 24
711 12
1813 10 10
6965
57 57
4135
4740
16
34 3426
13 107 7 72 49
29
99 16
0
50
100
150
7/20/1999 8/20/1999 9/20/1999 10/21/1999 11/21/1999 12/22/1999 1/22/2000 2/22/2000
DATE
DA
YS
RF
WF
NP
DO
First meeting with Primary Care Executive Council
9/20/99Met with HS Primary Care providers and support staff
2/3/00Provided educational Grand Rounds program for providers at both locations
August 1999Discussed return rates and conducted chart reviews with FM providers. Discontinued auto-reschedule for no-shows
Educational Program for full medical staff at annual meeting.
Implemented contingency plans at FM
Carve out Scheduling discontinued
Established appropriate panel sized based on provider's time in clinic (FM)
Measurement of Delay“Actual Waiting” Method
L e tte r S e n t
R e m in d e r C a ll
A p p o in tm e n tO c c u rs
A p p o in tm e n t M a d e A
B
Future Open Capacity
0
25
50
75
100
4-5 weeks
60-80-85%
Future Open Capacity
• Select a time period • Count total (open and full) appointment
slots within the period. This is the denominator.
• Then, count how many of those are open. This is the numerator.
• Graph this data on a run chart similar to the third next available appointment run chart.
Demand
How much work is there?
Demand ForAppointments
Panel
Universe” From Which Demand Comes Is……
Demand
Demand
Two Kinds of Demand
• External demand – work that comes from the world– Walk in– Call in– Write in– Referred in
• Internal demand – work we make for ourselves– Appointments we ask for in the future
Measuring Patient Demand
• Demand = – My patients appointment requests made
today for today or future– My patients walk-ins to the clinic– Patients “deflected” to Urgent Care / Walk-in
Clinic / Emergency Room/Partner– Done by hash marks on a paper
Predict Demand
External
From the “world”
Walk in
Call in
Write in
Includes “deflections” to other venues
Internal
From the provider herself
Which of these are counted as “demand”?
• Patient is seen today & rescheduled in 1 week?• Patient walks in asking for appointment?• Patient calls in requesting a med refill?• Patient writes a letter requesting appointment?• Pt. calls in asking the doctor to call her back?• Pt. requests appointment, but we’re full, so
they’re sent to the ER?• Pt. e-mail medical question to the nurse?• Patient asks for appt. today and receives it?• Pt. schedules appt. for 1 year from today?
How do I measure demand?
• Option 1: “Tic” marks on paper– Often done 1 week per month– Allows one to categorize demand easily– Takes time to train staff and implement
• Option 2: (If schedule computerized) Computer report of “number of appointments made”– Misses requests for appointments ultimately not
scheduled
Understanding Demand
• Demand is predictable• Must understand total or “true” demand• Must measure demand to really understand it
Demand Dr. Green Oct 14-18
0
5
10
15
20
25
30
35
40
Mon Tues Wed Thurs Fri
Appt. Requests
Internal MedicineTrue Demand Breakdown
6252 46 39
30
2724
30 20
60 98
84
56 66
52
13 8
3 17
19
0
20
40
60
80
100
120
140
160
180
200
MON 1-28-02 TUE 1-29-02 WED 1-30-02 THU 1-31-02 FRI 2-01-02
# o
f ap
po
intm
ents
Call-ins Walk-ins Other Venues
Deflections Follow-ups (scheduled) Follow-ups (placed on recall)
InternalDemand
ExternalDemand
Check by hour of day
Average Emergency Dept Demand by Day
02468
10
12a.m.
2a.m.
4a.m.
6a.m.
8a.m.
10a.m.
12p.m.
2p.m.
4p.m.
6p.m.
8p.m.
10p.m.
Day of Week
# o
f V
isit
s
Total Appointment Requested Per Day of Week- Hiawatha
0
20
40
60
80
100
120
140
Monday,April 07,
2003
Monday,July 28,2003
Monday,October 27,
2003
Tuesday,February 04,
2003
Tuesday,November12, 2002
Wednesday,August 06,
2003
Wednesday,March 05,
2003
Wednesday,September10, 2003
Thursday,January 09,
2003
Thursday,October 02,
2003
Friday,August 22,
2003
Friday, May02, 2003
Friday,September
20, 2002
Day of request
# o
f re
qu
ests
Monday Tuesday Wednesday Thursday Friday
Supply
How much resource is there to meet the demand?
Supply Measure
Supply
Measuring Supply
• Number of appointments available in a given day.– Must consider appointment length and
bookable hours available
How It Works
Backlog Of Appts
Supply
Activity Or“SupplyUsed”
Measuring Supply
• 21 appointments per day (20 minutes each for 7 hours)
• 24 appointments per day (15 minutes each for 7 hours)
• 7 appointments per day (1 hour each for 7 hours)
• 15 appointments per day (20 min for 4 hours plus 1 hour each for 3 hours)
Supply Dr. Green Oct 14-18
0
5
10
15
20
25
Mon Tues Wed Thurs Fri
Appt. Avail
Balance Supply and Demand
Dr. Green Supply/Demand Oct 14-18
0
5
10
15
20
25
30
35
40
Mon Tues Wed Thurs Fri
DemandSupply
Putting it Together
Individual Clinic Trend
Understand D and S Bottom Line
• 1. Establish equitable panels/case loads
• 2. Measure demand for appointments
• 3. Measure supply of appointments
• 4. Measure activity (“supply used”)
• 5. Use the information to plan and track improvements!
Panels in PCCase Load in SC
Demand ForAppointments
Panel
Universe” From Which Demand Comes Is……
Panels
• Why are panels important?– They define which patients have
established a healing relationship with which providers
– The establish and promote continuity– They equitably distribute the work (in PC)– They are the “universe” from which
“demand” comes
Factors Affecting Panel Size
• Support Staff (10%+ variation)
• Rooms (5%+ variation)
• Midlevels (72% of MD panel size)
• Experience (Young providers less)
• New Providers (Take 15-18 months to build a full panel
• Part time vs Full time (equally productive)
Low High Male Female0 11 5.02 4.66
12 23 3.28 2.9924 35 2.05 1.9736 47 1.72 1.6248 59 1.47 1.4660 119 0.98 1.00
120 179 0.74 0.79180 239 0.54 0.72240 299 0.47 0.70300 359 0.60 0.82360 419 0.63 0.84420 479 0.66 0.86480 539 0.69 0.89540 599 0.76 0.98600 659 0.87 1.10660 719 1.00 1.20720 779 1.17 1.31780 839 1.36 1.46840 899 1.55 1.60900 959 1.68 1.70960 1019 1.70 1.66
1020 9999 1.57 1.39
Age (Mo.s) Rel. Wt.
Age and Gender Panel Adjustments
Panel
Effect of Panel Size
Panel
"Over and Under" Appointments - Provider 1
# of Appt slots Filled / # of Appt Slots Available
0%25%50%75%
100%125%150%175%
%
Panel Report Example
PRIMARY CARE PCMM ASSIGNMENTS EFFECTIVE 3/29/2002PTS/PER PRIMARY CARE ***
CL CLINIC HRS. PC STANDARD CURRENT OVER CAPACITYHR. FTEE PROVIDER PER WEEK PANEL SIZE PANEL SIZE UNDERCAPACITY PANEL SIZE STANDARD35 1.0 A 17 595 609 14 35 pts per clinic hr.28 0.6 B 7.5 210 248 38 for physicians35 1.0 C 0 0 028 0.6 D 7.5 210 272 62 28 pts per clinic hr.28 1.0 E 13 364 463 99 for mid-levels35 1.0 F 4 140 147 728 1.0 G 18 504 485 -19 35 pts per clinic hr.30 1.0 H 13 455 581 12628 1.0 I 14 392 314 -7835 1.0 J 19 665 654 -11
310 9.2 HS TOTALS 12.3 3535 3773 238
Panels in Canada**Note, these are estimates and may not be accurate
Theoretic Panel Size per FP Physician in Catchment Area
0500
100015002000250030003500
warne
r
lethb
ridge
card
ston
pinch
er cr
eek
tabe
r
willow cr
eek
rese
rves
crow
snes
t pas
s
Continuity
• “Of my patients visits to primary care, how many visits were to me?”
My patients visit to me
My patients total visits to primary care
ER Visits/Total Visits @ 10 Different Sites
A 16.15%
B 11.90%
C 17.26%
D 6.27%
E 2.84%
F 3.14%
G 0.89%
H 13.67%
I 2.52%
J 21.35%
Provider
Total visitsto
Primary Care/month
PCP Visits %
Team Visits %
OtherTeam % UC % ED %
100 75 75 15 15 5 5 5 5 12
6.25 50 6.25 20
Continuity Grid
TeamTotal 800 500 62.5 200 25.0 50
Continuity Report Example
Patient View
Visits1
Provider View -
Visits2
Provider View - PCMM
SSNs3
3. Provider view PCMM SSN's means the number of my assigned patients who saw me (numerator) Network Average 87.6 85.1 91divided by the number of my assigned pts. who saw me plus the number of other primary care providers SSN'sNetwork One SD 78.3 78.1 83.9 whom I saw (denominator) plus the number of other primary care providers SSN's whom I saw (denominator)Network Two SD 69.3 71 76.8
1. Pt. View Visits means the number of visits my panel made to me (numerator) divided by the number of visits my panel made to me plus the number of visits my panel made to other primary care providers (denominator).
A
ProviderNamePCMMABCDEFGHIJ
O P QE/(E+H) (E/C) D/(D+L)
Patient View
Provider View - Visits
Provider View - PCMM SSNs
98% 83% 84%66% 100% 100%83% 95% 96%99% 90% 93%92% 92% 92%91% 88% 88%67% 40% 80%83% 85% 88%
100% 97% 98%89% 100% 100%
PC Continuity
No Show
• No Show (“Lost Opportunity”)– % patients coded as no-show in computer– Conceptually includes those clinic
appointments cancelled AFTER the appointment was supposed to occur.
Lead Time Measure
Demand
Supply
Lead Time
Check-in to Nurse
Nurse to Room
Dr. in to Dr. out
Check-out to leave
Lead Time
Synchronization Point
System
Measuring Flow Through the Office
Lead Time - Single Clinic
0
10
20
30
40
50
60
70
6/5/1999
6/12/1999
6/19/1999
6/26/1999
7/3/1999
7/10/1999
7/17/1999
7/24/1999
7/31/1999
8/7/1999
8/14/1999
8/21/1999
8/28/1999
9/4/1999
9/11/1999
9/18/1999
9/25/1999
10/2/1999
10/9/1999
10/16/1999
10/23/1999
10/30/1999
11/6/1999
11/13/1999
Week Ending
Min
ute
s
Average Goal
AM HUDLE
Align Patients, Providers, Staff
Decreased Appointment Types
Real Time Work
Separated Tasks Lab in Exam Room
P a tie n t e n te rsc lin ic
R e g is tra tio n p ro c e s s
N u rs e c h e c k -in
P ro v id e r v is it
C h e c k o u t
L e a v e C lin ic
Time
Time
Time
Time
Time
Lead Time Study
Medicine Average Patient Flow Intervals
0:03
0:18
0:08 0:09
0:25
1:05
0:51
0:000:070:140:210:280:360:430:500:571:041:12
Arrival to ChartUp
Chart Up toTime Roomed
Time Roomedto Prov. Enters
Prov. Enters toProv. Leaves
Last Time
Prov. Leavesto Discharge
Arrival Time toDischarge
Appt. Time toDischarge
Note: Patients arrive an average 13 minutes before appt. timeN = 87
Hou
rs:M
inut
es
Time Intervals Standard
Medicine Average Patient Flow Intervals
0:03
0:18
0:08 0:09
0:25
1:05
0:51
0:000:070:140:210:280:360:430:500:571:041:12
Arrival to ChartUp
Chart Up toTime Roomed
Time Roomedto Prov. Enters
Prov. Enters toProv. Leaves
Last Time
Prov. Leavesto Discharge
Arrival Time toDischarge
Appt. Time toDischarge
Note: Patients arrive an average 13 minutes before appt. timeN = 87
Hou
rs:M
inut
es
Time Intervals Standard
How to Measure Cycle Time
• Option 1: Give patients a paper and ask them to record times they reach certain steps. Then tally the information.
• Option 2: Give patients a paper and ask staff to record times the patient reaches them.
• Option 3: Other
Flow Through the Office
Backlog SupplyActivity
Demand
Lead Time
Delay
DelayA
B
Measurement Summary
(C)
Measurement Interpretation
Placeholder for BB movie
Clinic Weekly Demand, SupplyClinic Weekly Demand, Supply and Supply Used
0
100
200
300
400
500
600
10/1
0/20
05
10/2
4/20
05
11/7
/200
5
11/2
1/20
05
12/5
/200
5
12/1
9/20
05
1/2/
2006
1/16
/200
6
1/30
/200
6
2/13
/200
6
2/27
/200
6
3/13
/200
6
3/27
/200
6
4/10
/200
6
4/24
/200
6
5/8/
2006
5/22
/200
6
6/5/
2006
6/19
/200
6
7/3/
2006
7/17
/200
6
7/31
/200
6
8/14
/200
6
8/28
/200
6
9/11
/200
6
9/25
/200
6
10/9
/200
6
10/2
3/20
06
11/6
/200
6
11/2
0/20
06
12/4
/200
6
12/1
8/20
06
Demand Supply Supply Used
Clinic Weekly Demand, SupplyClinic Weekly Demand, Supply and Supply Used
0
100
200
300
400
500
600
700
10/1
0/20
05
10/2
4/20
05
11/7
/200
5
11/2
1/20
05
12/5
/200
5
12/1
9/20
05
1/2/
2006
1/16
/200
6
1/30
/200
6
2/13
/200
6
2/27
/200
6
3/13
/200
6
3/27
/200
6
4/10
/200
6
4/24
/200
6
5/8/
2006
5/22
/200
6
6/5/
2006
6/19
/200
6
7/3/
2006
7/17
/200
6
7/31
/200
6
8/14
/200
6
8/28
/200
6
9/11
/200
6
9/25
/200
6
10/9
/200
6
10/2
3/20
06
11/6
/200
6
11/2
0/20
06
12/4
/200
6
12/1
8/20
06
Demand Supply Supply Used
Average Clinic Delay
Average Clinic Delay
0.00
5.00
10.00
15.00
20.00
25.00
30.00
7/6/
2005
7/13
/200
5
7/20
/200
5
7/27
/200
5
8/3/
2005
8/10
/200
5
8/17
/200
5
8/24
/200
5
8/31
/200
5
9/7/
2005
9/14
/200
5
9/21
/200
5
9/28
/200
5
10/5
/200
5
10/1
2/20
05
10/1
9/20
05
10/2
6/20
05
11/2
/200
5
11/9
/200
5
11/1
6/20
05
11/2
3/20
05
11/3
0/20
05
12/7
/200
5
12/1
4/20
05
12/2
1/20
05
12/2
8/20
05
1/4/
2006
1/11
/200
6
1/18
/200
6
1/25
/200
6
2/1/
2006
2/8/
2006
2/15
/200
6
2/22
/200
6
3/1/
2006
3/8/
2006
3/15
/200
6
3/22
/200
6
3/29
/200
6
4/5/
2006
4/12
/200
6
4/19
/200
6
4/26
/200
6
Average Clinic Delay
0.00
5.00
10.00
15.00
20.00
25.00
30.00
7/6
/20
05
7/1
3/2
00
5
7/2
0/2
00
5
7/2
7/2
00
5
8/3
/20
05
8/1
0/2
00
5
8/1
7/2
00
5
8/2
4/2
00
5
8/3
1/2
00
5
9/7
/20
05
9/1
4/2
00
5
9/2
1/2
00
5
9/2
8/2
00
5
10
/5/2
00
5
10
/12
/20
05
10
/19
/20
05
10
/26
/20
05
11
/2/2
00
5
11
/9/2
00
5
11
/16
/20
05
11
/23
/20
05
11
/30
/20
05
12
/7/2
00
5
12
/14
/20
05
12
/21
/20
05
12
/28
/20
05
1/4
/20
06
1/1
1/2
00
6
1/1
8/2
00
6
1/2
5/2
00
6
2/1
/20
06
2/8
/20
06
2/1
5/2
00
6
2/2
2/2
00
6
3/1
/20
06
3/8
/20
06
3/1
5/2
00
6
3/2
2/2
00
6
3/2
9/2
00
6
4/5
/20
06
4/1
2/2
00
6
4/1
9/2
00
6
4/2
6/2
00
6
Clinic Weekly Demand, Supply and Supply Used
0
100
200
300
400
500
600
700
10
/10
/20
05
10
/24
/20
05
11
/7/2
00
5
11
/21
/20
05
12
/5/2
00
5
12
/19
/20
05
1/2
/20
06
1/1
6/2
00
6
1/3
0/2
00
6
2/1
3/2
00
6
2/2
7/2
00
6
3/1
3/2
00
6
3/2
7/2
00
6
4/1
0/2
00
6
4/2
4/2
00
6
5/8
/20
06
5/2
2/2
00
6
6/5
/20
06
6/1
9/2
00
6
7/3
/20
06
7/1
7/2
00
6
7/3
1/2
00
6
8/1
4/2
00
6
8/2
8/2
00
6
9/1
1/2
00
6
9/2
5/2
00
6
10
/9/2
00
6
10
/23
/20
06
11
/6/2
00
6
11
/20
/20
06
12
/4/2
00
6
12
/18
/20
06
Demand Supply Supply Used
Possible Reasons for D>S Pattern With Delay Measure Stable or
Decreasing
• No Shows
• Discontinuity
• Excessively Short RVI (Churning)
• Panel too big
• Deflections
• Other?
Average Clinic DelayAverage Clinic Delay
0.00
5.00
10.00
15.00
20.00
25.00
30.00
35.00
40.00
45.00
50.00
7/6/
2005
7/13
/200
5
7/20
/200
5
7/27
/200
5
8/3/
2005
8/10
/200
5
8/17
/200
5
8/24
/200
5
8/31
/200
5
9/7/
2005
9/14
/200
5
9/21
/200
5
9/28
/200
5
10/5
/200
5
10/1
2/20
05
10/1
9/20
05
10/2
6/20
05
11/2
/200
5
11/9
/200
5
11/1
6/20
05
11/2
3/20
05
11/3
0/20
05
12/7
/200
5
12/1
4/20
05
12/2
1/20
05
12/2
8/20
05
1/4/
2006
1/11
/200
6
1/18
/200
6
1/25
/200
6
2/1/
2006
2/8/
2006
2/15
/200
6
2/22
/200
6
3/1/
2006
3/8/
2006
3/15
/200
6
3/22
/200
6
3/29
/200
6
4/5/
2006
4/12
/200
6
4/19
/200
6
4/26
/200
6
Clinic Weekly Demand, Supply and Supply Used
0
100
200
300
400
500
600
700
10
/10
/20
05
10
/24
/20
05
11
/7/2
00
5
11
/21
/20
05
12
/5/2
00
5
12
/19
/20
05
1/2
/20
06
1/1
6/2
00
6
1/3
0/2
00
6
2/1
3/2
00
6
2/2
7/2
00
6
3/1
3/2
00
6
3/2
7/2
00
6
4/1
0/2
00
6
4/2
4/2
00
6
5/8
/20
06
5/2
2/2
00
6
6/5
/20
06
6/1
9/2
00
6
7/3
/20
06
7/1
7/2
00
6
7/3
1/2
00
6
8/1
4/2
00
6
8/2
8/2
00
6
9/1
1/2
00
6
9/2
5/2
00
6
10
/9/2
00
6
10
/23
/20
06
11
/6/2
00
6
11
/20
/20
06
12
/4/2
00
6
12
/18
/20
06
Demand Supply Supply Used
Average Clinic Delay
0.00
5.00
10.00
15.00
20.00
25.00
30.00
35.00
40.00
45.00
50.007/6
/2005
7/1
3/2
005
7/2
0/2
005
7/2
7/2
005
8/3
/2005
8/1
0/2
005
8/1
7/2
005
8/2
4/2
005
8/3
1/2
005
9/7
/2005
9/1
4/2
005
9/2
1/2
005
9/2
8/2
005
10/5
/2005
10/1
2/2
005
10/1
9/2
005
10/2
6/2
005
11/2
/2005
11/9
/2005
11/1
6/2
005
11/2
3/2
005
11/3
0/2
005
12/7
/2005
12/1
4/2
005
12/2
1/2
005
12/2
8/2
005
1/4
/2006
1/1
1/2
006
1/1
8/2
006
1/2
5/2
006
2/1
/2006
2/8
/2006
2/1
5/2
006
2/2
2/2
006
3/1
/2006
3/8
/2006
3/1
5/2
006
3/2
2/2
006
3/2
9/2
006
4/5
/2006
4/1
2/2
006
4/1
9/2
006
4/2
6/2
006
Possible Reasons for D>S Pattern With Delay Measure Increasing
• Growing demand or shrinking supply – Panels too big?– Losing providers?
Supply/Supply UsedClinic Weekly Demand, Supply and Supply Used
0
100
200
300
400
500
600
10/1
0/20
05
10/2
4/20
05
11/7
/200
5
11/2
1/20
05
12/5
/200
5
12/1
9/20
05
1/2/
2006
1/16
/200
6
1/30
/200
6
2/13
/200
6
2/27
/200
6
3/13
/200
6
3/27
/200
6
4/10
/200
6
4/24
/200
6
5/8/
2006
5/22
/200
6
6/5/
2006
6/19
/200
6
7/3/
2006
7/17
/200
6
7/31
/200
6
8/14
/200
6
8/28
/200
6
9/11
/200
6
9/25
/200
6
10/9
/200
6
10/2
3/20
06
11/6
/200
6
11/2
0/20
06
12/4
/200
6
12/1
8/20
06
Demand Supply Supply Used
Supply/Supply UsedClinic Weekly Demand, Supply and Supply Used
0
100
200
300
400
500
600
700
800
10/1
0/20
05
10/2
4/20
05
11/7
/200
5
11/2
1/20
05
12/5
/200
5
12/1
9/20
05
1/2/
2006
1/16
/200
6
1/30
/200
6
2/13
/200
6
2/27
/200
6
3/13
/200
6
3/27
/200
6
4/10
/200
6
4/24
/200
6
5/8/
2006
5/22
/200
6
6/5/
2006
6/19
/200
6
7/3/
2006
7/17
/200
6
7/31
/200
6
8/14
/200
6
8/28
/200
6
9/11
/200
6
9/25
/200
6
10/9
/200
6
10/2
3/20
06
11/6
/200
6
11/2
0/20
06
12/4
/200
6
12/1
8/20
06
Demand Supply Supply Used
Possible Reasons for Supply>Supply Used
• Panel too big
• Short RVI (Churning)
• Too little clinic supply relative to panel
Consequence of Supply>Supply Used
• Increase productivity ($)
• Burnout (eventually)
Supply/Supply Used
Clinic Weekly Demand, Supply and Supply Used
0
100
200
300
400
500
600
10
/10
/20
05
10
/24
/20
05
11
/7/2
00
5
11
/21
/20
05
12
/5/2
00
5
12
/19
/20
05
1/2
/200
6
1/1
6/2
00
6
1/3
0/2
00
6
2/1
3/2
00
6
2/2
7/2
00
6
3/1
3/2
00
6
3/2
7/2
00
6
4/1
0/2
00
6
4/2
4/2
00
6
5/8
/200
6
5/2
2/2
00
6
6/5
/200
6
6/1
9/2
00
6
7/3
/200
6
7/1
7/2
00
6
7/3
1/2
00
6
8/1
4/2
00
6
8/2
8/2
00
6
9/1
1/2
00
6
9/2
5/2
00
6
10
/9/2
00
6
10
/23
/20
06
11
/6/2
00
6
11
/20
/20
06
12
/4/2
00
6
12
/18
/20
06
Demand Supply Supply Used
Supply Variation
Clinic Weekly Demand, Supply and Supply Used
0
100
200
300
400
500
600
10/1
0/20
05
10/2
4/20
05
11/7
/200
5
11/2
1/20
05
12/5
/200
5
12/1
9/20
05
1/2/
2006
1/16
/200
6
1/30
/200
6
2/13
/200
6
2/27
/200
6
3/13
/200
6
3/27
/200
6
4/10
/200
6
4/24
/200
6
5/8/
2006
5/22
/200
6
6/5/
2006
6/19
/200
6
7/3/
2006
7/17
/200
6
7/31
/200
6
8/14
/200
6
8/28
/200
6
9/11
/200
6
9/25
/200
6
10/9
/200
6
10/2
3/20
06
11/6
/200
6
11/2
0/20
06
12/4
/200
6
12/1
8/20
06
Demand Supply Supply Used
ChristmasVacation
JamaicaWinterRetreat
SummerFamilyHoliday
Demand VariationClinic Weekly Demand, Supply and Supply Used
0
100
200
300
400
500
600
700
800
10/1
0/20
05
10/2
4/20
05
11/7
/200
5
11/2
1/20
05
12/5
/200
5
12/1
9/20
05
1/2/
2006
1/16
/200
6
1/30
/200
6
2/13
/200
6
2/27
/200
6
3/13
/200
6
3/27
/200
6
4/10
/200
6
4/24
/200
6
5/8/
2006
5/22
/200
6
6/5/
2006
6/19
/200
6
7/3/
2006
7/17
/200
6
7/31
/200
6
8/14
/200
6
8/28
/200
6
9/11
/200
6
9/25
/200
6
10/9
/200
6
10/2
3/20
06
11/6
/200
6
11/2
0/20
06
12/4
/200
6
12/1
8/20
06
Demand Supply Supply Used
Fall Winter Summer Fall Winter
Advantages of Measuring Demand
• Plan for “big picture” variation– Seasons (Holiday, snowbird, return from
snowbird, flu, vacation)– Contingency plan for staff– Vacation plan for staff
• Provides information about Red Zone Length
TAKT Time
• Supply divided by demand• Example:
480 minutes supply TAKT = 24 min 20 per day demand
480 minutes supply TAKT = 16 min 30 per day demand
No-ShowsAverage Clinic No-Show %
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
7/4
/200
5
7/1
1/2
00
5
7/1
8/2
00
5
7/2
5/2
00
5
8/1
/200
5
8/8
/200
5
8/1
5/2
00
5
8/2
2/2
00
5
8/2
9/2
00
5
9/5
/200
5
9/1
2/2
00
5
9/1
9/2
00
5
9/2
6/2
00
5
10
/3/2
00
5
10
/10
/20
05
10
/17
/20
05
10
/24
/20
05
10
/31
/20
05
11
/7/2
00
5
11
/14
/20
05
11
/21
/20
05
11
/28
/20
05
12
/5/2
00
5
12
/12
/20
05
12
/19
/20
05
12
/26
/20
05
1/2
/200
6
1/9
/200
6
1/1
6/2
00
6
1/2
3/2
00
6
1/3
0/2
00
6
2/6
/200
6
2/1
3/2
00
6
2/2
0/2
00
6
2/2
7/2
00
6
3/6
/200
6
3/1
3/2
00
6
3/2
0/2
00
6
3/2
7/2
00
6
4/3
/200
6
4/1
0/2
00
6
4/1
7/2
00
6
4/2
4/2
00
6
30%
10%
No-ShowsAverage Clinic No-Show %
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
50.0%
7/25
/200
5
8/1/
2005
8/8/
2005
8/15
/200
5
8/22
/200
5
8/29
/200
5
9/5/
2005
9/12
/200
5
9/19
/200
5
9/26
/200
5
10/3
/200
5
10/1
0/20
05
10/1
7/20
05
10/2
4/20
05
10/3
1/20
05
11/7
/200
5
11/1
4/20
05
11/2
1/20
05
11/2
8/20
05
12/5
/200
5
12/1
2/20
05
12/1
9/20
05
12/2
6/20
05
1/2/
2006
1/9/
2006
1/16
/200
6
1/23
/200
6
1/30
/200
6
2/6/
2006
2/13
/200
6
2/20
/200
6
2/27
/200
6
3/6/
2006
3/13
/200
6
3/20
/200
6
3/27
/200
6
4/3/
2006
4/10
/200
6
4/17
/200
6
4/24
/200
6
5/1/
2006
5/8/
2006
5/15
/200
6
7%
45%
Case Study
Measurement Basics
• What is Aim?• Is data connected to aim?• What are the data definitions?• Is the data collection sufficient?• Is the data collection reasonably accurate?• How is the data displayed?• What does it mean?• Where is it going?
What is the first question?
Average Clinic Delay
0.00
5.00
10.00
15.00
20.00
25.00
30.00
7/6/
2005
7/20
/200
5
8/3/
2005
8/17
/200
5
8/31
/200
5
9/14
/200
5
9/28
/200
5
10/1
2/20
05
10/2
6/20
05
11/9
/200
5
11/2
3/20
05
12/7
/200
5
12/2
1/20
05
1/4/
2006
1/18
/200
6
2/1/
2006
2/15
/200
6
3/1/
2006
3/15
/200
6
3/29
/200
6
4/12
/200
6
4/26
/200
6
What is the next question?
Clinic Weekly Demand & Supply
0
100
200
300
400
500
600
7/4/
2005
7/18
/200
5
8/1/
2005
8/15
/200
5
8/29
/200
5
9/12
/200
5
9/26
/200
5
10/1
0/20
05
10/2
4/20
05
11/7
/200
5
11/2
1/20
05
12/5
/200
5
12/1
9/20
05
1/2/
2006
1/16
/200
6
1/30
/200
6
2/13
/200
6
2/27
/200
6
3/13
/200
6
3/27
/200
6
Demand Supply
Why is D>S?
Average Clinic No-Show %
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
What is the effect of no-shows on D>S?
Date Demand Supply D-S D * 0.80 (D * 0.8) - S10/24/2005 417 345 72 333.6 -11.410/31/2005 354 362 -8 283.2 -78.811/7/2005 324 220 104 259.2 39.2
11/14/2005 262 180 82 209.6 29.611/21/2005 223 140 83 178.4 38.411/28/2005 254 151 103 203.2 52.2
What else could be causing more D than S?
Average % Clinic Continuity
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
7/4/
2005
7/18
/200
5
8/1/
2005
8/15
/200
5
8/29
/200
5
9/12
/200
5
9/26
/200
5
10/1
0/20
05
10/2
4/20
05
11/7
/200
5
11/2
1/20
05
12/5
/200
5
12/1
9/20
05
1/2/
2006
1/16
/200
6
1/30
/200
6
2/13
/200
6
2/27
/200
6
3/13
/200
6
3/27
/200
6
89% Continuity
67% Continuity
What if continuity was better?
Date Demand Supply D-S D * 0.80 (D*0.8) * 0.9 Corr D - S10/24/2005 417 345 72 334 300 -4510/31/2005 354 362 -8 283 255 -107
11/7/2005 324 220 104 259 233 1311/14/2005 262 180 82 210 189 911/21/2005 223 140 83 178 161 2111/28/2005 254 151 103 203 183 32
How “fast” do we need to go to do all the work today?
DemandDate Dr. 2 TAKT D (min)
11/17/2005 28 14 Thurs
11/18/2005 26 15 Fri
11/21/2005 39 10 Mon
11/22/2005 25 16 Tues
11/23/2005 15 27 Wed
11/24/2005 0 Thurs
11/25/2005 0 Fri
11/28/2005 33 12 Mon
11/29/2005 26 15 Tues
11/30/2005 11 36 Wed
