Valley County Medical Clinic
Valley County operates a walk-in medical clinic (VCMC) to meet the nonacute medical needs of its approximately 15,000 citizens. Patients arriving at the clinic are served on a first-come, first-served basis.
As part of a new total quality management program, VCMC conducted an in-depth, four- month study of its current operations. A key component of the study was a survey, distributed to all county citizens. The purpose of the survey was to identify and prioritize areas most in need of improvement. An impressive 44 percent of the surveys were returned and deemed usable. Follow-up analysis indicated that the people who responded were representative of the population served by the clinic. After the results were tabulated, it was determined that the walk-in medical clinic was located near the bottom of the rankings, indicating a great deal of dissatisfaction with the clinic. Preliminary analysis of the respondents’ comments indicated that people were reasonably satisfied with the treatment they received at the clinic but were very dissatisfied with the amount of time they had to wait to see a caregiver.
Upon arriving at the clinic, patients receive a form from the receptionist requesting basic biographical information and the nature of the medical condition for which treatment is being sought. Completing the form typically requires two to three minutes. After the form is re- turned to the receptionist, it is time-stamped and placed in a tray. Clerks collect the forms and retrieve the corresponding patients’ files from the basement. The forms typically remain in the tray for about five minutes before being picked up, and it takes the clerk approximately 12 minutes to retrieve the files. After a patient’s file is retrieved, the form describing the medical problem is attached to it with a paper clip, and it is placed in a stack with other files. The stack of files is ordered according to the time stamps on the forms.
When the nurse practitioners finish with their current patient, they select the next file from the stack and escort that patient to one of the treatment rooms. On average, files remain in the stack for ten minutes, but this varies considerably depending on the time of day and the day of the week. On Monday mornings, for example, it is common for files to remain in the stack for 30 minutes or more.
Once in the treatment room, the nurse practitioner reads over the form describing the patient’s ailment. Next, the nurse discusses the problem with the patient while taking some standard measurements such as blood pressure and temperature. The nurse practitioner then makes a rough diagnosis, based on the measurements and symptoms, to determine if the ail- ment is one of the 20 that state law permits nurse practitioners to treat. If the condition is treatable by the nurse practitioner, a more thorough diagnosis is undertaken and treatment is prescribed. It typically takes about five minutes for the nurse practitioners to make the rough diagnosis and another 20 minutes to complete the detailed diagnosis and discuss the treat- ment with the patient. If the condition (as roughly diagnosed) is not treatable by the nurse practitioner, the patient’s file is placed in the stack for the on-duty MD. Because of the higher cost of MDs versus nurse practitioners, there is typically only one MD on duty at any time. Thus, patients wait an average of 25 minutes for the MD. On the other hand, because of their greater training and skill, the MDs are able to diagnose and treat the patients in 15 minutes, despite the fact that they deal with the more difficult and less routine cases. Incidentally, an expert system for nurse practitioners is being tested at another clinic that—if shown to be effective—would initially double the number of ailments treatable by nurse practitioners and over time would probably increase the list even more as the tool continued to be improved.
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