By Zachary Stucki, systems analyst, Valley Perinatal Services LLC, Mesa, Ariz.; Maryam Khorshidi, MBA candidate, Arizona State University; Justin Jones, MBA candidate, Arizona State University; Peter Bovaird, MBA candidate, Arizona State University; Myke Scaffidi, MBA candidate, Arizona State University; and Jin-Chang Zhou, MBA candidate, Arizona State University
For one week, patient flow — from the moment they walked in the door to the moment each one left the clinic — was tracked with a stopwatch at a perinatal services group. With this data, analysis was done to identify process utilization, identify a bottleneck, categorize visit types into “quick” or “comprehensive” visits, create a process diagram and identify potential points of improvement.
On average, the clinic serviced 37.5 encounters a day, split between comprehensive visits (CVs), which included at least one provider consult following an ultrasound scan, and quick visits (QVs), which did not.
CVs lasted about three times longer (92.4 minutes) on average than QVs (30.3 minutes). Of in-clinic time, CV patients spent 24% of their time (21.5 minutes) waiting, while QV patients spent 16% of their total time (4.9 minutes) waiting. Most of the wait times concentrated around the ultrasound exam or a visit with a maternal-fetal medicine (MFM) specialist.
One of the three processes begins when a new patient arrives at the clinic. The patient is immediately checked in by a medical assistant (MA), given new patient paperwork, and asked to provide ID and insurance cards for digitization, returning all paperwork to the MA. Depending on the availability of an MA, the patient may be taken back immediately or have a brief wait before the MA brings him or her back to collect vitals before either being taken to the ultrasound room or waiting for the scan, based on availability.
After the scan, the new patient will either be allowed to leave while the sonographer writes the report or may be expected to wait for two more brief appointments — first to see the specialist then the nurse practitioner (NP), depending on whether the patient will be co-managed. After seeing the specialist and NP, the patient will then have a blood draw and schedule a return appointment before departing.
The returning patients’ process is more streamlined: They enter, check in, wait for the sonographer to call them back for the scan and, upon finishing the scan, are allowed to depart while the sonographer writes the report. They may have to wait to see either the specialist or NP briefly, depending on any complications that may arise during the scan or the type of appointment scheduled.
When co-managed patients arrive, they check in, and wait for their scan. After finishing the scan, the co-managed patients wait for the appointment with the NP or specialist while the sonographer report is completed. After meeting with the NP or specialist, the co-managed patient will have a blood draw and schedule a follow-up appointment before he or she leaves.
Using the calculations (see Table 1), the sonographer was identified as a bottleneck — with 75% utilization — and the ultrasound room as the next constraint.
To enhance this process, wait times can be overlapped with productive steps, unnecessary work can be offloaded from ultrasound technicians to MAs, and report writing can be assigned to sonographers, allowing scanning to increase their capacity. Re-ordering the necessary steps during the process would reduce the input variability to the bottleneck, avoiding idle time due to delays in previous steps. By implementing this change, the overall wait time of the CV patients would be reduced about 46% from a long average wait time of 21.5 minutes to 11.5 minutes. The overall time spent at the clinic for those patients would also be cut by about 10%, reducing the burden to spend time off from work at the center. Hiring or assigning a reporting sonographer to write reports in real time effectively adds up to 7.4 patients per day and would add 115.2 minutes per sonographer per day, increasing profitability by $154,643.18 per year in this office alone. System capacity would increase by 4%, while bottleneck utilization would decrease by 3% and shift from the sonographer to the ultrasound room (the costliest resource in this process).
Analysis identified the bottleneck of this process as the sonographer, currently utilized at 75%. The next critical resource is the ultrasound room, which is utilized at 72% (The sonographers must prepare the room for the patient, scan the patient and write the report as well). However, the main goal of the center is to facilitate fast, high-quality service to patients, and all non-real-time patient-related tasks should be secondary to the center’s main goal. Therefore, resource allocation is drastically unbalanced with respect to this process. Further breakdown of the data shows that the capacity of the system for CV (24 patients/day) is much less than QV (81 patients/day). Non-critical resources are scarcely used (or not used at all) for “quick visits.”
It is also important to note that the office staff hypothesized that the total process flow time was related to appointment time, believing that early patients would be late and delay the schedule, increasing wait times. While observed occasionally, analysis indicates wait time is not correlated with walk-in time (R2= 0.17), and the demand is relatively evenly distributed throughout the day.
Currently, the scheduling system does not account for demand variability and schedules patients regardless of their visit type. In addition, the appointment system accounts for the type of patient but not the type of visit (CV vs. QV) when allocating time to each patient. Therefore, the system does a poor job of controlling the imposed variability on its resources. This is largely due to the central role the sonographer bottleneck plays in the system.
While the costliest resource of the process in terms of revenue generation is the ultrasound room, the sonographer is the bottleneck, and the system is not being effectively managed around it. The initial paperwork and other steps in the process set the bottleneck back and create unnecessary downtime. The bottleneck is assigned to write and deliver a report, which adds additional work to the bottleneck’s already valuable time.
Another major observation was about a critical team resource: the specialist, whose inconsistent arrival time introduced added variability to the system. Although not critical to every patient’s flow time, it could delay the CV patients and impose even more wait time.
Lastly, patients brought some level of variability to the system. For instance, the bathroom breaks they took during or after the scan added a layer of unpredictability to the resources downstream. While this type of variability could not be entirely controlled, some of its impact could be alleviated by accounting for such occurrences through an assigned break before the scan begins.
One of the most important concepts of operations management is bottleneck management and how it relates to overall profitability, efficiency and effectiveness of a system. Although there are nine rules to managing a system’s bottlenecks, only a few are directly applicable to the practice’s system. These rules are:
- “An hour lost to the bottleneck is an hour lost to the system.”
- “Increase the capacity of the bottleneck in any way you can.”
- “Have small inventory at the bottleneck to serve as a capacity cushion to absorb system variability.”
These rules, coupled with the understanding of the system and the analysis were used to produce recommendations to improve system efficiency, the clinic’s operational capacity and profitability.
- Overlap wait times with productive steps
- Vital after the scan as the patient waits for the specialist: Although this won’t impact the bottleneck load, moving the point at which the MA takes the patient’s vitals to after the scan when the patient is waiting for the specialist reduces the overall wait time by 14% for CV patients. Considering the overall wait time of 21.5 minutes for CV patients, about three minutes would be reduced from their visit and wait time variability would decrease by about 1.5 minutes. This simple reordering of steps moves the bottleneck up in the process, reducing variability before the bottleneck due to unexpected delays during vital checkups.
- No dedicated paperwork slot: CV patients who fill out paperwork take 18.08 minutes to complete it. This step introduces a high variability to the system for all CV patients as well (standard deviation of 10 minutes). Such patients, mainly new to the center, have also arrived late to the center to fill out that paperwork, leading to even more delays to the schedule. This leaves the bottleneck idle while they are preparing paperwork and getting their vitals checked. To solve this, practices should ask patients to fill out only the first three pages and allow patients to fill out the rest of the paperwork throughout their visit as they are waiting for next steps. Our analysis shows that such flexibility would reduce idle patient wait time and reduce overall wait time by 32% (between 7.5 minutes to 18.13 minutes). This would also decrease the overall variability in the system prior to the bottleneck, improving the consistent flow to the bottleneck. This change would only apply to the QV patients.
- Offload report writing to assigned sonographer: As mentioned, all sonographers should be effectively utilized in scanning patients. These reporting sonographers would read images, write reports and deliver them to the specialist where necessary. The practice would only need one reporting ultrasound technician for every four ultrasound rooms. According to data, each report takes an average of 9.25 minutes and takes up 24% of the total exam and report writing time. By offloading this responsibility, it would effectively increase sonographer capacity from 28 to 36 patients per day and bring more revenue to the center, despite adding a 3/4 FTE cost. Profitability would increase by $177,500 per year in this one office alone (all cost estimates are based on practice historical data). This change would also reduce the system variability affecting visits by the specialist further down the process. System capacity would increase by 30%, while bottleneck utilization would decrease by 17% and shift from the sonographer to the ultrasound room. This office could then benefit from its most expensive resource (the ultrasound equipment) more effectively and utilize it more consistently.
- Offload unnecessary work to MAs: MAs have a current utilization rate of 3% as it relates to the process, whereas the bottleneck is utilized at 75%. This doesn’t mean that they are not contributing to the process, they simply have excess capacity and can take some basic responsibilities from the sonographer, such as cleaning and preparing the ultrasound room, and taking the patient to the room while the sonographer is writing or delivering the report (if recommendation two is not adopted). Making this change would pare sonographer responsibilities to their explicit expertise and promote greater sonographer productivity. Monetary impact would depend on the time it takes to clean and prepare the ultrasound room and take a patient back, which wasn’t noted during this study. However, let’s assume it takes three minutes to clean and prepare the room on average and four minutes to bring patients back (take their weight, send them to the bathroom to clear their bladder and show them to the ultrasound room). This saves the sonographer 56 minutes in a day, or one CV patient or two QV patients. Using an average of $300 revenue per patient, this comes to approximately $78,000 to $156,000 per sonographer per year.
- Rotating schedule of three sonographers in four scheduled rooms: As an extension of recommendation three, this would lay out a rotating schedule that would allow the full operation of four rooms with only three sonographers. Essentially, an MA would handle all the clean and preparation work for the ultrasound room and bring the patient back. The available sonographer would go into the room and scan the patient. This would occur in a cascading format from rooms one through four at evenly spaced intervals to allow a more continuous flow of patients entering and exiting the system. This recommendation would require further analysis to understand the impact on the daily operations of the clinics, as well as the costs. It may require an additional MA for certain locations, which could increase costs, but would increase revenue through the addition of an operating ultrasound room without the cost of hiring another sonographer.
- Digitize patient paperwork: As mentioned, on average, new patients take 18.08 minutes to fill out new patient paperwork. Those patients rarely arrive early to their appointment to fill out that paperwork, which pushes back the schedule, making the bottleneck sit idle while patients are preparing paperwork and getting their vitals. To solve this, practices can create a digital form on their website that can be filled out by the patient on a smartphone, tablet or home computer. The digital paperwork would be sent to the appropriate office and entered into the system by the MA, which would cut down the time it takes for a patient to fill out paperwork and reduce idle time of the bottleneck. If recommendation 1-B is adopted, the impact would be lessened, because the bottleneck wouldn’t be affected as much by the paperwork.
- Shorten scan times: On average, an ultrasound technician performs 8.2 scans per day. Of those scans, 2.2 are detailed ultrasounds (approximately 27%). By shortening the detailed ultrasound slot by 15 minutes, the practice gains on average 33 minutes per sonographer. This opens a slot for one QV patient. Using an average of $300 revenue per patient, this is approximately $78,000 per sonographer per year.
- Perform vitals post-scan, while the patient waits for the specialist
- Patients fill out paperwork throughout the course of the visit; digitize wherever possible
- Offload report writing to assigned sonographer
- Reduce patient grace period from 15 to 10 minutes
- Create a capacity cushion of patients who could fill a gap
- Shorten scan times
- Make sure the maternal-fetal medicine specialist is on time and accessible
Currently, patients spend up to 60% of their total in-clinic time waiting. The inherent variabilities and inefficiencies in the processes contribute to long and potentially unpleasant experiences and impose inconsistent load to the human resources at the center, wasting expensive resource time.
These recommendations would increase bottleneck capacity by about 30% and open space for 7.4 more visitors daily at the observed office, adding revenue of $177,500 or more per year. By moving productive work such as patient vitals or paperwork to unproductive periods, wait times would decrease by 46% and overall visit times would be reduced by 10 minutes per CV patient. As a practice that values its patients most, this would result in not only more revenue, but happier patients who would choose the practice for their future ultrasound exams.
By the numbers
- 108:39 — New patient appointment duration
- 67:54 — Established patient appointment duration
- 104:57 — Co-managed patient appointment duration
- 14% overall wait time reduction (Visit reduction by three minutes, variability reduction by about 1.5 minutes)
- $154,643 profit in target clinic (by assigning one reporting sonographer per four rooms)
- 7.4 more patients per day