Prozessoptimierung in der Krankenhaussprechstunde: Erfahrungen und Ergebnisse unter Berücksichtigung der Möglichkeiten von Informationstechnologie

Introduction: Process oriented thinking and acting is getting more and more important in medicine. This survey investigates possibilities of optimizing processes in the field of ambulatory care at the hospital. Outline of Problems and Goals: By means of a clinical-trial it will be explored if a processmodell derived from software-engineering can be successfully applied to a processoptimization project in an ambulatory consultation unit at a hospital. IT-support for clinical workflows will be introduced. The overall criteria for success will be the increase in patient satisfaction. One aspect is the development of an appointment schedule implemented in the hospital-information-system (HIS) and its adaption by a generator-tool. Will shorter patientwaiting-times and better supply of patient records be achieved? Another aspect is the introduction of “Computerized Physician Order Entry“(CPOE) for radiology-examinations. Is this feasible from the technical and organisational point of view? Can a higher process-quality and shorter process-duration be archived through this measure? Materials and Methods: Subject of the trial is the outpatient consultation unit of the traumatology department of an university hospital. The collection of the data took place in fall 2002 and spring 2004. It consisted of a patient- survey including a patient- satisfaction questionaire, documentation of waiting- and process-times as well as a staff-survey. Between 2002 and 2004 a process-optimization was performed by using a process-modell which is derived from the modell of Lenz and Kuhn for softeware-development in a hospital.(See (Kuhn KA, Lenz R et al. 2003)) The model consists of an exploration- and an analysis-phase for structured collection of problems and critical-areas and for data-collection. This is followed by the phase of redesign in which process-changes and IT-applications are developed. These are realized technically and organisationally in the phase of implementation. After the phase of staff-training, the phase of routine-operation is reached. Finally a second analysis is conducted which allows to measure the success of the project. Results: The process-optimization was successfully conducted according to the processmodell described above. The introduction of an appointment-schedule for outpatients and ambulatory surgery in the HIS was successfully performed including the process of making appointments during writing of the discharge letter in the hospital. The orders for radiologyexaminations have been changed to a CPOE-procedure, a proceeding for direct radiology appointments has been established. The staff accepted these changes; the IT-applications that have been introduced are predominantly regarded as positive. The number of documented appointments of the patients rose significantly to 67,5% (p=0,000). The availability of patient records at time of patient arrival climbed to 47,8% (p=0,000). The arrival of the patient at the unit took place significantly later (p=0,000) and was spread more constantly over the whole time of consultation. Patient waiting-times for their first call to the exam room decreased significantly from 69min. (n=344) to 43min. (n=317) (p=0,000). At the same time the duration of the overall visit of the outpatient significantly decreased from 128min (n=293) to 100min. (n=288) (p=0,000). But the waiting-time for the radiology-examination was extended significantly (p=0,045) by 5 minutes. The duration of the radiology examination itself was prolonged significantly (p=0,039). Neither rose the percentage of patientes beeing appointed directly to radiology exams nor decreased the waiting time of these patients. Overall patient satisfaction rose between both measurements (p=0,001). Discussion: By using the process-modell a process-optimization employing IT-applications can successfully be conducted in an ambulatory consultation unit at a hospital. Important factors for success are short iterations, an open type of communication, early involvement of the user and an interdivisional approach. Splitting the overall-project into sections is beneficial. In IT-supported interventions the key to success is a highly participatory, iterativly softeware-development-process in combination with a holistic HIS. A „generator-tool“ in the HIS allows a quick development of clinical applications. By this method of processoptimization patient-satisfaction can rise significantly. An appointment-schedule for outpatients and ambulatory surgery in the HIS can reduce the waiting-time for the first call to the treatment-room as well as improve the availability of patient records at time of patient arrival. The adoption of an existing CPOE for radiology exams in the hospital to the ambulatory consultation unit is possible by technical and organisational means. This leads to a higher process-quality, but as well to additional work for the doctor and longer waiting-times for the patient. Direct appointments for radiology exams by CPOE are possible but do not lead to shorter waiting times for the patients. In the fields of thinking in processes and information technology in patient care this study shows a sucessful modell of optimization in ambulatory patient care at the hospital.