Nicole Brown, Front Office Manager (Project Coordinator)
Dr. Eric Heggland, Sports Medicine/Orthopedic Surgeon
Rachael Esplin, Medical Assistant
Summer Secord, Scheduling Coordinator
Bonnie Jasman Cech, President, Cech Systems (Project Consultant)

Decrease care delays (office waits/cycle times, and time to third next available appointment) by 50 percent within 12 weeks.

• Third next available appointment for consults and short follow-up visits
• Average cycle time for consultation appointment
• Average number of minutes late starting with the first patient of the morning and first patient of the afternoon clinic
• Average number of minutes late starting with the last patient of the morning/afternoon clinics
• Average number of patients arriving late for their appointment
• Average minutes late to room the patient
• Average minutes late for the physician to enter the room after the patient was roomed
• Average patient turnaround time
• Average number of minutes that expire between patient visits
• Average number of minutes of physician-patient (face-to-face) time by appointment type
• Other physician “vital sign” measures included:
  • Average number of patients seen per hour available
  • Percent of patients double booked
  • Number of hours of  excess capacity per week
  • Number of visit hours that remained open (unfilled)

• Measured demand and capacity, and determined appropriateness of open access scheduling
• Worked down appointment backlog and incorporated backlog management tools into weekly physician reporting
• Analyzed patient flow data, clarified amount of time needed for each appointment type, and established new appointment increments.  Physicians and staff experienced a higher degree of predictability and consistency in office flow each day.
• Reduced/eliminated double bookings
• Focused scheduling and back office staff on the importance of optimizing throughput and reducing excess capacity
• Streamlined patient flow processes (e.g., check-in, rooming, late patient procedure) to run on a more timely basis.  Physicians/staff went home earlier each day, and had a greater sense of completion at the end of the day, while maintaining or increasing the total number of patients seen.
• Developed patient education materials and staff scripts to communicate new processes/procedures appropriately to patients
• Streamlined paper flow processes (e.g., telephone triage, test tracking and results reporting, filing, mail sorting/routing) to enable physicians/staff to complete more of their work throughout the day, rather than at the end of the day
• Designed new interoffice communication tools that were easier for the physicians/staff to complete at the time of visit

• Maintaining a focus on the overall objective/desired outcome of the project — in this case, to increase throughput, while simultaneously decreasing care delays and operating inefficiencies — provides a helpful framework (“rudder”) when discussing changes/improvements to individual parts of the process/system.
• It is important for all “stakeholders” to be involved in the discussion and change process.  This not only helps to identify issues earlier in the process, but also obtains buy-in along the way, and significantly increases the clinics ability to sustain the changes in the long run.
• Incremental changes via the rapid cycle testing is an effective way to make changes, experience improvement, make appropriate adjustments, and continue to build (add improvements) on successes.  
• Communication is the key.  What is stated and written in an organization is what is important.  It’s easier to sustain the changes when the organization is committed to continuous dialogue/press about the process and results achieved.
•  Strong commitment from senior leadership is crucial. 

Nicole Brown
Intermountain Orthopaedics
nbrown@intermountainortho.com

[Storyboard presentation at IHI's National Forum, December 2004]