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?