Skip to main content
SpringerLink
Log in

Optimizing management and financial performance of the teaching ambulatory care clinic

  • Original Articles
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

OBJECTIVE: To examine how to optimize teaching ambulatory care clinics performance with regard to access to care, access to teaching, and financial viability.

DESIGN: Optimization analysis using computer simulation.

METHODS: A discrete-event simulation model of the teaching ambulatory clinic setting was developed. This method captures flow time, waiting time, competition for resources, and the interdependency of events, providing insight into system dynamics. Sensitivity analyses were performed on staffing levels, room availability, patient characteristics such as “new” versus “established” status, and clinical complexity and pertinent probabilities.

MAIN RESULTS: In the base-case, 4 trainees: preceptor, patient flow time (registration to check out) was 148 minutes (SD 5), wait time was 20.6 minutes (SD 4.4), the wait for precepting was 6.2 minutes (SD 1.2), and average daily net clinic income was $1,413. Utilization rates were preceptors (59%), trainees (61%), medical assistants (64%), and room (68%). Flow time and the wait times remained relatively constant for strategies with trainee:preceptor ratios <4:1 but increased with number of trainees steadily thereafter. Maximum revenue occurred with 3 preceptors and 5 trainees per preceptor. The model was relatively insensitive to the proportion of patients presenting who were new, and relatively sensitive to average evaluation and management (E/M) level. Flow and wait times rose on average by 0.05 minutes and 0.01 minutes per percent new patient, respectively. For each increase in average E/M level, flow time increased 8.4 minutes, wait time 1.2 minutes, wait for precepting 0.8 minutes, and net income increased by $490.

CONCLUSION: Teaching ambulatory care clinics appear to operate optimally, minimizing flow time and waiting time while maximizing revenue, with trainee-to-preceptor ratios between 3 and 7 to 1.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. McCaig L. National Hospital Ambulatory Medical Care Survey: 1995 outpatient department summary. Adv Data. 1997;284:1–17.

    PubMed  Google Scholar 

  2. Law A, Kelton D. Simulation Modeling and Analysis. New York: McGraw-Hill; 1991.

    Google Scholar 

  3. Handbook of Simulation. Principles, Methodology, Advances, Applications, and Practice. Banks J, ed. New York: John Wiley and Sons; 1998.

    Google Scholar 

  4. Aharonson-Daniel L, Paul R, Hedley A. Management of queues in out-patient departments: the use of computer simulation. J Manag Med. 1996;10:50–8.

    Article  PubMed  CAS  Google Scholar 

  5. Benneyan J. An introduction to using computer simulation in healthcare: patient wait case study. J Soc Health Syst. 1997;5:1–15.

    PubMed  CAS  Google Scholar 

  6. Clague JE, Reed PG, Barlow J, Rada R, Clarke M, Edwards RH. Improving outpatient clinic efficiency using computer simulation. Int J Health Care Qual Assur Inc Leadersh Health Serv. 1997;10:197–201.

    PubMed  CAS  Google Scholar 

  7. Hashimoto F, Bell S. Improving outpatient clinic staffing and scheduling with computer simulation. J Gen Intern Med. 1996;11:182–4.

    Article  PubMed  CAS  Google Scholar 

  8. Huarng F, Lee M. Using simulation in out-patient queues: a case study. Int J Health Care Qual Assur. 1996;9:21–5.

    Article  PubMed  CAS  Google Scholar 

  9. Reilly T, Marathe V, Fries B. A delay-scheduling model for patients using a walk-in clinic. J Med Syst. 1978;2:303–13.

    Article  PubMed  CAS  Google Scholar 

  10. Swisher J, Jacobson S. Evaluating the design of a family practice healthcare clinic using discrete-event simulation. Health Care Manag Sci. 2002;5:75–88.

    Article  PubMed  Google Scholar 

  11. Banks NJ, Palmer RH, Berwick DM, Plsek P. Variability in clinical systems: applying modern quality control methods to health care. Jt Comm J Qual Improv. 1995;21:407–19.

    PubMed  CAS  Google Scholar 

  12. Ly N, McCraig L, Burt C. National Hospital Ambulatory Medical Care Survey: 1999 Outpatient Department Summary. In: Advanced Data from Vital and Health Statistics. Hyattsville, Md: National Center for Health Statistics; 2001.

    Google Scholar 

  13. Xakellis G, Bennett A. Improving clinic efficiency of a family medicine teaching clinic. Fam Med. 2001;33:533–8.

    PubMed  Google Scholar 

  14. Oddone E, Guarisco S, Simel D. Comparison of housestaff’s estimates of their workday activities with results of a random works-sampling study. Acad Med. 1993;68:859–61.

    Article  PubMed  CAS  Google Scholar 

  15. Nahvi S, Kesan SH, Coppola J, Crausman RS. Precepting in a community based internal medicine teaching practice; results of a time-motion study. Med Health RI. 2001;84:267–8.

    CAS  Google Scholar 

  16. Melgar T, Schubiner H, Burack R, Aranha A, Musial J. A time-motion study of the activities of attending physicians in an internal medicine and internal medicine-pediatrics resident continuity clinic. Acad Med. 2000;75:1138–43.

    Article  PubMed  CAS  Google Scholar 

  17. Hasler J. Do trainees see patients with chronic illness? BMJ Clin Res Ed. 1983;287:1679–82.

    Google Scholar 

  18. Parrish H, Bishop M, Baker A. Time study of general practitioners’ office hours. Arch Environ Health. 1967;14:892–8.

    PubMed  CAS  Google Scholar 

  19. Baker A. What do New Zealand general practitioners do in their offices? N Z Med J. 1976;83:187–90.

    PubMed  CAS  Google Scholar 

  20. Collyer J. A family doctor’s time. Canadian Family Physicians. 1969;63–9.

  21. Andersson S, Mattson B: Length of consultation in general practice in Sweden: views of doctors and patients. Fam Pract. 1989;6:130–4.

    Article  PubMed  CAS  Google Scholar 

  22. Blumenthal D, Causino N, Chang YC, et al. The duration of ambulatory visits to physicians. J Fam Pract. 1999;48:264–71.

    PubMed  CAS  Google Scholar 

  23. Partridge J. Consultation time, workload, and problems for audit in outpatient clinics. Arch Dis Child. 1992;67:206–10.

    Article  PubMed  CAS  Google Scholar 

  24. Radel SJ, Norman AM, Notaro JC, Horrigan DR. Redesigning clinical office practices to improve performance levels in an individual practice association model HMO. J Healthc Qual. 2001;23:11–5.

    PubMed  CAS  Google Scholar 

  25. Schwab RA, DelSorbo SM, Cunningham MR, Craven K, Watson WA. Using statistical process control to demonstrate the effect of operational interventions on quality indicators in the emergency department. J Healthc Qual. 1999;21:38–41.

    PubMed  CAS  Google Scholar 

  26. Harris K, Schultz J, Feldman R. Measuring consumer perceptions of quality differences among competing health benefit plans. J Health Econ. 2002;21:1–17.

    Article  PubMed  Google Scholar 

  27. Maslach C, Jackson S. Burnout in Health Professions: A Social Psychological Analysis. Hillsdale, NJ: Erlbaum; 1982.

    Google Scholar 

  28. Maslach C, Schaufli W, Leiter M. Job burnout. Annu Rev Psychol. 2001;52:397–422.

    Article  PubMed  CAS  Google Scholar 

  29. Bower GH, Hilgard ER. Theories of Learning. Englewood Cliffs, NJ: Prentice Hall; 1981.

    Google Scholar 

  30. Bursch B, Beezy J, Shaw R. Emergency department satisfaction: what matters most? Ann Emerg Med. 1993;22:586–91.

    Article  PubMed  CAS  Google Scholar 

  31. Dansky K, Miles J. Patient satisfaction with ambulatory healthcare services: waiting time and filling time. Hosp Health Serv Adm. 1997;42:165–77.

    PubMed  CAS  Google Scholar 

  32. Maitra A, Chikhani C. Waiting times and patient satisfaction in the accident and emergency department. Arch Emerg Med. 1993;10:388–9.

    PubMed  CAS  Google Scholar 

  33. Satyanarayana N, Kumar V, Satyanarayana P. The outpatient experience: results of a patient feedback survey. Int J Health Care Qual Assur Inc Leadersh Health Serv. 1998;11:156–60.

    Google Scholar 

  34. Thompson DA, Yarnold PR, Williams DR, Adams SL. Effects of actual waiting time, perceived waiting time, information delivery, and expressive quality on patient satisfaction in the emergency department. Ann Emerg Med. 1996;28:657–65.

    Article  PubMed  CAS  Google Scholar 

  35. Zoller J, Lackland D, Silverstein M. Predicting patient intent to return from satisfaction scores. J Ambulatory Care Manage. 2001;24:44–50.

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Received from the Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass

    James E. Stahl MD, CM, MPH

  2. the Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass

    James E. Stahl MD, CM, MPH & Scott Gazelle MD, MPH, PhD

  3. the Department of Medicine, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pa

    Mark S. Roberts MD, MPP

Authors
  1. James E. Stahl MD, CM, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mark S. Roberts MD, MPP
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Scott Gazelle MD, MPH, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to James E. Stahl MD, CM, MPH.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Stahl, J.E., Roberts, M.S. & Gazelle, S. Optimizing management and financial performance of the teaching ambulatory care clinic. J GEN INTERN MED 18, 266–274 (2003). https://doi.org/10.1046/j.1525-1497.2003.20726.x

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1046/j.1525-1497.2003.20726.x

Key words

Search

Navigation