Small Changes, Big Efficiency Boosts at Medical Practices

A medical office is not an assembly line, but the two share at least one characteristic:  The same discrete tasks are performed over and over again.

In manufacturing, any task that consistently takes widely divergent amounts of time to perform is considered out of control, and a sign that something is wrong with the process.  The same is true in a medical office.  Let's look at an example:

Organizing charts for patient visits

In an office with 15 providers seeing close to 200 patients a day, records personnel pull the charts for the next day's visits.  The files are delivered to the reception area the next morning, in alphabetical order by patient last name.  This is a very efficient process for the records clerks since both the pull list and the charts are organized by patient last name. When a patient checks in, one of two receptionists retrieves the patient's file, clips the superbill to the front, and places both in a file for the appropriate provider. 

Total time of process: .25 minutes to retrieve a chart X 200 patients per day = 50 minutes per day

The reality, however, is very different. The receptionists have significant trouble locating a patient’s chart about 10 percent of the time (taking about 20 minutes to locate each missing chart).  Sometimes the chart was not pulled in the first place; sometimes it was misplaced during the course of a busy day.  Clinic staff often has to come to the front to look for the chart, and providers are often idle waiting for a patient's chart to be found. 

Ignoring the impact on other parts of the practice, making a chart available for a provider actually takes an average of almost two minutes longer than estimated. Here’s why:

Total time of process:

.25 minutes X 200 patients per day X 90 percent = 45 minutes per day
20 minutes X 200 patients per day X 10 percent = 400 minutes per day
45 minutes + 400 minutes = 445 minutes per day

OR

445 minutes/200 patients = 2.2 minutes per patient
445 minutes/60 minutes = about 7.5 hours per day

Instead of the process taking less than an hour per day, it amounts to a full-time job due to the extreme variability of the task.  The process is very quick when a chart is where it is supposed to be, but each misplaced chart takes a lot of time to resolve. 

The key to an effective solution is to minimize the percentage and number of misplaced charts.

A more efficient solution:

Part of the solution for the practice described above is to have records personnel pull charts by provider, making 15 passes through the alphabet for the next day's patients.  The downside of multiple passes is more than offset by four factors:

• When records are pulled using a single list of patients, several staff members divide the list and work on it concurrently.  The pieces do not always get assembled correctly.
• When individual records clerks pull charts by provider it allows for accountability.  The records clerk who pulls charts for a particular provider signs the pull list.
• Each provider's staff checks the pulled charts against the list of the next day's patients to identify missing charts before the patient presents for the appointment.
• When looking for a particular chart, the receptionist only looks through the charts for the appropriate provider.  Even if charts are out of order alphabetically, it is not difficult to flip quickly through the twenty or so charts for the provider's patients for the day and locate it.

An added bonus:
A number of providers and their staff members decide they like the idea of having the day's charts in their pods.  Their initial motivation is to make sure they can find them when needed.  Over time, they find it convenient to have the charts readily at hand during the day.

Results:
• Some charts are still missing, but they are identified the day before a scheduled visit.
• Records clerks, not receptionists, look for missing charts.  Since the clerks are responsible for the care of the charts, this aligns responsibility and consequences.
• Almost half of the receptionists' actual daily work is eliminated, giving them time to attend to tasks that had been neglected.

Lessons Learned:
• Estimates of time required to complete a task need to come from observation over time, so that variability can be taken into account.
• Accountability improves results.
• The sooner a problem is identified, the easier it is to deal with.
• It is easier to find a needle in a small pile of straw than in a haystack.