Tuesday, April 8, 2008

Group Practice Levels Scheduling

Do you ever get pissed-off at a colleague because you’re positive you’re working harder or seeing more patients? Nah – me neither. I then read an article at Curious Cat Management about computer programmers and how they can have an order of magnitude (10x) difference in productivity while writing code and that it’s unrelated to skill or experience and I started to wonder if we had the same amount of variation between doctors.

I understand there is a difference in creative work versus menial work (and pulling teeth is menial) but I started to wonder what the difference would be in our own practice. We have an agreement between the doctors that we set global guidelines (block booking) for the schedule in conjunction with our staff & managers then let the front desk run with it. There are, of course, ups and downs and constant critiques but the blocks of time are set 3-4 times a year.

In OFFICE1 there are always multiple surgeons present. In OFFICES 2, 3 and 4 there is only one per day. I had a theory that there would be more pressure in OFFICE1 to conform to the scheduling guidelines. This would result in less variation in the number of appointments per day in OFFICE1 with more variation in OFFICES 2, 3 and 4. In other words, some of the doctors would have more variation in efficiency without peer pressure.

I pulled data for the year 2007 (251 days, 4 offices, 5 surgeons) and compared all offices and doctors. I then preformed multiple statistical tests to prove my theory. To my surprise, there is no difference in the amount of variation per office between doctors. In fact, when you compare each doctor in each office there is absolutely no clinically significant difference over OFFICES 1, 2 and 3. OFFICE 4 is smaller, so we expect to see fewer appointments but it’s uniformly less between the doctors. Putting numbers to it, if we have an average of 22 +/- 5 appointments per day, there is a variation of 0.8 appointments that can be accounted for by a different doctor. That is a whopping 4% of the variation. Compare this to the 10x seen in computer programmers. In fact, the total amount of variation in the average number of appointments seen per day is 7% for all four offices or 4% if OFFICE4 is excluded.

From this data I conclude that:

  • We all have the same number of appointments and there are only modest differences between the offices

  • That there is statistically no difference between the doctors in the number of appointments

  • Setting scheduling policies globally has a profound effect on minimizing variation.

  • Group practice applies another major pressure to work efficiently to the standards & expectations of others in the group.

I cannot stress enough the effect of minimizing variation (or leveling a process). It is the single biggest factor in poor patient satisfaction (because some patients will be left waiting much longer than expected) and resources planning. It is much easier to manage a practice when you know that the error on the number of appointments will be +/-0.8 instead of +/-10. In this case we’ve used good lean principals to level a process (scheduling) and block booking which increases efficiency. With the marriage of technology and good practice management this minimizes the health care wait times in our office.

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