Orthopaedics

Team Improves Referral Process to Orthopaedics; Cuts Delays

Long delays in the approval of new patient consult requests from referring physicians to the UMHS Department of Orthopaedic Surgery were causing dissatisfaction among both physicians and their patients.

In the past three years, the Department's clinic volume of 52,000 visits has grown by nearly 10 percent, and higher growth is projected during the next two to three years. The Department serves as a resource locally, but also has a significant out-of-state patient base. With increased patient volume and limited clinic space, the Department has implemented several measures to improve patient access to their seven busy clinics, including: adding clinic sites, recruiting faculty and increasing operating room time. Despite these improvements, access remained a concern.

After reviewing data from pre-workshop meetings in January 2005, the team discovered six problem areas:

• Patient demand exceeds Department's provider supply.
  
• The Department’s capacity cannot be expanded in the short term.
  
• The Department lacks a current referral database, so no system exists to effectively track new patient consult requests.
  
• There is a lack of clinical expertise and sub-specialty scheduling protocols in the orthopaedic call centers.
  
• There is a long history of individual orthopaedic physician ownership over his or her own clinic appointments, which can contribute to challenges in adapting to a standardized system.
  
• The long lead times to obtain an initial appointment adversely affect the payer mix and reimbursement.
  

With the goal of improving the process for managing new patient consult requests and scheduling appointments, the Orthopaedic Referral Management Team participated in a three-day lean workshop March 16-18. The workshop was conducted by John Long, M.D., of Lean Concept, Inc. and used techniques of the Michigan Quality System.

The Background

When a patient needs to be seen by an orthopaedic specialist, the following sequence of events takes place prior to appointment scheduling. With the current process, a consult request can bounce back and forth over a period of days or even weeks and between several orthopaedic specialists prior to being approved/denied.

• The Department receives a new patient consult request form for an appointment (via fax) from a referring physician.
  
• Clinic Coordinator approves subset of requests.
  
• A clinic coordinator reviews the form, collects additional information, and creates a packet of clinical related information for requests that require physician review.
  
• Packet is given to physician for review and approval/denial.
  
• If approved, the clinic coordinator turns the new patient consult request over to a scheduler.
  
• The scheduler then schedules the appointment based on urgency of the medical condition and availability of the orthopaedic specialist.
  
• An acknowledgement of the scheduled appointment is mailed to the patient. (If the referring physician is a member of the MLine referring physician network, an acknowledgement of the scheduled appointment is faxed to the physician).
  
• If the request is denied, the clinic coordinator contacts the patient to let the person know. Or, the coordinator sends the patient's paperwork to another orthopaedic specialist for review, approval and scheduling.

The Participants
Susan Maxwell - Orthopaedics (Taubman Center)
Dr. Andrew Urquhart - Orthopaedics (Taubman Center)
Laurie Schley - Orthopaedics (MedSport)
Dr. Edward Wojtys - Orthopaedics (MedSport)
Julie Agbabian - Orthopaedics (MedSport)
Dr. Connie Standiford - Internal Medicine
Dr. Jim Carpenter - Orthopaedics (Chair)
Tom Daly - Contracting
Kathleen Moore - Finance
Matt Plachta - Ambulatory Care
Quinta Vreede - Ambulatory Care
Grant Winston - Orthopaedics
Debi Zahn - Ambulatory Care
Philippe Sammour - Faculty Group Practice
Amy Perry - Facilitator - UMHS
Annemarie Lucas - Faculty Group Practice
John Long, Lean Concept, Inc.

Decision Panel: A decision panel of institutional leaders was selected to approve the outcome of the project and facilitate implementation, as follows: Allen Lichter, M.D. – Dean, Medical School, David Spahlinger, M.D. – Senior Associate Dean, Medical School, and Jeanne Rizzo – Chief Administrative Officer, Ambulatory Care Services.

Lean Thinking Workshop
Using value stream mapping and other tools, the team developed a visible diagram (current state map) of the clinical review and approval process for new patient visits, highlighting the complexity of scheduling a visit and the steps involved.
Dr. Long suggested that to accurately scope the project the team document the process through a review of Suppliers, Input, Process, Output, and Customers. SIPOC defined the suppliers and customers, inputs and outputs.

Pinpointing Problems - Current State Map

Day One. The team split into two groups: Taubman Center and MedSport, and developed a current state map for each site.
As part of the value stream mapping process, the team measured the amount of process time (actual time spent working on the process), wait time (actual time work is waiting to be processed), and identified areas of waste that were slowing the process down.

MedSport

The team identified five problem areas from the current state map, as follows:

• Process time ranged from 11 to 31 minutes.
  
• Wait time took up to 36 days pending clinical review.
  
• Very few consult requests were denied as a result of the clinical review process.
  
• Some consult requests were scheduled within a day, due to informal scheduling guidelines.
  
• The probability of scheduling an appointment that met the “customer requirements” of both the referring physician and patient was low.

Taubman Center

The team identified five problems from the current state map, as follows:

• Process time varied considerably, from 10 minutes to one hour.
  
• Wait time spanned an astounding four to 60 days, due to multiple hand-offs among the different divisions.
  
• Very few consult requests were denied as a result of the clinical review process.
  
• Some requests were scheduled within a day due to informal scheduling guidelines.
  
• The probability of scheduling an appointment that met the “customer requirements” of both the referring physician and patient was low.

Pinpointing Solutions: Future State Map

Day Two: The team developed a future state map for how the work would be done. It identified changes that would permit scheduling 90 percent of the patients with the correct orthopaedic specialist -- at the time of the initial call. The future state map would require that all consult requests come via patient telephone calls, ensuring all information necessary for scheduling would be available at the time of the request.

This new process, called the “Fast Track” process, will reduce wait time from a high of 60 days to just a few minutes for scheduling an appointment, while reducing handoffs to zero. The scheduler would do a quick assessment (based on protocol) and if the request fit into the protocol, an appointment would be scheduled at the time the call was received from the patient.

For the remaining 10 percent of the patients who could not be handled by a scheduler and required physician review, the wait time to obtain an appointment might be increased by up to seven days. Success would be measured by tracking the number of appointments scheduled with one call.

Implementation Plan

Day Three. Finally, members developed an implementation plan to determine:

• Who was responsible for each objective.
  
• The target measurement.
  
• The timeline for implementation (overall goal was 90 days).
• Support necessary for success.
  
• The action/methods necessary to achieve the objective. An implementation plan for the next 30, 60 and 90 days was created.
  

Detailed steps, accountability and time frames were organized into four major categories:

• Standard Work: Write and endorse triage criteria and protocols for scheduling appointments or redirecting patients.
• Meet Customer Demand: Establish call center infrastructure and feedback loops to achieve one-call scheduling and employee satisfaction.
• Learning Loops: Implement learning loops for call center staff, Orthopaedic providers and referring physicians.
• Standard Input: Develop, endorse, train and publish consult request entry criteria and education.

At the conclusion of the workshop, the team agreed to meet monthly to review progress towards implementation goals. The team also agreed to meet again at project completion.