You have a job assisting the Medical Director at a Family Medical Clinic in New York City.

The Medical Director is concerned about the long wait times of patients visiting the clinic and would like to improve operations. The following are facts about the clinic: The patients are seen in the clinic between the hours of 9:00 A.M. and 12:00 P.M. and between 1:00 and 5:00 P.M. On average the clinic sees 150 patients per day. Nine physicians are usually on duty to see patients at the clinic.

Physicians arrive at 9:00 A.M. and are on duty until 5:00 P.M. with a one-hour break during the day. They are supported by seven medical assistants who take vital signs and put patients in exam rooms. Four registration clerks are present to register patients, enroll them in federal and local aid programs, prep their medical records, and collect copayments. There are three coordinators who make follow-up appointments and arrange referrals.

Coordinators see patients from 9:00 A.M. until 5:30 P.M., with a one-hour break during the day. There is one security guard who is available from 7 A.M. to 6 P.M. There is one pharmacist, and two pharmacy technicians. The pharmacy is open from 9:00 A.M. to 5:30 P.M., with a lunch break from noon to 1:00.

The facility itself has a security window at the front door with a guard-controlled entry door, a large waiting area, five registration windows, 11 provider rooms (3 of which are used for taking vitals and 8 by physicians for exams), and four coordinator’s desks. Patient Flow Through the Clinic An average of 120 patients have appointments at the clinic each day. An additional 30 patients come for prescription refills each day.

Step 1—Security/Check-in When patients arrive, they all must first pass through security. Often, there is a small wait outside at the door. The average wait time at security is 10 minutes, while the average processing time is 2 minutes.The guard at the door double-checks the appointment time and issues the patient a colored card with a number on it—either red or yellow. Red cards are reserved for patients without appointments who need only medication refills. These patients must pass through registration but do not need to see a provider.

Step 2—Registration All patients then proceed to the waiting room where they wait for their color and number to be called. This wait can often be quite long, but on average takes 24 minutes. Once patients are called by a registration clerk, their information is verified. This process can take anywhere from 1 minute up to 40 minutes if the patient is new and needs to be enrolled in several programs. On average, eight new patients come per day. The average time to complete registration is 7 minutes for returning patients and 22 minutes for new patients, with an overall average registration time of 8 minutes. Patients seeking medication refills (with red cards) proceed directly to the pharmacy (step 6) after registration.

Step 3—Vitals The yellow card patients return to the waiting area and wait another 15 minutes to be called by a medical assistant to have their vital signs taken. This takes 6 minutes, after which they return again to the waiting area.

Step 4—Doctor Visit Patients wait 8 minutes more in the waiting room and are then called back to a provider room. Once in a provider room, the patient waits 17 minutes, on average, for the provider (doctor) to arrive. Providers spend approximately 20 minutes with each patient.

Step 5—Coordinator/Follow-up After the patient has seen the doctor, the patient’s chart goes to a coordinator. The patient waits 25 minutes to be called by a coordinator who schedules further laboratory tests, get referrals to specialists, and makes follow-up appointments, which takes an additional 7 minutes. On average, 50 percent of patients with appointments (yellow cards) continue onto the pharmacy following their medical visit. page 670

Step 6—Pharmacy If the patient needs a prescription, the wait is 13 minutes before the pharmacy calls them to process the prescription, with an average of 11 minutes spent filling the prescription. Each pharmacy technician works independently and fills the prescription after consulting the pharmacist. In general, patient satisfaction with the quality of medical services at VFC remains high, but there are still complaints each day about the waiting times for these services. Wait times are critical for these patients, because they often directly lead to lost income during the hours spent waiting. The Physicians’ Workflow Each physician is assigned to a team; A, B, or C. These groups of two or three physicians all see the same patients, helping to ensure continuity for the patients. Each patient, therefore, will see one of the team’s physicians at any given visit and has a higher likelihood of seeing the same doctor each time.

Physicians arrive at 9:00 A.M. and wait for their first patients to arrive. Often, due to the lag at registration and the wait for open rooms for the medical assistants to take vitals, patients are not in the exam rooms until well after 9:30. In addition, because of the team system, one provider may have three patients waiting, while another is still waiting for his or her first patient to check in at registration. The registration desk has no communication link to the physicians’ area or other form of coordination; so clerks may check in three patients in a row for one team, but none for another. Added to this, new patients are randomly assigned to teams regardless of who is busiest that day. Once a patient is in an exam room, the chart is placed in a rack for the physician to review prior to seeing the patient.

If key lab report or X-ray results are missing, the physician must call for medical records or call outside facilities and wait for the results to be faxed or called in before seeing the patient. This happens 60 to 70 percent of the time, causing a 10-minute delay per patient. These challenges often lead to inefficient use of the provider’s time. After seeing a patient, the physician will either have the patient wait in the waiting room to see the coordinator or have the patient wait in the exam room for further testing or nursing procedures. Rarely, if no follow-up or prescriptions are needed, the patient is free to leave the clinic.

The physicians generally are extremely committed to the clinic’s mission but are frustrated with their patients’ long wait times, the incomplete medical records, and the disorganized patient flow through the clinic. The Registration Clerks’ Workflow At the start of each day, the four registration clerks prepare by printing out copies of that day’s scheduled appointments. Charts of patients with appointments are pulled the night before and placed within easy reach of the clerks.

The four clerks work from 8:30 until 11:00 A.M. and close the registration windows until 12:30 P.M. During this time, in addition to eating lunch, the clerks pull the charts for the afternoon clinic and finish up paperwork. At 12:30, the registration windows are reopened for the afternoon clinic and patients are checked in until 4:00 P.M.

Questions Calculate the capacity and utilization of each resource (people, rooms) and identify bottlenecks.

Calculate the average wait and time in service for patients with appointments (new and returning) and for those seeking a prescription refill.