Crittenton Outpatient Imaging Center Registration and Technician Process Improvement

Crittenton Outpatient Imaging Center Registration and Technician Process Improvement

Robert Boylan

Oakland University

Rochester Hills, MI 48309

United States

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Abstract

Successful process improvement projects have the opportunity to save companies tens of thousands of dollars that otherwise would have been wasted on inefficient or problem-filled processes. The Crittenton Outpatient Imaging Center on Squirrel Road in Rochester, Michigan was experiencing a bottleneck during registering of their patients, causing long wait times and unhappy paying customers. The average wait time for registration was timed at 9.75 minutes before the project began. Through the use of data collection/analyzing, industrial engineering tools, and mathematical/statistical models a more capable process was created. This new process allowed patients to flow through the system and complete their image testing in much less time. With the use of ARENA software, an accurate model of the Imaging Center was also created and allowed for potential changes to the process to be made without impacting the current office flow of patients. The overall savings of this project was a reduction of over two minutes in time per patient for registration clerks, valued at $22,560 annually. Technicians also yielded a six minute reduction in time per patient, which is valued at $31,902 annually. Additional process improvement projects are now being looked at in the wake of this project.

1.0 Introduction

The focus of the proposedsenior design project will be modeling, analyzing and designing improvements forthe process of outpatient radiology orders from the time at which the patient calls in to schedule an appointment to the time a patient receives the results of their test. When the project began, no statistical data was being recorded; a process map of any kind was not in place, and a general consensus of what each employee’s specific job duties was not detailed. Crittenton Hospital wanted to know if there were any areas that were lowering the efficiency and as well as their patient satisfaction scores.

The team worked to focus on the goal of process improvement and standardization. In turn, the flow of the patient willin turn be better. To do so, mathematical and statistical models are used to assess the raw data that was collected daily. Mathematical models used to assess the data include: a simulation based model, x bar control charts and bar and line graphs. Industrial engineering tools used include: a process map, spaghetti diagrams, a fishbone diagram and standard work instructions.

The data collection analysis is crucial for this project for pre and post implementation of changes due to the fact that it is a basis for discovering process improvement opportunities. There exists seven data points that are tracked throughout the study. Ultimately, the assessment of the data concluded that the registration process needed to be improved since it showed to be the bottleneck.

2.0 Defining the Problem

2.1Creating the COIC Patient Testing Process Map

As the senior design team was first introduced to the team at Crittenton, there was no process map that existed. The first task that needed to be accomplished was to map out the process so that both teams as a whole could understand how both the patient and their files were being handled. As time went on and the process map was studied with the team at Crittenton, it was determined that there were only a few sections that there was enough time to really be able to make an impact on in this project. The process map as shown in Figure 1 represents the point at which the patient schedules an appointment to the results of the exam(s). This allowed the teams to understand the interaction of causes where there may be time delays.

Figure 1: COIC Patient Testing Process Map

2.2 Registration Process Map Creation

The registration workers met to help create a detailed registration process map. While creating the process map, some of the clerks had differing ideas as to the order of the steps. This helped reinforce the idea that all of the clerks needed to be re-trained the same way. A process map was eventually created as shown below in Figure 2,it produced the ability to dig deeper into the elements inside the registration process and the problems that were occurring at each of the elements.

Figure 2: Detailed Registration Process

2.3 Fishbone Diagram and Final Focus of Project

With each of the elements of the registration process individually analyzed, problems that occurred at each step were discussed. With the very limited length of the timeframe to finish the project, a number of problems that were mentioned had to be ignored. These ignored problems were ones that either had no potential solutions or improvements, were out of the control of the COIC and their staff, or were too large to fix during the semester. After the ignored problems were thrown out of the fishbone diagram, the process improvement team had the final scope of the project to work with. Shown in Figure 3 below is the fishbone diagram detailing all of the problems that were looked at for potential solutions.

Figure 3:Fishbone Diagram Detailing Problems of Registration Process

3.0 Improvement Areas and Goals

With the help of discussions, brainstorming sessions, and research, potential solutions to be implemented at the COIC were created. The solutions and the problems grouped accordingly to the solution that could potentially solve them are detailed below.

3.1 Phone Call Reminder

To solve the problems dealing with patient variability, including showing up early or not on the right day, the staff at COIC will call the patients ahead of time in order to remind them of details about their appointment. This includes the time and date of their appointment, as well as the location of COIC facility (some patients were going to the actual Crittenton Hospital Medical Center and not to the Imaging Center). The reminder will also inform the patient that he/she will need a signed and dated doctor’s order, up to date ID, and their Insurance Card.

By reminding and informing the patients ahead of time about what is needed for their appointment, the number of patients not showing up for their appointments is forecasted to decline. The reminders will also help to keep the schedule on time and patients flowing through the system smoothly.

Reminders were also discussed to possibly be changed from a phone reminder to a postcard or even an email. These alternate reminders would require less of the staff time at COIC, but again due to the limited timeframe of the project, the setup of these are too time consuming to become feasible. In the future, these alternatives will be evaluated once again and discussed as to whether or not they will be implemented.

3.2 Standardization of Registration Worker’s Process

By using the detailed registration process map, a set of standard work instructions (SWIs) has been created. This set of SWIs describe step-by-step the tasks and also the order of said tasks to be done to register a patient properly. By standardizing the registration process, less time is spent on unnecessary or excessively done steps. Also, if a new registration worker is hired, it will be easier to train them and that will speed up the learning curve seeing as how they have a quick reference to look at.

Standardizing the registration process also involved informing newer hires about a “standardized registration process sheet” that was created by some of the more experienced clerks. On this sheet are the codes for the most commonly used tests. By informing the new hires about this sheet it will help reduce the number of wrong codes being entered as well as the number of look-ups in the larger reference book that holds the hundreds of codes for each test that is available.

3.3 Movement of Patient History Form

Through analyzing the data and observations of the overall process at COIC, it was noticed that many times the patient would not have the patient history form filled out in time when the technicians went to begin the testing. The history form was given to the patient as he/she went into the changing room, after the registration process and before the testing. The technician would then have to either wait for the patient to finish working on the history form or to help them finish it themselves. To correct for this wasted time, the patient history form was moved to the waiting room when the patient first signed in to the COIC. A sign informing the patient to fill out the form was put up and also the front desk clerk was informed to tell the incoming patients to fill out the form. If the patient failed to fill out the form in the waiting room there was another stack of history forms that are placed in the registration room. These forms are handed out to the patient after their personal information and other necessary personal information is gathered by the registration clerk.

By moving the patient history form to these two locations earlier on in the process, the technicians do not have to wait for the patient to complete the history form given; there is ample time for the patient to finish filling out the form.

3.4 AS400 Copying and IDOC Printing

Patients sometimes ask to have a printed copy of their doctor’s order or other documents that are associated with their testing visit. When this occurs the registration clerk will have to walk out to the copying machine in the hallway outside the registration area. This is considered a waste since the documents can be printed from the IDOC system (standard data structure for electronic data interchange), eliminating the need to go out to the hallway to copy documents. All of the registration clerks are educated with this from the information technology worker from Crittenton Hospital Medical Center.

Another reason that the registration clerks would walk out to the copy machine was to copy the AS400 form. This occurred so that the technician would have multiple copies to keep on file.

3.5 Registration Walking Changes

The original registration walking process consisted of:

1. Pick up patient, bring to registration area and complete enough registration so that all information that is needed from the patient is complete
2. Escort patient to dressing room
3. Walk back to registration area and finish registering patient
4. Walk to printer in hallway and pickup paperwork
5. Bring paperwork to technician area
6. Walk back to registration area

The new registration walking process consists of:

1. Pick up patient, bring to registration area and complete entire registration
2. Bring paperwork to technician area
3. Escort patient to dressing room
4. Bring paperwork to technician area
5. Walk back to registration area

By having the registration worker complete the entire registration process before escorting the patient down to the dressing room it saves the worker the walk back and forth. Also on the way down to drop off the patient the registration worker drops off the paperwork in the technician area. By implementing these changes a savings of 168 feet per patient was achieved.

3.6 Technician Walking Changes

The original technician walking process consisted of:

1. Walk to printer and check if there is paperwork
2. Walk back to technician area and complete paperwork
3. Walk to dressing room and get patient
4. Escort patient to testing room and perform test

The new technician walking process consists of:

1. Complete paperwork
2. Walk to dressing room and get patient
3. Escort patient to testing room and perform test

Instead of walking to the printer and checking to see if there is paperwork for tests, the registration worker now always brings it down and drops it off in the technician’s room. Thus eliminating a significant amount of time for the technician and allowing them to focus on getting the paperwork done and the patient through the testing. By eliminating the walk to the printer and the walk back to the technician area, a savings of 200 feet per patient was achieved.

4.0 Effects of Improvements

The improvements that were made generated time as well as monetary savings. The test technicians and saved approximately 6 minutes per patient due to the walking and history sheet savings. The registration clerks saved approximately 2 minutes per patient due to the walking savings, making copies in IDOC, and also the set of standard work instructions. In dollar amounts this equates to a savings of $132 per day if 59 patients are tested for the test technicians, $31,902 annually. The registration clerks save approximately $94 per day if 80 patients are registered a day, $22,560 annually.

The history sheet was moved from the test room to the waiting room/registration room. This was a 5 minute savings in the test room itself per patient.

With the changes that were made in the walking for registration and techs--the total potential savings is 135 minutes per day and about 33,000 ft.

In all of the data collection, there was no personal information of any kind disclosed to the public. No one was injured or in danger at any time. The changes that were implemented impacted society by keeping existing patients and attracting new ones. The improvements made ensure that a consistently good service is being delivered. The process improvement and standardization prevents errors and saves time and money at Crittenton Hospital.

5.0Simulation Model

5.1 Purpose of Simulation Model

• Quickly shows changes to the system without impacting the current office flow of patients

Shows how many tests (units of service) per day the entire system can process without bottlenecking the process

Shows how the utilization of technicians and clerks can be quickly evaluated by changing the model’s values.

5.2 Defining Criterion for the Simulation Model

To help create a statistically sound model, the modeling software ARENA was used. This software was chosen for its ease of use, conformity to what was needed, and the numerous analyzing tools that are available once the model was built. The most frequently occurring schedule for the COIC wasused in the model in order to accurately represent the flow of patients. Other criterion used to build the model included the way that the patient flowed through the COIC described in the Patient Testing Process Map (Figure 1) and all of the data that was analyzed in order to get the times of the patient traveling through each of the events of the process.

5.3 Final Simulation Model

After numerous revisions to the layout and the structure of the model, a finalized simulation model that accurately replicates the COIC patient flow was reached. As the finalized model shows, there were distinct repeatable areas that could be used to break the create block in ARENA into each different segment of the schedule. By doing this, those patients that had multiple tests were able to register only one time in the system. The model was able to closely mimic the events at the imaging center. Five different numbers were assigned to the different combinations of tests to go through the registration process. This allowed the model to make more test completions than registrations.

Figure 5: Final ARENA Model

5.4 Running and Analyzing the Model

5.4.1 Running the Model with October 12th, 2009 Data

The first date that there was good data to use was October 12th, 2009. Statistically, the registration time was: lognormal with mean equal to 9.74; standard deviation equal to 4.48. This data was used to populate the first run of the model verification. A full schedule of 91 tests with 82 appointments (accounting for the double test previously mentioned) was utilized to run the model. The results of this run are exactly as the team predicted with the observations of the office flow. The registration process was not capable of processing this many patients at this high of a tact time.

5.4.2 Running the Model with November 02nd, 2009 Data

The next date evaluated was on November 02nd, 2009. Statistically, the registration time was: lognormal with mean equal to 8.06, standard dev equal to 3.78.

Again, the model was tested. The model with the new data results showed the improvements that were expected; to register more patients is clearly apparent in the model. There are still many patients that could not be registered at the current staffing levels.

5.4.3 Running the Model with November 17th, 2009 Data

After the improvements in registration were completed, further data was gathered and analyzed. The new registration time distribution analyzed the data as: lognormal mean equal to 6.24 and std dev equal to 2.56. Figure 6 below shows this distribution.

With a full schedule most of the patients will now make it through the registration process and get bottlenecked further into the process at Mammo testing.

Figure 6: ARENA Model Run with November 17th, 2009(New create module for the 6.02 registration time; when running the model, at 510 minutes, clearly there is a backup in registration if all appointments are full)