Chapter 24, Problem 4CQ

Dr. Susan Fleishman is Medical Director of the Venice Family Clinic in Southern California (VFC). She is concerned about the long wait times of patients visiting the clinic and would like to improve operations. The situation is as follows: The patients are seen in the clinic between the hours of 9:00 A.M. and 12:00 P.M. and between 1:00 and 5:00 P.M. The clinic sees, on average, 150 patients per day. Nine physicians are usually on duty to see patients during each clinic session. They are supported by seven medical assistants who take vital signs and put patients in exam rooms. Four registration clerks are present to register patients, enroll them in federal and local aid programs, prep their medical records, and collect copayments. In addition, there are three coordinators who make follow-up appointments and arrange referrals, a security guard, a pharmacist, and two pharmacy technicians. The facility itself has a security window at the front door with a guard-controlled entry door, a large waiting area, 5 registration windows, 11 exam rooms (3 of which are used for taking vitals), and 4 coordinator’s desks.

Patient Perspective

Most patients make appointments (120 per day), but 30 additional patients come for prescription refills. When patients arrive, they must first pass through security. Often, there is a small wait outside at the door, but it can be fairly long early in the morning. The average wait time at security is 10 minutes, while the average processing time is 2 minutes. The security guard is present from 7 A.M. to 6 P.M. The guard at the door double-checks the appointment time and issues the patient a colored card with a number on it—either red or yellow. Red cards are reserved for patients without appointments who need only medication refills. These patients must pass through registration but do not need to see a provider. All patients then proceed to the waiting room where they wait for their color and number to be called. This wait can often be quite long, but on average takes 24 minutes.

Once patients are called by a registration clerk, their information is verified. This process can take anywhere from 1 minute up to 40 minutes if the patient is new and needs to be enrolled in several programs. On average, eight new patients come per day. Average time to complete registration is 7 minutes for returning patients and 22 minutes for new patients with an overall average registration time of 8 minutes. The patients then return to the waiting area and wait another 15 minutes to be called by a medical assistant to have their vital signs taken. This takes 6 minutes, after which they return again to the waiting area and wait 8 minutes more to be called back to a provider room. Once in a provider room, the patient waits 17 minutes on average for the provider (physician) to arrive. Providers spend approximately 20 minutes with each patient, but if the patient needs urgent labs or nursing procedures, this time can be longer. After the patient has seen the doctor, the patient’s chart goes either to a coordinator or to the pharmacy if prescriptions are to be filled. On average, 50 percent of patients continue onto the pharmacy following their medical visit. The patient waits 25 minutes to be called by a coordinator to schedule further laboratory tests, get referrals to specialists, and make follow-up appointments, which takes an additional 7 minutes. Coordinators see patients from 9:00 A.M. until 5:30 P.M. with a one-hour break during the day. If the patient only needs a prescription, the wait is 13 minutes before the pharmacy can process the prescription and an average of 11 minutes for the prescription to be filled. Each pharmacy technician works independently and fills the prescription after consulting the pharmacist.

The pharmacy is open from 9:00 A.M. to 5:30 P.M., with a lunch break from noon to 1:00.

In general, patient satisfaction with the quality of medical services at VFC remains high, but there are still complaints each day about the waiting times for these services. Waiting times are critical for these patients, as they often directly lead to lost income during the hours spent waiting.

Physician Perspective

Each of the staff physicians is placed on a team, A, B, or C. These groups of two or three physicians all see the same patients, helping to ensure continuity for the patients. Each patient, therefore, will see one of the team’s physicians at any given visit and has a high likelihood of seening the same doctor each time.

Each day, a specific team is assigned to a group of exam rooms. Patients placed in those rooms will see providers for that team only. Physicians arrive at 9:00 A.M. and wait for their first patients to arrive. Often, due to the lag at registration and the wait for open rooms for the medical assistants to take vitals, patients are not in the exam rooms until well after 9:30. In addition, because of the team system, one provider may have three patients waiting while another is still waiting for his or her first patient to check in at registration. The registration desk has no communication link to the physicians’ area; consequently, clerks may check in three patients in a row for one team, but none for another. In addition, new patients are randomly assigned to teams regardless of who is busiest that day. Once a patient is in an exam room, the chart is placed in a rack for the physician to review prior to seeing the patient. If key lab or X-ray results are missing, the physician must call for medical records or call outside facilities and wait for the results to be faxed or called in before seeing the patient. This happens 60 to 70 percent of the time, causing a 10-minute delay per patient. These challenges often lead to inefficient use of the provider’s time.

After seeing a patient, the physician will either have the patient wait in the waiting room to see the coordinator or have the patient wait in the exam room for further testing or nursing procedures. Rarely, if no follow-up or prescriptions are needed, the patient is free to leave the clinic. VFC physicians generally are extremely committed to the clinic’s mission but are frustrated with their patients’ long wait times, the incomplete medical records, and the disorganized patient flow through the clinic.

Administration Perspective

At the start of each day, four registration clerks prepare by printing out copies of that day’s scheduled appointments. Charts of patients with appointments are pulled the night before and placed within easy reach of the clerks. The four clerks work from 8:30 until 11:00 A.M. and close the registration windows until 12:30 P.M. During this time, in addition to eating lunch, the clerks pull the charts for the afternoon clinic and finish up paperwork. At 12:30, the registration windows are reopened for the afternoon clinic and patients are checked in until 4:00 P.M.

What are your recommendations for improvement?