University of Michigan Health System
C.S. Mott Children’s Hospital
Program & Operations Analysis
Pediatric Hematology, Oncology & Infusion
Patient Flow Analysis
Final Report
Prepared For:
Nicole Haskett, Project Client
Clinic Manager; Pediatric Hematology, Oncology, BMT & Infusion
C.S. Mott Children’s Hospital
Kevin DeHority, Project Coordinator
Lean Transformation Director
Michigan Quality System
Carali Van Otteren, Project Coordinator
Industrial Engineer
Program & Operations Analysis
Course Instructor:
Professor Mark Van Oyen
Prepared By:
IOE 481 - Team 8
Andre Lilly
Madeline McCormick
Brendan Roeschel
Alexa Weiser
Date of Submission:
December 16, 2016
Table of Contents
Executive Summary 2
Introduction 7
Background 7
Key Issues 9
Project Goals 9
Project Scope 9
Methodology 10
Findings 14
Data Analysis 14
Interviews 20
Literature Search 20
Conclusions 21
Recommendations 21
Expected Impact 22
References 23
List of Figures and Tables
Figure ES-1: Pediatric Hematology and Oncology Clinic and Infusion Center Patient Flow 2
Figure ES-2: Distribution of Patient Arrivals at Infusion Center 4
Figure ES-3: Relationship Between Wait Time at Infusion Center and Tardiness 4
Figure 1: Pediatric Hematology and Oncology Clinic and Infusion Center Patient Flow 8
Figure 2: Final Patient Flow Form 12
Figure 3: Distribution of Patient Arrivals at Infusion Center 15
Figure 4: Proportion of On-time vs. Late Patients 15
Figure 5a: Relationship Between Wait Time at Infusion Center and Tardiness 16
Figure 5b: Relationship Between Wait Time at Infusion Center and Tardiness 16
Figure 6a: Relationship Between Minutes Late and If the Patient Sees a Provider 17
Figure 6b: Relationship Between Minutes Late and If the Patient Sees a Provider 17
Figure 7a: Relationship Between Day of the Week and Wait Time 18
Figure 7b: Relationship Between Day of the Week and Wait Time 18
Figure 8a: Relationship Between Infusion Appointment Length and Wait Time 19
Figure 8b: Relationship Between Infusion Appointment Length and Wait Time 19
Figure 9: Proportion of Patients that See a Primary Nurse 20
Executive Summary
In basic patient flow within the Pediatric Hematology and Oncology (Peds Hem/Onc) Clinic at C.S. Mott Children’s Hospital in the University of Michigan Health System, patients typically go from their appointment with a provider in the Ped Hem/Onc Clinic immediately to an appointment in the Infusion Center for treatment. The Infusion Center and Ped Hem/Onc Clinic are separate but adjacent units that work closely together. Staff members of the clinic believe that current patient arrivals into the Infusion Center from the Ped Hem/Onc Clinic are not aligned with nurses’ servicing capacity in the Infusion Center; this lack of alignment leads to long wait times for patients and poorly utilized nurses. The clinic would like to better understand the current state of patient flow between the clinic and Infusion Center and identify opportunities for improving nurse-to-patient alignment. They asked a team of four senior Industrial and Operations Engineering Students from the University of Michigan to document the current state of patient flow in the clinic and identify sources of the problem. With this information, the clinic members will have a robust knowledge foundationregardingcurrent operations and know where to focus future efforts toward improvement.
Background
Patient flow between the Pediatric Hematology & Oncology Clinic and the Infusion Center relies on several different staff members and varies greatly with each patient. Typical patient flow can be seen in Figure ES-1, which is based on observation and interviews.
Figure ES-1: Pediatric Hematology and Oncology and Infusion Center Patient Flow
Typically, a patient will: (1) Check in at the front desk; (2) Sit in the waiting area until a Medical Assistant calls the patient; (3) Have vitals taken by a Medical Assistant; (4) Enter exam room with provider; (5) Check out of the clinic, enter Infusion Center, and wait to be called by a nurse; and (6) Begin infusion treatment in Infusion Center. According to the Clinic Manager, patients experience an average wait time of 30 to 45 minutes between the end of their doctor’s appointment in the clinic and the start of their infusion treatment (5) during these peak periods.
There are many factors to take into consideration when identifying causes of these wait times. Nurses have reported the belief that primary nursing has increasingly contributed to wait times in the Infusion Center. Primary nursing is a relationship-based care model in which one nurse is continually responsible for the care of one patient throughout all of the patient’s visits. Primary nursing can be problematic because it affects the utilization of nurses and can cause appointments to back up if one nurse is sitting idle while a patient is waiting for a busy nurse. The Nurse Manager has also expressed a concern with patient safety, as an over-utilized nurse is more likely to make a mistake, as he/she must work quickly to get from one patient to another.
Project Goals
To determine how to improve nurse-to-patient alignment, the student team targeted the following objectives:
●Understand the current patient scheduling process
●Collect timestamps for Clinic and Infusion Center patient flow
●Understand thepros and cons of current care model
●Identify key variables that affect patient arrival rate
With this information, the team developed recommendations to:
●Balance nurse utilization
●Reduce patient wait times
Methodology
To achieve the project goal of improving nurse-to-patient alignment, the team conducted 16 hours of patient flow observation in the clinic and Infusion Center; interviewed two members of each of the scheduling, infusion center, and managerial staff; performed a literature search to discover similar studies and project methodologies that can be utilized in this project; and developed, distributed, and collected 89 patient flow forms, which were completed by patients and Medical Assistants (MAs). The purpose of the interviews and observation was to better understand the problem and identify all possible sources of data that would be beneficial to quantify in order to address the problem of poor nurse-to-patient alignment. The purpose of the literature search was to discover methodologies that other hospitals and engineers have developed to address similar problems. The purpose of the patient flow forms was to collect substantial and reliable data that could be used for modeling and analyzing the issues that were leading to poor nurse-to-patient alignment and long patient wait times. The team stored the patient flow form data in Microsoft Excel and analyzed it using hypothesis tests and ANOVA analysis through Minitab Statistical Software in order to determine which factors lead to the best and the worst nurse-to-patient alignment. Nurse-to-patient alignment was quantified by the amount of time a patient would sit in the waiting room before a nurse could see them in the Infusion Center.
Findings and Conclusions
The following findings and conclusions have been deduced from the patient flow, observations, literature search and interview data. From Figure ES-2 below, 90% of patients are arriving at the Infusion Center between the hours of 9:00 am - 11:00 am.
Figure ES-2: Distribution of Patient Arrivals at Infusion Center
The team also found that 52% of patients arrive to their appointments over 15 minutes late. From Figure ES-3 below, the patients who are arriving on time wait significantly longer than patients who arrive late.
Figure ES-3: Relationship Between Wait Time at Infusion Center and Tardiness
By observing the current care model of Primary Nursing, the team found that 41% of patients wait to see their Primary Nurse rather than seeing whichever nurse is available to give them their treatment at the time. This offsets the schedule and has a similar effect as patients arriving late: poor nurse-to-patient alignment and longer patient wait times.
Finally, by conducting a literature search, the team found a study highlighting the benefits of modular nursing in comparison to primary nursing. Modular nursing focuses on patient centered care and cost effective use of available personnel. It divides workers into teams, led by one Registered Nurse (RN) who delegates tasks to members of the team based on ability and availability so that each member is ‘used’ at the level of which they are capable and expected to perform. The study found that a shift from Primary to Modular Nursing in a chemotherapy unit improved utilization of nurses and kept the Patient Caring Index relatively constant. However, this study was done on an adult chemotherapy unit, so the perception may differ in a pediatric unit.
Patient Flow Data
●Peak arrivals are between 9:00am - 11:00 am
●On-time patients are currently waiting longer than late patients
●Late patient arrivals offset the schedule and contribute to worse nurse-to-patient alignment and longer wait times for patients
●Primary nursing is an inefficient system and is contributing to worse nurse-to-patient alignment and longer wait times for patients
●Modular nursing is an effective tool to improve nurse utilization
Recommendations
From the conclusions drawn from data analysis, the team developed six recommendations to balance nurse utilization and reduce patient wait times.
Immediate Impact Recommendations
The team suggests implementing the following immediate impact recommendations as soon as possible, as there is significant evidence from the Findings and Conclusions that suggests patient-to-nurse alignment and patient wait times will be improved:
●Shift from the Primary Nursing Care Model to Modular Nursing Care Model
●Enforce a rule where patients need to call the Clinic if they are going to be more than 15 minutes late so that the Infusion Center can plan for these arrivals
●Do not see patients before their scheduled time if they arrive early to their infusion appointment, as it will offset the schedule and result in worse nurse-to-patient alignment
Delayed Impact Recommendations
The team suggests implementing the delayed impact recommendations as a placeholder if the immediate impact recommendations cannot be implemented due to hospital policies or other constraints. These recommendations are a second alternative as they will not have as immediate of an effect on patient-to-nurse alignment and patient wait times.
●Put up signs and send out emails to remind patients to arrive on time for their appointments
●Distribute surveys to the patients to get feedback on why they are not arriving on time to see if it is a fixable issue
●Increase communication between the Clinic and the Infusion Center so that the Infusion Center can be aware if there are irregular circumstances or delays with a patient they are scheduled to see
Risks
There are several risks associated with implementing these recommendations in the Clinic. First, eliminating primary nursing may affect patient satisfaction. Treatments at the Clinic are extremely sensitive and any added comfort that the Clinic can provide is of great benefit. However, after interviewing the Clinic Manager and nurses, the team believes that the positive impact of having shorter wait times outweighs the negative effect of the patient seeing multiple nurses throughout treatment. Additionally, to mitigate this risk, the team suggests that the patients be made aware (through email or in-person by a MA) that all nurses are equally qualified to treat them.
Next, patients may forget to call the Clinic if they are running late. Therefore, to mitigate this risk, the team suggests that patients be constantly reminded of this new policy during the first few months of its implementation. These reminders could be given orally from the schedulers as they schedule patients’ next appointments.
Introduction
The Pediatric Hematology and Oncology (Peds Hem/Onc) Clinic at C.S. Mott Children’s Hospital in the University of Michigan Health System (UMHS) treats patients under the age of 18 who have been diagnosed with cancers or tumors. Adjacent to this clinic is the Infusion Center, which provides various treatments to patients from the Peds Hem/Onc Clinic. The majority of patients in the Infusion Center have an appointment with a provider in the Peds Hem/Onc Clinic an hour before their appointment for treatment in the Infusion Center. Current patient arrivals into the Infusion Center from the Peds Hem/Onc Clinic are not aligned with nurses’ servicing capacity in the Infusion Center. Appointments often overlap and multiple patients arrive to the Infusion Center at the same time. Consequently, the nurse manager has reported that nurses in the Infusion Center are both under and over utilized at times and patients often have to wait before getting treatments. Therefore, both the Clinic Manager and the Nurse Manager of the Peds Hem/Onc Clinic would like to know how to improve nurse-to-patient alignment.
The Clinic Manager and the Nurse Manager of the Pediatric Hematology and Oncology Clinic have asked a team of senior Industrial and Operations Engineering students from the University of Michigan to analyze the current patient scheduling process and determine why it does not optimally align patient arrivals with nurses’ servicing capacity. The team has documented the current state of patient flow by interviewing faculty and staff, observing the clinic, and distributing Patient Flow Forms. This report provides the details of the project, including methods, findings, conclusions, high level recommendations, and the expected impact.
Background
According to the Clinic Manager, patients experience an average wait time of 30 to 45 minutes between the end of their doctor’s appointment in the clinic and the start of their infusion treatment during these peak periods. With many phases of this patient flow relying on each other, there are many factors to take into consideration when identifying the root cause of these wait times.
The typical flow of a clinic and infusion patient can be seen in Figure 1 below. Each patient checks in with the clerk at the front desk of the Peds/Hem Onc Clinic and waits in the seated waiting area. The Medical Assistant (MA) will then call the patient to take his or her vitals and places the patient in an exam room to be seen by a physician or nurse practitioner. The Infusion Center typically requires patients to first be seen by a doctor and have their vitals taken to ensure that they are healthy enough to receive their scheduled infusion treatment. The duration of a doctor’s appointment can vary greatly, but is usually one-hour long. If a patient’s vitals or blood cell count do not meet the requirements for their treatment, the patient must reschedule the appointment for another day. Because it is fairly common for a patient to reschedule, the relatively expensive treatments are not prepared until the patient’s vitals are taken and meet the required blood cell count. This factor affects how quickly some patients with more expensive treatments ($3,000 - $20,000) can move to the Infusion Center, because the medicine can take up to an hour to prepare. However, the majority of treatments are relatively inexpensive ($2,000-$3,000) and can be prepared by the hospital pharmacy before the patient’s appointment.
Figure 1: Pediatric Hematology and Oncology Clinic and Infusion Center Patient Flow
The client reported that the majority of patients arrive to the Infusion Center between 9:00 am and 1:00 pm on Mondays, Tuesdays, and Thursdays. Appointments are made using MiChart software, the primary platform for patient documentation as well as order entry. When a scheduler makes an appointment in MiChart, the scheduler cannot see how many other patients are scheduled during that time. Clinic staff have reported that patient flow during these peak hours is overwhelming and that they struggle to serve patients in a timely manner. Staff have also reported feeling underutilized during the later hours of the day when patient volume drops dramatically. Many nurses have reported that they believe the problem is patient scheduling and arrival times, not the number of patients.
Predicting when patients will be ready for infusion is difficult and results in problems for both nurses and patients. Infusion treatment time can last from 30 minutes to 8 hours and is known when appointments are scheduled. However, it can be longer due to unforeseen issues such as difficulty drawing blood or an uncooperative patient.
Nurses have also reported their belief that primary nursing has increasingly contributed to wait times in the Infusion Center. Primary nursing is a relationship-based care model in which one nurse is continually responsible for the care of one patient throughout all of the patient’s visits. Many patients have become attached to one nurse in the Infusion Center and thus insist on waiting for that nurse to be available to begin their treatment. Primary nursing can be problematic in this setting, because it affects the utilization of nurses and can cause appointments to back up if one nurse is sitting idle while a patient is waiting for a busy nurse. The Nurse Manager has also expressed a concern with patient safety, as an over utilized nurse is more likely to make a mistake as he/she must work very quickly to get from one patient to another.
Additionally, Medical Assistants (MAs) in the Infusion Center have reported feeling overworked during these peak hours, as they do not have the resources to move multiple patients to infusion at the same time.
Key Issues
The following key issues were identified as the driving factors behind this project:
●Patients have significant wait times during peak hours
●Staff have reported feeling overwhelmed by patient flow
●Patient volume is unknown on any given day