Professional Documents
Culture Documents
David Wylie, Director of Babson College Case Publishing, worked with Professors Ashok Rao, Jay Rao and Ivor Morgan, Babson College, to prepare this case as a basis for class discussion rather than to illustrate either effective or ineffective handling of an administrative situation. Copyright by Babson College 2000 and licensed for publication to Harvard Business School Publishing. To order copies or request permission to reproduce materials, call (800) 545-7685 or write Harvard Business School Publishing, Boston, MA 02163. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any means electronic, mechanical, photocopying, recording, or otherwise without the permission of copyright holders.
BAB034
The Primary Care Clinic (PCC) served most medical needs. As elsewhere in SHS, physicians, nurses and nurse practitioners provided care. For continuity of care, patients were encouraged to choose a primary care clinician to act as a principal health care provider. In addition to meeting basic health needs, this clinician could act as an excellent resource for other health concerns. The PCC also offered walk-in care that did not require an appointment. It was geared toward the diagnosis and treatment of minor medical problems. Because of the demand for the limited walk-in spaces, patients were sometimes asked, after having a condition assessed by a triage nurse, to return at another time especially when a particular doctor or nurse practitioner was scheduled to be on duty. Usually clinicians would set separate appointments for follow up care directly with the patient, thus circumventing triage nurses. Time was scheduled every week for clinicians to devote to such appointments. Referral appointments were also available to the specialty clinics. Specialty Clinics provided specialized care when referred by another SHS clinician. Services included immunization, dermatology, orthopedics, surgery, internal medicine, allergy, head and neck, ophthalmology, urology and neurology.
BAB034
Note: Staff members were considered to be full time if they worked more than 30 hours per week.
Joan Carwin was director of the PCC, reporting directly to the Director of the Student Health Services. (See Exhibit 2, Organizational Chart). She was a doctor and held a masters degree in public health. Her responsibilities as director of the PCC, however, precluded a fulltime medical practice. She split her time evenly between her role as an administrator and a physician. She had been working at the clinic for twelve years, and at her current position for six years. In the fall of 1997, the PCC was scheduled to move out of its current location in the basement of the Student Health Center facility into a new building specifically designed for the clinic. While there was a high level of excitement coupled with the usual degree of apprehension associated with such a move, Carwin and her colleagues saw this imminent move as an opportunity to review and improve the way in which services were being delivered to the students. Several factors had prompted this self-examination. First, the opening of the new WCU Medical Plaza within the university campus offered students easy access to qualified WCU physicians private practices, posing a direct threat to the SHS customer base, and ultimately to its funding. Second of all, an independent study in 1995 of patient satisfaction, by a WCU student, as detailed below, suggested that there was room for improvement. Some of the students interviewed commented as follows: ...every time I come in I become very frustrated. I usually have to wait about 30 minutes before being seen. However, once I am seen I am very satisfied. The doctors and nurses are great - it just takes patience to get a chance to see them.... ...highly satisfying - excellent care and counseling from my primary care physician...the only bad thing is trying to schedule the time to see her on a student's schedule....
BAB034
...its just very frustrating and nerve-wracking until you've been to student health a few times and understand how it works (complicated - going to several different stations for a simple visit).... ...other than lengthy waiting times (45 minutes - 1 hr), the people have been very helpful, courteous, cheerful.... ...I have used the system a lot over the past 6 years...mainly because of my physician...for many years I refused to see anyone but him because he is very thorough.... ...I chose my doctor. He became my primary physician even though that's not how things are run here.... The combination of the threat of decreased usage and the promise of improvement prompted an examination of the systems and procedures being used at the PCC. As the move into the new facility loomed, Carwin knew that she would have to make some definitive recommendations.
Conjoint analysis is a research technique which requires respondents to make choices between competing combinations of attributes and which provides an understanding of preferences.
BAB034
* The survey was conducted using a four-point scale: very satisfied, somewhat satisfied, somewhat dissatisfied, and very dissatisfied. Percent Favorable Ratings referred to the percent of ratings that fell into the two positive categories. No neutral category was included.
In a follow-up study, 26.5% of the respondents noted excessive waiting times, 14% difficulty in obtaining appointments in a timely fashion, and 6.7% facility problems. After meeting with members of her staff, Carwin formulated three broad objectives for improving the operations and service at the PCC: x x x Reduce the waiting time for seeing a healthcare provider. Transform the perception of the clinic as an impersonal bureaucracy. Improve student perceptions (especially non-users) about the performance and effectiveness of the PCC.
Carwins concern for waiting times was expressed in a recent memo to all the clinicians, In order to accomplish PCCs objectives, we will need to use all of our skills and experience thoughtfully and in a timely manner. That includes being present and on time, especially for that first appointment of each day. Tardiness at the beginning of the day will no longer be tolerated as before. If it occurs, patients will be shifted to other staff, and the tardy staff member will be held accountable. Frequent tardiness will be dealt with in the context of the performance evaluation.
BAB034
Upon arriving at the PCC, each patient registered at the front desk and was asked to complete a short form indicating the nature of the medical problem (see Exhibit 3). While the student waited in a central waiting room, the staff at the front desk reviewed this form and requested that the students medical record be pulled from the central files and given to a triage nurse. Only a few patients ever required urgent care. These patients were taken immediately to the first available nurse practitioner or doctor. The staff at the front desk was also in charge of checking student identification, entering account information, identifying no-shows, scheduling staff, rotating nursing and medical students, and reconciling billing disputes. Every walk-in patient who did not require emergency care had to see the triage nurse. The triage nurse would make an assessment of the patients condition to determine if either an NP or an MD should see him or her. (See Exhibit 4 for a list of conditions requiring the attention of a doctor). Whenever possible, the patient was scheduled to see his or her chosen primary care physician. Often, however, that clinician was not on duty in the walk-in clinic and the patient would have to return when he or she was on duty. The triage nurse therefore screened the walkin patients and directed the patients to the clinicians. The screening was influenced by the medical condition of the patient, the patients request to see a particular provider, if any, and each clinicians commitment for pre-scheduled appointments. If the triage nurse determined that a clinician should see a patient, the patient took the medical file to the MA (who served three clinicians) located just outside the clinicians office. All the full time clinicians had their own offices. The part-timers shared offices. Carwin and the head NP, who were part-time administrators and part-time clinicians, had their own offices. The clinician offices served as examination rooms as well. The PCC had 15 offices (See Exhibit 5 for PCC Layout). The MA checked vital signs (temperature and blood pressure) and was responsible for paperwork, requesting lab tests, updating charts as noted by clinicians, returning charts to the filing area, and gathering charts for those who had appointments. They also filled out lab slips, performed various routine tests, fitted ortho devices, and washed wounds and ears. The actual attention given by the MA to each patient only took on average 3.5 minutes. Then they waited for the clinician to become available at which point they would meet in the clinicians office. Typically the clinician was with the patient for about 20 minutes. Then as the patient left the clinician would take 5 minutes to make notes and add to the patients file. Those patients who had come earlier but who had chosen to return when their clinician was on duty also checked in at the front desk. They then went directly to the medical assistant assigned to the clinician they wanted to see. During the previous six months, physicians had treated 9,005 patients and nurse practitioners 6,760 patients. Sixty percent of patients were walk-ins, while the rest had appointments directly with clinicians. Twenty-one percent of all patients had a specific clinician. If a walk-in patient had a specific clinician they would request that person. If that person was not available, the patient would ask when the person would be available and plan to return at that time. Sometimes they had to wait two or even three days before their clinician would be available. If the triage nurse felt the patient should be seen earlier, he or she would try to persuade the patient to see one of the clinicians present. Usually, however, the patient would
BAB034
simply return when their clinician was available. On a typical day forty-five percent of the patients coming for walk-in care were returning to see their specific clinician. Twenty-two percent of the meetings with MDs could have been treated by NPs, but were not due to patient preference for single clinician care. The mix of patients requiring MD versus NP attention did not vary meaningfully at different times of the day or the week. Overall traffic at the clinic did, however, change substantially both by the day and the day of the week. This system worked, but waiting times were excessive. (See Exhibit 6 for process flow diagram of the current system, Exhibit 7 for that of the new system, Exhibit 8 for a summary of arrivals and Exhibit 9 for the schedule of individual clinicians).
BAB034
Most of the NPs were enthusiastic about the move, realizing that the new facility would create a more pleasant work and treatment environment. As with any design, however, they also had some concerns. The examination rooms and clinician offices had little natural light, for example, and the only elevator seemed to be very slow. The clinicians had signed up for one or more groups to work on operational issues for the move. These relocation work groups dealt with inventory, displays, security, waste disposal, space assignments, emergency and patient flow issues. The operations coordinator, Jean Sarti, described the response from the NPs and staff to be very positive. Even though the MDs had signed up for these teams, they were described as apathetic and silent during team meetings. In fact MDs chose not to participate on 1/3 of the teams. Reactions to the formation of the proposed clinician provider teams were not too different. The RNs and MAs were enthusiastic and up beat about the proposed changes. Some thought that the team approach was a great way to improve communications among providers and between patients and the PCC. Some noted as long as we have to share offices, we might as well belong to teams," "I have always felt the need for a mentor," "Ive heard that the team structure is working great at the WCU internal medicine division." Most of the MDs, however, were taciturn. Carwin thought that they actually were distressed but reluctant to express their opinions. She was unsure how to convince them of the benefits of the program and thus get their support. While Carwin knew the new system would provide some improvement, she had not yet determined how many medical assistants should be assigned to the pool at various times, nor did she know the composition of the clinical teams. She felt the composition of the clinical teams was of utmost importance. If structured properly it would reduce the waiting times as well as reduce the number of returns. The present system was effectively a team of one. So, if the clinician were not available the patient requesting that clinician would have to return. She knew that sometimes this meant the patient would have to return as much as three days later. She was also acutely aware that this contributed significantly to the poor perception of the services offered. However, if she went to the other extreme and said that everyone belonged to the same team, then in effect the patient would no longer have the choice to choose a specific clinician. She knew that this extreme would be unsatisfactory to patients. She was also well aware that many of the clinicians would criticize this approach as being too impersonal and detract from the quality of care. This was an argument to which she was sympathetic.
Guidelines
As Carwin considered the problem she realized she would need some help. Having used a WCU student before, she wondered if another would be available to help with this problem. As a first step she called some of the senior clinicians together for the purpose of outlining some concrete goals. The group came up with the following guidelines: xTotal waiting time of 20 minutes or less. xLess than five percent of patients unable to see their specific team when they came to the walk-in clinic.
8
BAB034
xThe maximum delay for seeing a team clinician should be one day. The ultimate goal was to improve the level of service to the patients. She also realized that one key to making the transformation smooth and effective was to gain the full support of the clinical staff.
BAB034
Monday MD NP MA 2 1 1 2 1 1 2 1 1 2 0 4 4 4 2 1 0 2 2 2 1 1 0 2 2 2 1
Appointment Coverage
Monday MD NP 4 4 4 4 5 6 5 6 0 0 4 4 4 4 4 4 6 5 Tuesday MD NP 0 0 4 4 4 4 4 4 0 0 4 4 4 4 4 4 4 4 Wednesday MD NP 3 1 5 1 5 3 5 3 0 0 1 2 1 2 1 2 3 2 Thursday MD NP 5 3 5 3 6 5 6 5 0 0 5 4 5 4 5 4 5 4 Friday MD NP 4 4 4 4 4 4 2 3 0 0 4 3 4 3 4 3 4 3
2 MD - Doctors, NP Nurse Practitioners, MA - Medical Assistants. The NPs took turns at the triage function so one was always on duty.
10
BAB034
Doctors / Physicians
11
BAB034
Exhibit 3 Registration Form WCU STUDENT HEALTH SERVICE - REQUEST FOR SERVICE
Present this card with your current registration or optional health card and photo ID to the eligibility screener desk. REGISTRATION # LAST NAME FIRST DATE OF BIRTH MIDDLE
1-OUTCARD 2-ACCOMPANY
12
BAB034
13
BAB034
CLINIC ASST.
CLINIC ASST.
CLINICIAN OFFICE
BOOK SHELF
CLINICIAN OFFICE
CLINICIAN OFFICE CLINICIAN OFFICE WASH ROOM BATH ROOM CLINICIAN OFFICE
SUPPLY ROOM
CLINIC ASST.
CLINICIAN OFFICE RECOVERY ROOMS OFFICE MAG. TABLE ATRIUM BOOK SHELF
CLINICIAN OFFICE
CLINIC ASST.
JOANS OFFICE
CLINICIAN OFFICE
STUDENT ASST.
MAGAZINE TABLE
WRITING DESK
PHARMACY
INFO. ROOM
ENTRY / EXIT
14
BAB034
Front Desk
Clinical Assistant
Clinical Assistant
NP
MD
NP
MD
15
BAB034
Front Desk
y
Want specific team
Clinical Assistants
NP NP NP
MD MD MD MD
NP NP NP
MD MD MD MD
Team
Team
16
BAB034
Exhibit 8 Summary of Arrival and Waiting Times Average Patient Arrival Times for Walk-in Clinic
8-9 9 - 10 10 - 11 11 - 12 12 - 1 1-2 2-3 3-4 4-5 Total 13 12 12 12 Closed 13 12 8 3 85 13 12 12 12 Closed 12 12 8 3 84 12 11 10 11 Closed 11 10 7 3 75 11 10 9 10 Closed 10 10 7 2 69 10 9 8 9 Closed 10 9 7 2 64
17
BAB034
18