Business Process Management

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PAEDIATRIC ORTHOPAEDIC CLINIC AT THE CHILDREN’S HOSPITAL OF WESTERN ONTARIO

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Manpreet Hora wrote this case under the supervision of Professor Robert D. Klassen and Dr. Kellie Leitch solely to provide material for class discussion. The authors do not intend to illustrate either effective or ineffective handling of a managerial situation. The authors may have disguised certain names and other identifying information to protect confidentiality.

Ivey Management Services prohibits any form of reproduction, storage or transmittal without its written permission. Reproduction of this material is not covered under authorization by any reproduction rights organization. To order copies or request permission to reproduce materials, contact Ivey Publishing, Ivey Management Services, c/o Richard Ivey School of Business, The University of Western Ontario, London, Ontario, Canada, N6A 3K7; phone (519) 661-3208; fax (519) 661-3882; e-mail cases@ivey.uwo.ca.

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Dr. Kellie Leitch glanced at the data on wait times collected from the patients in one of her clinics. As Chief of Paediatric1 Orthopaedic surgery at the Childrens Hospital of Western Ontario (CHWO), she was very concerned by the long times that the young patients (and their parents) were experiencing in the daily clinic. Long wait times tended to aggravate the already pent-up distress and concern that they were feeling, and parents were understandably irritated at missing significant time at work. Currently, on an average, patients were spending roughly two hours in the clinic.

Patient health was not Dr. Leitchs only concern. Clinical staff had increasingly complained about being over-extended, yet budgetary pressures to reduce the cost of service continued to mount. She was not convinced that all staff was being effectively utilized, and there was an unresolved request from the Radiology department for more advanced equipment. Dr. Leitch also served on several government task forces. From these, she knew that federal and provincial policy-makers were increasingly concerned with the economic impact that health-care wait times had on national economic productivity.

In a moment of weakness, Dr. Leitch recently had volunteered her clinic to hospital management as a test case to demonstrate that patient care could be done in a more timely fashion, without increasing costs. An objective of reducing wait times by 20 per cent was established to show meaningful improvement that would be clearly evident to patients, staff and management. A monthly executive meeting was fast approaching, and expectations were starting to run high that Dr. Leitch would present preliminary recommendations that would offer significant reductions.

PAEDIATRIC ORTHOPAEDIC CLINIC

As part of London Health Sciences Centre, located in the city of London, Ontario, Canada, CHWO was a large, regional health-care centre that provided specialized paediatric services to children. The population

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1 Paediatric orthopaedics is the branch of medicine that deals with the treatment of injuries to or conditions involving the musculoskeletal system in children.

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of the 10 counties forming the primary catchment area for CHWO was 1.4 million, including approximately 400,000 children. Many of the CHWOs specialty services also attracted referrals from across Ontario, as well as from neighboring provinces and states in Canada and the United States.

The Paediatric Orthopaedic Clinic was one treatment centre of CHWO that was jointly managed with the Division of Surgery (see Exhibit 1). After experiencing a severe or complex bone trauma and following emergency treatment elsewhere a child might be referred to the Clinic for further examination and treatment. Family doctors, walk-in clinics and urgent care centres through the catchment area also sent their young patients needing specialized care to the clinic. Patients typically returned for ongoing treatment as healing progressed.

The Clinic was open for three half-day sessions per week, Monday through Wednesday, from 8:30 a.m. to 1:00 p.m. During the remainder of the week, the facilities were used by other sub-specialties of surgery. Staffed by a surgeon, two senior resident students, three clerks, four registered nurses and a cast technician, the Clinic examined about 80 patients during each half-day session, of which 60 per cent were returning for a follow-up appointment (and so termed follow-up patients). In addition to the staff noted above, other medical students might spend up to one month training in the Clinic.

PATIENT FLOW AT THE CLINIC

Front Desk: Registration & Verification of Documents

The Registration desk was the first point of contact for the patients at the clinic, with the first appointment being scheduled for 8:30 a.m. While the patients rarely were scheduled for an appointment after 11:30 a.m., the last patient frequently went for examination by the scheduled surgeon or senior resident student at about 12:45 p.m. Three clerks managed the Registration desk. As each patient arrived, a clerk noted the arrival against the master schedule, checked the status of the patients insurance health card and accepted any referral documents the patient brought along. The patient then returned to the main Waiting Area while a nurse verified the status of his or her medical file.

After a patient registered, three nurses were available to verify any medical documents submitted by the patient. For example, for new patients, a nurse checked the doctors referral and made any necessary notes on a generic form that was given to the patient. This document served as an internal referral form that identified which X-rays or examinations needed to be done. All new patients were then sent immediately to the nearby Radiology department, located about 25 metres away from the Clinic in another part of the hospital, for an X-ray of the area undergoing treatment.

In contrast, for follow-up patients, a nurse would retrieve their files and note whether a new X-ray was needed during this visit. Only about 85 per cent of follow-up patients needed to be sent for an X-ray. If none was needed, the patient was immediately directed back to the Waiting area, to be later called into an Examination room for consultation when a surgeon or resident student became available.

Radiology Department: Taking and Developing an X-Ray Image

Upon arrival in the Radiology department, the patients submitted the internal referral form at the front desk. This form reported specific information about which part of the body required an X-ray. Patients were required to wait in the Reception area of the Radiology department until an X-ray machine was

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available. When the patients name was called, a technician escorted the patient into one of six imaging rooms. Because parental (or guardian) consent was needed for an X-ray, the technician briefly explained the procedure to the parent and child.

At this point, the X-ray machine often needed major adjustment depending on the type of X-ray image taken of the previous patient. There were two generic types of X-rays: upper extremity, from the shoulder to the finger (to obtain images of the elbow, lower arm, upper arm, wrist, hand and fingers); and lower extremity, from the knee to the toe (to obtain images of the knee, lower leg, upper leg, ankle, foot and toes). On average, to adjust the machine from one extremity to the other took several minutes. If the previous patient had had the same type of X-ray, the machine needed no major adjustment. The technician then helped the patient to adopt the required posture for the X-ray.

After the X-ray image was taken, the patient returned to the reception area to wait to collect the X-ray image on film. While the patient waited, two activities occurred: first, the X-ray film was developed, and second, a radiologist reviewed and annotated the image to assist later examination of the patient by a surgeon. The development of the film was an automated process, and the X-ray equipment could simultaneously take new images and develop previous images. Following review by the radiologist, the X-ray film was given to the patient, who then made the return journey to the Clinic.

In total, the Radiology department had one clerk at the front desk and three radiologists. In addition, six technicians operated six X-ray machines. The department was a shared resource in the hospital. In addition to serving the needs of the patients from the Clinic, it provided X-rays for patients from the Emergency department, the Urology clinic and the Chest clinic. Only about two-thirds of the time between 8:30 a.m. and 12:30 p.m. was allocated to the Paediatric Orthopaedic Clinic. Although patients were generally served on a first-come, first-served basis, exceptions were frequently made for some patients from Emergency who required an X-ray immediately.

Hand-off of X-Ray to Clinic

After returning to the Waiting area in the Clinic, patients passed or handed off the X-ray film (including the radiologists accompanying comments) to one of the three nurses at the Registration desk. (These nurses split their time between this activity and the earlier Verification activity.) A fourth nurse was responsible for placing the X-ray film in the patients file. This nurse also was responsible for calling patients into particular examination rooms as rooms became available, and for preparing the rooms between patients.

Examination Room

Either the surgeon or one of the two senior residents performed the medical examination of the patient. The surgeon examined all new patients and about 30 per cent of the follow-up patients with greater complexity or complications. A senior resident examined the remaining follow-up patients. (The other senior resident accompanied the surgeon as she or he examined patients. The two residents alternated duties every other day).

Finally, if adjustments or alterations to or removal of a patients cast were necessary, the cast technician was asked to come to the patients examination room. The cast technician saw about 25 per cent of new patients and 15 per cent of follow-up patients.

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After the completion of the examination, the patient was formally discharged. Depending on the surgeons analysis and consultation, the patient might return to the Clinics Registration desk to schedule a future appointment. Alternatively, the patient might visit the pharmacy or the café in the hospital.

DATA COLLECTION

Although Dr. Leitch had heard of some complaints from patients of long waiting times, it was not clear to her how long patients were spending at each activity in the process. Patients were asked to help with the data collection during six half-day sessions over a two-month period. As patients arrived at the Registration desk, their parents or guardians were given a questionnaire to complete during the visit (see Exhibit 2). As each patient moved through the Clinic, the parent recorded the timing, along with her or his impressions of the process. Later, after the treatment was completed for that appointment, the patient returned the questionnaire to the Registration desk. The survey was strictly voluntary, and a total of 218 completed surveys were returned. Given the daytime hours of the Clinic, many parents were forced to take time off work to bring the patient for examination and treatment (the average annual earnings for full-time workers in London were about $44,0002). Aggregate data reported by the patients are tabulated in Exhibit 3, and a sample of their comments is summarized in Exhibit 4. Finally, staff was asked to estimate activity times based on their years of experience and observation (see Exhibit 5).

MOVING FORWARD

While wait times could not be eliminated altogether, Dr. Leitch believed that it was possible to significantly reduce the total time that patients and their parents spent in the Clinic. Staff and patients had offered a number of suggestions, which had been narrowed to three options. First, both patients and nursing staff had observed that patients in the Radiology department were all too often made to wait when Emergency patients had to be X-rayed on short notice. If four X-ray machines (and the required technicians) could be dedicated to the Clinic when it was open, these interruptions could be avoided.

The Radiology department presented a second option: the purchase of an additional X-ray machine. It was difficult to precisely calculate the reduction in waiting time this extra machine would effect, but one estimate was that patients wait time in Radiologys Reception area would be cut by 25 per cent. The capital cost for a new machine was about $30,000, and typically a machine required about $5,000 in annual maintenance costs. The Radiology department would also need another qualified technician to operate the machine, at an annual cost of about $75,000.

Finally, Dr. Leitch wondered if better scheduling of patients appointments and assignment of staff in the Clinic might offer benefits. She was unsure if grouping certain types of patients would reduce the waiting times at various activities in the Clinic. As she contemplated her next steps, Dr. Leitch knew that any actions she proposed would come under close scrutiny. And, in the event her recommendations improved wait times in this test case at her own Clinic, could they be applied elsewhere in the hospital?

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2 Statistics Canada, 2001 Community Profiles, London, Ontario (city), Earnings and Income, available online at www12.statcan.ca/english/profil01/CP01/Index.cfm?Lang=E, accessed January 7, 2007.

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Exhibit 1

FUNCTIONAL AREAS IN LONDON HEALTH SCIENCES CENTRE (LHSC)

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LHSC

Cancer and

Women and

Surgery

Medicine

Mental Health

Diagnostics

Children

Care

Radiology

CHWO

Department

Radiologists

Paediatric Orthopaedic Clinic

Technicians

Surgeon

Senior Resident Students

Cast Technician

Nurses

Unit Clerks

Source: Internal records.

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Exhibit 2

PATIENT QUESTIONNAIRE ABOUT WAIT TIMES

Hi there! Thank you for taking the time to fill out this brief survey. The reason that we are asking you to answer these questions is that we are trying to reduce waiting times for our patients and need to collect some data. This will enable us to work to reduce backlogs in any areas that are currently facing them.

What is your hospital ID number? _________________

1. Front Desk

a. What time did you register in the Ortho Clinic? _________________

2. Radiology Department

What time did you go to X-ray department?

_________________

What time did you have your X-ray done?

_________________

What time did you receive your X-ray film?

_________________

3. Hand-off of X-Ray to Clinic

a.
What time did you hand in your X-ray into the Ortho Clinic? _________________

4. Examination Room

a. What time did you get called into the Exam Room? _________________

b. Did you see a Surgeon, Resident or Cast Technician? (please circle all that apply.)

Surgeon / Resident / Cast Tech

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