University Health Care Services: Walk-In Clinic

Several existing problems precipitated the creation of the triage system implemented by Kathryn Angell in an effort to deliver improved medical care. The main problem was a lack of coordination in service delivery. This lack of coordination caused excessive wait times on the order of anywhere from 23 to 40 minutes to see a nurse, 40 to 50 minutes to see a doctor, and as long as 55 minutes to get a prescription filled. The practice of all nurses being involved initially in seeing all patients caused duplication of efforts, including repeating questions and examinations, and resulted in procedural bottlenecks. Additionally, there were inconsistent levels of service and extreme variation in treatment because of the different experience and skill levels of the nurses. The overall view by patients was that the clinic was inefficient and impersonal.

The triage system was introduced in September 1979 to overcome these problems. One of the immediate changes was to establish a preliminary evaluation and referral system which dedicated two triage coordinators (highly experienced nurses) to evaluate the patients and assign them to the next appropriate step in the treatment process (i.e., seeing a nurse practitioner or physician). Unfortunately this process did not result in greater procedural efficiency. Wait time for a patient to see a triage coordinator was about 20 minutes, with an additional 38 minute wait to see the nurse or physician. In fact, according to Exhibit 5 in the reading, the wait time to see physician actually increased from 10 minutes to 25 minutes. The wait time for those seeing a specific provider increased from 25 minutes to 34 minutes.

There were several causes for the long waiting times in the Walk-In Clinic after the triage system was created. First, patients were triaged to a nurse practitioner if their ailments fell under one of 13 categories. Any other ailment required either a physician's attention or the nurse to get a physician's authorization. However, the nurse would have to take time to find a doctor who could sign the record, which added to the patient waiting time.

Second, when the nurse practitioners were backed up, triage coordinators classified patients as "MD/NP" which essentially meant the patient should see the first medical provider available, regardless of the patient's ailments. In effect, this added an unnecessary step and completely ignored the purpose of the triage system, which was meant to schedule patients to the appropriate location (MD or NP) depending on their level of care needed.

Third, after the triage system was implemented, the percentage of patients who asked to see a specific doctor or nurse increased from 19 percent of all patients to 24 percent. These patients were still required to see a triage nurse first, even though it was already determined whom the patient would be seeing. Compounding the problem was the fact that many patients pre-arranged walk-in appointments with their physicians. This was not efficient because a walk-in clinic was meant for patients who require immediate care to walk-in without an appointment. As a result, doctors who were occupied with these prescheduled walk-in appointments had no time for the true walk-in patients without an appointment, who subsequently filled up the waiting room. Most doctors actually preferred seeing patients in their office rather than in the clinic.

In order to calculate capacity utilization of the major resources in the clinic we must first determine the arrival rate of the patients (л) and service rate of the patients (м). Arrival rate of patients per hour can be determined from Exhibit 2 in the reading, where an average of 143 patients are shown to visit the clinic per day, or approximately 15 patients per hour. Calculating the arrival rate of patients to the major resources in the clinic requires the use of percentages given in Exhibit 6. Service rates for the major resources in the clinic are found using Exhibit 4 for average staffing levels and Exhibit 5 for average processing times. This data is then used to calculate capacity utilization for each of the major clinic resources and is summarized in Table 1 below. Note that it is assumed that 100 percent of the patients treated by specifically requesting a physician or nurse practitioner are treated by a physician. It is also assumed that three of the eight physician rooms permanently assigned to physicians as their UHS offices are not utilized by the physicians for the walk-in clinic use.

As can be seen in Table 1 below, the resources causing the long wait times are