Joslin Diabetes CenterAffiliated Programs Annual Meeting

Sarah O’NeillAmbulatory DirectorBeth Israel Deaconess Medical CenterOct. 25, 2011

Exam Room Utilization: Simple Analysis for Constructive Discussion

Background

Tertiary Care Teaching Hospital 631 licensed beds

429 medical/surgical beds 77 critical care beds 60 OB/GYN beds

Beth Israel Deaconess Medical Center

Background

625,000 outpatient visits annually 15% Primary Care 85% Specialty Care

350,000 (56%) of outpatient visits Med/Surg office practice BIDMC owned facilities

BIDMC Ambulatory Services

Background

Faculty physicians part of separate partner organization

Faculty physician schedules complex – Clinical, Teaching, Research

MD Trainee education integrated into outpatient practice 83 Fellows 257 Residents and Interns

Academic Medical Center

Context

Medical office practice growing on average 4% a year

2007 three year strategic development – MD recruitment in many ambulatory areas

Market analysis indicated optimal location in Boston

GME credentialing required expanded outpatient experience

Context

Space tight on campus Increased need for additional space for on

campus off practice Cost of significant renovations prohibitive

The Goal

Understand utilization – are we truly using what we have

Develop standard and fair measure to inform decision making

Decision Making to Date

Based on room reservation schedules Anecdotal reports of actual practice sessions

Ad hoc site visits range from overflowing to empty Little detail beyond # of planned physician

recruits Failed efforts to assess use based on patient

time in room

Beginning the Conversation

Initial analyses reviewed Weekday use Reservation use

Weekday Use

Request for more space based on peak usage

Is usage even across the week?

Ambulatory Services FY 06 Office Practice Annual Scheduled Hours by Day of Week

% of Weekday Capacity

53%69%72%74%

67%

0

20,000

40,000

60,000

80,000

100,000

120,000

Monday Tuesday Wednesday Thursday Friday

Ann

ual H

ours

Scheduled Hours (incl. factor for room turnover)

Exam Room Weekday Capacity in Hours (at 85% util.; adj. for Holidays and Peak Factor)

Ambulatory Services FY 06 Office Practice Annual Scheduled MORNING Hours by Day of Week

% of Weekday Capacity

86%88%87%94%87%

0

10,000

20,000

30,000

40,000

50,000

60,000

Monday Tuesday Wednesday Thursday Friday

Ann

ual H

ours

Scheduled Morning Hours (incl. factor for room turnover)

Exam Room Weekday Capacity in Hours (at 85% util.; adj. for Holidays and Peak Factor)

Ambulatory Services FY 06 Office Practice Annual Scheduled AFTERNOON Hours by Day of Week

% of Weekday Capacity

41%

56%73%67%63%

0

10,000

20,000

30,000

40,000

50,000

60,000

Monday Tuesday Wednesday Thursday Friday

Ann

ual H

ours

Annual Scheduled Hours

Exam Room Weekday Capacity in Hours (at 85% util.; adj. for Holidays and Peak Factor)

Weekday Use

Helped identify unused capacity – reduced the anecdotal “noise”

Data for analysis not readily available Analysis at the appointment level – huge amount

of data Limited ability to dig in to detail by service or

provider

Reservation Use

Exam room “reserved” for regular weekly session

Reserved session = 4 hours

Utilization of Reserved Exam Room TimeUse of Reserved Hours

red bold = >92% or 48 weeks workedgreen bold = < 85% or 44 weeks worked

practice location Annualized Reserved Hours

FY 07 Total Actual SCHED Hours

% of time in the year reserved hours open

% of time in the year reserved hours used

Equivalent weeks worked out of

52/yrWeeks Open

Shapiro 5b 12,450 13,082 -5% 105% 55 (3)

Shapiro 8a 16,000 16,154 -1% 101% 53 (1)

Shapiro 6,1 60,050 53,069 12% 88% 46 6

Shapiro 2c 11,300 9,608 15% 85% 44 8

Shapiro 7b 19,300 14,845 23% 77% 40 12

Shapiro 8b 32,400 20,520 37% 63% 33 19

Rabb 1 8,650 5,374 38% 62% 32 20

Shapiro 2a 4,400 2,310 48% 53% 27 25

Shapiro 3a 6,400 3,277 49% 51% 27 25

Shapiro 7c 18,400 8,223 55% 45% 23 29

  252,400 191,053 24% 76% 39 13

LMOB 7 4,175 4,638 -11% 111% 58 (6)

LMOB 5a 2,950 2,841 4% 96% 50 2

LMOB 5 5,500 4,982 9% 91% 47 5

LMOB 4 8,050 7,051 12% 88% 46 6

LMOB 3a 2,750 2,329 15% 85% 44 8

LMOB 1 5,450 3,619 34% 66% 35 17

LMOB 6 3,800 2,283 40% 60% 31 21

LMOB 3b 4,000 1,332 67% 33% 17 35

LMOB 2a 3,000 445 85% 15% 8 44

  65,250 45,969 30% 70% 37 15

Annualized Reserved

Hours (50 weeks)

Actual Scheduled

Hours

red bold = >92% or 48 weeks workedgreen bold = < 85% or 44 weeks worked

Range 15% - 105%

Reservation UseHelpful Highlights wide variation

Clinical contract oversight – length of sessions, cancellations, make ups, etc.

Ongoing review of space available for others to reserve Reinforced existing space still available

Long term usefulness Evaluates reserved time only More provider use of reserved time versus space use Depends on managers providing schedules Based on a snapshot in time (schedules change)

Finding a Simpler Metric

Use more readily available data Not dependent on practice management Evaluates 12 months – level seasonal and

academic variation From scheduling system – existing data extract Available at clinic and provider level Analyses exam room versus provider use

Premise of Metric

Physician schedule reliable - needs to reflect real average time needed for each visit type

Begin generously Scheduled versus kept activity All visits – within session or add on Based on weekday use – any extended hours

improves metric

Exam Room Availability

Assume room available 8 hours, M-F Two 4 hours sessions 250 days a year (less 10 holidays) One room available 2,000 hours/year

For each practice suite - include all clinics/ providers (MDs, NPs, etc.) using exam room space in that location

Calculation at Practice Level% Utilization =

Annual Scheduled Hours # exam rooms x 2,000 hrs

PROVIDER TIME IN ROOM

Practice Location Available Exam Rooms Total Actual Scheduled Visits % of time exam room used by provider (b,e)

Shapiro 2c 9 24,997 51%

Shapiro 8b 18 28,602 53%

Shapiro 9 21 32,375 54%

Shapiro 7a 8 9,698 48%

Shapiro 6,1 60 114,498 44%

Shapiro 3b 14 24,826 34%

Shapiro 7c 13 19,546 36%

Shapiro 2a 10 14,802 31%

Shapiro 5a 6 6,125 20%

Shapiro 3a 3 3,135 26%

TOTAL EAST 205 372,204 44%

LMOB 4 7 11,970 45%

LMOB 1 3 4,240 50%

LMOB 8b 4 7,986 38%

LMOB 7 5 7,715 40%

LMOB 8a 5 10,138 33%

LMOB 0B 9 10,679 33%

LMOB 5 7 8,851 25%

LMOB 3b 3 2,860 24%

LMOB 6 6 5,489 18%

LMOB 2a,b 2 1,351 13%

TOTAL WEST 67 95,139 29%

% Time Provider in RoomRange 13% - 54%

Calculation at Practice Level

% Utilization =

Annual Scheduled Hours + Room turnover

# exam rooms x 2,000 hrs

PROVIDER “PLUS” TIME IN ROOM Simple standard/ average factor Based on variety of observations

Practice Location Available Exam Rooms Total Actual Scheduled Visits % of time exam

room used by provider (b,e)

Average Minutes/ Visit Exam Room Utilization

Shapiro 2c 9 24,997 51% 37 86%

Shapiro 8b 18 28,602 53% 52 69%

Shapiro 9 21 32,375 54% 52 67%

Shapiro 7a 8 9,698 48% 61 61%

Shapiro 6,1 60 114,498 44% 38 60%

Shapiro 3b 14 24,826 34% 36 53%

Shapiro 7c 13 19,546 36% 39 49%

Shapiro 2a 10 14,802 31% 35 43%

Shapiro 5a 6 6,125 20% 33 38%

Shapiro 3a 3 3,135 26% 42 37%

TOTAL EAST 205 372,204 44%   62%

LMOB 4 7 11,970 45% 44 63%

LMOB 1 3 4,240 50% 53 62%

LMOB 8b 4 7,986 38% 33 55%

LMOB 7 5 7,715 40% 41 53%

LMOB 8a 5 10,138 33% 30 50%

LMOB 0B 9 10,679 33% 43 42%

LMOB 5 7 8,851 25% 39 41%

LMOB 3b 3 2,860 24% 40 32%

LMOB 6 6 5,489 18% 33 25%

LMOB 2a,b 2 1,351 13% 31 18%

TOTAL WEST 67 95,139 29%   42%

% Time Provider in RoomRange 13% - 54%

Provider plus turnover timeRange 18% - 99%

The New Metric

Adding turnover time helped Appropriately adjust for shorter visit, higher room

turnover time needed Shift focus to relative variation versus absolute %

The relative outcomes passed the “smell” test – fit known practice experience

Discussion turned to use of existing space Increased interest in ways to use space more

efficiently

Why the Range?

Review of space model Offices integrated into practice Practice suite separate from offices

Optimal practice size Small (5 or less) suites less flexible 10 to 12 exam rooms with proper support space

most efficient Critical for specialties balancing OR/ procedure and

office visit time Physician clinical commitment oversight

Options for maximizing Space Move support functions out of exam rooms Limit physicians to 2 rooms per session Start and end sessions on time Shared space use Schedule meetings outside of practice hours Rearrange commitments so full session used Shift session to offsite facilities Extend hours – evenings and weekends

Further Analysis at MD LevelKEPT Visits Unigue Patients/ PANEL Throughput

(Based on scheduled activity)

Provider Total Kept

% Not Kept

New to Clinic (b) % New (b) Panel Last

12 Mos

Panel/ RESERVED

ROOM

Avg. Visits/ Patient

Annual visits/

RESERVED ROOM

at 50 weeks/

year (h); Visits/

RESERVED ROOM

Avg. Weeks Worked

per RESERVED ROOM

at avg. weeks

worked; Visits/

RESERVED ROOM

Provider 9 314 21% 192 61% 221 221 1.4 314 6.3 55 6

Provider 8 418 16% 242 58% 260 173 1.6 279 5.6 44 6

Provider 6 737 21% 218 30% 361 120 2.0 246 4.9 35 7

Provider 3 316 20% 77 24% 240 240 1.3 316 6.3 32 10

Provider 7 358 24% 108 30% 214 107 1.7 179 3.6 27 7

Provider 2 1,373 13% 138 10% 695 116 2.0 229 4.6 22 10

Provider 5 858 20% 140 16% 342 68 2.5 172 3.4 21 8

Provider 1 1,719 15% 233 14% 1,178 168 1.5 246 4.9 18 14

Provider 4 237 22% 27 11% 172 86 1.4 119 2.4 14 8

Total 6,330 18% 1,375 18% 3,683   1.7 119 2.4 25 5

Outcome from use of new metric Generated a broad guideline to begin to filter/

prioritize space requests Eventually moved to kept rather than

scheduled hours

Utilization Guideline

Current guidelines using KEPT VISITS as base

>60% 50% TO 60% 40% TO 50% < 40%

Approaching maximum use - request space

and or implement

decompression opportunities

Optimal space utilization - usage that

adjusts for peaks and allows for urgent add on

sessions without difficulty.

Reasonable use but with potential for

growth or sharing

underused sessions

Under use - consider

consolidation with other services

Exam Room Utilization

Practice Exam Rooms

FY 08 FY 09 FY 10

Shapiro 7b 14 60% 61% 61% cannot add sessions

Shapiro 2c 17 49% 51% 54% limited ability to addShapiro 8a 18 56% 56% 53%

room for growth

Shapiro 8b 22 57% 61% 51%

Shapiro 9 21 43% 43% 52%

Shapiro 3b 13 46% 46% 48%

Shapiro 7a 8 53% 53% 47%

Rabb 1 9 39% 43% 43%

Shapiro 2b 4 13% 39% 47%

Shapiro 2a 10 43% 39% 40%

  234 46% 48% 48%

LMOB 8a 5 48% 60% 60% limited ability to add LMOB 1 5 47% 49% 48%

room for growth

LMOB 7 6 43% 44% 49%

LMOB 4 9 49% 52% 55%

Deac 1 5 8% 11% 49%

LMOB 8b 4 44% 51% 55%

LMOB 5 4 35% 35% 38%

B/P Span 3 6 40% 40% 37%

LMOB 6 5 25% 34% 32%

LMOB 3a 5 21% 19% 19%

  73 41% 43% 46%

Outcome – Improved use of existing space Simplified/standardized use of scheduling

templates Reduced cancellations due to competing

commitments in research and teaching Encouraged creative options for existing

space Better sharing across divisions Office/exam room for more full time clinicians

Minimized/delayed the need for renovations

Outcome – Improved use of existing space

Annual Volume increased by 64,000 visits

14 exam rooms added during that time

Questions?