The University of Michigan Health System Metabolism ...ioe481/ioe481_past_reports/F1405.pdf · Mary G. Duck, Industrial Engineer Expert, University of Michigan Health System Dr. Mark

The University of Michigan Health System

Metabolism, Endocrinology & Diabetes (MEND) Clinic Flow Final Report

To: Maureen Howell, Clinic Manager, MEND

Craig Jaffe, M.D., Clinical Medical Director, MEND

Jennifer Wyckoff, M.D., Medical Director, Adult Diabetes Education Program, MEND

CC: Tammy Ellies, Project Manager and Lean Coach, Department of Internal Medicine

Katie Schwalm, Industrial Engineer Associate, Department of Internal Medicine

Mary G. Duck, Industrial Engineer Expert, University of Michigan Health System

Dr. Mark P. Van Oyen, Associate Professor, Industrial and Operations Engineering

Mary Lind, Technical Communications Lecturer, Industrial and Operations Engineering

From: Team 5 – Brooks Allwardt, Joel Cousineau, Nikila Ravi, Cody Schwartz

Date: December 9, 2014

Table of Contents

Executive Summary ........................................................................................................................ 1

Introduction ..................................................................................................................................... 5

Background ..................................................................................................................................... 5

Key Issues ................................................................................................................................... 6

Goals and Objectives .................................................................................................................. 6

Project Scope .............................................................................................................................. 6

Methods........................................................................................................................................... 6

Data Collection ........................................................................................................................... 6

Time Studies ........................................................................................................................... 7

MiChart Patient Data Query ................................................................................................... 7

Physician Surveys ................................................................................................................... 8

Staff Interviews ....................................................................................................................... 8

Literature Search ..................................................................................................................... 8

Data Analysis .............................................................................................................................. 8

Time Studies & MiChart Data ................................................................................................ 8

Physician Surveys & Staff Interviews .................................................................................... 9

Findings & Conclusions .................................................................................................................. 9

Total Visit Time Breakdown from Check-In to Check-Out – Endocrinology ........................... 9

Total Visit Time Breakdown from Check-In to Check-Out – Podiatry .................................... 11

Exam Room Waiting Time Factors – Endocrinology............................................................... 13

Exam Room Waiting Time Factors – Podiatry ......................................................................... 18

Total Exam Room Time – Endocrinology & Podiatry ............................................................. 24

Findings from Staff Interviews ................................................................................................. 27

Findings from Physician Surveys ............................................................................................. 28

Conclusions Summary .............................................................................................................. 29

Recommendations ......................................................................................................................... 29

Reduce Patient Time to Check-Out .......................................................................................... 29

Reduce Patient Wait Time for the Physician ............................................................................ 30

Reduce Patient Wait Time for the Trainee ............................................................................... 30

Modify General Scheduling of Patients .................................................................................... 31

Reduce Patient Wait Time in Waiting Room and Intake .......................................................... 31

Expected Impact............................................................................................................................ 32

Appendix A: Time Study Data Sheet Templates .......................................................................... 33

Appendix B: Total Visit Time Breakdown By Primary Diagnosis Category ............................... 35

Appendix C: Tables Used to Generate Total Visit Time Breakdown .......................................... 38

Appendix D: Staff Interview Questions ........................................................................................ 42

Appendix E: Physician Survey Questions .................................................................................... 43

Figures and Tables

Figure 1. New Patient Total Visit Time Breakdown with Event Average Times in Minutes for

Endocrinology ............................................................................................................................... 10 Figure 2. Return Visit Total Visit Time Breakdown with Event Average Times in Minutes for

Endocrinology ............................................................................................................................... 11

Figure 3. New Patient Total Visit Time Breakdown with Event Average Times in Minutes for

Podiatry (Single MA Visit) ........................................................................................................... 11 Figure 4. Return Visit Total Visit Time Breakdown with Event Average Times in Minutes for

Podiatry (Single MA Visit) ........................................................................................................... 12 Figure 5. New Patient Total Visit Time Breakdown with Event Average Times in Minutes for

Podiatry (Dual MA Visit) ............................................................................................................. 12 Figure 4. Return Visit Appointment Total Visit Time with Event Average Times in Minutes for

Podiatry (Dual MA Visit) ............................................................................................................. 13 Table 2. Patient Exam Room Wait Time in Relation to Visit Type ............................................. 14 Figure 7. Patient Exam Room Wait Time in Relation to Diagnosis – Endocrinology ................. 14 Figure 8. Patient Waiting Time in Relation to Total Number of Diagnoses ................................ 15

Figure 9. Patient Waiting Time in Relation to Age - Endocrinology ........................................... 16 Figure 10. Patient Waiting Time in Relation to Time of Day of Appointment – Endocrinology 17 Figure 11. Patient Waiting Time in Relation to Lateness to Appointment ................................... 18

Figure 12. Patient Waiting Time in Relation to Time of Day Single Visit - Podiatry .................. 19 Figure 13. Patient Waiting Time in Relation to Time of Day, Dual Visit - Podiatry ................... 19

Figure 14. Patient Waiting Time in Relation to Lateness, Single Visit - Podiatry ....................... 20 Figure 15. Patient Waiting Time in Relation to Lateness, Dual Visit - Podiatry ......................... 21 Figure 16. Patient Waiting Time in Relation to Primary Diagnosis of Diabetes, Single Visit -

Podiatry ......................................................................................................................................... 22

Figure 17. Patient Waiting Time in Relation to Primary Diagnosis of Diabetes, Dual Visit -

Podiatry ......................................................................................................................................... 22 Figure 18. Patient Waiting Time in Relation to Number of Diagnoses, Single Visit - Podiatry .. 23

Figure 19. Patient Waiting Time in Relation to Number of Diagnoses, Dual Visit - Podiatry .... 23 Figure 15. Patient Waiting Time in Relation Age - Podiatry ....................................................... 24

Figure 16. Frequency of Total Exam Room Times Experienced – Endocrinology Return Visits 25 Figure 17. Frequency of Total Exam Room Times Experienced – Endocrinology New Patient

Visits ............................................................................................................................................. 25 Figure 18. Frequency of Total Exam Room Times Experienced – Podiatry Return Visits (Single

Visit) ............................................................................................................................................. 26 Figure 19. Frequency of Total Exam Room Times Experienced – Podiatry New Patient Visits

(Single Visit) ................................................................................................................................. 26 Figure 20. Frequency of Total Exam Room Times Experienced – Podiatry Return Visits (Dual

Visit) ............................................................................................................................................. 27 Figure 21. Frequency of Total Exam Room Times Experienced – Podiatry New Patient Visits

(Dual Visit) ................................................................................................................................... 27

Figure B-1. Return Visit Total Visit Time Breakdown with Event Average Times in Minutes

(Primary Diagnosis – Diabetes Mellitus) ...................................................................................... 35 Figure B-2. New Patient Appointment Total Visit Time with Event Average Times in Minutes

(Primary Diagnosis – Diabetes Mellitus) ...................................................................................... 35


(Primary Diagnosis – Osteoporosis/Calcium/Parathyroid) ........................................................... 35 Figure B-4. New Patient Appointment Total Visit Time with Event Average Times in Minutes

(Primary Diagnosis – Osteoporosis/Calcium/Parathyroid) ........................................................... 36


(Primary Diagnosis – Thyroid) ..................................................................................................... 36 Figure B-6. New Patient Appointment Total Visit Time with Event Average Times in Minutes

(Primary Diagnosis –Thyroid) ...................................................................................................... 36 Figure B-3. Return Visit Total Visit Time Breakdown with Event Average Times in Minutes

(Primary Diagnosis – Other) ......................................................................................................... 37 Figure B-4. New Patient Appointment Total Visit Time with Event Average Times in Minutes

(Primary Diagnosis – Other) ......................................................................................................... 37 Table C-1. Total Visit Time Breakdown Event Average and Standard Deviation Values for All

Endocrinology Appointments ....................................................................................................... 38 Table C-2. Total Visit Time Breakdown Event Average and Standard Deviation Values for All

Podiatry Single MA Visit Appointments ...................................................................................... 38 Table C-3. Total Visit Time Breakdown Event Average and Standard Deviation Values for All

Podiatry Dual MA Visit Appointments ........................................................................................ 39 Table C-4. Total Visit Time Breakdown Event Average and Standard Deviation Values for

Endocrinology Appointments – Primary Diagnosis: Diabetes Mellitus ....................................... 39

Table C-5. Total Visit Time Breakdown Event Average and Standard Deviation Values for

Endocrinology Appointments – Primary Diagnosis: Osteoporosis/Calcium/Parathyroid ............ 40


Endocrinology Appointments – Primary Diagnosis: Thyroid ...................................................... 40 Table C-7. Total Visit Time Breakdown Event Average and Standard Deviation Values for

Endocrinology Appointments – Primary Diagnosis: Other .......................................................... 41

1

Executive Summary

The University of Michigan Metabolism, Endocrinology, and Diabetes (MEND) clinic was

interested in analyzing the current workflow of the clinic and identifying wasted time during

inpatient and outpatient care. Therefore, the Clinic Manager, Medical Director, and the Associate

Medical Director asked an Industrial and Operations Engineering (IOE) 481 student team from

the University of Michigan to evaluate this current workflow through data collection and

analysis of the process with an emphasis on reducing the amount of time a patient spends inside

the exam room. This evaluation consisted of time studies, physician surveys, clinic staff

interviews, and a literature search. The team is using these methods to develop recommendations

to improve the workflow of the clinic and to reduce patient time in the exam room.

Background

The MEND clinic reported extreme variability in patient appointment lengths which could take

anywhere from 5 minutes to 220 minutes. Lengthy patient times can create inefficiencies in the

clinic that can cause unhappy patients and staff. The IOE 481 student team focused primarily on

the time that a patient spends inside of the exam room. This means that anything that happens

with a patient before or after they enter the exam room in the clinic is considered out of scope.

Therefore, the team began analyzing and collecting data from patient visits when the Medical

Assistant (MA) takes a patient to their exam room and ends after the corresponding physician’s

consultation and any other consultations take place in the exam room. Additionally, the Podiatry

section of the clinic, separate from the Endocrine section, has a significantly different process

from the rest of the clinic. The Podiatry section was therefore analyzed separately from the

Endocrine clinic. The clinic was particularly concerned about the amount of time that a patient

spends waiting inside of the exam room for their physician, MA, or other providers required for

the visit. Another concern was the variable length of time that different patient visit types take

compared to how long they are actually scheduled for. The goal for the team was to provide

recommendations to help improve the clinic workflow and reduce patient time spent inside the

exam room, focusing specifically on patient wait time.

Methodology

The team performed four types of tasks to evaluate and improve the workflow of the clinic and

reduce patient time in the exam room:

Time Studies: The team created time study sheets that were completed by the MA and the

corresponding provider (Physician, Registered Nurse, Fellow, etc.) who visited with the

patient. These time study sheets allowed the provider inside of the room to document

when they entered the room, and when they exited. Additionally, attached to each of

these sheets was the patient’s Medical Registered Number (MRN), which, allowed the

team to access MEND clinic data about that patient and that visit. This MRN was used to

validate our data as well as verify visit types. The Podiatry section of the clinic used the

same time study sheets, but the team separated them out during the analysis portion of the

project.

2

Physician Surveys: The physicians were sent a Qualtrics survey that asked several

questions about the clinic workflow. 13 clinic physicians completed the survey. These

surveys were completed online and were used by the team to gain the physicians’

perspectives on inefficiencies in the clinic and support findings.

Staff Interviews: Members of the Medical Assistant staff as well as clerks who scheduled

patients were interviewed. The interviews were completed in person and aimed at

understanding the MA’s perspective on workflow and patient waiting times. These

qualitative responses were documented by the team and were be used to help identify

areas of waste in the clinic.

Literature Search: The team utilized a previous IOE 481 workflow project at the MEND

clinic to understand the steps needed for this project. Although the scope of this previous

project was different than the current project scope, the previous project proved

beneficial in understanding the clinic and in providing background for the current project.

Findings and Conclusions

Using the methods listed above, the findings and conclusions on those findings are listed below:

Time Studies: The team analyzed data collected from the time studies using Microsoft

Excel and was able to create breakdowns for an average patient visit. The clinic

specifically asked to separate the visits between new patients and returning visits to help

provide more precise data. Tables 1 and 2 below, show how patient visits were

represented on average for new patients and returning patients.

Figure 1. New Patient Total Visit Time Breakdown with Event Average Times in Minutes for Endocrinology

Sample Size: 82; Source: IOE 481 Team Time Study & MiChart; Collection Period: September 26, 2014 & October

2 – 17, 2014

3

Figure 2. Return Visit Total Visit Time Breakdown with Event Average Times in Minutes for Endocrinology

Sample Size: 379; Source: IOE 481 Team Time Study & MiChart; Collection Period: September 26, 2014 &

October 2 – 17, 2014

These breakdowns helped illustrate how long each distinct section of the visit took for

patients at the clinic. The areas in the lighter grey represent all of the waiting times for

the patients while the darker grey represents the time a patient spent with a staff member

of the clinic. From the above breakdowns, the team chose to focus on the time spent in

between the last provider leaving the exam room and when the patient checks out, the

patient wait time for the physician, the time spent in the waiting room and intake area, the

physician time, and the time spent waiting for the trainees in the clinic (M3s, residents,

and fellows). The team noted that these times appeared to add length to patient visits.

From the breakdowns, the team also found that the average appointment length was 89

minutes for new patients and 70 minutes for returning patients. These times were

significantly greater than the 45 minutes scheduled for new patients, and the 15 minutes

scheduled for returning patients. This scheduling issue was another area of concern the

team chose to focus on from the breakdowns.

Physician Surveys: After receiving results from 13 of the clinics physicians, the team was

able to summarize some of the thoughts of the physicians. 83% of them believed that

appointments should be scheduled for longer for both new and returning patients.

Another main finding was there was not a standardized method of notifying the

physicians when a patient was in the exam room waiting for them. The team again chose

to focus on the scheduled length of a visit as well as the clinic’s system of notifying

providers when their patients are ready.

Staff Interviews: 5 of the Medical Assistants of the clinic were interviewed successfully

as well as the head of the Medical Assistants at the clinic’s weekly huddle meeting. The

general findings from the interviews of the MAs of the clinic were relatively unanimous.

The three main issues with the clinic that they saw were as follows: there was not enough

time for return visits (scheduled for only 15 minutes), there was an overload of patients

and staff in the clinic and adding more space would be beneficial, and patients arriving

late created bottlenecks in the clinic schedule. From these results, the team again looked

at the scheduled length of the return visits in the clinic.

4

Recommendations

After taking into consideration collected data as well as the qualitative findings from the staff

interviews and physician surveys, the team broke up the recommendations into 5 categories:

Reduce Patient Time to Check-Out: The total visit time breakdowns showed that it was

taking on average 10 to 14 minutes from when the final provider left the exam room, to

when the patient actually checked-out of the clinic. To reduce this time, the team suggests

implementing a new system of handing a folder with labels inside for the patient to take

to check-out. This would give the patients something physical and would signify the end

of the visit for the patient instead of leaving them confused inside of the exam room.

Additionally, educating the providers on clearly notifying the patients exactly when the

visit is over is suggested.

Reduce Patient Wait Time for the Physician: The total visit time breakdowns also showed

a 12 to 13 minute period where the patient is waiting for the physician to enter the room

for consultation. To improve this process, the team suggests creating a new procedure of

notifying the physicians that a patient is waiting for them inside of the exam room.

Furthermore, a study that looks at the clinic processes from a physician perspective as

opposed to a patient perspective would prove beneficial in understanding these delays.

Reduce Patient Wait Time for the Trainee: Similar to the physicians, the patients also

spent anywhere from 1 to 17 minutes waiting for the various trainees that entered the

clinic. The recommendations for the trainees are therefore the same as those listed above

for the physicians (system of notification, new study from trainee perspective). In

addition however, the team also suggests considering modifying patients visit lengths

based on when trainees are in clinic.

Modify General Scheduling of Patients: Several recommendations were made in this

category due to the inconsistency of patient visit lengths. The first recommendation is to

increase the allotted time for returning patient visits. This seemed to be a general

consensus across the clinic staff as mentioned in the Findings and Conclusions section

above. The team also recommends changing appointment lengths to take into account the

total exam room time instead of just the physician time. Finally, the team also found from

the clients that physician schedules were not level throughout the week and that the

number of physicians could vary depending on the day or time of day. The team suggests

levelling out the physician schedules to create a balance of physicians day to day.

Reduce Patient Wait Time in Waiting Room and Intake: While taking note that this

section was outside of the scope for the project, it was hard for the team to ignore the 18

– 19 minutes that patients were waiting before actually entering the exam room. The team

suggests creating a further study here to address this waiting time for both new and

returning patients.

5

Introduction

The University of Michigan Metabolism, Endocrinology and Diabetes (MEND) clinic offers

comprehensive inpatient and outpatient services and educational programs in endocrine and

metabolic disorders. The Clinic Manager, Medical Director, and the Associate Medical Director

are interested in analyzing the current workflow of the clinic and want to identify areas of wasted

time that occur with patient care. To address this problem, the Clinic Manager and the Medical

Directors have asked an Industrial and Operations Engineering (IOE) 481 student team from the

University of Michigan to analyze the current state of the clinic and provide an improved

workflow and a more efficient process. The workflow will describe the complete process of the

clinic including movement of physicians and patients. The specific segment that was asked to be

addressed in the workflow process starts when a patient enters the exam room and ends when

that patient leaves the exam room for check-out. After conducting a series of observations,

interviews, creating a time study, and analyzing the data collected, the team will make

recommendations on how to improve the general flow within the clinic and present the time

study as a tool for future use. This proposal provides a plan to determine the major inefficient

areas within the MEND clinic and to help develop recommendations that will be used to improve

the general workflow and specific processes occurring inside the exam room.

Background

The University of Michigan MEND clinic is located at Domino’s Farms and is open Monday to

Thursday, 7:30 a.m. to 5 p.m. and Fridays 7:30 a.m. to 12 noon. The MEND clinic is designed to

provide expert care for patients with various endocrine and metabolic conditions.

The current process in the clinic begins when a patient is called in from the waiting room to the

intake area. The patient’s background information and vital signs including blood pressure,

height and weight are checked by the Medical Assistants (MA’s). After completion of the intake

procedures, the patient is brought to an exam room in one of the three pods that the clinic is

separated into. Here the patient waits until the doctor has been notified and comes to treat or

consult with the patient. After the doctor’s consultation, a Registered Dietician (RD), a

Registered Nurse (RN), a Licensed Practical Nurse (LPN), an MA, or a social worker may enter

the exam room to consult with the patient. At the end of the visit, the patient leaves the room

and returns to the waiting area to complete check-out.

Between July 2013 and May 2014, the Clinic experienced nearly 24,000 patient visits. Of these

24,000 visits, 74% of patients arrived early or on time and 26% of the patients arrived late

according to the statistics gathered by the MEND clinic’s MiChart report. The staff believes

these varying patient arrival times, as well as the varying times that physicians spend with their

patient have caused inconsistent and lengthy visit times in the MEND clinic. Long, unknown,

patient waits inside the exam rooms have made scheduling patients increasingly difficult. The

team’s analysis of the MEND clinic will identify areas within this process during which time is

wasted and offer recommendations to reduce this waste.

6

Key Issues

The following key issues are contributing factors to the need for this study:

Provider times with patients for each visit type are inconsistent

Waiting times inside exam room are causing visits to take longer than scheduled

The causes of long patient wait times inside the exam rooms are unknown

Goals and Objectives

To analyze and improve the current workflow of the MEND clinic at Domino’s Farms with a

focus on patient wait time inside of the exam room, the student team will complete the following

tasks:

Conduct a series of observations and time studies to understand the current workflow

Create a future state diagram of the system that eliminates waste and increases efficiency

With this information, the team will develop recommendations to:

Identify inefficiencies in the clinic by determining how much time the patient actually

spends with the physician

Determine an optimal workflow in the clinic, relating specifically to activities occurring

in the exam room

Project Scope

The scope of the project includes the analysis of the workflow of the MEND clinic at Domino’s

Farms. The segment being studied begins when a patient enters the exam room and ends when

the patient leaves the exam room. The only types of visits that are in scope are thyroid

ultrasounds as well as new and return visits for the following visit types: bone, cystic fibrosis,

general, obstetrics, osteoporosis, Podiatry and preconception.

Any task that happens outside of the exam room is out of the scope for this study. The team will

not study the activities associated with the patient from arriving at the clinic to entering the exam

room or from exiting the exam room to checking out.

Methods

The primary goal of the project is to determine the major inefficient areas within the MEND

clinic and develop recommendations that will be used to improve the general workflow of the

processes occurring inside the exam room. The team collected clinic workflow data and

formulated methods for analyzing this data.

Data Collection

After an initial observation of the MEND clinic, the team developed a time study to collect data

required for the project. After determining what collected data was important, the team obtained

MiChart (the MEND clinic’s electronic medical record system) patient data that was relevant for

the project and would be used in the analysis.

7

Time Studies

The team conducted time studies from October 2, 2014 – October 17, 2014 which resulted in 835

datasheets in total. Initially, a test of the time study was performed on September 26, 2014 to

determine the effectiveness of the datasheets and that data was kept and included for analysis.

For the time studies, the clinic staff was provided with datasheets to be completed for each

patient within the scope of the project. The MAs were instructed to take a datasheet with them

when placing a patient in the exam room, place a patient medical record number (MRN) sticker

on the datasheet, and write in their entry and exit times from the exam room. Each staff member

that subsequently entered the room was asked to record their entry and exit times. Once the

patient exited the exam room, the MA would clean the room, retrieve the datasheet, and bring the

datasheet to a central location for regular pickup by the student team.

To validate the data, team members visited the MEND clinic at random times throughout the

time study period and recorded entry and exit times for staff members. These observed times

were then compared with the times recorded on the datasheets to ensure data accuracy. Through

this comparison, the data was successfully validated. An obstacle that occurred during the time

study was the receipt of multiple incomplete or out-of-scope data sheets. However, the team

determined that this accounted for less than 5% of the datasheets collected and that the total

number of completed, in-scope, data sheets was sufficient for analysis.

The response rates for the time studies are given in Table 1. The response rate can be interpreted

as the percentage of appointments for which a datasheet was filled out during the time study

period.

Table 1. Time Study Response Rates

MiChart Patient Data Query

The project coordinators provided sample patient data from MiChart that could be matched with

the data obtained in the time studies. Based on the sample provided, the team identified which

variables from the MiChart data would be relevant to the project and how the data would be

grouped or separated for analysis. Finally, the team requested two datasets: the encounter cycle

time report and the diagnosis codes report. These two datasets contained the patient’s MRN,

Appointment Type Response Rate

Endocrinology – All 52.8%

Return Visit 59.2%

New Patient 37.8%

Diabetes Mellitus 54.5%

Osteoporosis/Calcium/Parathyroid 49.2%

Thyroid 40.6%

Other 61.9%

Podiatry – All 73.3%

Return Visit 72.7%

New Patient 75.4%

8

which was used to combine the datasets with the time study data. At the completion of the time

study, the project coordinators provided the team with MiChart data that contained the requested

variables for the period of the time study: September 26, 2014 and October 2, 2014 – October 17,

2014.

An obstacle that the team encountered when considering the sample of the MiChart data was that

many patients had multiple diagnosis codes associated with a single visit, and no primary

diagnosis was identified. After discussing this issue with the project client and coordinators, the

team decided to consider both the number of diagnosis codes and the identification of a few key

diagnosis codes in relation to the visit time.

Physician Surveys

Based on a preliminary analysis of the time study and MiChart data, the team developed a set of

questions related to patient waiting time in the exam room. These questions were aimed at

targeting the root causes for long patient wait times and total visit length time. The questions

were sent to all current full-day clinic and partial-day clinic physicians in a Qualtrics survey

originating from the section chief of the MEND clinic to ensure full participation.

Staff Interviews

Based on an initial analysis of the time study and MiChart data, the team interviewed a total of

ten clinic staff members including scheduling clerks (both in the call center and at the check-out

desk), MAs and nurses. These interviews helped the team gather information on the possible

causes of patient waiting times in the exam rooms. In addition, the interview questions were

asked at a meeting on November 20th consisting of the head staff members for each staff

designation at the MEND Clinic. Similar to the physician surveys, the interview responses were

used in the root cause analysis to find the causes of long patient wait and total visit times.

Literature Search

The team has searched past IOE 481 clinic workflow projects for methods of collecting data,

analyzing data, and formulating recommendations based on similar workflow processes. A

previous IOE 481 project was considered that was also done in the MEND clinic. Although the

scope was slightly different from the current scope as it focused on processes outside of the exam

room, the project was used to help the team better understand the clinic and provide background

for the current project. Previous workflow projects were also considered when developing data

collections methods.

Data Analysis

The team considered all data collected to identify inefficiencies in the workflow inside the exam

room. In addition, the team considered the current scheduling system and any relevant changes to

this system to improve the general workflow. First, the time studies and MiChart data were

considered to identify bottlenecks. Second, the physician surveys and staff interviews were

considered to isolate the root causes of these bottlenecks.

Time Studies & MiChart Data

Clinic throughput data was pulled from MiChart for the dates that the time study was conducted.

The team matched up data from MiChart with data from the time study for individual patient

9

visits. Next, the team sorted the combined data based on patient type, diagnosis code, age, and

types of staff seen. The MiChart data includes scheduled appointment time, arrival time, wait

time, total visit length, and diagnosis codes for the two and a half weeks the time study was

conducted.

Through the data analysis the team determined which aspects of patient appointments take the

longest and how that correlates to the patient type and the patient’s diagnoses. The team also

determined how M3s and fellows impacted overall patient visit time in the clinic when they were

present. The team analyzed the data largely using Microsoft Excel to create tables of visit time

and graphs of the visit time distribution. These tools will aided in identifying the inefficiencies in

the exam room workflow.

An obstacle encountered during the time study data entry and connection to MiChart data was

that many Podiatry patients had multiple entry and exit times for individual staff members. After

discussing this issue with the project client and coordinators, the team decided to analyze all

Podiatry patients seen in the MEND clinic separately.

Physician Surveys & Staff Interviews

The team used the physician surveys and staff interviews to identify causes of inefficiencies

within the clinic process in the exam rooms. The team compared and contrasted the staff

responses from 12 completed surveys and identified patterns that correlated with the data

collected from the time studies and MiChart. By considering correlations between the numerical

data from MiChart and the time studies, the team was able to identify possible root causes for

inefficiencies that cause longer patient visits.

Findings & Conclusions

The analysis of the collected data yielded results that were considered to form an idea of the

general breakdown of each visit and also to identify areas for improvement within the workflow

of the MEND clinic, especially within the exam room. New patients (NP) were considered

separately from returning patients (RV). In addition, the Podiatry pod was analyzed separately

from the Endocrinology pods.

Total Visit Time Breakdown from Check-In to Check-Out – Endocrinology

Using the time study and MiChart data, the team calculated the time patients spent in the exam

room with each staff member and the time patients spent waiting for each of those members.

Each minute of the appointment was accounted for, with focus on a detailed breakdown of the

events occurring in the exam room. Figures 1 and 2 give the total visit time breakdown for new

patient appointments and return visit appointments, respectively, for all Endocrinology visits.

10

Figure 1. New Patient Total Visit Time Breakdown with Event Average Times in Minutes for Endocrinology


2 – 17, 2014

The check-in time is given as a range calculated from the scheduled appointment time. All other

times given are the average length of the event in minutes. The percentage of appointments that

include an educator consultation is given by the percentages of each educator type; no

appointment included more than one educator consultation. The percentage of appointments that

include a trainee consultation is given by the percentages of each trainee type; no appointment

included more than one trainee consultation. In addition, the standard deviation for each event

can be found in Table C-1 for Figures 1 and 2.

These figures show the large amount of time that a patient is spent waiting in the exam room,

27.5% of the time in exam room for new patients and 36.7% of the time in exam room for return

visits. A large portion of this time is waiting for the physician. In addition, for appointments

with a trainee, the waiting time for the trainee is up to 17 minutes, with the trainee’s consultation

itself being up to 20 minutes. So, when a trainee is present with the physician, the appointment

is lengthened, however there is no scheduling mechanism in place to consider this extra time; the

physician is simply expected to adjust.

In addition, the industry standard for a patient to be ready to be seen by the physician is 15

minutes. However, Figures 1 and 2 show that the patient is not ready to see the physician until

22-24 minutes after check-in. Due to the fact that close to three quarters of patients check in

early, the patient is often ready within 15 minutes of their scheduled appointment time, however

it is not reliable to depend on the patient to arrive early in order to meet this standard.

Finally, an incidental, out of scope, finding of this project was that there is a large amount of

time spent in the waiting room and intake and also a large amount of time between the last

provider exiting the room and check-out. On average 28-33 minutes are spent in the clinic for

these two segments.

11

Figure 2. Return Visit Total Visit Time Breakdown with Event Average Times in Minutes for Endocrinology


October 2 – 17, 2014

Also, the client requested total time visit breakdowns for primary diagnosis groups to illustrate

the difference in time required by patients with three commonly encountered disease types in the

clinic: Diabetes Mellitus, Thyroid, Osteoporosis/Calcium/Parathyroid, and Other. These

breakdowns, however, did not affect how the team shaped their recommendations since it is not

feasible to block times in a provider’s schedule for individual diagnosis types, so these

breakdowns have been included for reference in Appendix B with their corresponding standard

deviation tables included in Appendix C.

Total Visit Time Breakdown from Check-In to Check-Out – Podiatry

Similar visit time breakdowns were created for appointments in Podiatry. It is important to note

that the Podiatry visits were divided into two sets. The first set had patients that were first taken

into the exam room and worked up by an MA, and then they were seen by a physician. Some of

these patients were been seen by a Nurse simultaneously with the physician or separately after

the physician left the exam room, percentages of this occurrence are given in the figures. Figures

3 and 4 give the total visit time break downs for new patients and return visits for this set of

appointments. In addition, the standard deviation for each event can be found in Table C-2 for

Figures 3 and 4.

Figure 3. New Patient Total Visit Time Breakdown with Event Average Times in Minutes for Podiatry (Single MA

Visit)


2 – 17, 2014

12

Figure 4. Return Visit Total Visit Time Breakdown with Event Average Times in Minutes for Podiatry (Single MA

Visit)


2 – 17, 2014

The second set of patients were also taken into the exam room and worked up by an MA, then

they were seen by a physician, and finally the MA returned to see the patient a second time after

the physician left the exam room. During this time study period, only new patients within this

set were observed to have a Nurse visit simultaneously with the physician, percentages of this

occurrence are given in the figure. Figures 5 and 6 give the total visit time break downs for new

patients and return visits for this set of appointments. In addition, the standard deviation for each

event can be found in Table C-3 for Figures 5 and 6.

Figures 3, 4, 5, and 6 show a large waiting time in the exam room of 9-11 minutes for the

physician. This time is slightly less than the time the physician spends consulting with the

patient. In addition, these breakdowns show that the patients spend approximately 35-40% of

their time in the exam room waiting. Finally, Figures 3 and 4 show a large waiting time of 8-13

minutes for the Nurse, when required.

Figure 5. New Patient Total Visit Time Breakdown with Event Average Times in Minutes for Podiatry (Dual MA

Visit)


2 – 17, 2014

13

Figure 4. Return Visit Appointment Total Visit Time with Event Average Times in Minutes for Podiatry (Dual MA

Visit)


2 – 17, 2014

Overall, the times were similar for physician waiting in Podiatry were similar to those of

Endocrinology appointments. Also, the incidental finding of long times in waiting room and

intake and from the last provider’s exit to check-out in Endocrinology is also apparent in the

Podiatry appointments.

Also, a third set of appointments were seen in Podiatry. These appointments had multiple re-

entries into the exam room by the MAs, physician, and Nurse. However, the sample size for

these appointment types was too small to draw meaningful conclusions; therefore these records

were excluded from the team’s analysis.

Exam Room Waiting Time Factors – Endocrinology

In addition to the appointment breakdown, the patient waiting time was analyzed in relation to

multiple factors including: visit types, primary diagnosis category, total number of diagnoses,

age, time of day of appointment, and patient lateness to appointment. In this section, the analysis

will focus on the patients seen in the Endocrinology section of the clinic.

Table 2 gives the average exam room wait time, in minutes, associated with each visit type

within the scope of this project. Some visit types originally listed within scope are not included

in the table below due to no visits of those types being recorded during the time studies.

14

Table 2. Patient Exam Room Wait Time in Relation to Visit Type

Figure 7 shows the average exam room wait time, in minutes, in relation to the primary diagnosis

identified at the visit by the physician. As seen in the figure, diagnosis does have an effect on

exam room wait time. This could largely be due to different types of diagnoses requiring other

staff members to enter the exam room after the physician causing more wait time in the exam

room.

Figure 7. Patient Exam Room Wait Time in Relation to Diagnosis – Endocrinology

Sample Size: 379 RV & 82 NP; Source: IOE 481 Team Time Study & MiChart; Collection Period: September 26,

2014 & October 2 – 17, 2014

Figure 8 gives the average exam room wait time, in minutes, in relation to the total number of

diagnoses identified by the physician at the visit for both new and returning patients. There is a

substantial correlation between number of diagnoses and exam room time for both new patients

and return visits. As the number of diagnoses increases so does the time spent in the exam room.

This supports the theory that more complicated patients require more time treat.

205 84

3058

23

33

4

21

101112131415161718

DiabetesMellitus

Thyroid Osteoporosis Other

Wa

it T

ime

(M

inu

tes)

Type of Diagnosis

Average Patient Exam Room Wait Time by Diagnosis (Endocrinology)

RV

NP

New Patients Returning Patients

Visit Type Sample

Size

Average Wait in

Minutes

Sample

Size

Average Wait in

Minutes

General 75 15 369 14

Bone 3 3 3 13

Obesity 1 0 2 20

Preconception 2 32 4 16

Cystic Fibrosis 1 18 3 9

Totals 82 15 381 14

15

Figure 8. Patient Waiting Time in Relation to Total Number of Diagnoses


2014 & October 2 – 17, 2014

Figure 9 gives the average exam room time, in minutes, in relation to the patient’s age. The

patient age was divided into two categories, with a cut point of 70 years of age, which was

identified by the project’s clients. Although the clients predicted that the time would be longer

for patients who are older than 70, the team did not find any significant correlation between

exam room time and age.

0

20

40

60

80

100

120

1 2 3 4 5 6 7 8 9

To

tal

Ex

am

Ro

om

Tim

e (

Min

)

Number of Diagnoses

Average Time in Exam RoomBy Number of Diagnoses (Endocrinology)

RV

NP

16

Figure 9. Patient Waiting Time in Relation to Age - Endocrinology


2014 & October 2 – 17, 2014

Figure 10 gives the average exam room wait time, in minutes, in relation to the time of day of the

patient’s appointment. Based on the findings for exam room wait time, the team can conclude

that the peak waiting times for Endocrinology are at approximately 11AM and between 2-3PM.

This is largely due to the build-up of patients and delays throughout the morning, which causes

excessive wait time just before the lunch hour. When the afternoon clinic begins, wait time is

less, but it builds up to a peak around 2PM, and then tapers off until the end of the day.

312 69

75 7

0

10

20

30

40

50

60

<70 >=70

To

tal

Ex

am

Ro

om

Tim

e (

Min

)

Age (Years)

Average Time in Exam Room by Age (Endocrinology)

RV

NP

17

Figure 10. Patient Waiting Time in Relation to Time of Day of Appointment – Endocrinology


2014 & October 2 – 17, 2014

Figure 11 below gives the average exam room wait time, in minutes, in relation to magnitude of

the patient’s early or late arrival to their appointment. The is no correlation between patient

waiting time and lateness to appointment for Endocrinology indicating that there is no bias

placed on late patients by the provider. The late patients are not penalized for arriving late and

are experiencing similar wait times as those patients that arrive early or on time. However, the

data collected does not support or refute the contribution of late patients to a bottleneck in the

clinic. The effect of late patients is primarily on subsequent patient waiting times and there is no

effective way to determine whether this relationship exists from this project.

0:00

0:05

0:10

0:15

0:20

0:25W

ait

Tim

e (

Min

)

Time of Day

Average Patient Exam Room Wait Time by Time of Day (Endocrinology)

NP RV

18

Figure 11. Patient Waiting Time in Relation to Lateness to Appointment


2014 & October 2 – 17, 2014

Exam Room Waiting Time Factors – Podiatry

The analysis of the podiatry data was conducted in a similar manner as the Endocrinology data.

The same factors were considered in relation to exam room wait time. As mentioned, the

Podiatry data was divided into two sets: the first set had a single MA visit before the physician

entered the exam room and the second set had dual MA visits, one before the physician entered

the exam room and a second after the physician exited the exam room.

Figures 12 and 13 show the average exam room wait time in relation to the time of day for single

entry by the MA and by dual entry by the MA, respectively. From the data collected the peak

wait time occurs around 1PM for single visit by the MA which can likely be attributed to the

morning backup of patients. For multiple visits by the MA there is not a strong correlation

between wait time and time of day.

0

5

10

15

20

25

Wa

it T

ime

(M

in)

Lateness to Appointment (Min)

Average Patient Exam Room Wait Time by Lateness to Appointment (Endocrinology)

RV

NP

19

Figure 12. Patient Waiting Time in Relation to Time of Day Single Visit - Podiatry


2014 & October 2 – 17, 2014

Figure 13. Patient Waiting Time in Relation to Time of Day, Dual Visit - Podiatry


2014 & October 2 – 17, 2014

0:00

0:02

0:05

0:08

0:11

0:14

0:17

0:20

8:00 9:00 10:00 11:00 12:00 13:00 14:00 15:00

Wa

it T

ime

(M

in)

Time of Day

Average Patient Exam Room Wait Time By Time of Day (Single Visit)

RV

NP

0:00

0:07

0:14

0:21

0:28

8:00 9:00 10:00 11:00 12:00 13:00 14:00

Wa

it T

ime

(M

in)

Time of Day

Average Patient Exam Room Wait Time By Time of Day (Dual Visit)

RV

NP

20

Figure 14 and 15 below shows exam wait in relation to lateness to appointment for single visit

MA and multiple visits, respectively. As with Endocrinology, there is no significant correlation

between a patient’s lateness and their respective wait time. There is no discernable bias given by

the Podiatry providers to penalize a late patient. However, this does not support or refute the

theory that late patients create a bottleneck later in the day.

Figure 14. Patient Waiting Time in Relation to Lateness, Single Visit - Podiatry


2014 & October 2 – 17, 2014

0:00

0:02

0:05

0:08

0:11

0:14

0:17

0:20

0:23

Wa

it T

ime

(M

in)


Average Patient Exam Room Wait Time by Lateness to Appointment (Single Visit)

RV

NP

21

Figure 15. Patient Waiting Time in Relation to Lateness, Dual Visit - Podiatry


2014 & October 2 – 17, 2014

Exam room wait time with regards to whether or not a patient has a primary diagnosis of

diabetes is shown in Figures 16 and 17 for single MA visit and dual MA visit, respectively. For

single MA visits, the patients with a primary diagnosis of diabetes have a longer wait time on

average however for dual MA visits this trend is reversed. Therefore, no relationship can be

drawn from this comparison.

0:000:020:050:080:110:140:170:200:230:25

Wa

it T

ime

(M

in)


Average Patient Exam Room Wait Time by Lateness to Appointment (Dual Visit)

RV

NP

22

Figure 16. Patient Waiting Time in Relation to Primary Diagnosis of Diabetes, Single Visit - Podiatry


2014 & October 2 – 17, 2014

Figure 17. Patient Waiting Time in Relation to Primary Diagnosis of Diabetes, Dual Visit - Podiatry


2014 & October 2 – 17, 2014

The average total exam room time in relation to number of diagnoses of a patient is displayed in

Figures 18 and 19 for single MA visit MA and dual MA visit, respectively. The data used to

2464

8

28

0:00

0:02

0:05

0:08

0:11

0:14

0:17

Yes No

Wa

it T

ime

(M

in)

Primary Diagnosis of Diabetes

Average Patient Exam Room Wait Time by Diagnosis of Diabetes (Single Visit)

RV

NP

2555

28

0:00

0:02

0:05

0:08

0:11

0:14

0:17

Yes No

Wa

it T

ime

(M

in)

Primary Diagnosis of Diabetes

Average Patient Exam Room Wait Time by Diagnosis of Diabetes (Dual Visit)

RV

NP

23

create. There is a significant correlation for single MA visits that supports the theory that more

complicated patients take longer to treat. The correlation is less pronounced for dual MA visits

which is most likely due to a smaller sample size of patients with a greater number of diagnoses.

Figure 18. Patient Waiting Time in Relation to Number of Diagnoses, Single Visit - Podiatry

Sample Size: 88 RV & 36 NP; Source: IOE 481 Team & MiChart; Collection Period: September 26, 2014 &

October 2 – 17, 2014

Figure 19. Patient Waiting Time in Relation to Number of Diagnoses, Dual Visit - Podiatry


2014 & October 2 – 17, 2014

Total exam room time in relation to whether or not the patient was over the age of 70 is shown in

Figure 20. Patients over the age of 70 spend on average a few more minutes in the exam room

0:00

0:14

0:28

0:43

0:57

1 2 3 4 5 6

To

tal

Ex

am

Ro

om

Tim

e

(Min

)

Number of Diagnoses

Average Time in Exam Room by Number of Diagnoses (Single Visit)

0:00

0:14

0:28

0:43

0:57

1:12

1 2 3 4 5 6 7

To

tal

Ex

am

Ro

om

Tim

e

(Min

)

Number of Diagnoses

Average Time in Exam Room by Number of Diagnoses (Dual Visits)

24

than those under the age of 70. However, since this difference is so small and the standard

deviation for this data is quite large, no firm conclusion drawn from this comparison.

Figure 15. Patient Waiting Time in Relation Age - Podiatry


2014 & October 2 – 17, 2014

Total Exam Room Time – Endocrinology & Podiatry

In order to identify feasible appointment lengths for return visits and new patient visits, the team

plotted the frequency of total exam room times experienced during the time study period.

Figures 16-21 give these plots.

From these plots, the team can conclude that an optimal length for return visits would be 30-45

minutes and an optimal length for new patients would be 45-60 minutes.

61 2731 5

44 368

2

0:00

0:07

0:14

0:21

0:28

0:36

0:43

0:50

<70 >=70

To

tal

Ex

am

Ro

om

Tim

e (

Min

)

Age (Years)

Average Time in Exam Room by Age

RV - Single Visit

NP - Single Visit

RV - Multiple Visits

NP - Multiple Visits

25

Figure 16. Frequency of Total Exam Room Times Experienced – Endocrinology Return Visits


October 2 – 17, 2014

Figure 17. Frequency of Total Exam Room Times Experienced – Endocrinology New Patient Visits


2 – 17, 2014

0

20

40

60

80

100

120

140

160

15 20 25 30 45 60 75 90 More

Nu

me

be

r o

f P

ati

en

ts

Time in Exam Room (Min)

Number of Patients by Time in Exam Room (RV)

0

5

10

15

20

25

30

30 45 60 75 90 More

Nu

me

be

r o

f P

ati

en

ts

Time in Exam Room (Min)

Number of Patients by Time in Exam Room (NP)

26

Figure 18. Frequency of Total Exam Room Times Experienced – Podiatry Return Visits (Single Visit)


2 – 17, 2014

Figure 19. Frequency of Total Exam Room Times Experienced – Podiatry New Patient Visits (Single Visit)


2 – 17, 2014

11

40

24

85

0

10

20

30

40

50

15 30 45 60 More

Nu

mb

er

of

Pa

tie

nts

Total Exam Room Time (Min)

Number of Patients by Time in Exam Room (RV - Single Visit)

1

18

79

1

0

5

10

15

20

15 30 45 60 More

Nu

mb

er

of

Pa

tie

nts


Number of Patients by Time in Exam Room (NP - Single Visit)

27

Figure 20. Frequency of Total Exam Room Times Experienced – Podiatry Return Visits (Dual Visit)


2 – 17, 2014

Figure 21. Frequency of Total Exam Room Times Experienced – Podiatry New Patient Visits (Dual Visit)


2 – 17, 2014

Findings from Staff Interviews

The Staff Interviews involved the team interviewing several of the Medical Assistants and heads

of the various departments in the MEND clinic. These interviews were used to gain insight and

perspective into the general process and workflow of the clinic, and additionally to help identify

potential bottlenecks. A list of the questions that were used to guide the interviews is located in

Appendix D. The general findings and conclusions from the staff were as followed:

0

19

41

18

2

0

10

20

30

40

50

15 30 45 60 More

Nu

mb

er

of

Pa

tie

nts


Number of Patients by Time in Exam Room (RV - Dual Visit)

1 1

5

2

1

0

1

2

3

4

5

6

15 30 45 60 More

Nu

mb

er

of

Pa

tie

nts


Number of Patients by Time in Exam Room (NP - Dual Visit)

28

Return Visits scheduled for 15 minutes which is consistently not long enough

Overload of patients in clinic (not enough exam rooms)

Overload of MA’s and Physicians in POD (Adding more space)

Some physicians arrive late/spend time talking which creates a backup that can last the

entire day

Patients arriving late always causes bottleneck through the day

Some patients do not realize their appointment is complete and are found sitting in the

exam room waiting for further instruction.

When one MA is sick, no backup MA’s are brought in, this may delay the process in

getting patients set up by creating more work for the MA’s who have to make up for the

missing person

Podiatry patients scheduled with some consideration if patient is having a procedure, but

patient’s needs may still be unpredictable.

Physicians schedules do not contain any allowance for the existence of a trainee. The

exception is the Friday fellows’ clinic, which has an altered structure due to the regular

weekly presence of fellows in the clinic.

Findings from Physician Surveys

The physician surveys provided insight into what physicians see as current potential causes of

bottlenecks that could keep patients waiting in the exam room longer than necessary. A list of

questions that were included in the surveys is located in Appendix E. Below is a list of findings

from the surveys based on patterns in the responses:

A majority of physicians surveyed say they spend between 45 and 60 minutes when

consulting with a new patient and between 15 and 30 minutes when consulting with a

returning patient, while some noted that time is heavily varied from case to case.

All but two physicians said visits take longer than scheduled. Most noted that return

visits need to be scheduled for more than the standard 15 minutes.

Physicians say they know when a patient is scheduled in MiChart and when the patient

checks in. They are notified by an MA when the patient is ready.

Physicians rarely have to wait for patients to be placed in exam rooms. Some noted that

they might wait between 5 and 20 minutes in the mornings, but this is not a normal

occurrence.

Some physicians believe it takes a long time to room patients due to rooms being

unavailable and that leads to bottlenecks. Also, meter downloads were noted to take a

long time and could cause visits to take longer than scheduled.

29

Conclusions Summary

Multiple conclusions were drawn from the analysis of the time studies, MiChart data, physician

surveys, and staff interviews. Below is a list that summarizes the team’s key conclusions that

were considered when developing recommendations:

The time from when the last provider leaves the exam room to when the patient checks

out is longer than expected and may be due to patients not realizing their appointment is

finished.

A large proportion of the time the patient spends in the exam room is spent waiting. For

some appointment types, an average of up to 40% of the time spent in the exam room is

spent waiting.

There is no standard method of notifying the physician that the patient is ready to be

seen.

If a trainee is present, the time spent in the exam room is lengthened significantly. Both

total waiting time and total consultation time are affected leading to an increased total

appointment time.

Some new patient visits and most return visits are scheduled for an inadequate amount of

time.

The time from check-in to the time the patient is ready to be seen by the physician is

longer than the standard of 15 minutes. In addition, the time that the patient spends in the

waiting room and intake is longer than expected and contributes to this longer than

expected time for the patient to be ready to be seen by the physician.

Recommendations

After analyzing the time study data, the responses from the physician surveys and the input from

the project coordinators and other staff involved with the MEND Clinic, the team was able

formulate recommendations. These recommendations are targeted to improve the workflow of

the clinic and focus on reducing the time a patient spends in the exam room while also improving

communication between staff members. The recommendations are broken up to target specific

parts of the workflow at the clinic and are meant to be used as suggestions for improvements.

Reduce Patient Time to Check-Out

It takes on average 10-14 minutes for a patient to check-out of the clinic after seeing their last

provider. This time is much longer than expected and is a part of the process that could be easily

amended to reduce the total time a patient spends in the clinic. The team suggests a solution that

was previously being used at the MEND Clinic and is used at other clinics throughout the

University of Michigan Health System.

To reduce the time to check-out, the team suggest a system of handing a folder to a patient with

their labels inside to bring with them to the check-out desk. Patients are waiting in exam rooms

even when their last provider is finished with them, sometimes simply because the patient does

not know that their appointment is over. Being handed a folder will remind patients that the

appointment is over and they need to proceed to check-out to schedule their next appointment or

30

get paperwork for bloodwork that has been requested by the physician. Also, educating

physicians and other providers to let patients know explicitly that their appointment is over and

they need to proceed to check-out if they are the last provider the patient will see will essentially

eliminate patients from waiting in an exam room when they are no longer required to. This is a

simple recommendation, but one the team feels will greatly reduce total appointment times in the

clinic and free up exam rooms that were previously occupied much quicker than in the current

state.

Reduce Patient Wait Time for the Physician

Physicians do not spend more time with patients than the time they are scheduled to as shown in

Figure 1 and Figure 2 in the Findings section with physicians spending 29 minutes with new

patients and 13 minutes with returning patients on average. These times are below the 45 and 15

minutes allotted to physicians to consult with new and returning patients respectively; however

total appointment time for both new and returning patients has been shown to be too long at 89

and 70 minutes respectively. A majority of this total appointment time is due to the time a

patient spends in the exam room either waiting for or being attended to by a physician. As

patients spend more time in the exam room than scheduled, rooms may be unavailable for a

patient at their scheduled appointment time as the clinic usually schedules the clinic to fill all the

exam rooms. Patients spend more time at the clinic before seeing a physician than the 15

minutes allotted for a patient to be fully worked up and readied for a physician. In conclusion,

an increase in the scheduled appointment times is necessary as patients spend much more time in

the exam room than expected and cause delays in the workflow.

Physicians are also scheduled to see patients back to back with little time to complete other tasks

that are necessary for them to complete their jobs. A physician may only see a new patient for

29 minutes and a returning patient for 13 minutes on average, yet a physician needs to

summarize what happened during the visit and complete other tasks relevant to each visit.

Physicians also schedule patients simultaneously, leaving little time to effectively consult with a

single patient and stay on schedule. Patients are waiting in exam rooms as physicians do not

have enough time between visits to accommodate patients scheduled back to back or at the same

time. Longer appointment times will enable physicians to have more time to complete the other

tasks they are required to complete and reduce the time patients wait for physicians who are not

ready to see them.

Reduce Patient Wait Time for the Trainee

Patients are waiting for trainees just as they are waiting for physicians and can spend anywhere

from 1 to 17 minutes waiting in the exam room. Similar to the team’s recommendation for

waiting time for physicians, implementing a pager system or a better system of notifying trainees

that a patient is ready for them will reduce time patients spend waiting in the exam room.

Another recommendation the team suggests is modifying patient appointment lengths when a

trainee will be present. As the clinic staff do not know when trainees will be present, this

recommendation is challenging, however if there were a way to better anticipate when trainees

will be present, modifying the appointment length for a patient could reduce waiting time in the

31

exam room. Patients will be scheduled for more time giving trainees more time visit with

patients, thus reducing the time patients are waiting while a trainee is with another patient.

Modify General Scheduling of Patients

The time study data shows that patient visit lengths are inconsistent and current visit lengths are

not scheduled for long enough. The team suggests increasing the scheduled appointment length

for return visits from 15 minutes to 20 minutes. This will help improve patient throughput as

physicians will be less likely to fall behind their schedule which in turn will make patients wait

less and spend less time in clinic. Another suggestion for scheduling patients is to look at the

total exam time when scheduling patients instead of just the time a physician spends with a

patient. As patients are spending between 30 and 40 percent of their time waiting in the exam

room on average, scheduling for this total exam room time could help reduce the time spent

waiting in the waiting room and improve the occupancy percentage of exam rooms in general.

The last recommendation on scheduling the team suggests is leveling the number of physicians

in clinic on any given day. Currently physicians choose what days they want to work which

creates uneven occupancy in the clinic throughout the week. By setting a standard schedule for

the number of physicians who are in clinic on any given day, a general workflow could be

implemented and times patients spend in clinic could be more standardized. Standardization

would help the clinic staff point out future improvements as bottlenecks would become clearer.

Reduce Patient Wait Time in Waiting Room and Intake

A patient on average is not seen by a physician 15 minutes after their scheduled appointment

time as the data shows patients being seen 23-24 minutes after their scheduled appointment time

on average. These 23-24 minutes on average take into account the time a patient spends in the

waiting room and intake, with an MA in the exam room, and waiting in the exam room for a

physician.

A physician knows a patient is in an exam room through a couple of ways: either the physician

knows when a patient is scheduled in MiChart and assumes a patient is in the exam room 15

minutes after this scheduled time or the MA notifies a physician if they are working at their desk.

Therefore, a physician is assuming the patient is in the exam room and there is no clear way of

knowing if in fact the patient is in the exam room. Moreover, physicians are not at their desks

every time an MA is finished with their patient and try to notify the physician the patient is ready

to be seen. A physician must return to their desk if they were not there and check to see if the

MA dropped off the patient’s paperwork meaning the initial workup has been completed. Both

of these methods do not provide an effective tool for communicating to a physician that a patient

is ready to be seen as there are too many variables involved with each.

A system to better notify a physician that a patient is ready to be seen would reduce the time a

patient spends waiting in the exam room after the initial MA workup. If each physician had a

pager that could notify them when their next patient was ready, then communication breakdowns

between an MA and a physician would be remedied as a physician would know exactly when a

patient was ready. This may also help physicians use their time with patients more effectively if

they are notified that their next patient is available while they are still consulting with a patient.

They might not want to keep the next patient waiting, so being conscious of when the next

32

patient is ready may in turn reduce consultation time and reduce the overall time patients spend

in the clinic. Also, physicians may be able to use time without patients more effectively as well

as a physician would not be left guessing when a patient was ready if they were not ready on

time; they could complete other tasks knowing they will be notified when the patient was ready.

Expected Impact

The project will provide the following data:

Qualitative assessment and identification of bottlenecks from clinic staff interviews

Quantitative information regarding time usage of clinic staff members using time studies

The project will result in the following changes:

Improved general clinic flow

Reduced overall patient waiting time

33

Appendix A: Time Study Data Sheet Templates

34

35

Appendix B: Total Visit Time Breakdown By Primary Diagnosis Category

Figure B-1. Return Visit Total Visit Time Breakdown with Event Average Times in Minutes (Primary Diagnosis –

Diabetes Mellitus)


October 2 – 17, 2014

Figure B-2. New Patient Appointment Total Visit Time with Event Average Times in Minutes (Primary Diagnosis –

Diabetes Mellitus)


2 – 17, 2014


Osteoporosis/Calcium/Parathyroid)


2 – 17, 2014

36


Osteoporosis/Calcium/Parathyroid)

Sample Size: 4; Source: IOE 481 Team Time Study & MiChart; Collection Period: September 26, 2014 & October 2

– 17, 2014


Thyroid)


2 – 17, 2014


Thyroid)


2 – 17, 2014

37


Other)


2 – 17, 2014


Other)


2 – 17, 2014

38

Appendix C: Tables Used to Generate Total Visit Time Breakdown

Table C-1. Total Visit Time Breakdown Event Average and Standard Deviation Values for All

Endocrinology Appointments

Appointment Event

Return Visit (RV) New Patient Visit (NP)

Average

(Minutes)

Standard Deviation

(Minutes)

Average

(Minutes)

Standard Deviation

(Minutes)

Lateness -11.0 18.5 -12.7 18.7

Waiting Room Time + Intake 18 14 19 14

MA 4 2 5 3

Wait for Physician Without Trainee 13 15 14 14

Physician Without Trainee 21 10 34 14

Wait for Physician After Trainee 7 14 9 7

Physician After Trainee 11 5 12 7

Wait for Fellow 13 13 6 9

Fellow 13 5 20 12

Wait for Resident 12 10 11 6

Resident 13 3 17 5

Wait for M3 17 10 1 -

M3 10 4 6 -

Wait for Nurse 7 1 3 3

Nurse 8 5 21 17

Wait for Nurse Assist 1 2 - -

Nurse Assist 6 3 - -

Wait for Dietitian 5 3 0 -

Dietitian 8 2 10 -

Time to Check Out 10 29 14 34

Whole Appointment 70 39 89 45

Exam Room Time 41 19 55 23


Podiatry Single MA Visit Appointments

Appointment Event


Average

(Minutes)

Standard Deviation

(Minutes)

Average

(Minutes)

Standard Deviation

(Minutes)

Lateness -12.2 20.0 -9.4 20.0


MA 3 1 5 2

Wait for Physician 11 11 10 11

Physician 11 6 16 8

Nurse In Addition to Physician

Time 11 5 15 -

Wait for Nurse Alone 8 6 13 -

Nurse Alone After Physician Exits 11 7 16 -

39





Podiatry Dual MA Visit Appointments

Appointment Event


Average

(Minutes)

Standard Deviation

(Minutes)

Average

(Minutes)

Standard Deviation

(Minutes)

Lateness -14.1 23.4 -2.4 16.6


MA 4 1 5 3

Wait for Physician 9 8 9 10

Physician 10 5 15 7

Nurse In Addition to Physician

Time 2 2 - -

Wait for 2nd MA Visit 4 4 3 3

2nd MA Visit 8 3 8 5





Endocrinology Appointments – Primary Diagnosis: Diabetes Mellitus

Appointment Event


Average

(Minutes)

Standard Deviation

(Minutes)

Average

(Minutes)

Standard Deviation

(Minutes)

Lateness -12.4 17.2 -13.7 13.7


MA 4 2 6 3






Fellow 16 6 22 11

Wait for Resident 13 12 7 4

Resident 14 3 18 4

Wait for M3 11 7 - -

M3 10 4 - -

Wait for Nurse 7 1 3 4

Nurse 8 5 30 14

Wait for Nurse Assist 0 - - -

Nurse Assist 4 - - -

40

Wait for Dietitian 5 6 0 -

Dietitian 9 1 10 -





Endocrinology Appointments – Primary Diagnosis: Osteoporosis/Calcium/Parathyroid

Appointment Event


Average

(Minutes)

Standard Deviation

(Minutes)

Average

(Minutes)

Standard Deviation

(Minutes)

Lateness -17.1 20.3 -6.3 15.3


MA 4 3 5 0



Wait for Physician After Trainee 9 6 - -

Physician After Trainee 10 6 - -

Wait for Fellow 13 5 - -

Fellow 17 4 - -

Wait for Resident 16 2 - -

Resident 8 2 - -

Wait for M3 21 - - -

M3 15 - - -





Endocrinology Appointments – Primary Diagnosis: Thyroid

Appointment Event


Average

(Minutes)

Standard Deviation

(Minutes)

Average

(Minutes)

Standard Deviation

(Minutes)

Lateness -5.0 20.5 -10.0 16.6


MA 3 2 5 3






Fellow 11 3 16 7

Wait for Resident 12 - 12 5

41

Resident 10 - 17 7

Wait for M3 36 - 1 -

M3 5 - 6 -

Wait for Nurse Assist 3 - - -

Nurse Assist 9 - - -

Wait for Dietitian 4 - - -

Dietitian 5 - - -





Endocrinology Appointments – Primary Diagnosis: Other

Appointment Event


Average

(Minutes)

Standard Deviation

(Minutes)

Average

(Minutes)

Standard Deviation

(Minutes)

Lateness -11.5 16.9 -17.1 25.6


MA 4 3 5 3






Fellow 13 7 24 18

Wait for Resident 7 3 22 -

Resident 11 1 16 -

Wait for M3 14 - - -

M3 10 - - -

Wait for Nurse - - 5 -

Nurse - - 5 -

Wait for Dietitian 5 - - -

Dietitian 11 - - -




42

Appendix D: Staff Interview Questions

For Schedulers:

1. Do you consider whether a physician has a trainee when scheduling appointments for that

physician?

2. Do you schedule Podiatry patients differently if they require an MA to file their toe nails?

For MAs:

1. Do you think patients wait longer than expected for the attending physician?

2. When you finish meeting with a patient, how do you notify the physician that the patient

is ready to be examined?

3. What do you see as the biggest bottleneck that keeps patients in the room longer than

expected?

43

Appendix E: Physician Survey Questions

1. When consulting with new patients, how much time do you spend?

2. When consulting with returning patients, how much time do you spend?

3. Do you think visits are scheduled for an adequate amount of time? Are there any specific

visit types that regularly take longer than scheduled?

4. Are you aware of how long a patient is waiting in the exam room before you enter? If so,

please explain how you receive this information.

5. On average, how long are you waiting for a patient to be placed in a room for you to see?

6. Do you see bottlenecks in the work flow of the clinic? If so, please specify and explain.

Documents

The University of Michigan Health System Metabolism ...ioe481/ioe481_past_reports/F1405.pdf · Mary G. Duck, Industrial Engineer Expert, University of Michigan Health System Dr. Mark