- Providing timely responses to patients’ and referring providers’ needs is a critical component of excellent patient care and inherent to provide exceptional service.
- During spring/early summer 2013 a hospital’s referring oncology providers communicated to administration that the turnaround time to schedule outpatient oncology imaging procedures was overly burdensome, took too much time, and was frustrating to their staff and patients; and because of it they were considering directing their business elsewhere.
- An analysis of the data at that time suggested it took the hospital an average of more than 9 days from receipt of request to actually schedule a procedure.
- In order to provide safe, quality, compassionate health care, it was critical that this scheduling process be improved as quickly as possible.
- Between July 2013 and spring 2014 the hospital implemented several process changes that resulted in decreasing the turnaround time for scheduling these procedures to <1 day.
By May 2014, the hospital’s Access Services will decrease the average turnaround time (TAT) for the scheduling of outpatient oncology imaging procedures from an average of 9 days to ≤ 1 day. This will be accomplished through workflow analysis, staffing adjustments, policy review, staff education and workflow redesign.
- Improving this scheduling process can minimize lost revenue as the procedures impacted by it have charges that range from $976 to almost $8,000.
- One hospital scheduler worked two days at another hospital to learn its process (16 hours x $16/hour = $256).
- Scheduling supervisors from other system facilities (60 hours x $25/hour =$1,500) were utilized to provide support for staffing shortage (2 FMLAs) during the time this project was in process.
- Staff training was just in time while working, so no large scale staff education cost was incurred.
Patient and Family Centeredness Implications:
- Patients need to trust their community hospital to respond to their needs in a timely manner so care can be delivered as efficiently and effectively as possible. This is particularly true for oncology patients as many of the procedures needing scheduling are vital to direct next steps in their care. Confirmed or potential oncology diagnoses cause great stress so being able to minimize wait times for diagnosis or treatment is very helpful to decrease anxiety for these patients and their families.
- Community perception matters. Great strides have been made to improve the perception and confidence in the care provided at the hospital. Because the scheduling process was failing, we were not achieving our vision. By failing to respond to our patients and providers in a timely manner, we were also failing to support the positive changes made to our community image.
- Work in Progress (WIP): The number of appointment requests that have arrived by 1630 that were not scheduled by 1700 that same day.
- Turnaround Time (TAT) for scheduling individual appointments.
- Volume of procedures scheduled.
- Concerns from Radiology staff impacted by the process changes occurring within Access Services. This would require working closely with the radiology team to communicate changes before they occurred.
- Increased procedure volume from more efficient scheduling could potentially impact staffing for Interventional Radiology resulting in competing with Cardiac Cath Lab for staffing resources.
- Staff morale: Three staff members were near the point of leaving due to frustration – they were working hard but unable to feel successful due to scheduling backlog.
Rapid Cycle Improvement: Cycle 1
Plan: Focus on process to identify volume of work and staffing needed to meet volume.
Do: Brought in schedulers from other system facilities to assist with coverage; reassigned registration reps and coordinator to assist with call volume; printed received orders and placed in folders to track number of calls attempted; prioritized procedure packets by placing in separate folder; observed the work in process (WIP) electronic process at another system facility.
Check: Turnaround times began decreasing, moving towards but not yet hitting the goal.
Act: Work processes adopted for continued use.
Rapid Cycle Improvement: Cycle 2
Plan: Improve “Packet Procedures” to further decrease scheduling TAT.
Do: Revised work flow of process: Scheduler receives packet – routes to Interventional Radiology (IR) Nurse for review/consult with Radiologist – IR Nurse sends back to scheduler – scheduler contacts patient to schedule – scheduler forwards patient to pre-op department to schedule pre-op appointment; implemented spreadsheet to track packets including reasons for delays; responded to noted delays by working with IR Nurse and Radiology to fax packet to IR department (visual cue); created and educated physician office staff on check list for requesting procedures.
Check: TAT continued to improve and now approaching target.
Act: Process changes adopted for ongoing use and continued to look for additional process improvements.
Rapid Cycle Improvement: Cycle 3
Plan: Focus on staff and people to be sure process adequately supported.
Do: Hired additional scheduler; documented and implemented new process for new hire orientation; scheduling supervisors from other system facilities assisted in staff training on new electronic system and customer service standard scripting; all staff signed the hospital’s “Promise to My Peers” to establish personal accountability; initiated weekly meetings with Radiology staff to brainstorm through issues and better define roles and responsibilities; installed call recording system.
Check: TAT continues to be near and at times achieve goal, but inconsistent performance.
Act: Processes adopted and continued.
Rapid Cycle Improvement: Cycle 4
Plan: Eliminate external road blocks to patient scheduling.
Do: The hospital administration approved the waiver of insurance pre-certification prior to scheduling procedures.
Check: The amount of rescheduling due to no authorization was reduced; minimal post scheduling denials occurred; all high dollar denials were appealed successfully.
Act: Adopt elimination of required scheduling pre-cert and communicate the success of this process change to the system and other system hospitals.
- Daily log in place to monitor WIP and electronic work folders allow all staff access to WIP.
- Weekly staff meetings to review performance and analyze and remove barriers.
- Scheduling and Radiology now conduct a weekly meeting to keep the lines of communication open for scheduling related issues.
- Scheduling staff roles are now more clearly defined.
- The scheduling process is reviewed in detail during new hire orientation.
- As part of the hospital’s Lean Management System implementation, a daily huddle has recently started in this department. The WIP is reviewed as part of that daily huddle.
Next Steps & Lessons Learned:
- Visual management is a very effective tool to help ensure timely response and raise staff awareness of workload.
- Standardizing processes (creating “standard work”) helps to improve process flow and more clearly identify roles and responsibilities.
- Effective team member communication is very important for departmental success.
- Developing and maintaining a staff skills matrix allows management to be aware of staff training needs and resource availability.
- Eliminating the ability/need for Scheduling Staff to tell a provider or a patient “No” had a domino effect on the entire organization. All staff members are empowered to find a way to say “yes” even though getting there may be challenging. This has been a true culture change in our organization.