Case analyses and applications

¶ … WCUSHS is moving to a new location. The head, Dr. Carwin, wants to take advantage of the opportunity to rectify some of the problems the clinic is facing, in particular with respect to wait times.

The situation she faces is that the clinic scores highly on service scores and poorly on wait times. Thus, she must balance between lowering wait times while retaining high levels of service, which are driven by patients being able to select their own physician.

The external environment of WCUSHS is generally positive. The clinic has a captive market, comprised of students from the university. This market pays for the clinic through its fees, such that the clinic delivers its services at a very competitive rate. The university is generally supportive of the clinic, but concerns may be raised if the clinic becomes too expensive to operate.

In terms of the competitive environment, there is one significant threat, which is the WCU Medical Plaza. This gives the students access to the private practices of some WCU physicians. This represented a threat on several levels. One, it provided an on-campus alternative, which had not existed previously. The physicians at the PCC may be able to set up private practice there as well, taking their customers with them. Thus, the new Medical Plaza represents a threat to not only the supply of customers but also the supply of doctors.

Internally, the greatest threat is that of the physicians. They have not been engaged by the change process. Their participation is minimal and half-hearted. Yet, they have the option to set up private practice in the new Medical Plaza. Therefore, the physicians need to be kept happy. One factor in physician happiness that has been identified is that they prefer to have exclusive patients, in part because this allows them to provide better service.

Analysis of the Problem

Carwin believes that the wait times are significant problem. She also believes that the composition of the clinical teams was of utmost importance. This would involve matching capacity needs to demand needs. I agree that these are the most significant problems facing Carwin. She also is concerned with rebuilding the PCC's perception, to defend against the pending competition. I feel that this is not an important concern. If the other concerns are dealt with, the negative perceptions will ease. The nature of the market is that it turns over with each successive graduation and commencing class. Perceptions can change quickly in such an environment, if the clinic's performance changes.

The main area where the PCC suffers is with respect to wait times. An analysis of capacity shows that the total capacity is not the issue. The system works because overall there is more than enough capacity to meet demand. Patient visits take around 20 minutes, with 5 more minutes allocated to writing charts. If we assume 5 minutes of lost time (bathroom, etc.) that gives us 2 visits per hour per clinician. In total, the capacity for six months in total between MDs and NPs, and between appointments and walk-ins, is 26,258 versus total demand in that period of 15,765.

However, we can see that the walk-in side is under capacity.

Walk-ins account for 60% of patients, yet only 31.8% of scheduled clinician capacity. As a result, walk-in demand for six months is 9459 patients, and the scheduled walk-in capacity is 8370 patients.

Thus, treatment of walk-in patients at present is being covered by unused capacity among those scheduled for appointments. There are 11,582 excess patient visits worth of capacity on the appointments side.

Carwin's proposed system will address some of the wait time issues by shifting some of the work from MDs to NPs. The teams will be comprised of both MDs and NPs. Patients can currently request a specific provider. Given the choice, most will choose an MD. However, this negates the work of the triage staff, whose job is to assign a clinician based on medical need. As a result, 22% of MD patients, a total of 1981, could have been served by an NP. This is an inefficiency from both an operational perspective and a cost perspective.

However, this shift from NP to MD does not address the lack of capacity on the walk-in side. The main capacity issue is with respect to overcapacity on the appointment side. For appointments, capacity between the two classes of clinicians is 17,888 versus demand of 6306. Among walk-ins, 45% are returning to see a specific clinician. Thus, 3784 visitors classed as walk-ins could be dealt with as appointments instead. Carwin's plan does not address this.

If those 3784 were not asked to come back as walk-ins but rather to come back as appointments, the total demand for walk-ins would be 5675 and appointments would be 10,090. There would now be capacity for both walk-ins and appointments to meet demand.

This is without even addressing the issue of scheduling. Carwin's plan is deficient in that it does not address the issue of scheduling. At present, Tuesday is grossly under capacity. There is capacity for only 48 patient visits on Tuesday, compared with demand of 84. There are also capacity shortages on Monday, Wednesday, and Thursday. On Friday, however, capacity is 84 compared with demand of 64. This capacity includes both MD and NP, which means that Carwin's plan will still leave a capacity shortfall on four out of five days.

The success measures are laid out by Carwin are perfectly reasonable. They are geared to the most pressing challenges at WCUSHS. They address average wait times, the number of users who must return, and the length of time for a return. Whether Carwin's proposed solution will result in meeting these goals is debatable.

Recommendations propose a different set of recommendations. The first is that patients who prefer to return to see a specific clinician be given appointments, rather than treated as walk-ins. This will reconcile the relative demand for walk-ins and appointments with demand. If a patient wishes to see a specific provider, there is no reason for them wait in the walk-in queue when capacity exists in the appointment system. For the most part, this recommendation will also meet the objective of reducing the amount of time a patient must wait to see their chosen clinician. An exception is with respect to some of the part-timers, who can go a couple of days without serving appointments.

Thus, I also recommend creating loose teams. These would be structured along the same lines as Carwin's teams, but would be less formal. In other words, teams would still consist of specific NPs and MDs, but patients would not necessarily be assigned to a team. If a patient wanted a specific clinician and that clinician, that clinician was not going to have appointment times for the coming few days, and the triage nurse did not feel that the patient needed to see a clinician right away, the patient would be given an option. They could wait a few days for their specific clinician, or they could see somebody else from that team. This puts the onus on the patient to make this decision. What that will do is make it difficult for the patient to complain about any delays in receiving an appointment because they had the option to receive an earlier appointment from somebody on the same team as their clinician.