A Case Study in Outpatient Registration
Overview of Project
For a seven week internship between my junior and senior year at Saint Vincent College I was placed in a local hospital’s outpatient registration department. At this particular hospital, registration took place in it’s own department, which registered for different areas such as radiology, CAT scan, and other outpatient areas. Over my time there I grasped and mapped out the current situation, trained the team in problem solving and the eight wastes, worked with that team to make future recommendations, and piloted the recommendations in pre-registration with success. Throughout that experience of improving the outpatient registration process, though, I began to see first hand how important having the right culture is.
At the beginning of the internship, I realized that in order to make recommendations and understand the process I was observing, I needed to know how to do the job of the registrar. Consequently, for the first week I attended a training seminar. During the seminar, registrars learn how to input information into the computer system. I observed different problems and opportunities for improvement. Double entering of information, unnecessary keystrokes, and inconsistent training concepts versus actual practices were a few of the problems. However, from the patient’s perspective these weren’t critical.
A review of results from outpatient satisfaction surveys, showed significantly low scores. Digging down deeper to the next level of the cause the largest number of the lowest scores were because of wait times. This justified value stream mapping of the outpatient registration area. Following Figure 1, the value stream map identifies what the registrar is doing as well as what the patient is doing.
The Process: Current State
Value Stream Map of Current Processes shown in One Page Report.
In the registration process (for those who are not pre-registered), once the patient arrives at the front of the hospital immediately they see the outpatient desk, where they are entered into the system for the first time, and handed a beeper and told to have a seat. The patients were equipped with a beeper similar to one that you would receive at a busy restaurant – or in this case, a restaurant that was completely vacant!
From the waiting room the patient is beeped by the registrar, who then leaves the registrar’s booth to greet the patient, and together they walk back to the booth. The registrar then opens the computer system and begins checking the patient’s information, and inserting the necessary information for their hospital work for the day. Dialogue continues between the registrar and the patient as the patient sits and waits and the registrar maneuvers around the different computer systems.
At this point the registrar needs to scan certain information into the computer screen. The information includes personal identification and insurance card(s) if they have not already been scanned, as well as a consent form and the doctor’s order. Although bounded by federal law, some patients would come in for blood work three times per week, and each time they would have to fill out the same consent form. One of the major problems though, lay within the scanning, or lack there of, of the doctors orders.
Some wait times from when the patient was actually entered into the system and given a beeper were upwards of an hour. Through some observations, which didn’t take too long, many of the long wait times were because the patient came in without a doctor’s order. Sometimes multiple patients came in without a doctor’s order. The lack of a doctor’s orders began an unpleasant process for everyone.
As the patient was waiting angrily and not understanding why he couldn’t have his hospital work done with out a doctors order, the registrar began to track down the order. This took phone calls, sorting through papers, checking fax machines, calling doctor’s offices around the area, etc. Now the registrar was flustered, the patient was angry, the lady working the front desk was trying to help both of them, while waiting on others and answering questions from patients passing by. On top of all of this, there were other patients coming in the door wanting their hospital work done, but were delayed because of this situation.
Additionally, the insurance company comes into play. Once a patient’s doctor’s order is scanned into the system, his insurance must be verified by weaving in and out of a number of different programs in order to have verifications from different insurance companies. This is very troublesome to the registrars, and was a top priority for the department and information services at the hospital to be integrated into the current system. Looking at the numbers though, time could be cut in other places, which would make a larger impact.
For example, completely eliminating the insurance verification part of the outpatient registrar’s process this would reduce about two minutes of wait time per patient. The same amount of time would be eliminated if different systems were in place so that the registrars didn’t have to walk the patient around. One idea is a difficult, expensive, and time-consuming process; whereas the other could (and was) as simple as printing out clear directions for the patient, both saving the same amount of time.
The Future State Value Stream Map is shown in One Page Report.
Future recommendations essentially planned on taking the wait time from nearly 23 minutes on average to less than five minutes. The future state of outpatient registration for this step of improvement consisted of a few minor changes, which would impact the system as a whole. First off, the variation of the system needed to be isolated so that the process was more consistent.
Upon the patient’s arrival in the new system, he would be asked whether or not he had a doctor’s order. If no, he would be labeled in the system with a “TS” for troubleshooter, in front of his name. At different times, there would be a designated person for troubleshooting. Immediately work could be done on that patient in regards to tracking down his doctor’s order. While the registrars were waiting on Patient A’s doctor’s order, s/he could begin to work on the next trouble shooter’s doctor’s orders, until the order was faxed or the doctor’s office returned the call.
The next idea to cut back on some time was the development of simple maps. These maps were made to direct patients around the hospital to different outpatient departments. Some were very close to registration; whereas, while some were easy to get to, they were very distant. These maps were not the usual road maps that one might see, but rather pictures of landmarks to show where patients turn, or open a door, or take an elevator.
Conclusion and Further Recommendations
See One Page report.
The internship was designed to get a grasp on the current state the outpatient registration process and allow me to make recommendations on the future state. Some of the concepts were immediately implemented after being piloted, and some other concepts were piloted. The future state of pre-registration was piloted one of the final days of the internship, and the results were astonishing. The average wait time dropped from 23 minutes to nearly 1 minute!
However, some further recommendations are much deeper than that of rearranging the layout, or using different systems, or speeding up processes by elimination of wastes. The most significant way to continuously improve an organization is by developing and nurturing a culture of change. If people believe in the tools and techniques that the people of Toyota believe and are coached properly, a culture of continuous improvement and mutual trust and respect can develop with time.
Now, let’s take a look at this from the patient’s perspective. Everything should begin with the question, “Does this add value to the patient?” Through my observations of the doctor’s orders, I have concluded a few different items. The way in which doctor’s orders (in general) are designed is to make it the easiest for the doctor’s writing them out. Doctor’s handwriting results in at times, the wrong test being administered to the patient, the wrong medication given to the patient, and much time wasted by all parties on tracking down the doctor for a clarification.
Now, being completely honest, there’s not a patient out there that would say, “Of course I want to go through a 30 minute registration process to get my blood drawn!” So, that means that the registration process is not value added in the mind of the patient. Shouldn’t then the registration process be as quick and easy as possible for the patient yielding the highest quality results?
The fact is that most hospitals do not have the true the idea of “patient first.” They are associated with much larger problems – design and communication. As well as plenty of smaller problems. In order to truly tackle healthcare, there must be a complete culture change within the healthcare community. Everyone from the front line workers to the chief executive officer of the organization needs to have the patient first and heading for true north.