General Surgery ClinicBMC

Operations Team 4Asad Butt

Eszter HamoriDinesh Kurian

Cristina PedrozaJoel Samen

Boston Medical Center (BMC)

“Exceptional care without exception”

• Private Non-profit• Located in South End• BU’s Teaching

Hospital

34%

32%

18%

7%

4%4% 1%1%

WhiteBlack / African-AmericanHispanic /LatinoOtherAsianDecline / NAMiddle EasternBlankAmerican Indian / Native Ameri-canNative Hawaiian / Pacific Islander

37%

63%

NewEstab-lished

Meet the Patients

Appen

dix

Other

Herni

a

Cysts

Stab

/Cut

G tube

repl

acem

ent

0

2

4

6

8

10

12

14

16

0%

20%

40%

60%

80%

100%

120%

Pa

tie

nts

pe

r ca

se

…Their Medical Concerns

…And Medical Care Competitors

Environment

•Medical Assistants•Nurse Practitioners•Reception Staff

•Attendings•Residents•Students

•Patients•Examination Rooms

Patient´s Perspective

StartPatient checks

in

Patient is waiting in

sitting area (Wait 1)

Patient is called

Patient is escorted to examination

room

Patient is examined by

resident

Patient waits for attending

doctor (Wait 3)

Patient is examined by resident and

attending doctor

Patient’s vitals are taken

Is resident available?

Patient waits for resident

(Wait 2)

Is attending doctor

available?

Patient checks out

Is follow-up appointment necessary?

Patient gets schedules new appointment

End of processIs a

specialist requried?

Patient is examined by

specialist

Patient leaves examination

room

Yes

Yes

No No

Yes

Yes

No

Yes

No

Patient is escorted

to Examinatio

n Room

Consultation Process

Medical AssistantMedical

Assistant (MA) calls the

patient

MA escorts patient into examination

room

MA takes patient’s

vitals

Examination room

available?YesStart End

Resident Doctor

Staff´s PerspectiveConsultation Process

Resident examines the

patient

Attending doctor

available?

Resident enters the examination

room with attending doctor

Resident exits the room

Resident enters the room

Resident waits for attending in

conference room or the hallway

Consultation by resident and

attending

Resident explains details to attending in

conference room or hallway

Resident exits the examination

room

Start

No

Yes

End

New patient in examination

room?Yes

Resident waits for new patient, writes notes for previous patients, answers

pages

No

Attending Doctor

Wound Care Ostomy Nurse (Specialist)

Staff´s PerspectiveConsultation Process

Resident enters the examination

room with attending doctor

Consultation by resident and

attending doctor

Resident explains details to attending in

conference room or hallway

Attending doctor exits the

examination room

Start End

Resident approaches attending to present new

patient

Wound care and ostomy nurse enters the

examination room

Wound care and ostomy nurse

educates patient on their condition

Wound care and ostomy nurse exits the room

Start EndWound care and

ostomy nurse examines patient

Wound care and ostomy nurse

requried?Yes

07:18 08:30 09:00 09:30 10:00 10:30 11:000

1

2

3

4

5

6

7

Patient Check-In by Time

Check-In Time

Num

ber

of

Pati

ents

07:1

8:00

AM

07:4

5:00

AM

08:0

9:00

AM

08:1

1:00

AM

08:4

4:00

AM

09:0

9:00

AM

09:1

7:00

AM

09:1

8:00

AM

09:2

4:00

AM

09:2

7:00

AM

09:2

8:00

AM

09:3

1:00

AM

09:5

5:00

AM

10:0

4:00

AM

10:1

0:00

AM

10:1

7:00

AM

10:2

2:00

AM

10:3

4:00

AM

10:5

8:00

AM

11:0

0:50

AM

11:1

1:00

AM

0:00:00

0:07:12

0:14:24

0:21:36

0:28:48

0:36:00

Wait (1)

Tim

e S

pent

Wait

ing

Why You Wait at the Doctor

Variability in Demand

Patient Type

Case Type

AvailabilityStaff

Effectiveness vs. Efficiency

Shared Resources

Attendings

Non-English Speaking Patients

TrainingProgram

Small Number ofTranslator Phones

Machinery Measure

Manpower

On the Job Learning

Method

Throughput Time

Issues with the Process

Socioeconomic

FactorsCan´t Skip Work

No Children Care

Clinic Premises

Limited Parking

Dark, Boring, Narrow

Transportation

Insurance Coverage

No Car

Limited / No-Coverage

Machinery Measure

MaterialsMethod

Lack of Escort

Access to Public Transportation

Uncomfortable Seating

Absenteeism

Market Research

Benchmark

Service Guidelines

No Written Procedures

Role Ambiguity

Staff Working As a Silo

Measure

Method

Customer Satisfaction

Survey

Data Collection

Measure

Manpower

Disconnection with Top

Management

Lack of Process

Statistics

No Targets Set

Expectation Misalignment

Step in ProcessAverage Time

(Minutes)Maximum Minimum σ

Wait (1) 7:31 33:26 0:50 9:21Triage 4:01 7:54 0:55 2:00Wait (2) 12:16 34:17 0:48 9:06Examination 12:52 21:20 1:17 5:04Wait (3) 6:23 26:22 0:36 7:28Consultation 6:25 17:12 1:00 4:57Throughput 52:50 92:00 0:21 0:18n = 21 patients

Quality of Service: Process Specifications

Doctor Patient

Expectation:To be simultaneously effective and efficient

Short time with each patient

Expectation:Spend approximately 39 minutes with medical staff

Misalignment

Quality of Service: Process Expectations

25 Minutes with Medical Staff

Address No-Show Rate

Reduce Schedule Variability

Decrease Throughput

Time

Manage Expectations

Improve Waiting

Experience

Recommendations

Notice Form

Reminder to Patient

Documentation for work

Travel Help

Pre-Paid MBTA Tickets

Parking Validation

Insurance Informatio

n

Available Before

Appointment

Open Exchange of Information

Recommendation: Address No-Show Rate

Separate Scheduling of New and Old

Patients

Consider Type of Appointment

Standardize

Patient Times

Recommendation: Reduce Schedule Variability

27 Minute

s of Waiting

25 Minutes

with Medical

Staff

52 Minute

Throughput

Time

Standardize Patient Times

Evenly Distribute

Appointments

Decrease Paging

Incentivize Effectiveness and Efficiency

Add More Translation

Phones

Recommendation: Decrease Throughput Time

Medical Staff

Feedback

Write Formal Process

Guidelines

Collect Data to Track Process

Recommendation: Manage Expectations

Recommendation: Improve Waiting Experience

Happier Patients

Address No-Show Rate

Reduce Schedule Variability

Decrease Throughput

Time

Manage Expectations

Improve Waiting Area

Creating a Better Patient Experience

Appendix: Resident Time with Patient

0 5 10 15 20 250:00:00

0:02:52

0:05:45

0:08:38

0:11:31

0:14:24

0:17:16

0:20:09

0:23:02

Time with Resident

Appendix: Attending Time with Patient

0 5 10 15 20 250:00:00

0:02:52

0:05:45

0:08:38

0:11:31

0:14:24

0:17:16

0:20:09

Time with Attending

Tim

e e

lapsed