Procedure Scheduling in Healthcare

Reducing time from referral to a confirmed appointment 

At a healthcare organization patients would sometimes wait up to 3.5 months to get a confirmed appointment for a particular medical procedure.

Using a LEAN process engineering approach the Procedure Scheduling Improvement Team was able to reduce processing time from 8 hours to 5. But they were only able to reduce wait time by 2 weeks, still far short of the target time of 4 weeks. It took them 3 workshop days over a 2-week period to identify these improvements.

It appeared that something else was going on around the process to cause the time delays. In other words the problem was not the process itself - it was the ecosystem around the process. The team decided to expand their analysis with a Value Network Analysis (VNA) - resulting in reduced wait time to 4 weeks, insights and action steps, in one workshop day.

Role definition

Procedure scheduling involved interactions with other departments and groups in the medical center. Some schedulers used their informal networks and relationships to reduce the wait times, but the ability to do this was very inconsistent. By identifying the contributing roles, those relationships began to become visible. The team initially identified six key roles involved in scheduling.

Figure 1 procedure scheduling: Roles in the procedure scheduling process.

Mapping process to the value network

With the roles defined, the processes could be mapped as sets of interactions between roles.

Scheduling began when someone received a Referral from a physician. The physician could be from their own medical group, Group Physicians, or an external Referring Physician. In the original process model below this was shown as one simple step - Handle Referral.

However, this referral could take multiple pathways, all ending with Department Administration. The actual complexity of this activity was immediately apparent in the VNA. There was not one simple transaction to manage - there were five!

Each step of the process had key outputs or handoffs, so processes in the network showed up as deliverables from one role to another. Because these were formal process interactions they were tangible deliverables.

Figure 2 procedure scheduling: The process for a referral.

Beginning to map the process to the value network

The team mapped the tangible deliverables and interactions required to execute the formal steps in the process. This is what the formal process looked like mapped as a value network.

Ctrl+scroll to see larger.

 Figure 3 procedure scheduling: The procedure scheduling process 

mapped as a value network with tangible deliverables.

Mapping intangibles to the value network

Next the team began to map the informal or intangible deliverables that were working within the value network. For example, Patient Records were often supplemented with informal discussions about a patient. These conversations provided important information about the patient, but because they were informal that information might not reach the reviewing physicians or the surgeon.

The completed value network map

Figure 5 procedure scheduling: Value network map showing all roles, 

transactions, and deliverables.

Often when people describe intangibles they find people and roles that had been overlooked.

In this case the team identified an overlooked role of Surgery Coordinator. Notice this role had no tangible deliverables. Yet this role was very active and influential in how and when procedures were scheduled.

Figure 6 procedure scheduling: Identifying an overlooked role.

Over time Surgery Coordinators had become strong influencers for scheduling. They determine which doctors are assigned to reviews and how patients are paired with Surgeons.

The team addressed this issue in their action steps.

Sequencing deliverables

The map below shows the intangible deliverables sequenced right along with the tangible deliverables. Generally the intangible is sequenced at the first instance it would happen in a typical situation.

It is usually best to not duplicate numbering. However, in this example there are duplicates in deliverables "1 Referral" and "2 Referral." This was because any of the "1 Referral" activities could trigger the procedure scheduling activity. The initial referral needed to end up with the role of Department Administrator, who would then set the rest of the sequence in motion with "3 Records Request."

For more about information about this step see Sequencing.

Identifying participants

Any value network can also be mapped with the names of individuals who play the roles in the activity. This allows a finer level of detail in the mapping, showing which participants are handling specific deliverables. Below is a simple notation device for designating who actually fills the roles in procedure scheduling.

Figure 8 procedure scheduling: Value network map with names of 

participants who fill the roles.

Fixing the real problem

Mapping the intangible interactions actually revealed "work-arounds" where the process or flow of the activity was broken. The informal conversations slowed the process and contributed to errors.

1. Create a shared scheduling application:

- Consultation, Procedure, and Review dates were all scheduled upon receipt of a recommendation.

- Logging a recommendation generated automatic record requests.

- Schedule alerts helped staff stay on schedule.

- Physicians and surgeons made their own scheduling decisions.

- Coordinator responsibilities changed to only handling equipment and room requirements - not MD schedules.

2. Tighten records handling:

- Changed to a web-based patient history where notes and comments could easily be added to the records.

Business results

Tangible value gains from value network improvements:

- Cost reductions due to fewer Admin hours devoted to scheduling.

- Cost reductions due to fewer hours required for RNs to collect patient data.

Time efficiencies in reduced time from referral to procedure:

- Process time reduced from 8 hours to five.

- Wait times reduced from 3.5 months to 4 weeks.

Efficiency gains from redefining roles:

- Better allocation of RNs and Admin resources with better role definition

- Reduced turnover of RNs and Surgery Coordinators

- Cost savings in time to handle patient records with automated system.

- Revenue gains from scheduling rooms and doctors more efficiently.

Intangible value gains from value network improvements:

- Improvement in patient satisfaction.

- MD satisfaction with more control over their own schedules.

- Increased surgeon confidence with better patient records.

- Improved competency with better knowledge base.

- Reduction of friction due to unclear roles and process.

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