Methodist Dallas Medical Center



Methodist Dallas Medical CenterKyle ChesterKristin EvantoEmily GrayEMIS Senior Design5/10/2010A study conducted of the personnel and processes involved in the outpatient laboratory of Methodist Dallas Medical Center. Technical and Managerial Recommendations for the improved efficiency of technician and patient time spent. Contents TOC \o "1-3" \h \z \u Management Summary PAGEREF _Toc261195893 \h 3Background PAGEREF _Toc261195894 \h 4Analysis of the Situation PAGEREF _Toc261195895 \h 6Analysis and Managerial interpretation PAGEREF _Toc261195896 \h 7Recommendations and Conclusions PAGEREF _Toc261195897 \h 10APPENDIX PAGEREF _Toc261195898 \h 13Management SummaryMethodist Dallas Methodist Center (herein MDMC) services a wide variety of patients from all across North Texas, with treatment ranging from simple physician checkups to life saving cardiovascular surgery. Physicians and surgeons practicing at MDMC utilize a large external network through the Methodist Health Services network for comprehensive treatment. However, the majority of services required by physicians and surgeons for their patients are available within the Methodist Dallas Medical Center campus. A “hub” of activity at MDMC is the Outpatient Services department. Outpatient Services exists to serve the needs of physicians and surgeons alike with routine x-rays, blood draws to test for Tuberculosis or other ailments, or diagnostics to assess patient health. Many patients who come to Outpatient Services are preparing for surgery and thus need to undergo preliminary screens such as blood draws and EKGs. All of these functions, and many more outside the scope of this investigation, are housed within MDMC’s Outpatient Services. The focus of this project is the observation and analysis of the administrative and technical operations within the laboratory component of Outpatient Services. This scope excludes the Radiology laboratory, which shares office and waiting spaces with Outpatient Services. However, our observations of the contrasting management and administrative practices between the two divisions (Outpatient lab and Radiology) provided useful qualitative and quantitative data during our study. Outpatient Services aims to reduce its patient wait times throughout the entire duration of a patient’s stay in Outpatient Services. Management has expressed a desire to reduce patient wait times such that 95% of all patients wait less than 15 minutes for the Outpatient laboratory department. After spending time with Outpatient employees, observing the Outpatient process holistically and on a micro level, and gathering months of self reported data from Outpatient Registration, we have developed a number of tangible recommendations for MDMC management that will help Outpatient Registration achieve their wait time goals.BackgroundThe Outpatient Services lab at Methodist Dallas Medical Center experiences undesirably long wait times. The consequence of long wait times is simplistic, yet crucial to the operation of the hospital: unhappy patients. Methodist Dallas is “Where Life Shines Bright;” however, one would not see this motto illustrated on the faces of patients waiting to be called into the laboratory. Patient satisfaction is critical to the success of the entire hospital operation in that patients who are repeatedly dissatisfied with the services they receive will inevitably take their business elsewhere. Clearly, increasing patient satisfaction must be a priority for Outpatient Services. One central issue when analyzing patient wait times in the Outpatient lab is the relation between staffing levels and the unpredictable nature of patient arrivals. The Outpatient lab currently has 2.75 full-time employees who conduct all administrative and medical operations within the lab. The purpose of this project aims to circumvent obvious, and costly, solutions such as “hire more employees.” Not only does hiring additional staff increase costs, but it also fails to address the root cause of patient waiting: inefficiencies throughout the process. Matching employee levels with a distribution of patient arrivals is a very tricky process. Although technicians may observe that “Wednesdays are busy” and “Friday is slow,” there are deeper variables impacting the number of patients arriving on a given day. Patients are often required to fast before undergoing a pre-operation lab or blood analysis to eliminate discrepancies caused by blood glucose levels and other variables. Also, the patients who patronize MDMC are stereotypically overweight, elderly, and from low income. This demographic often does not have the ability to undergo treatment at their convenience, whether due to lack of required assistance or due to limited transportation to the hospital. Moreover, many doctors have preferred days for appointments, which are randomly distributed and entirely unpredictable for the purpose of matching staff to demand. On those preferred days, the smooth operation of the lab may be compromised. Currently there are three lab technicians, two of which are full-time employees and one employee is part-time. One full-time technician has been employed by MDMC for quite some time and is very familiar with the systems and processes; however, as result, she may be the least receptive employee to change. The second full-time employee was hired within the past three months and although she is still learning the intricacies of the lab operations at this particular hospital, she has prior experience as a lab technician at St Paul’s Medical Center in Dallas. For any recommended changes to be successful, the current laboratory staff will need to feel vested in the process. MDMC has proposed a renovation solution that will aid in reaching their wait time goal if the proposal is matched by management’s execution of necessary process changes in Outpatient Services. The room adjacent to the laboratory, currently housing a help desk and telephone associates, would be added to the current lab space, approximately doubling the size of the current operation.Observation of the laboratory operations was the most significant data source in determining the root cause of inefficiencies. A detailed observation of the flow of activities within the laboratory revealed that, while safety and health procedures are closely followed, there is no standard sequential order of tasks to be completed with each patient. Rather, technicians follow an ad hoc approach to each patient. These secondary activities do not add face-to-face time with the patients; they are non-value add activities that, while necessary, should be streamlined such that their place and time significantly improve the speed at which technicians can serve patients. An area of concern is Outpatient Services’ patient logs and overall data entry procedures. Prior to 2010, the only records of patient arrivals and services were the logs from the registration desk, which encompass both Radiology and Outpatient Services. Outpatient Services did not track patient wait times, arrival times, or service times. Starting in 2010, arrival times and call times were manually recorded on a sign-in sheet and used for logging wait times. However, these recorded times significantly under-represent the actual amount of time patients spend waiting in the lab. This issue will be addressed in more detail later in this report. Because there are no accurate representations of historical patient distributions, a significant part of time spent in this analysis was devoted to salvaging all available manual patient logs. Since the patient logs analyzed contained sensitive information, we were required to sign HIPA confidentiality agreements. Analysis of the SituationInitial visits to learn the operations at Outpatient Services provided the opportunity to meet personnel of the administrative and laboratory functions and gain their perspective on the current state of the operation’s efficiency. The “veteran” lab technician was very willing to walk through the different procedures. We soon learned that the qualifications of the lab technicians was not a source of concern, as each can easily perform all tasks associated with the handling of the patient. Main concerns within the laboratory were focused on the claustrophobic lab room physical space. There are efficiency concerns associated with excess patients, who are not being serviced, waiting in the middle of a high volume walkway in the lab. Also, due to a lack of scheduling, there are health concerns with the treatment of newborn babies, who are often treated amongst elderly patients being treated for illness. Aggregated patient logs for March and April, which are the only logs that record patient arrival times, call times, and can infer wait times, illustrated a distribution of patient arrival times per hour that is skewed towards the late morning. Laboratory visits were conducted to discover a distribution of service and wait times separate from MDMC’s self reported logs, as well as to observe each step in the lab process and isolate critical activities for improvement. Time spent entering patient orders at a computer terminal appears to be a roadblock that halted progress on each patient. Technicians often had to leave the lab and seek out confirmation or clarification on a patient’s order. This process added at least five minutes of idle time in each instance that the technician needed to leave the lab. This delay slowed down the entire operation of the lab, putting excess strain on the other technician(s).Analysis and Managerial InterpretationAfter the first few weeks of observing the people and processes involved with Outpatient Services, a general belief developed that the patient entry procedure played a major part in heightened patient wait times. When we approached management with the hypothesis that the computer terminal was the root cause of chaos within the lab, they were hesitant to accept. Investigating the practices of the other unit within Outpatient Services, the Radiology lab, we discovered that they have a process flow similar to our proposed process. Separation of the administrative functions within the lab from the technical/lab functions will significantly reduce high wait times due to complex patient orders that technicians have to enter. Also, by creating a step-by-step procedure for both the administrative and laboratory functions within the lab, there is less opportunity for time wasted caused by a lack of a set order of tasks for each patient. (See Appendix)One of the issues inherent in the operations and procedures of the Outpatient lab rests in their patient logging. Currently, as shown in the diagram above, technicians call in patients to fill up two extra seats in the lab. At this point, Outpatient Services records the patient’s service time as having started. However, once the patient is inside the lab, in seats 4/5, there is still at least 5-10 minutes more of waiting. Although this cannot be verified, as this “limbo” time was not recorded during our process of observing the lab process to obtain a service time and breakdown, this current method of recording patient wait times artificially decreases the actual wait time for patients. Underestimating the time patients spend in the throughput of Outpatient Services lab is a critical error that must be remedied. It leads to a false sense of security; management sees numbers that are acceptable by their standards, and reinforces to the technicians that they are meeting or exceeding expectations. Complacency will only cause the issue to worsen, and the first step in not being complacent is to change the lab’s practice of recording patient times. Additionally, it is worth considering altogether eliminating chair 4/5, as they seem to serve little purpose other than as a boost to the patient log times while allowing additional waiting.Waiting does not stop once a patient is called to chair 1/2/3 for their laboratory procedure. Based on a breakdown of all tasks in the patient throughput inside the lab, four major categories were constructed to categorize each step in the process. The first category, ADMIN, covers administrative tasks and is the primary target for operational improvement. The computer terminal is used to manually enter in patient orders and print labels for specimens to be delivered throughout the hospital. The process is necessary for each patient; however, the way in which the Outpatient lab approaches computer entry hurts the efficiency of the entire operation. The second category, WAIT, is the time the patient is in chair 1/2/3, but is idle because the technician is not servicing or performing administrative tasks related to the patient. The third category, SERVICE, is the actual procedure taking place in the lab. The time frame for this category is when the technician is directly in contact with the patient.The last category is PREP, which is time where the patient and/or technician are preparing for a blood draw, EKG, or NBS. In the case of the technician, this task category includes preparing vials for a draw, washing hands, etc. The breakdown of patient time spent in the lab, their “service” time (excluding time waiting in chair 4/5). This shows how much non-value-add time there is compared to the actual procedure:From observation, 60% of the patient’s time in the laboratory is spent waiting while a technician does administrative tasks on the computer or is working on another patient. Throughout the entire process, patients have had to now wait for service in four separate stages. Patients wait to be registered at the front desk; from observation this process is quite slow as well. There are 3-4 administrative workers who register patients, but the registration desk encompasses more than just the Outpatient lab. After registering, patients move to the second waiting area where they wait to be called into the lab. Once in the lab, the patient sits in chair 4/5, where they spend more idle time. Even when chair 1/2/3 is available and the patient is able to bypass char 4/5, there are often times when a technician has to run out of the lab to confirm orders, and the patient is again left to wait. By stopping the patient’s logged wait time when they are called into the laboratory, thereby not including time spent waiting in any chairs, OPS are significantly underestimating its wait time. Whereas they estimate their wait time at around 10-15 minutes, and their daily logs show an average wait of 18 minutes, they disregard up to an average of 14 minutes of time in the laboratory when patients are left idle. The data from laboratory observation was collected and compiled to create a Poisson distribution of arrival times. A Poisson distribution is memoryless, that is, the length of the time interval from the current event to the occurrence of the next event does not depend on the circumstances of the occurrence of the previous event. Even with the relatively inaccurate reporting methods utilized by OPS, queuing theory has applications for predicting worst case scenarios, as well as giving us a relative efficiency metric of the current lab process versus the proposed process. The service time had to be manually calculated, as OPS’ self-representation of their service and wait times are underestimates. Under the current lab conditions of two technicians, an arrival rate of 4.33 patients per hour was determined, as well as a service rate of 8.61 patients per hour. A utilization rate of .25 was observed with two technicians. This is clearly not how the process actually is; the lab flow is hindered by the administrative tasks on the computer, which are not included in the service time. However, this data is good evidence that the problem is indeed not a staffing issue, so OPS has the opportunity to improve their efficiency with better process protocols. Recommendations and ConclusionsHaving spent hands on time with the employees within the Outpatient Services lab, and observed the complexity of the process, we have agreed on several recommendations that are defensible by data, observation, and other hospital administration practices. The chief issue is clearly the administrative tasks conducted at the computer during a patient’s visit to the lab. The entire throughput for each patient thereafter is due to the time spent entering and confirming patient orders. To eliminate the bottleneck that so often arises from this step in the procedure, Outpatient Services should separate the administrative function from the laboratory function. That is, have a designated technician whose primary responsibilities (on a given day, a rotation will be established between the technicians) revolve around entering patient orders, confirming doctor requests, and preparing each patient’s file for their lab, pre-op, or other procedure. Having this process run in parallel to the other two technicians who are able to focus solely on servicing patients will make both processes flow more smoothly. Dividing the attention of the technicians in the way that the computer terminal does with patients is very counterproductive and the root cause of extended wait times in Outpatient Services. The Administrative lab technician will be a responsibility that rotates between the three technicians. During peak hours this position is most crucial, as this is when the process can stall due to excessive strain caused by high volumes of patient arrivals. By dividing the responsibilities, the service rate of each technician will drastically improve. When discussing this proposal among ourselves, we analyzed the Radiology department’s process as grounds for comparison. We discovered that they operate a parallel process very similar to the one we proposed. This corroborating evidence for change right across the hall should help convince OPS that the Administrative Lab Tech position is an ideal solution. Additionally, the distribution of patient arrivals by hour and day is very conducive to allowing a block scheduling system for certain procedures. As discussed earlier, matching staffing levels to patient levels is often infeasible due to the constraints of the patients’ schedules and the unpredictable nature of patient arrivals. Walk-ins will still always be accepted, but OPS should inform its constituents of the potential for scheduled appointments based on their required procedure. One of the main concerns is the potential health hazard from failing to separate the newborn babies receiving PKU screens from the sick elderly are receiving care. If screaming babies can be limited to certain afternoons, everyone will be happier. This scheduling procedure does not need to interfere with the current operations, nor is it intended to be a paradigm shift in the way OPS administers care. It is simply meant to smooth demand throughout the week by scheduling appointments during the non-peak hours that occur in the afternoon and latter parts of the week. The use of the already established Scheduling Department within MDMC will aid the establishment of optional schedules for OPS.Finally, Outpatient Services needs to improve its patient tracking logs. Accurate metrics are crucial for monitoring the capacity and efficiency of the lab operations. Improving the patient logs begins with eliminating chairs 4/5 in the laboratory. These chairs serve no purpose other than reducing the “on paper” patient wait time. However, bringing the patients from one waiting room to another serves only to irritate a waiting patient. Hours of observation provided the opportunity to see this phenomenon first hand. Patients would walk into the lab with a sigh of relief, after already undergoing multiple stages of waiting. When they were told to wait in chair 4/5, many patients would simply ask to wait outside due to the claustrophobic conditions of the lab.This investigation of Outpatient Services at Methodist Dallas has revealed key areas for improvement of the laboratory throughput. The lingering concern is if management has the wherewithal to push for these changes. Complacency is clearly an issue, with a tenured laboratory technician who is set in her ways and quite content with the status quo, in addition to management that promotes the status quo through inaccurate patient metrics. If the Outpatient Services laboratory can take these first steps towards improving the efficiency of its processes, results will follow, in the form of bright shining smiles that which Methodist Dallas Medical Center aims to deliver. APPENDIXOld Process:NEW PROCESS:# PatientsAverage Wait1-Mar550:13:002-Mar240:05:003-Mar510:14:004-Mar340:17:005-Mar340:06:008-Mar390:20:009-Mar340:20:0010-Mar220:31:0011-Mar450:50:0012-Mar410:39:0015-Mar420:12:3916-Mar300:11:5417-Mar270:14:1418-Mar330:21:2519-Mar350:16:1022-Mar350:50:1523-Mar440:27:2524-Mar310:25:5625-Mar370:17:0026-Mar420:16:0829-Mar550:21:0130-Mar580:20:4931-Mar330:13:001-Apr510:16:002-Apr510:14:005-Apr630:15:006-Apr520:28:007-Apr520:14:008-Apr630:34:009-Apr340:14:0012-Apr730:13:0015-Apr430:06:0016-Apr440:08:0019-Apr610:16:0020-Apr450:04:0021-Apr450:06:0022-Apr380:06:0023-Apr470:12:0016430:18:08 ................
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