Transcript Work Process - Brandeis University

The South Side Clinic – An
Operations Management Analysis
Richards, Michael, M.Div., L.P.C.C., Rafelson, William, Nabi, Emara,
M.S., M.B.B.S., Kingson, Aaron, Nguyen, Mai, M.S., M.D.
The Heller School for Social Policy and Management. Brandeis
University. [email protected]
SERVICE CONCEPT
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Target Customer: Dually-diagnosed, physicianand hospital-referred patients
Out-patient dual-diagnosis addiction clinic
Treats only hospital PCP’s and affiliated
providers patients
Complete range of outpatient clinical substance
abuse services offered:
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Assessment and evaluation, intensive outpatient
group therapy, individual therapy, medication
management, provider training and consultation
Programs customized according to the needs of
the individual patient
SERVICE CONCEPT
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Full-service dual-diagnosis addiction clinic
Clinical Director attends quality meeting every
month with hospital quality committee
Patient satisfaction surveys
As a part of NIATx protocol, quality improvement
committee aiming to reduce wait time to zero
(process quality)
Supervision of clinical staff
Training of staff three times a year
Efficiency measured in terms of productivity for
psychologists, social workers
Service Delivery System
Facility:
 Capacity: 10 consultation rooms, each has one
health worker.
 Separate from main hospital building
 Warm and welcoming servicescape atmosphere
 Recently renovated
 Recipient of internal hospital awards
 No handicap access
 No room for expansion
 Clinicians’ room equipped with panic buttons
 Old building that has replacement plans
Service Delivery System
Staff:
 Psychiatrists, psychologists, social workers, a
case manager, and a nurse
 Medical director and clinical director supervise
clinic
IT:
 IDX system and Microsoft Outlook used for
scheduling appointments
 Possibility
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for better integration
Telephone used to schedule appointments
Patients:
 Dual-diagnosis mental illness/substance abuse
treatment
Work Process
1: Phone or walk-in:
2: Case manager: Assessments (6-10 per week)
Primary, critical quality-related bottleneck
3: Counselors: 6-7 Social workers, 30 hrs. of
clinical time scheduled. But with no-show’s,
probably less. Secondary Bottleneck
3’: Referral to hospital primary care physician
3’’: Intensive group outpatients program (Run by
one psychologist and social workers)
4: Psychiatrists : patients are diagnosed and
treated according to consultations and progress.
(Two full-time and two part-time psychiatrists)
Work process: Referral through entry into treatment
3’
Referral back to PCP
WT: 2 weeks
WT: 3 weeks
1
WT: 2 weeks
3
Walk-in or call
Assessment
Social workers or
Psychologist
WT variable
5
4
Psychiatrists
2-3 patients/hour
Discharge to
Maintenance
Care Program
1-2 patients/hour
3’’
Total Wait Time (WT) to Medication = up to 7 weeks
Intensive Outpatient Group
Work process
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AR: 35 patients/day (range: 15-60)
Output rate (Assessments): 6-10 per week
Output rate (Ongoing patients): 33-34 patients
per day average (Highly variable)
Highly customized
Clinic is downstream in supply chain from
hospital, PCP services
Two staged throughput:
Throughput includes intake and assessment (4-7
weeks), and treatment (6 weeks to 2+ years)
Work Process
 Referral and registration
 Assessment
 Approval
 Assignment to Providers
 Treatment
 Intensive Outpatient Group (IOP)
 Individual treatment
 Family treatment
 Medication
 Measurement and Assessment
 Customer Satisfaction
 Other critical metrics? (e.g., PCP reports, readmit data, etc.)
 Follow Up
 Maintenance Care
 PCP Follow-up
 Long-term care (e.g., self-help group, “after-care” session,
etc.)
Work Process: Assessment
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Current wait for assessment is 3 weeks
6 to 10 Assessments per week
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one “no-show” per week, on average
 1 hour long
 Patients arrive 15 minutes early for registration
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All patients have to call in on Tuesdays to
reconfirm appointments
Evaluated for “readiness” by Medical Director
Most new patients “ready” for treatment
Customer co-production: registration, cooperation
Work Process:
Approval and Assignment
Approval:
 Medical director has to approve all new patients, wait time
is one week
Assignment:
 After Ax, wait to see clinician, Pt then referred to medical
appointment also if necessary
 Ax to 1st appt, 3 weeks, depending on clinicians schedule
 2 week wait for IOP
 Psychiatrists see 75-85% of patients seen by clinicians for
medication
 Medical director does therapy with a few patients
 Recently, the entire process was several months long
 It has since been reduced to 4-7 weeks
Work Process: Treatment Supply
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First approval by Medical director
Therapy with social worker, psychologist
Psychologists are part-time and have own
practices, on productivity pay model
Social workers are salaried, 6 hrs clinical time a
day, most are 9-5 and get productivity reports
6-7 social workers (2 assigned IP)
Arrivals on the hour
1 hour appointments, ½ hr for short-term, 1 hr
for family
Medication appointments are 20 min, (2-3 per
hr.) by Medical director, fellow and 2 part-time
doctors
Work Process: Treatment Demand
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Fridays are slowest
Wednesdays and Thursdays are busiest
15-60 patients per day
35 average per day
No shows 20%, higher for new arrivals
Third no-show, meet with clinical director
One psychologist charges $15 for no-show, donates revenue
to charity
Research actually suggests that “carrot” is better than
“stick”  Positive reinforcement (e.g., pt’s favorite candy)
is a better incentive for patients to attend than negative
reinforcement (e.g., a fine)
 Negative reinforcement could exacerbate no-show behavior
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Work Process: Intensive Outpatient (IOP)
 IOP 12 people in group, 1 ½, ½ hr with psychologist
 For more serious cases than individual therapy alone
 3x per week, 9AM-12PM
 One evening slot, Tuesday at 6pm
 Step down from IOP:
Relapse prevention program
1 hr for 2-8wks
 Programmed patients also receive individual
counseling
 Our findings: IOP can eliminate / crash the line by
immediately accepting newcomers to the WEC
Quality
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Patient satisfaction survey: Graduates of program
More outcome quality measures are needed
How does the WEC define quality?
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Clearly define critical measurements, indicators for success
and quality
Weekly staff meeting
Starting to implement NIATx protocols
Move to evidence-based best practices
Quality change team: baseline measurement, length of intake
SOS-10 every 13 weeks, formal tool for clinicians
Make these results available for analysis
 Need to be integrated with quality program, shared with PCPs
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Supervision
Quality meeting
Change team is collecting data for first process improvement:
move to no-wait intake.
Problems with Process
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Current three week wait time for assessment; up
to 7 week wait for Medication. Research has
shown that this is too long for substance abusers
 Dually-diagnosed
Pt’s require are even more sensitive
to wait time
 1-week delay for approval: unnecessary for Pts
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Calling every Tuesday before appointment:
discouraging process for patients. Although it
may reduce no-show rate, it raises the cancel
rate. What happens to those cancelled patients
“lost to follow-up?”
Possible lack of integration of PCPs into the
process
Program assessment and evaluation needs to be
fully integrated into Tx Model
The Epidemic of Substance Abuse
 22 million Americans experienced dependence or
abuse in 2002. This is nearly 1 out of every 10
Americans 12 years or older.1
 Only 4 million of the more than 20 million
Americans suffering from substance
dependence/abuse sought treatment in 2006.2
Both internal and external obstacles.
Of these, about 1.1 million were treated by
outpatient mental health centers
 According to the Department of Health and
Human Services, about 17.7 million Americans
seeking substance abuse treatment were unable
to access it.3
The Societal Cost of Substance
Abuse
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Alcohol- and drug-related deaths are among the
leading causes in the country, and pose a serious
public health risk.1
76% of illicit drug users are employed; 81% of the
43 million adult binge drinkers are employed;
80% of the 12.4 million heavy drinkers are
employed.4
Alcohol and drug abuse costs American
businesses more than $100 billion in lost
productivity each year.5
The Cost of Waiting
 Over 50% of substance abusers no-show on
intake8 (National Average)
Reduced productivity for providers
Reduced access for fellow patients
Risk of relapse for no-show patient
 Experimental study: 24 hour intake, versus 3 or 7
days.7
24-hour intervention 4x more likely to show
 BU Study: Comorbid psychiatric diagnoses  81%
less likely to complete regimen.9
A Study by Festinger et al.6
A Randomized Trial 7
Appointment Delay as Most
Significant Variable6
NIATx
 Network for the Improvement of Addiction Treatment
 Partnership
Robert Wood Johnson
STAR
Addiction treatment organizations
 4 Goals
Reduce waiting time between first contact and first
treatment
Reduce the number of no-show’s
Increase the capacity for those needing treatment
Increase retention throughout the treatment session
Plan Do Study Act (PDSA)1
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Plan: Identify aim of effort (e.g., reducing wait
time)
Do: Trial run, using few clients for short period
of time
Study: Staff looks at benefits and drawbacks of
the trial
Act: Staff fixes trial if imperfect results, or
implements it in regular practice if no significant
problems
Arcadia Hospital: A Case Study
Arcadia Hospital: Before NIATx
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Bangor, ME Addictions Hospital
4,397 outpatient substance abuse visits / year
Only 25% who first-contacted showed up for
assessment
Only 19% followed up with treatment
Arcadia Hospital: After NIATx
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Staff told new callers to come in 7:30AM
following morning; treatment would immediately
follow assessment.
Time to first contact reduced from 4.1 to 1.3
days
65% of the 225 of new callers per month showed
up for appointment (compare to 25%,
previously).
Similarly, 52% (not 19%) made it into treatment
Process Improvement at Arcadia1
With Increased Access, Increased
Revenue
Because of the increased number of patients
being seen per month, new counselor hired
 Revenue increased by 56%
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Increased Access  Increased Utilization 
Increased Productivity  Increased
Revenue
Conclusion
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“All health care organizations, whether providing
addiction treatment or not, are faced with the
challenge of finding ways to increase output and
achieve better results with fixed resources.
Therefore, the successes experienced by
organizations in the NIATx initiative should be
useful for implementing change in other fields of
service delivery.”1
The lessons learned from NIATx are not
addictions-specific: because addictions
treatment holds the highest amount of risk for
“loss to follow-up,” they must innovate first.
The lessons learned by Arcadia and other NIATx
members can be translated to many, if not all,
outpatient settings.
Recommendations - Access / Capacity
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One-time extra hours/staff to reduce or eliminate backlog of
patients waiting for assessments. AKA “Crashing the backlog.”
 Assuming 40 hours of clinical time per social worker, this
would only require 1-2 weeks
 Hire extra psychiatrist to eliminate bottleneck and crash the
backlog of patients awaiting medication, therapy
On-demand staff for “anytime” assessment of walk-in patients
 The social worker’s “no-show”/ “down” time could be
converted to “anytime” hours (currently 20%+ of scheduled
time)
Clarify policies such as standardized time from first contact to
assessment to treatment (no longer than 72 hours) and quality
improvement measurements
Reduce wait time to counseling and pharmacotherapy through
consolidating assessment, medical director approval and
psychiatrist visit into one visit
Evening hours? Research shows that patients utilize the ER
when their PCPs are only available 9-5  Increase capacity:
 Shifted availability of some, but not all, SW’s
 Staggered schedules
 “Flex time”
Immediate group therapy openings
Recommendations - Quality
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Better tracking of efficiency of psychiatrists,
psychologists, and social workers
Need a specific mission statement
To assure quality, PCPs must be integrated into
the process
 Collect outcome data from, and for, these
physicians
More positive reinforcement for Pts to attend
(e.g., favorite candy)
References
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1. Capoccia, et al. “Making ‘Stone Soup’: Improvements in Clinic Access and Retention in Addiction Treatment.”
Joint Commission Journal on Quality and Patient Safety. February 2007
Volume 33 Number 2
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2. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Office of
Applied Studies. “Results from the 2006 National Survey on Drug Use and Health: National Findings.”
http://www.oas.samhsa.gov/nsduh/2k6nsduh/2k6Results.pdf
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3. Wisdom, et al. “Addiction Treatment Agencies’ Use of Data: A Qualitative Assessment The Journal of Behavioral
Health Services & Research 33:4 October 2006
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4. Lowe, Cheryl. “Addiction in the Workplace.” Behavioral Health Management. September/October 2004: pp. 2729.
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5. Duda, Marty. “Drug abuse’s costly toll on workers.” Behavioral Health Management: November/December 2005.
pp. 49-50.
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6. Festinger et al., “Pretreatment Dropout as a Function of Treatment Delay and Client Variables.” Addictive
Behavior, Vol. 20, No. I. pp. 111-115, 1995
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7. Stasiewicz, et al. “A Comparison of Three ‘Interventions’ On Pretreatment Dropout Rates In An Outpatient
Substance Abuse Clinic.” Addictive Behaviors, Vol. 24, No. 4 pp. 579-582. 1999.
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8. Festinger, David S. “From telephone to office: Intake attendance as a function of appointment delay.” Addictive
Behaviors 27 (2002) 131–137
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9. McCarty et al., “Improving the Care for the Treatment of Alcohol and Drug Disorders.” The Journal of Behavioral
Health Services & Research 2008.
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10. Amodeo, et al. “Client retention in residential drug treatment for Latinos.” Evaluation and Program Planning 31
(2008) 102–112
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11. Berry et al., “Innovations in Acces to Care: A Patient-Centered Approach.” 7 October 2003 Annals of Internal
Medicine Volume 139 • Number 7
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12. White et al., “A Model to Transcend the Limitations of Addiction Treatment.” Behavioral Health Recovery
Management. May/June 2003: pp. 38 – 44.
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13. Petry et al. “Fishbowls and Candy Bars: Using Low-Cost Incentives to Increase Treatment Retention.” Science &
Practice Perspectives. August 2003: pp. 55-61.
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14. Fitzgerald, Maureen. “Improving Substance Abuse Treatment Delivery.”