Ambulatory Patient Scheduling
How could clinical schedules be managed to positively affect patient outcomes and reduce leakage in community care facilities?
Project Overview
This project was focused on improving centralized ambulatory scheduling centers to provide both patients and clinicians more efficient and seamless appointment management. The specific center we worked with was part of a broader hospital system located in the mid-west United States. The staff supported their patients with external scheduling needs ranging from regular check-ups to specialized testing and cancer treatments.
My Role
As the lead researcher and experience designer, I was responsible for the planning, execution, and analysis of the customer research as well as the definition and design of our proposed solution. Partnering with the lead product manager, we conducted in-depth research, defined the problem space, and developed a system-based workflow solution.
Project Goals
The following goals were identified through collaborative sessions with hospital leadership:
Provide the best possible care to the patient.
Improve patient and physician satisfaction.
Enable seamless coordination between all parties to best support the patient.
Increase efficiency and transparency of the referral/scheduling process.
Decreased associated costs and patient leakage.
Stakeholders
Patient - The patient, in the most general form, is a person who needs an appointment scheduled. The appointment itself may be a single or recurring event initiated by the patient him/her-self or a clinician.
Scheduling Center - The facility who centrally coordinates scheduling as the focal point between patients, clinics, and insurance companies. The center is organized into teams based on specialties and modalities, with a subset of team members having associated medical expertise needed to support their patients effectively.
Sending Clinic - Often the Primary Care Physician (PCP), this stakeholder refers the patient to another location (a receiving clinic) for an ordered diagnostic test or a specialized visit. In the context of this project, the definition was broadened to include any clinical location that sends a patient to another location.
Receiving Clinic - This person/clinic receives the patient based on a referral or ordered test from the sending clinician, such as an imaging or diagnostic lab. Similar to the sending clinic, the receiving clinic in this project includes any clinical location receiving a patient.
Discovery
Goal Alignment
Our kick-off with hospital leadership began with introductions and quickly moved into establishing a shared understanding of the project's goals and activities. This was an essential step to ensure that the time, effort, logistics, and importance of our various research activities were acknowledged by the client.
Contextual Interviews
Much of our research revolved around embedding ourselves in the scheduling center side-by-side with the staff as they handled incoming and outgoing calls from patients, clinicians, and health insurance companies. We listened to calls through a headset, observed the staff's secondary actions, and asked questions during the downtime between calls. This ending up being a critical part of our research as it led us to a much deeper understanding of just how much they juggled on and off the phone simply to get a patient correctly scheduled.
Fly-on-the-Wall Observation
During this time, we also conducted fly-on-the-wall observations of the overall scheduling center. This unobtrusive approach allowed us to capture the activity that occurred outside of an individual phone call and employee. Since the staff were organized into teams based on specialties and modalities, we were able to capture a variety of information, tasks, communication, challenges, and interruptions common throughout the center as well as specific to each group and their team leads.
Group Interview - Team Leads
To gain a different perspective, we spent several hours with the four team leads addressing our initial research with the front-line staff followed by gathering additional information on their backgrounds, priorities, goals, and challenges. Based on these discussions, I facilitated several ideation and prioritization activities including Rose-Thorn-Bud (RTB), affinity clustering, and statement starters to help tease out their needs and opportunities from the leadership’s point of view.
Interviews - Sending & Receiving Clinicians
The scheduling center was the biggest piece of the puzzle, but not the only one. To truly identify the problem to be solved and asses the current state, we also had to understand the sending and receiving clinicians. Given the tight timeline and clinician availability, we were only able to interview one PCP over the phone and visit two specialty clinics. While more time and more stakeholders would have been helpful, we were prepared with data and insights from the scheduling center that allowed us ascertain their circumstances, further validate our insights, and make previously-unknown connections back to centralized scheduling.
BONUS: Contextual Interviews - Internal Scheduling
As an added bonus, we unexpectedly learned about a parallel internal scheduling department located in the same building and had the opportunity to conduct contextual interviews with them. Demonstrating the importance of research and due diligence, we only learned of this department’s existence by a quick mention during the team leads group interview. While housed in a separate area of the same facility, this group had similar goals and activities as external scheduling but only supported appointments within their hospital's walls.
Findings & Insights
Scheduling Center Statistics
Employs over 50 representatives with 15-20 of them possessing a clinical background.
Handles roughly 500 calls a day, with each call lasting approximately 5-7 minutes.
The average scheduling request, from initial call to securing the appointment, takes 2-3 days to complete.
Conducts an average of 3-5 phone calls between the patient and the receiving clinic to coordinate a single appointment.
Scheduling Center Staff
The center’s staff are deeply invested in the patient and their care. They consider themselves an advocate for the patient between their care settings and develop relationships with them. From the health system's perspective, the staff is a tremendous asset in championing for patient care and keeping the patients in their hospital system's network. The team leads are considered "roadblock ninjas" by themselves and their staff, eliminating or reducing any barriers.
PCP (Sending)
The PCPs see themselves as responsible for their patients’ health and deeply invested in their care. To better manage this care, they require ongoing feedback and transparency about their patients throughout their healthcare journey. However, they often don’t receive the information they need from the scheduling center or other clinics, limiting their impact.
Specialty Clinics (Receiving)
Specialty clinics place a huge value on having the most appropriate patients in the most appropriate time slots. For example, they may not accept an ENT patient, only see new patients in the afternoon, and require a PCP referral. The scheduling center ensures that these requirements are met, so the specialty clinics tend to tolerate the additional steps required to coordinate with them.
Current Process
The scheduling center processes were generally repetitive and manual. The staff worked concurrently between 2-3 different systems including an EHR, spending a considerable amount of time copying and pasting information between applications. They often had to reference printed protocol binders because most receiving clinics and/or insurance companies required specific procedures be followed before an appointment could be scheduled. Many of their work stations were also covered with post-its containing notes they needed to navigate the applications and reminders about patients. Additionally, because scheduling relied on the relationship between an employee and a patient, there were risks of a significant slow-down if another staff member had to step in.
Information Access & Visibility
In addition to the manual and repetitive processes, information needed by the center's staff as well as the sending and receiving clinics were dispersed across multiple systems. This required additional time and frustration as they had to 'hunt and gather' for that information. Each stakeholder also needed feedback throughout the process but were rarely able to get it.
PCPs were unable to receive feedback on their patients across their care journey.
Receiving clinics didn't see evidence of the efficiency and patient focus the call center claimed to provide, making their work more challenging.
Call center staff and leadership had to manually compile data just to understand referral trends. This was due to the difficulty keeping metrics current because of the lack of data access and manipulation.
Patient Needs
For many patient appointments, the call center was only path to scheduling, especially when the clinics were in-network. Even with their inefficiencies and their patients requesting improvements such as self-scheduling and text/email reminders, this single method of scheduling through the call center via phone calls remained intact. We identified this as a significant missed opportunity for the center to support their patients in other ways while achieving several of their project goals including increased efficiency, reduced costs, and decreased leakage.
Clinic Needs
Both the sending and receiving clinics received little to no value in the call center's software, which was required to be used in their offices for scheduling. Many of these clinics had to use the call center's application alongside their own, and similar to the call center staff, were required to copy and paste between applications and their office calendars. They found that it added time and steps to the scheduling process, leaving less time to help patients.
Definition
Moving from research into the definition phase, our first step was to target the overarching theme of each stakeholder group.
The Patient - Empowerment throughout their scheduling and appointment journey.
The Physician/Clinician - Visibility and trust through effective data and feedback to support their patients and offices.
The Health System (including the scheduling center) - Better system-level planning and data-driven insights.
Whiteboard Mapping
To tease out the considerations, information, and mechanisms around these themes along with possible gaps and opportunities, I facilitated a whiteboard mapping session with user researchers, UX designers, product managers, and clinical/operational subject matter experts in the ambulatory space. The session started off slow, but quickly evolved into a highly engaging and collaborative event. For example, people took it upon themselves to build out selected sub-themes (recommendation engines, PCP-patient coordination, etc.) on every other available whiteboard in the room.
We wrapped up the session by asking everyone to take a step back and discuss what they see. By zooming out, each participant shared a different perspective and the results of our collective efforts came into greater focus. They made more connections between sub-themes located in different grouping and identified additional gaps and opportunities that our solutions could address.
Journey Alignment
Armed with research insights and the whiteboard session’s outcomes, the lead product manager and I took our own advice and stepped back to form the broader story of the patient and their appointment. We soon realized that the patient journey had a strong correlation to an airline traveler's journey, which proved to be essential in how our solution was structured.
To validate our hypothesis about the correlation of the traveler and patient experiences, we aligned the appointment process to each step of the traveler's user flow. This exercise proved beneficial in distilling down the appointment process to its essential elements and driving towards a more efficient workflow solution. The details of this analysis are displayed below.
Initiation
Patient's medical need
Planning
Appointment need identified
Medical protocols determined
Logistical protocols determined
Booking
Patient queue, work lists, next call
Serve appointments
Apply criteria & select appointment
Purchasing
Schedule (secure) the appointment
Remove barriers (ex: pre-certifications)
Get medical and logistic protocols
Pre-Trip
Medical and logistic reminders
Acceptance, denial, or appointment change
Departure
Travel to the appointment and check in
Provide updates as needed (ex: being late)
In-Flight
Attend the appointment
Post-Trip
Check out and receive follow-up
Design
Our proposed solution follows the patient from their initial visit through scheduling and attending the diagnostic appointment. As visualized below, the flow leverages the traveler's story to the patient's appointment journey and not just the call center scheduling portion identified in the original scope. A self-scheduling option was also included to address the patient need and achieve several project goals.
The process itself is structured by each step of the appointment journey (columns) and each stakeholder (color-coded rows) that plays a primary or secondary role. The white boxes contain information and capabilities needed to support that particular step and as in most process flows, the diamonds represent a choice to be made.
Initial Visit
The patient begins by feeling sick (their motivation) followed by high-level steps of scheduling, visiting with the PCP, receiving a diagnostic test order, and deciding whether to self-schedule their next appointment or go through the call center. While mapping out this section, we were aware of the other steps a patient may go through between their arrival and the diagnostic testing. There are also additional interactions between the patient and the PCP during the visit. While these interactions are essential for patient care, they weren't critical in demonstrating the scheduling workflow. To keep the focus on the appointment itself, only the steps and interactions related to the diagnostic results, ordering, and communication were included.
Call Center
This redesigned flow is more streamlined than the current call center process with a system view that prioritizes relevant and timely information based on criteria such as urgency, diagnosis, and complexity. This approach provides the staff with appointments corresponding to the specific patient and context, removing the need to 'hunt and gather' for information. Communication/reminder preferences and logistic protocols are also added to the patient's profile for a more seamless scheduling experience now and in the future. In addition, the staff have multiple opportunities to proactively suggest self-scheduling and guide the patient in that direction.
You'll notice that this is the only section that incorporates the system view. This was done on purpose to target the scheduling center's needs and opportunities. If the project had continued as planned, we would have conducted deeper research into the systems of the sending and receiving clinics and mapped out how information and tasks flowed between the various stakeholder roles and locations.
Self-Scheduling
If the patient chooses to self-schedule, the call center reverts to a supporting role for both the patient and the sending/receiving clinics while maintaining full visibility into the medical order, appointment, and clinical schedules as needed. The patient has access to relevant information that allows them to make more informed decisions such as a visit criteria, physician reviews, location proximity, and proactive date/time recommendations. Once the appointment is scheduled, the seamless experience continues with capabilities like adding to their calendar and booking transportation if needed (ex: Uber). At any point, the patient also has the option to request that the call center take over their scheduling.
Preparation & Arrival
This last process flow breaks down the final steps leading up to the appointment itself. Built-in reminders take into account the logistics of getting to the appointment (ex: ride details, location), the medical protocols to adhere to, and confirmation of the appointment itself. During arrival and check-in, the patient has a frictionless method of communicating any unintended delays and registering at the time of arrival or beforehand. Both the patient and the clinic are up-to-date in real-time and can actively respond to any changes, included a last-minute need to reschedule or cancel. At the end of the appointment, the same frictionless communication is used to follow-up on any medical and logistic requirements.
Circular Design
The unique power of this process and the subsequent technical solution is how it continually supports itself as both an individual flow and an ongoing circular flow. As seen below, the receiving clinician could become the sending clinician who directs the patient to another specialty clinic or back to their PCP. In the second case, the PCP who began as the sending clinician is now the receiving clinician. This circular flow becomes essential when designing a reusable, flexible system that supports scheduling, feedback, and transparency for all parties involved. While certain information and tasks may be unique to the sending or receiving role, overall data flows, interactions, and outcomes are no longer confined to specific use cases or roles.
Outcomes
While we identified and solved for multiple areas of frustration and opportunities for improvement, the project was unfortunately paused by the client and we were unable to continue developing our solution. That said, our research, operational approach, and proposed flows were well received with positive feedback from both their leadership and front-line workers. If given the chance to continue, I'm confident we would have achieved every project goal with the added bonus of addressing the needs of the sending and receiving clinics as well as their patients.
Lessons Learned
While I felt we conducted the appropriate amount of research with the scheduling center itself, we would have benefited from additional discovery with the other stakeholder groups including different types of clinics (size, specialty, etc.), more than one PCP, and any number of patients. Additionally, I would have incorporated the internal scheduling center into our solution even though it was classified as out of scope. I believe our delivered solution would have addressed the majority of the internal center's needs as well in one unified scheduling system regardless of who needed the appointment and where the appointment was located. This would have also successfully met the project goals of providing exceptional patient care, physician satisfaction, efficiency, and transparency at a reduced operational cost.
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