Centralized Scheduling

Children’s Hospital’s Journey

Maribeth Quinn

Director, Business Process Improvement

Presentation Agenda

n Background for Columbus Children’s Hospital

n Project Background

n Goals for Centralizing the Process

n Initial Scheduling Process (Past State)

n What We Wanted for the Future State

n Steps We Took Along the Wayn Before Approval

n After Approval

n After Selection

n Outcomes Produced from the Project

Columbus Children’s Hospital

n 110 year historyn Teaching hospitaln Strong commitment to researchn 2004 statistics:

n 323 licensed bedsn 48 leased off-site beds n 14,012 inpatient dischargesn 15,652 surgeriesn 64,851 ED visits, plus approx. 20,000 Urgent Care Visitsn Approx. 47,000 off-site urgent care visitsn More than 400,000 outpatient visits

Scheduling Project Background

n Completely decentralized process

n Almost all our clinics require a referral from a primary care physician (pediatrician) and most clinics were using a fax referral to schedule from

n Some clinics were taking two weeks to “triage” patient information and provide an appointment back

n Most clinics were then relying on the primary care physician to notify the patient of their appointment date and time

+50 Clinics & Procedures

Customers(both

internal and external)

Separate phonecall or fax for each

area with a differentprocess to follow +15 Scheduling

Systems

Original Scenario (2003)

* New form and process now being used to create more consistency

across clinics

Customer Service “Horror” Stories

Pickerington Family Practice Debbie Foly - Nurse ManagerPhone: 833-0880 x230

•Main concern: Takes weeks to get an appointment. Ex-CHI nurse who understands the wait times, but feels that weeks of waiting just to get an appointment is unacceptable. She spoke of continuing problem but named the ENT and GI clinics as recent examples of poor service.

•ENT Clinic - Patient had painful ear infection with drainage. After two weeks of daily phone calls requesting an appointment to see CHI specialist without any response, patient was forced to go to ED for treatment. ENT Clinic finally called after ED visit, saying they were trying to reach PCP and parent the whole time...

•After a frustrating two weeks of waiting for an appointment in the GI Clinic, they sent their patient to another location for service.

•Pickerington belongs to a group of 26 family practice offices who share info like this along with alternative locations to send their patients

Goals for Centralized Scheduling Project

n Improve customer service to both referring physicians and parents by providing “one-stop” shopping for all their scheduling needs

n should also reduce the time required to register when they arrive for their appointment

n Increase productivity associated with clinic and diagnostic schedules and productivity

n higher productivity will increase revenue

n provides an opportunity to create consistent policies across areas

n Improve access to clinics and diagnostic areas through better ability to fill open slots

n could reduce overall wait times in some of the areas

n Reduce labor associated with scheduling (estimated to be significant due to decentralized system)

n Improve the pre-registration process which will lead to increased collections

n Reduce no-show rate

SchedulingCenter

+50 Clinics & Procedures

Customers(both

internal and external)

One phonecall or fax

for everything

One SchedulingSystem

Ultimate Proposed Scenario

SchedulingSystem

View

* Referred to as Central ACCESSwhich is the top request for referring physicians

Benefits of Ultimate Process

n Customer Servicen Physician Relations - referring physician’s staff spend large amounts of

time trying to coordinate several appointments on behalf of the patient. They are currently frustrated with our process.

n Parent Relations -providing parents with the ability to make one call for all procedures and clinic visits

n Consistency/Quality - having one process allows for more standardization of policies and procedures in scheduling practices thus improving access to care. Rules will also prevent tests being ordered in the wrong order, etc.

n Patient Education - having an intelligent robust system allows for reliable information to be consistently provided to the patient and family when scheduling procedures and clinic visits.

Benefits of Ultimate Process

n Return on Investment

n Increased revenue - Many hospitals reported increases in volume after implementing centralized scheduling through better management of clinic throughput and easier access

n Increased revenue - currently it is estimated that most of our clinics experience a 25% no-show rate and above. Although some areas handle this through over booking many areas do not. With a more customer friendly system it is estimated that no-show rates will decline improving overall revenue.

n Reimbursement - centralized scheduling processes include pre-registration and could ensure that required authorizations are completed prior to any appointments

n Time Savings - hospital staff spend large amounts of time trying to coordinate schedules between departments. OhioHealth estimated a savings of over 20 FTE’s.

Issues/Concerns

n Triage capability - Currently many of the areas practice some type of triaging to determine how quickly a patient should be seen. A new process for triage would have to be developed than the current one.

n Each area loses some control of their “immediate” schedule in that except for emergencies, schedules would not be changed. Long term schedules are determined by the areas themselves.

n It will take a lot of work to redesign all the current scheduling processes.

n A new system will need to be purchased to provide sufficient search and education capabilities for one area to have the knowledge and expertise to schedule for all areas.

Project Steps Before Approval

n Interviewed all clinics to determine how they were schedulingn What system they were using

n How much staff time it was taking

n A sense of the process they were following

n Compiled that data into a table to present to the Steering Committee

n Contacted other hospitals to determine if they had achieved a Central Scheduling process

n ROI Analysis based on estimated costs using improved throughput (projected)

n Took a site visit with key physicians to Cincinnati Children’s who were in the process of centralizing the scheduling process

Initial Data CollectionSummary of Current Scheduling Areas Using SMS

Department/Clinic Pre-Register? Scheduling System FTE's

Estimated

Monthly

Volumes

Adolescent/Teen Health Clinic No SMS 0.90 543

Allergy Clinic No SMS 0.50 136

Bone Density No SMS 0.25

Cardiology Clinic No SMS 0.75 603

Central Scheduling Yes SMS 8.00 2394

Cerebral Palsy No SMS 0.67 91

CT Interventional No SMS 0.38 2376

Dermatology Clinic No SMS 0.50 222

Developmental Disability No SMS 0.60 42

Down Syndrome No SMS 0.60

Endocrinology Yes SMS 0.50 435

Eye Clinic No SMS 0.25 550

Fluoroscopy No SMS 0.13 506

General Radiology No SMS 0.13 5512

Hematology No SMS 1.00 866

Myelomeningocile No SMS 0.60 41

MRI No SMS 1.00 907

Nuclear Medicine No SMS 0.13 377

Orthopedics including hand clinic No SMS 0.67 606

Physical Medicine/Rehab No SMS 1.25 282

Primary Care Yes SMS

Sleep Lab No SMS 0.50 341

Sports Medicine No SMS 0.67 108

Ultrasound No SMS 0.13 731

Cleft Palate/Cranio Facial Yes Paper/Pencil & SMS 0.75 59

ENT No Paper/Pencil & SMS 0.75 422

Family Development No Paper/Pencil & SMS 0.38 85

Immune Deficiency (IDC) Yes Paper/Pencil & SMS 0.38 71

Estimated Monthly Total on SMS 22.34 18305

Department/Clinic Pre-Register? Scheduling System FTE's

Estimated

Monthly

Volumes

Behavioral Health Yes CMS 6.00 700

Behavior/Learning Disability Yes CSM database 1.50 106

Physical Therapy Yes Excel 0.75 808

Occupational Therapy Yes Excel 853

Pediatric Surgery (King, Teisch) No Medical Manager 1.00 838

Pulmonary Clinic - CF No MS Access 0.50 508

Arthritis Clinic/Rheumatology No Outlook 0.38 176

Infant Pulmonary Lab No Outlook 0.13

Interpreters Not Applicable Outlook 0.31

Nephrology No Outlook 0.38 162

Neurology Yes Outlook 0.75 446

GI Procedures Clinic Yes Outlook & SMS 1.50 743

Cardiology Diagnostic No Paper/Pencil 1.00

Dialysis Yes Paper/Pencil 0.03

EEG Yes Paper/Pencil 0.33 383

Genetics Clinic No Paper/Pencil 0.75

Infectious Disease Clinic No Paper/Pencil 35

Infusion Yes Paper/Pencil 0.19 170

Neonatology No Paper/Pencil 0.63 172

Pediatric Surgery (not King, Teisch) No Paper/Pencil 1.00

Pulmonary Lab No Paper/Pencil 0.13 561

Speech No Paper/Pencil 0.33 1278

Sweat Lab No Paper/Pencil 0.03

Dental Clinic No Softdent 1.50 2333

Estimated Monthly Total Not on SMS 19.10 10270

Initial Data CollectionSummary of Current Scheduling Areas Not Using SMS

Comparison with Other Hospital Systems

Area Hospital’s with Centralized Scheduling

n Cincinnati Children’s Hospital

n Mount Carmel

n OhioHealth (Radiology Only)

n Tod Children’s Hospital (Youngstown)

n St. Elizabeth North Unit (KY)

n TriHealth System (Cincinnati)

n Health Alliance System (Cincinnati)

Area Hospitals not using Centralized Scheduling

n Ohio State University Medical Center

n Rainbow Children’s

n Akron Children’s

n Dayton Children’s

n Toledo Children’s (plans to offer it within next two years)

Other Hospitals Using Centralized Scheduling

n Beaumont Hospital (MI) *

n Riverside Walter Reed Hospital (VA) *

n St. Elizabeth North Unit (KY)

Other Hospitals not using Centralized Scheduling

n Mayo Clinic (MN) *

n Johns Hopkins Hospital (MD) *

n University of Michigan Medical Center (MI) *

n Massachusetts General Hospital (MA)

n Barnes-Jewish Hospital (MO)

n University of California San Francisco Medical Center (CA)

n Stanford University Hospital (CA)

n Brigham & Women’s Hospital (MA)

* One phone number to call

($1,405,997) NPV using 10% and 1% improvements$4,713,822 NPV using 10% and 5% improvements

Centralized Scheduling $184 NPV using 10% and 2% improvements

Return on Investment Analysis

Average Monthly Clinic Billing $1,965,507

Average Monthly Scheduled Diagnostic Billing MRI, Ultrasound, CT, Nuclear Med., EEG, Cardiology $3,181,137

Average Monthly Clinic/Diagnostic Denials $97,000

Increased Revenue Year 1 Year 2 Year 3 Year 4 Year 5 TotalDecrease breakrate and/or increase physician productivity by 1% assuming 70% collection rate $165,103 $165,103 $165,103 $165,103 $165,103 $825,5131% increase in diagnostic productivity $267,215 $267,215 $267,215 $267,215 $267,215 $1,336,0771% decrease in denials $11,640 $11,640 $11,640 $11,640 $11,640 $58,200

$443,958 $443,958 $443,958 $443,958 $443,958 $2,219,790

Decrease breakrate and/or increase physician productivity by 5% assuming 70% collection rate $825,513 $825,513 $825,513 $825,513 $825,513 $4,127,5655% increase in diagnostic productivity $1,336,077 $1,336,077 $1,336,077 $1,336,077 $1,336,077 $6,680,3875% decrease in denials $58,200 $58,200 $58,200 $58,200 $58,200 $291,000

$2,219,790 $2,219,790 $2,219,790 $2,219,790 $2,219,790 $11,098,952

Required cash flow to break even using NPV $852,000 $852,000 $852,000 $852,000 $852,000 $4,260,000(Equates to approximately a 2% decrease in breakrate and or physician productivity and diagnostic productivity)

Investment & Ongoing Expenses Year 0 Year 1 Year 2 Year 3 Year 4 Year 5 TotalEquipment

Software 800,000$ 160,000$ 160,000$ 160,000$ 160,000$ 160,000$ 1,600,000$ Hardware 90,000$ Implementation 500,000$ 200,000$ 700,000$ Ongoing IT support 234,000$ 117,000$ 117,000$ 117,000$ 117,000$ 117,000$ 819,000$ Scheduling Manager 78,000$ 78,000$ 78,000$ 78,000$ 78,000$ 78,000$ 468,000$

Total Initial Investment 1,702,000$ 555,000$ 355,000$ 355,000$ 355,000$ 355,000$ 3,677,000$

Net Cash Flow

Net Cash Flow Annual using 1% (1,702,000)$ ($111,042) $88,958 $88,958 $88,958 $88,958 ($1,457,210)Net Cash Flow Annual using 5% (1,702,000)$ 1,664,790$ 1,864,790$ 1,864,790$ 1,864,790$ 1,864,790$ 7,421,952$ Net Cash Flow Cumulative using 1% (1,702,000)$ (1,813,042)$ (1,724,084)$ (1,635,126)$ (1,546,168)$ (1,457,210)$ Net Cash Flow Cumulative using 5% (1,702,000)$ (37,210)$ 1,827,581$ 3,692,371$ 5,557,161$ 7,421,952$

Net Cash Flow Required to Break Even (1,702,000)$ 297,000$ 497,000$ 497,000$ 497,000$ 497,000$ 583,000$ (1,702,000)$ (1,405,000)$ (908,000)$ (411,000)$ 86,000$ 583,000$

ROI Spreadsheet

What Sold the Project?

n The site visit to Cincinnati Children’s Hospital where we took 3 physicians (one of whom was particularly against the idea) was a key step. Cincinnati was having success and there were physicians there to attest that the centralization had not been a problem for them.

n Also, the small improvement required in throughput to pay for the system while improving customer service sold the project to Administration

Project Steps Once Approved

n Created a “Planning Committee” to write the RFP

n Using workflows what “exactly” did we need a scheduling system to be able to do (Rules Based System)

n Which needs were critical or which would be nice to be met

n Mostly clinical staff (including 3 physicians) so we met at 7:00 for an hour each week

n Sent out and scored the RFP responses

n Invited back the top 5 vendors

n Went on site visits for the top 2 vendors

n Selected a system in Summer, 2003 and then entered into contract negotiations

n Contract signed late August, 2003

Project Steps After Selection Process Completed

n System Manager training September, 2003 and began really building the system in October

n Central Scheduling moved to Westerville (off-site) February 27th, 2004

n Training completed the last week of February, 2004

n Began scheduling for Primary Care, ENT, Eye and Derm March 6, 2004

n Radiology live in April, 2004

n Rolled out clinics every few months after that

Baseline for Goals to Determine the Impact of the Project

n Physician and parent surveysn The director conducted a parent survey late 2003 for baseline

n A fax survey was sent to approximately 300 referring physician offices

n Clinic throughput (# of patients actually seen per day)

n Gather current wait times for being seen in clinic areas

n Cost per appointment measured before and after scheduling process/system is implemented

n Measure denials before and after (will not be affected until pre-registration is implemented)

n Measure no-show rates before and after

Children’s Hospital Scheduling Benchmarking Survey April 2004

1. How long does it take to schedule an appointment at Children’s Hospital:

Radiology Department? _____ Minutes _____ Hrs. _____ Days

Sub-specialty Clinic? _____ Minutes _____ Hrs. _____ Days

2. Please rate your satisfaction with Children’s Hospital’s current time (processing time) to schedule an appointment.

Very Satisfied Satisfied Neutral Unsatisfied Very UnsatisfiedRadiology o o o o o

Subspecialty Clinics o o o o o

EEG’s o o o o o

4. Does an RN in your office schedule the appointment?

_____ Yes _____No

3. Could your office accommodate the process of keeping the parent in your office while an appointment at Children’s Hospital is booked over the phone?

_____ Yes _____No

5. How would you rate your overall satisfaction with the scheduling process at Children’s Hospital? (e.g. Including ease of use, time required, response time received…)

Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied

o o o o o

Thank you for your time! Your feedback is greatly appreciated and will be used to help improve our scheduling process.

Please forward any questions to Joan Euans, Central Scheduling Supervisor at 722-5910.

Please fax completed surveys to Lee Velo, Dept. of Process Improvement 722-3370

Some Outcomes

Results from 1st Survey

Current time(processing time) to schedule an appt.

Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied Radiology 15 8 0 0 0

65.2% 34.8%Subspecialty Clinics 2 3 6 9 3 23

8.7% 13.0% 26.1% 39.1% 13.0%EEG's 4 9 10 0 0 23

17.4% 39.1% 43.5% 0.0% 0.0%

Could your office accommodate the process of keeping the parent in your office while an appt at CHI is booked over the phone?

Yes No 14 9

Does an RN in your office schedule the appt?

Yes No 16 7

Overall satisfaction with scheduling process at CHI

Very Satisfied Satisfied Neutral Unsatisfied

2 12 6 48.3% 50.0% 25.0% 16.7%

Results from 2nd Survey

Very Satisfied Satisfied Neutral Unsatisfied / Etc.Radiology 18 10 4 2

% 53% 29% 12% 6%Subspecialty Clinics 5 15 10 2

% 16% 47% 31% 6%EEG's 8 14 8 2

% 26% 43% 25% 6%

%Yes 18 51%No 17 49%

%Yes 19 52%No 17 48%

Very Satisfied Satisfied Neutral Unsatisfied Very Unsatisfied 12 9 7 5 0

37% 27% 21% 15% 0%

4. Does an RN in your office schedule the appt?

5. Overall satisfaction with scheduling process at CHI

2. Current time(processing time) to schedule an appt.

3. Could your office accommodate the process of keeping the parent in your office while an appt at CHI is booked

over the phone?

Some Comments from 2nd Survey

n Once you get a scheduler it moves fairly fast but the experience I've had with wait times has been too long. It seems to be getting a little better

n Much better than previouslyn Some kids need to get in quicker especially behavioral. We love Children's, the

only problem was getting in, that has been corrected. Thanksn Very nice change / improvementn Some of the specialty clinic utilize a triage system - this is probably the best way

to schedulen No complaints or problems; very good system. Thanksn I love the new scheduling process! Usual wait time on phone is minimal.

Telephone operators are always helpful and pleasant. n Response time ("on hold" time) prior to scheduling is a little lengthyn For the subspecialty clinics, I would much rather send/fax a written referral.

That is easier than calling. I have been on the phone for as much as 20 min. Radiology is o.k. except for when you need an appt. STAT because a lot of times the scheduline dept needs to contact radiology which is also time consuming.

Monthly Average Phone Queue Time

02040

60

80100120

140160

Secon

ds

JAN ‘04 MAY ‘05SEPT ‘04

Parent Surveys – Primary Care

Rating of Primary Care Scheduling Process

0.0%5.0%

10.0%

15.0%20.0%25.0%30.0%35.0%

40.0%45.0%50.0%

Excellent Very Good Good Fair Poor

Dec-03

Apr-04

Sep-04

Radiology Throughput Increases Compared to Expenses

Revenue/Margin Gains in Radiology

$0

$200,000

$400,000

$600,000

$800,000

$1,000,000

$1,200,000

$1,400,000

$1,600,000M

RI

Flu

oro

sco

py

Ultr

aso

und

CT

Nucl

ea

r

Me

dic

ine

Increased Revenue '03-04 (Sept. YTD)

Increased Margin '03-'04(Sept. YTD)

Clinic Throughput Increases