title: Patient access in plastic surgery: an operational and financial analysis of service-based interventions to improve ambulatory throughput in an academic surgery practice.
abstract: BACKGROUND
  Inefficient patient throughput in a surgery practice can result in extended new patient backlogs, excessively long cycle times in the outpatient clinics, poor patient satisfaction, decreased physician productivity, and loss of potential revenue. This project assesses the efficacy of multiple throughput interventions in an academic, plastic surgery practice at a public university.
  
  
  METHODS
  We implemented a Patient Access and Efficiency (PAcE) initiative, funded and sponsored by our health care system, to improve patient throughput in the outpatient surgery clinic. Interventions included: (1) creation of a multidisciplinary team, led by a project redesign manager, that met weekly; (2) definition of goals, metrics, and target outcomes; 3) revision of clinic templates to reflect actual demand; 4) working down patient backlog through group visits; 5) booking new patients across entire practice; 6) assigning a physician's assistant to the preoperative clinic; and 7) designating a central scheduler to coordinate flow of information. Main outcome measures included: patient satisfaction using Press-Ganey surveys; complaints reported to patient relations; time to third available appointment; size of patient backlog; monthly clinic volumes with utilization rates and supply/demand curves; "chaos" rate (cancellations plus reschedules, divided by supply, within 48 hours of booked clinic date); patient cycle times with bottleneck analysis; physician productivity measured by work Relative Value Units (wRVUs); and downstream financial effects on billing, collection, accounts receivable (A/R), and payer mix. We collected, managed, and analyzed the data prospectively, comparing the pre-PAcE period (6 months) with the PAcE period (6 months).
  
  
  RESULTS
  The PAcE initiative resulted in multiple improvements across the entire plastic surgery practice. Patient satisfaction increased only slightly from 88.5% to 90.0%, but the quarterly number of complaints notably declined from 17 to 9. Time to third available new patient appointment dropped from 52 to 38 days, whereas the same metric for a preoperative appointment plunged from 46 to 16 days. The size of the new patient backlog fell from 169 to 110 patients, and total monthly clinic volume climbed from 574 to 766 patients. Our "chaos" rate dropped from 12.3% to 1.8%. Mean patient cycle time in the clinic decreased dramatically from 127 to 44 minutes. Mean monthly productivity for the practice increased from 2479 to 2702 RVUs. Although our collection rate did not change, days in A/R dropped from 66 to 57 days. Mean monthly charges increased from U.S. $535,213 to U.S. $583,193, and mean monthly collections improved from U.S. $181,967 to U.S. $210,987. Payer mix remained unchanged.
  
  
  CONCLUSIONS
  Implementation of a PAcE initiative, focusing on outpatient clinic throughput, yields significant improvements in access to care, patient satisfaction as measured by complaints, physician productivity, and financial performance. An academic, university-based, plastic surgery practice can use throughput interventions to deliver timely care and to enhance financial viability.
authors.affiliation: From the *Division of Plastic Surgery, †Kenan-Flagler Business School, ‡Department of Family Medicine, University of North Carolina, Chapel Hill, NC.
authors.forename: Charles Scott
authors.initials: CS
authors.lastname: Hultman
authors.forename: Wendell G
authors.initials: WG
authors.lastname: Gilland
authors.forename: Samuel
authors.initials: S
authors.lastname: Weir
mesh_terms: D000046:Academic Medical Centers / Q000191:economics / Q000458:organization & administration* / Q000706:statistics & numerical data; D000554:Ambulatory Care Facilities / Q000191:economics / Q000458:organization & administration* / Q000706:statistics & numerical data; D017598:Efficiency, Organizational; D006297:Health Services Accessibility / Q000191:economics / Q000458:organization & administration* / Q000706:statistics & numerical data; D006801:Humans; D009657:North Carolina; D017060:Patient Satisfaction / Q000706:statistics & numerical data; D011216:Practice Management, Medical / Q000191:economics / Q000458:organization & administration* / Q000706:statistics & numerical data; D017064:Process Assessment, Health Care; D016730:Program Development; D015397:Program Evaluation; D011446:Prospective Studies; D058996:Quality Improvement; D019651:Plastic Surgery Procedures / Q000191:economics / Q000706:statistics & numerical data; D013997:Time Factors