Decrease Wait Times Research Articles

Use of patient flow analysis to improve patient visit efficiency by decreasing wait time in a primary care-based disease management programs for anticoagulation and chronic pain: a quality improvement study

BackgroundPatients with chronic conditions require frequent care visits. Problems can arise during several parts of the patient visit that decrease efficiency, making it difficult to effectively care for high volumes of patients. The purpose of the study is to test a method to improve patient visit efficiency.MethodsWe used Patient Flow Analysis to identify inefficiencies in the patient visit, suggest areas for improvement, and test the effectiveness of clinic interventions.ResultsAt baseline, the mean visit time for 93 anticoagulation clinic patient visits was 84 minutes (+/- 50 minutes) and the mean visit time for 25 chronic pain clinic patient visits was 65 minutes (+/- 21 minutes). Based on these data, we identified specific areas of inefficiency and developed interventions to decrease the mean time of the patient visit. After interventions, follow-up data found the mean visit time was reduced to 59 minutes (+/-25 minutes) for the anticoagulation clinic, a time decrease of 25 minutes (t-test 39%; p < 0.001). Mean visit time for the chronic pain clinic was reduced to 43 minutes (+/- 14 minutes) a time decrease of 22 minutes (t-test 34 %; p < 0.001).ConclusionPatient Flow Analysis is an effective technique to identify inefficiencies in the patient visit and efficiently collect patient flow data. Once inefficiencies are identified they can be improved through brief interventions.

Use of patient flow analysis to improve patient visit efficiency by decreasing wait time in a primary care-based disease management programs for anticoagulation and chronic pain: a quality improvement study

Use of patient flow analysis to improve patient visit efficiency by decreasing wait time in a primary care-based disease management programs for anticoagulation and chronic pain: a quality improvement study

CAN ALTERNATIVE MANAGEMENT STRATEGIES FOR SLEEP APNEA IMPROVE ACCESS TO CARE AND SAVE COSTS IN VETERANS?

PURPOSE: Long wait times for sleep evaluation in veterans has been suggested (AJRCCM 2004:169:668). In order to shorten wait times, alternative management (AM) strategies –screening pulseoximetry and automatic-positive airway pressure (APAP) therapy –have been performed (Chest 2006; 129:638). However, whether AM strategies improve access to care and save costs within the veterans healthcare system is unknown. Our objective was to determine whether an AM strategy for veterans with possible OSA can decrease wait times and costs compared to conventional management (CM).

Distribution of Willingness‐to‐Pay for Speed Reduction with Non‐positive Bidders: Is Choice Modelling Consistent with Contingent Valuation?

The paper addresses the issue of consistency between two commonly employed stated preference data—referendum contingent valuation (CV) and discrete choice modelling (CM)—with respect to estimated distributions of individual willingness‐to‐pay (WTP) for non‐market goods. The policy context is that of a local externality: effective speed reduction by means of traffic‐calming in towns crossed by fast roads. In particular, data from two independent samples of the same population are contrasted. The findings show that both methods indicate that speed reduction via traffic‐calming is valued in a polarized fashion. Results from both methods are consistent with the presence of two groups of preferences: a larger group holding positive values and a smaller one with non‐positive values. While the estimates of the relative proportions of the two groups are similar across the two data sources, once the econometric analysis of the CM responses allows for polarized preferences the estimates of the distribution of individual WTP differ substantially. The results from the choice modelling survey indicate that residents are also willing to pay for other benefits from traffic‐calming, such as noise reduction and a decreased waiting time for crossing, but preferences for these are also polarized, with WTP for aesthetic improvements being positive only for those supporting effective speed control. In comparing distributions of value estimates from CM and CV, surveys practitioners should account for the effects of taste heterogeneity over externalities and take advantage of the ability to derive individual‐specific WTP estimates from panel estimation rather than simply deriving estimates for common features of the WTP distribution.

Experience with an organ procurement organization‐based non‐directed living kidney donation programme

The organ procurement organization (OPO)-based non-directed living kidney donation programme was developed to decrease wait times for kidney transplants, and to meet the community's desire for altruistic living donation. Community awareness was encouraged through information about non-directed living kidney donation on the state donor registry Web site, and through the media. The OPO received all inquiries and responded with phone calls, e-mails, printed information, medical/social history questionnaires, interviews, and referrals to the transplant centres. Kidneys were allocated according to the United Network for Organ Sharing (UNOS) wait list for the evaluating transplant centre. Between March 2002 and 23 September 2005, there were 608 inquiries to the OPO about non-directed living kidney donation. In 41 months, 20 transplants occurred with kidneys from non-directed donors. The donor registry and OPO-sponsored publicity led to 578 of the 608 inquiries and 15 of the 20 transplants. OPO screening saved transplant centre resources by ruling out 523 inquiries, referring 76 to transplant centres for complete evaluations. Optional donor/recipient meetings appeared to be beneficial to those participating. OPO-based non-directed living donor programmes can be effective and efficient. Standardization of evaluation, allocation, and follow-up will allow for better data collection and more widespread implementation.

Managing Capacity to Reduce Emergency Department Overcrowding and Ambulance Diversions

Shady Grove Adventist Hospital implemented a series of housewide initiatives to decrease ambulance diversions, decrease wait times in the emergency department (ED), improve poor patient satisfaction, and decrease risks to patient safety. Process improvement teams addressed areas affecting overcrowding and inpatient bed availability. Teams met to identify, test, and implement process changes. The ED's ability to evaluate, treat, and transfer patients requiring inpatient admission was identified as the most critical factor in reducing ED crowding and ambulance diversions. From 2003 to 2004, the hospital reduced ambulance diversion hours from 2,365 to 655--a 72% reduction. It also decreased average in-hospital and ED lengths of stay, improved ED patient satisfaction scores, and decreased the number of patients "boarding" in the ED. Increases in the number of admissions and decreases in length of stay improved financial performance. The initiatives helped improve access to care for the rapidly growing community. Reductions in ambulance diversions and ED overcrowding reflected a team effort, which included the executive team as well as clinical and nonclinical staff, and a holistic approach to identifying and removing throughput barriers.

Appropriate Resource Utilization in Portable Noninvasive Vascular Studies: The Role of Disruptive Technology

Purpose Common reasons for avoiding portable noninvasive vascular laboratory (VL) studies include degraded study quality, repetitive stress injuries, the wear and tear of equipment, and inefficiency. We examined the efficiency of portable VL studies in the context of productivity and potential loss of revenue. Methods From January 2005 to March 2005, sonographers in the VL recorded the time required to conduct “in-lab” and portable studies with conventional full-size scanners. A blended average based on frequency of portable studies within different areas of the hospital was used to determine the additional time required to conduct a portable study. The sonographer also made a qualitative assessment on the necessity of the portable study in each case. Results The VL performed an average of 31 portable studies (18% of total studies) per week. On average, portable testing increased overall study time by 17.7 min per test and 1.8 h per day, resulting in 9.1 h of additional study time lost per week. The potential increase in study volume could result in incremental annual gross revenue of $41,204 to $77,258 for the VL. The sonographers estimated that 24% to 45% of portable procedures could have been conducted in the lab. Conclusions In addition to suboptimal imaging and sonographer/equipment wear and tear, the current practice of unrestricted portable tests performed with existing bulky equipment is economically inefficient. New “disruptive” technology, leading to high-quality bedside scanning and limiting portable studies to patients who genuinely need it, will allow for greater productivity, decrease wait time for elective outpatients, and generate incremental revenue for the VL.

The Value of Thoracic Computed Tomography Scans in Clinical Diagnosis: A Prospective Study

Computed tomography (CT) scans are used extensively to investigate chest disease because of their cross-sectional perspective and superior contrast resolution compared with chest radiographs. These advantages lead to a more accurate imaging assessment of thoracic disease. The actual use and evaluation of the clinical impact of thoracic CT has not been assessed since scanners became widely available. To identify patterns of utilization, waiting times and the impact of CT scan results on clinical diagnoses. A before and after survey of physicians who had ordered thoracic CT scans. Vancouver General Hospital--a tertiary care teaching centre in Vancouver, British Columbia. Physicians who had ordered CT scans. Physicians completed a standard questionnaire before and after the CT scan result was available. Changes in the clinical diagnosis, estimates of the probabilities for the diagnosis both before and after the CT scan, and waiting times. Four hundred fifty-four thoracic CT cases had completed questionnaires, of whom 80% were outpatients. A change in diagnosis was made in 48% of cases (25% with a normal CT scan and 23% with CT scan findings that indicated a different diagnosis). The largest change in probability scores for the clinical diagnosis before and after the CT scan was 43.9% for normal scans, while it was 36.3% for a different diagnosis and 26.3% for the same diagnosis. High-priority scans were associated with decreased waiting time (--7.89 days for each unit increase in priority). The CT scan results were associated with a change in diagnosis in 48% of cases. Normal scans constituted 25% of the total and had the greatest impact scores. Waiting times were highly correlated with increased urgency of the presenting problem.

The Magnetic Resonance Imaging Story: Assessing time to clinical competency and the future implementation of simulation

The Michener Institute for Applied Health Sciences The present clinical education model for allied health programs is fully dependent on the number of available clinical placements. A decrease in the number of available placements and the high cost of clinical education are presenting significant challenges to educational programs. Decreased available clinical spaces leads to a decreased number of applicants accepted into a program. The implications for future human resources and the effect on patient wait-times for diagnostic tests such as Magnetic Resonance Imaging (MRI) are immense. In response to these issues, The Michener Institute for Applied Health Sciences conducted a retrospective analysis in our MRI program to determine at which point during the students’ 12 week clinical rotation they were assessed as competent. It was found that a majority of students, 55%, reach competency by week 11, while a further 36% demonstrated competency by week 12, and 9% required more than the 12 weeks. These findings led to further inquiry into possible ways in which to deliver clinical education to each of these three groups of students to enhance their learning experience and assess the time to reach competency. The introduction of simulation activities into the curriculum prior to the clinical rotation is proposed to aid in reducing the length of the rotation, in improving the efficiency of time spent in the clinical site and provide remediation to those students in need of additional clinical experience. To investigate the impact of a simulated-enhanced curriculum on clinical education, a current funded project will allow for the introduction of two levels of simulation in the program’s didactic phase. The first is the implementation of unique, individual software-based simulators for protocol manipulation. The second is the installation of an MRI sham unit, an exact replica of a fully functional MR system without the need for a full and expensive magnet set-up. The first student cohort to experience the simulation-enhanced curriculum (SEC) will complete the program in the fall of 2006. Time to clinical competency for the SEC cohort will be calculated and compared to the previous cohort. In addition, semi-structured interviews with SEC students and their clinical educators will investigate the value of the SEC curriculum and its impact on the quality of the clinical experience. It is anticipated that the implementation of the SEC will better prepare students, lead to the reduction in clinical time thereby potentially contributing to decreased wait times, timely access to diagnostic tests and reduced workload of technologists and clinicians, ultimately benefiting patient care. Conflict of Interest: Authors indicated they have nothing to disclose.

Diagnostic Imaging in Canada

In Ontario, between 1993 and 2003, the annual number of MRI scans performed increased by more than 600 percent (Iron et al. 2003), and the number of CT scans increased threefold (Tu et al. 2005). Despite these massive increases, the Fraser Institute reported a median wait of five weeks for CT and thirteen weeks for MRI scanning in 2004 (Esmail and Walker 2004), and Canadians are increasingly concerned about the length of time they wait for diagnostic imaging. Because of this, politicians have made decreasing wait times for diagnostic imaging one of their top priorities (Health Canada 2004). This raises several interesting questions. Have the indications for CT and MRI really expanded that rapidly, or was there just a huge pent-up demand because Canada had fallen so far behind in acquiring modern imaging machines? Are physicians relying more on diagnostic imaging technologies and less on clinical skills? Are an increasing number of patients undergoing scans when there is a small likelihood that the results will change their management or improve their outcomes? Supporters of the view that Canada needs to expand its diagnostic imaging capacity point to the fact that we rank well behind many developed countries in terms of the number of diagnostic imaging machines per population (Canadian Institute for Health Information 2003: 33), and that improvements in imaging quality have expanded the indication for imaging. Supporters of the view that there is an increased and inappropriate reliance on technology over clinical skill point to the findings of a recent American study showing that the regions that spent the most on healthcare did not have better outcomes than the regions that spent less--indeed, the trend was toward poorer outcomes in the highest-spending regions (Fisher et al. 2003a, 2003b). One of the greatest differences between the highest- and lowest-spending regions was their expenditure on a variety of diagnostic tests, suggesting that more testing did not lead to better outcomes on a population basis. It may in fact have led to iatrogenic illnesses because of the workup of false positive results, and diverted attention away from simple interventions that have been shown to be effective (Fisher et al. 2003a). The truth is likely a combination of many factors. Some patients with clear indications for diagnostic imaging undoubtedly wait too long for their tests in Canada. At the same time, a number of patients undergo tests whose results have a very small likelihood of changing their management, which itself contributes to the access problem. Unfortunately there are no evidence-based benchmarks for the appropriate rate of diagnostic testing that can be used to determine the optimal supply of diagnostic machines and radiological personnel. In this article we discuss the reasons it has been so difficult to determine the optimal imaging capacity needed for a population, describe some factors that are "inappropriately" increasing the rate of imaging and suggest some solutions. Although many of our examples deal with CT and MRI scanning, our remarks apply more broadly to many other diagnostic tests.

Redesign of thoracic surgical services within a cancer network-using an oncology focus to inform change

Thoracic surgical services for one cancer network in London are based at one NHS Trust. Approximately 80% of the surgery performed in the period January-December 2003 was for the diagnosis, palliation or treatment of cancer. The range of different patient groups and needs is very wide, ranging from teenagers undergoing metastatectomy to adults and older adults undergoing resections or palliative surgery. An audit of lung cancer resections performed in 2001 on behalf of the Network lung tumour board indicated that the service was fragmented and there were several bottlenecks in the lung cancer pathway, causing patient delays and a feeling of dissatisfaction amongst referrers and patients. A clinician with oncology experience was appointed in 2002. Immediate action to track patients and ensure referrers knew the outcome of surgery and histology was taken. As part of the NHS Modernisation agenda, the local Cancer Services Collaborative then facilitated mapping the pathway for lung cancer, identifying problems and ways of tackling them. Changes from this, subsequent initiatives and adopting a collaborative approach have also had a positive impact on the lung cancer service. These strategies have been adapted to all thoracic surgery pathways for cancer or suspected cancer. Examples include decreased wait time, sector-wide patient information, multiprofessional working practice and educational initiatives.

Use of donors over 60 years old in liver transplantation: A decision and cost-effectiveness analysis

Abstract Introduction: Utilization of grafts from donors greater than 60 years old (older donors [OD]) presumably decreases wait time and improves overall survival; however, OD recipients have shortened survival, increased rejection and retransplantation. We examined the cost-effectiveness of using OD compared to donors less than 60 (younger donors [YD]) in liver transplantation. Methods: A Markov-based decision analytic model was created to simulate outcomes for liver transplantation with donors >60 versus donors Results: OD accounts for 10% of all transplants with a five-year survival of 60% versus 71% for YD (P = 0.003). After transplantation, recipients of OD averaged 4.7 QALYs (Quality Adjusted Life Years) at a cost of $69,000/QALY versus 5.7 QALYs at $56,000/QALY for YD. The wait list strategy combining OD and YD offers 5.6 QALYs at $57,000/QALY. Even assuming a 25% increase in wait list death with the elimination of OD, the YD strategy provides an average of 5.6 QALYs at $56,000/QALY to recipients. Conclusions: The current strategy combining OD and YD donors in the general donor pool offers no added benefit to overall survival and decreases the individual survival of some recipients. OD organs could be used more effectively in an alternative list for those with more controversial indications for transplantation.

Make your best better with a reporting system.

To decrease wait times and increase satisfaction for patients, one Chicago facility implemented an ED written report.

Russia: Omya — PCC

In 1976 an independent department was established for the emergency treatment of patients in the county hospital in Szolnok, Hungary. The new system changed the traditional structure of patient flow and the work plan of other departments, and it influenced the curing and nursing activities of the departments. The reorganization resulted in decreased waiting time, enhanced primary treatment, and a lessening in the mortality rate.

Reproductive history and allergic rhinitis among 31145 Danish women.

A successful pregnancy is associated with a strong skewing of the immune system towards a Th2-type immune response. Because such a deviation is also the hallmark of allergic disease, it was investigated whether allergic rhinitis in women was associated with an increased likelihood of becoming pregnant and having a successful outcome of pregnancies. Information on allergic rhinitis and reproductive history was obtained for 31145 pregnant women who participated in a national birth cohort study in Denmark during September 1997 to March 2000, and for whom complete information on siblings and place of residence and birth was available via the Civil Registration System. Data were analysed using logistic regression. Women who had previously been pregnant (OR = 0.91, 95% CI 0.85-0.98) or who had given birth previously (OR = 0.91, 95% CI 0.85-0.98) were less likely to report allergic rhinitis than others. The number of previous spontaneous abortions, gestational week of the first spontaneous abortion and fertility treatment were not associated with allergic rhinitis. Women who had waited less than a year to become pregnant more often had allergic rhinitis (OR = 1.18, 95% CI 1.06-1.32, P = 0.002) than women who had waited for more than a year. Early age at menarche was associated with an increased likelihood of allergic rhinitis (Ptrend = 0.003). Our findings did not support the hypothesis that an atopic genotype overall should be associated with an increased likelihood of successful outcome of pregnancies, but it might be associated with a decreased waiting time to pregnancy.

Applications of Business Process Redesign in Hotel Daily Operations

The growing yet competitive global economy necessitates businesses to continuously seek ways to execute more efficiently while delivering products or services to customer expectations of quality and timeliness. Business process redesign (BPR) is an approach to analyze, evaluate, and change existing processes and sub-processes in the product/service manufacture and delivery cycle. Delivery of services is more difficult due to the nebulousness of the customer final interpretation and the rapid evaporation of the delivery occurrence. The drop in American travel since September 11, 2001 has devastated hotel occupancy. Hotels delivering services matching or exceeding customer expectation will be more likely to survive the ebb of customer room night sales. This project applied BPR to a process of airport van delivery in a large US hotel. Following customer complaint, the hotel gathered staff to discuss and propose solutions to reducing customer wait times at the airport curb. An initial analysis by management indicated that communications and employee training were two interventions to the process that would likely improve the process. During the analysis period, customers riding in the van were surveyed to determine their satisfaction with the pickup service. The process was redesigned to add more communication devices to the concierge work area and to improve van driver training. Customers were resurveyed following the intervention. Significant improvement was noted in operator courtesy and friendliness and decreased wait time. Allowing time to analyze processes within an operation can yield rapid improvements often without major financial expenditure.

The use of midwives as first assistants in cesarean section

Introduction: In 1997, medical insurance gives limited financial reimbursement to physicians who first assist cesarean sections. Therefore, a formal program was developed at our community teaching hospital using midwives in place of physicians as first assistant in cesarean section. Midwives on the midwifery service were taught the principles and procedures of obstetrical anesthesia, anatomy, and physiology of the gravid abdomen. A team approach using obstetrician/gynecologist, anesthesiologist, midwives, and operating nurses performed the tracking in a 1-day course. A 28-minute video was developed to depict the role of the midwife as first assistant. Additionally, the principles of operation room set-up and instrumentation were taught. Result: All 24 midwives on the midwifery service were involved in the teaching of first assisting an attending obstetrician. After taking the course, nurse-midwives received formal certification from the department of obstetrics and gynecology and were approved by risk management. They also received clinical privileges outlining these guidelines. Their malpractice rates have not increased. The time to complete a cesarean section has not increased for the physician, and an emergency cesarean section is no longer delayed by waiting for an assistant to arrive. Patient satisfaction has increased because of decreased waiting time for a cesarean section and increased familiarity with the entire operating team. Discussion: Midwives can be trained to first assist the obstetrician/gynecologist in a cesarean section. Since the duration of a cesarean section is not prolonged, the patient will not experience increased blood loss or infection secondary to a prolonged procedure. The patient is more relaxed since they know that their provider during labor is also one of their surgeons for the cesarean section.

The Hungarian model of an emergency admission and care department

In 1976 an independent department was established for the emergency treatment of patients in the county hospital in Szolnok, Hungary. The new system changed the traditional structure of patient flow and the work plan of other departments, and it influenced the curing and nursing activities of the departments. The reorganization resulted in decreased waiting time, enhanced primary treatment, and a lessening in the mortality rate.

A Structured Logit Model of Auto Ownership and Mode Choice

For analysis of many transportation-related policies, it is useful to know the change which a particular policy would induce in the number of autos owned by households and the number of workers who take transit and auto to work. Models of households' choices of how many autos to own (called the auto ownership choice) and workers' choices of mode (called the work-trip mode choice) are intended to provide information about the effects of various policies. This information can be used, along with other information and ideas, in deciding which policies should be implemented. Previous studies of auto ownership and work-trip mode choices have generally been deficient in important ways.' First, most research has not confronted the simultaneity of the choices. Except for Lerman and Ben-Akiva (1975), past researchers have modelled either the auto ownership choice or the work-trip mode choice, not both. When modelling one of the choices, the simultaneity with the other choice has not been satisfactorily incorporated. Of the auto ownership models, Wharton (1977) included an explanatory variable defined as the number of autos the household uses for work trips, but did not adjust its estimation techniques to account for the endogeneity of this variable. None of the other auto ownership models included any variables relating to work-trip mode. In the work-trip mode-choice studies, more emphasis has been placed on the simultaneity of mode choice and auto ownership, but the results have been similarly unsatisfactory. Warner (1962), Lisco (1967), and Quarmby (1967) included auto ownership variables in their models with the (implicit) assumption that the number of autos is exogenous to the mode choice. On the other hand, Lave (1969) recognized that auto ownership is endogeneous and did not include an auto ownership variable on the grounds that his model formulation is a reduced-form equation. Train (1976b) used both approaches, estimating mode choice models with and without an auto ownership variable, and noted the problems inherent in each specification. Aside from the simultaneity problem, previous models have limited usefulness because they include only a few explanatory variables. This fact limits the number of policies and scenarios which can be analysed with the models. For example, in most mode choice models the time spent out of the vehicle (walking, waiting for a bus, and so on) is included as an explanatory variable. Since out-of-vehicle time is not decomposed into time spent waiting for transit and time spent walking to and from transit, the effect of policies trading off these two components cannot be analysed. (An example of such a policy is to place more buses on fewer bus lines, thus decreasing wait times and increasing walk times.) Analogously, most auto ownership models ignore the effect of family structure (household size and number of children, for example) on auto ownership decisions.2 The present study confronts these problems in the previous research. Models of mode choice and auto ownership are developed and estimated with explicit account taken of the interaction between the choices. Numerous explanatory variables are included so that a variety of policies and scenarios can be examined with the models. Throughout the study,