CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
A METHOD OF EVALUATING AND
MONITORING HOSPITAL OUTPATIENT SERVICES
A project submitted in partial satisfaction of the
requirements for the degree of Master of Science in
Health Science
by
Nicholas Altuchow
May, 1982
The project of
is approved:
·~rome
Cha1rrnan
California State University, Northridge
ii
To
~aba:
This project is dedicated to you, my wife,
whose hard work has helped me reach this
goal.
(Now we can begin to live again.)
iii
TABLE OF CONTENTS
Dedication
Abstract
iii
vi
CHAPTER ONE - Introduction
Problem
Significance of Problem
Target Population
Organization of Paper
1
2
3
4
6
CHAPTER TWO - Background
Review of Literature
Summary of Literature Reviewed
Setting of Study
7
7
8
14
CHAPTER THREE - Methodology
Statement of Project
Objectives of Questionnaires
Developing the Questionnaire
Objectives of Monitoring System
Sources of Data; Questionnaires
Analysis of Questionnaires
Sampling Size
Sources of Data; Monitoring System
Analysis Monitoring System
Limitations
Limiting Factors:
Reproducibility
Rate of Returns
Questionnaire Design
Data Interpretation
15
15
16
17
19
20
22
22
23
23
24
24
26
27
27
CHAPTER FOUR - Results
Evaluations
A Report Prepared for Administration
Background
Questionnaires Returned
Findings
Computer Program
Table 1.
Table 2.
Table 3.
Table 4.
Evaluation of Study Facility
Recommendations for the Study Facility
Recommendations for the Monitoring System
Follow-up
29
31
31
31
31
32
34
35
36
37
38
40
42
43
iv
.....
··...,.,
~,
TABLE OF CONTENTS
Continued
CHAPTER FIVE - Conclusions-RecommendationsSummary
Exhibit 1.
Exhibit 2.
Exhibit 3.
Exhibit 4.
Exhibit 5.
Exhibit 6.
Exhibit 7.
Exhibit 8.
46
50
52
53
54
56
57
59
60
References
61
Appendix A.
62
Appendix B.
82
v
ABSTRACT
A METHOD OF EVALUATING AND
MONITORING HOSPITAL OUTPATIENT SERVICES
by
Nicholas Altuchow
Master of Science in Health Science
Statistics indicate that the revenue from outpatient
services plays a significant role in the financial
viability of many hospitals and with the financial pressure
of inflation, competition and third-party reimbursements
will continue to do so to an even greater degree in the
future.
To remain financially sound, the hospital's
managerial staff will have to scrutinize the quality and
quantity of outpatient services to their customers and
provide the desired services to the satisfaction of their
clients in order to remain competitive.
A method has
been proposed to evaluate, monitor, and maintain these
outpatient services which is reasonably inexpensive,
easily tailored to the institution, and informative for
vi
the administrative staff, allowing them to make effective
decisions.
A rating scale type of questionnaire was developed
to evaluate the outpatient services provided to the
physicians who referred their patients to the study
facility.
The responses were coded and tabulated with a
computer program which was easily modified to the needs
of the facility.
A monitoring system was proposed to
determine which physicians admitted the most outpatients
and then to monitor their monthly outpatient admissions.
This monitoring system would provide the base numbers
with which comparisons would be made when improvement
programs were instituted.
The monitoring system would
also alert the administrator if a high-percentage
admitter was to show a significant decrease in admissions
so that the administrator could determine the cause and
take the necessary corrective measures.
The system was utilized to the satisfaction of the
study facility with a minimal amount of effort.
Although
the questionnaire and monitoring system were implemented
with the use of computers, it could also be simplified
for manual methods, and still generate a great deal of
information in relation to the effort involved.
vii
CHAPTER ONE - INTRODUCTION
The past decade has shown a trend toward increased
outpatient visits at a time when inpatient occupancy
rates and length of stay have been decreasing. (10:62)
This together with the financial squeeze caused by
inflation, governmental controls and third-party reimbursement restrictions will force hospitals to rely more
heavily on the patient revenue generated by outpatient
services.
Outpatients provided 13% of the average
hospital's total patient revenue in 1978. (8:45)
The
financial future of hospitals will thus rely heavily on
the revenue from outpatient services.
This will require
hospitals to provide the variety and quality of outpatient services which physicians require and to monitor
outpatient utilization for any decline in usage.
The hospital must take steps to compete with other
facilities for the physicians who admit these outpatients.
A questionnaire may help to provide the
competitive edge by evaluating the hospital's outpatient
service, by determining areas for improvement and by
indicating additional tests and procedures which physicians
require.
Developing a questionnaire for physicians to
evaluate the hospital's outpatient service will encompass
the first part of this project.
Once the physicians needs are determined, a method
1
2
for determining which physicians are the predominant
admitters of outpatients and a system to monitor the
number of outpatients admitted by these physicians will
be established.
This monitoring system will enable the
hospital to take steps to remedy any decline in outpatient admissions before it becomes too serious.
The
establishment of such a monitoring system will encompass
the second portion of this project.
By using the results
obtained from the questionnaire to indicate the types of
improvements to make, and by using the monitoring system
to provide the current number of admissions, one can make
comparisons to see if the improvement programs are having
the desired affect of increased outpatient admissions.
By using the monitoring system and repeating the survey
after the improvement program, one has a method for
evaluating, monitoring. and maintaining quality outpatient services.
PROBLEM
A.
Statement of Problem:
While hospitals may
closely monitor inpatient occupancy rates, most do very
little to monitor the outpatient admission rate.
Because
outpatient admissions will become a significant source of
patient revenues, a system is needed to monitor and
maintain high levels of outpatient admission.
The purpose of this project is to establish a system
to identify the physicians who admit the largest per-
3
centage of outpatients, determine what improvements they
desire from outpatient services, monitor the admission
rates for these physicians, and alert the administrator
of any significant decrease in admissions.
This project
will be applied to the specific needs of the institution
under study and then information learned can be used for
application in similar facilities.
B.
Significance of Problem:
If outpatient ser-
vices provide a significant percentage of the patient
revenues of a hospital and if a few physicians provide a
significant percentage of these outpatients, then the
loss of one of these physicians because of poor service
or simple retirement can cause a sharp drop in patient
revenues for the hospital.
Currently the hospital does
not have a system to identify the high percentage
admitters of outpatients nor a system for monitoring the
range of outpatient admission for these specific physicians. Such a monitoring system would signal significant decreases in outpatient admissions by these high
percentage admitters.
Appropriate investigation and
corrective action can then be taken to limit the revenue
loss before it becomes too serious.
By knowing which medical specialties admit the
greatest percentage of outpatients, recruitment and
expenditures for outpatient services can be made where
they will do the most good.
4
Currently the desire to improve outpatient services
provided by the laboratory had been voiced by the
laboratory department manager.
A few complaints from
physicians provided impetus to the existing concern of
how to provide better outpatient service to physicians
and patients.
The questionnaire was brought to the
department manager's attention and he, in turn, invited
the Administrator to comment.
The Administrator thought
that other department heads may want to use the opportunity to gain insight into what physicians thought of
the outpatient service they provided.
The questionnaire
was still in a state of evolution and further meetings
were held with department heads before the final product
was finished, presented to administration for approval,
and distributed to the physicians.
C.
Target Population:
Because this facility does
not have a walk-in clinic or emergency room at present,
the outpatient must be referred to the hospital by physicians.
This puts the emphasis of study on the
physicians unlike other studies which have examined the
attitude of the walk-in patient toward the outpatient
clinic.
The target population for receiving the questionnaire was all physicians on staff at Midway Hospital
Medical Center.
doctors.
As of June 30, 1981, this totaled 705
The Administrative Staff decided that all
5
physicians on staff were to receive the questionnaire.
The monitoring system is also coded to handle all of
the 705 physicians on staff, but the predominant
admitters of outpatients should not exceed 100
physicians.
6
ORGANIZATION OF PAPER
CHAPTER ONE - INTRODUCTION:
I. Introduction
II. Statement of Problem
A. Statement of Problem
B. Significance of Problem
C. Target Population
III. Organization of Paper
CHAPTER TWO - BACKGROUND
I. Review of Literature
A. Medlars II
B.
Index Medicus
C. Cummulative Review of Hospital Literature
D. Summary of Literature Review
II. Setting of Project
CHAPTER THREE - METHODOLOGY
I. Statement of Project
A. Objectives
B. Definitions
II. Sources of Data and their Measurement
III. Analysis
IV. Limitations
CHAPTER FOUR - RESULTS
I. Findings (How data will look)
II. Follow-up
CHAPTER FIVE - CONCLUSIONS RECOMMENDATIONS & SUMMARY
I. Conclusions
II. Recommendation
III. Summary
CHAPTER TWO - BACKGROUND
Review of Literature:
The following methods were
used in the literature search:
1.
A computerized bibliographic citation list was
generated by Medlars II using the National Library of
Medicine National Interactive Retrieval Service.
This
was a four-year search from 1977 to present.
Major headings used included Outpatient Hospital Care and
Ambulatory Hospital Care.
Subheadings used to further
pinpoint the desired literature were Standards, Utilization, Quality of Healthcare and Organization and
Administration. The search generated 172 citations of
which approximately 12 looked promising.
2.
An inspection of the Cumulative Review of
Hospital Literature for the years 1975 and 1976 was conducted using the headings Outpatient Care, Hospitals and
Ambulatory Care Hospitals with subclassifications of
Standards, Economics, Quality, Utilization and Organization and Administration.
Four pertinent publications
were discovered in this search.
3.
Index Medicus was inspected for the years 1975
and 1976 under similar headings and subclassifications as
listed above and two additional sources were noted.
These three methods covered a period of 6 years.
It was
assumed that any data prior to this would be outdated as
7
8
far as statistical and financial information was concerned.
Summary of Literature Review:
The majority of the
literature generated by the Medline search and that noted
in Index Medicus, and the Review of Hospital Literature
pertained to the attributes needed for the establishment
and operation of specialty type outpatient clinics such
as those for diabetes, psychiatry, arthritis, cancer,
etc.
A great deal of information was also available on
the evaluation of patient attitudes attending a variety
of the above mentioned specialty clinics in this and
various other countries.
There were very few listings
which dealt with the physician's evaluation of hospital
outpatient departments as would be needed for this
particular hospital which does not have an emergency or
walk-in department.
The literature reaffirmed the idea that outpatients
would generate a significant portion of the revenue of
hospitals in the future.
The ten years from 1969 through
1978 showed that outpatient revenue as a percentage of
total gross patient revenue increased by 120%.(8:45)
Cost per outpatient visit is a significant factor
involved in the net revenue generated by the outpatient
services.
According to Berman and Maloney as much as 70%
of the outpatient cost is largely uncontrollable. This
70% is composed of professional staff - 25%, cost of
9
ancillary services - 30%, and drugs and supplies 15%. (3: 99-107)
Revenues they feel are controlled by
price and volume.
Berman and Maloney feel that price is
determined by competition so the only factor left to be
controlled is volume.
For this particular hospital volume
is in the hands of the referring physician. This reinforces the need for providing the physicians with the
quality and types of procedures they require, hence the
need for the questionnaire and the need to monitor the
high percentage admitters necessitates some type of
monitoring system.
According to James Redmond, the cost of personnel is
determined to be the highest factor in outpatient costs
with ancillary services close behind. (9:93-95)
He
suggests the need for a system of evaluation and monitoring to identify cost factors and provide resources where
they produce optimal results.
The questionnaire may help
in determining where the need for resources exists, and
which resources would be most beneficial in encouraging
physicians to admit more of their outpatients.
In order for a community hospital to be economically
strong it must have strong specialty departments.
Specialists, however, exist on referrals from primary
care physicians and one of the goals of outpatient
services is to supply the resources and services necessary to attract and hold these primary care physicians. (2:92)
The monitoring system planned for this facility aims
10
to identify the high percentage admitters of outpatients
and their medical specialties.
Ambrose mentions that
monitoring the age of a medical staff as a whole can be
deceptive. (2:95)
A large shift in the mean age of
physicians in a major department can have a significant
impact if several of these physicians retire at a time
before replacements can be recruited.
Also if the
average age of the primary care physicians cause a
significant reduction in referrals to specialists, the
impact can have damaging results. This indicates the need
to think in terms of medical specialties and the impact
which the pertinent physicians have rather than the
medical staff as a whole. The monitoring system will help
facilitate this.
Much of the literature dealt with methods of
developing questionnaires and rating scales.
When using
a rating scale with numerical values such as the zero-toten scale of this study, it is recommended that the scale
be reversed at the midpoint of the questions.
This would
make the scale zero to ten for half the questions, and
ten to zero for the other half.
This reversal is used to
reduce the likelihood of an individual from choosing the
same value for all questions. (7:237)
This method was not
used because administration felt that if the physicians
took the time to answer and mail back the questionnaire,
they would answer the questions
carefully.
In addition,
the spaces for additional comment were used to verify the
11
ratings.
That is, if a physician consistantly gave very
low ratings for all questions, he would also make a
written statement which supported his displeasure.
A
similar situation occurred for physicians who gave high
ratings for all questions.
An important use of the rating scale is in determining what change, if any, occurred in the scores of
ratings given by respondents between two surveys. (4:79)
A general score or rating for all the respondents can be
added to obtain a grand total.
In the case of this
questionnaire there would be a grand total for each
question because each question deals with a different
department or subject. After an improvement campaign had
been underway for a long enough period of time for it to
have had a reasonable chance to cause a change in
attitude in the physicians, a second survey could be
compared to the first to see what change, if any, had
occurred.
Clover suggests using a weighted average
obtained by multiplying the score by the number of respondents.
Thus, if 50 physicians gave the question on
parking a 10, this would be 500. Add to this the 70 which
is from 30 physicians giving parking a score of 9, and
soon each total is added to the others to get a grand
total for that question.
This grand total is divided by
the number of respondents to get the weighted average.
Clover would then use this weighted average for comparisons to any future survey and suggests using this score
12
to develop standards which can be established by trade
associations. (4:80)
Mel Walton, the associate administrator, has
proposed that after an improvement campaign and the reasonable length of time to allow for an attitude change to
have occurred that each department manager personally
telephone each physician who gave the question pertaining
to that department a low score and ask the physician if
the change meets with his approval and if any other
improvements can be made.
This method only deals with
those physicians who gave low scores and does not take
into account the possibility that the improvement
campaign may have just the opposite affect on some
physicians. The method seems to be preferrable to another
questionnaire because the response rate on a second
questionnaire will be most likely much lower.
Because an individual physician can generate a very
large amount of revenue by the patients he admits, the
response of the individual physician is as important as
the average response of all physicians.
For this reason
many of the summation tests were not applied to the
responses.
Even if a high-percentage admitter should
answer the questionnaire, at the end of the scale which
is opposite to the answers of the majority of physicians,
this is still an important response and must be dealt
with because of the financial importance of that
particular physician.
13
Mailed questionnaires are particularly useful when
the universe is composed of a relatively homogenous group
of persons with similar interests, education, economic
and social backgrounds. (4:79)
A mail survey that is
sanctioned by a professional or other type of association
will usually bring in a high percentage of satisfactorily
completed questionnaires. (4:80)
It has been suggested that the best time to begin
the call-back procedure with reminders or follow-up
letters are 12 to 15 days after the first returns arrive.
The longer the period of time between first mailing and
the reminder, the less effect will the reminder have.
(1:88)
Missing data is handled with less importance in this
survey than others because the individual's response is
as important and in the case of the high-percentage
admitter, more important than the overall score for all
respondents.
The questionnaire seeks to find the
physicians who are dissatisfied with an aspect of outpatient service and then contact the individual to see
what remedies he would expect.
The overall score plays a
secondary role in this questionnaire.
This combined with
the fact that most researchers feel that non-respondents
are random, makes missing data less of a priority. (1:88)
Setting of Study:
The setting was Midway Hospital
Medical Center, a 230-bed acute care facility in Los
Angeles, California.
The facility services the Fairfax
14
and adjacent Beverly Hills areas.
The hospital serves a
large percentage of geriatric patients from the Fairfax
area and is also known by the medical community for its
excellent staff of plastic surgeons.
The hospital has 12
Cardiac Care Units, 12 Intensive Care Units, as well as
22 critical observation beds in addition to its
medical/surgical beds.
The facility does not have
pediatrics, labor and delivery, nor an emergency room.
This generally confines the patient mix to the 12-yearold and up category.
A walk-in, stand-by Emergency Room is in the construction phase, but at present outpatients must be
referred to the hospital by a physician and it is these
physicians that this project is aimed at.
CHAPTER THREE - METHODOLOGY
Statement of Project:
The first portion of this
project involved the development, distribution, and
interpretation of a questionnaire for physicians to use
in evaluating and improving the outpatient service
provided by the study facility.
Major steps included
were:
1.
Developing a questionnaire which met the needs
of the hospital under study.
2.
Submitting the questionnaire to the department
heads for evaluation, additions and revisions.
3.
Having the pathologist prepare a cover letter
to accompany the questionnaire.
4.
Submitting the questionnaire to administration
for revisions, approval and determination of target
population.
5.
Providing the questionnaire and cover letter to
the physicians whose responses were sought.
6.
Sending a follow-up reminder to the physicians.
7.
Coding the responses.
8.
Providing the input data and control data for
the SPSS programmed computer at California State
University, Northridge.
9.
Summarizing the findings and providing
recommendations for department heads and administrators.
15
16
The follow-up and resolution of problems elucidated
by the questionnaire were left in the hands of management
at this point.
Determining the average number of
admissions for physicians involved in the study would
serve as a pretest for future use, however, the
limitation of such a pretest should be investigated.
The second portion of this project was the
establishment of a monitoring system to determine the
range of outpatients sent in by each physician.
A coding
system was used to identify the physicians and facilitate
the use of computers to identify the physicians who admit
the greatest percentage of outpatients and what the
normal range of outpatient admissions per month for each
of these physicians is.
Major steps in Portion II were needed:
1.
To provide a numerical code to identify each
physician on staff.
2.
To instruct the admitting clerks in listing the
code on the outpatient information card (See Exhibit
2.) for each outpatient admitted.
3.
To discuss the project with the Computer
Programmer.
4.
To develop a printout which will be useful to
administration.
5.
See Exhibit 3.
To implement the monitoring system.
Objectives of Questionnaires:
The objective of
preparing and distributing questionnaires to the
17
physicians dealt with the maintenance part of this
project.
In this particular facility a need to improve
outpatient services was established by some department
heads after receiving complaints from physicians.
One would want to make these improvements in areas
where the physicians feel the need for improvement
exists. For example, a department head may feel that a
new machine which sells for $100,000 may be needed to do
complete blood counts (CBCs).
He believes the new
machine will process results much faster and thus make
results available to the physician on the same day in
which he sent in his outpatient.
The physician, however,
can process these CBCs in his own office and sees the
need for the hospital to provide drug level testing which
neither this hospital, nor his office is currently
equipped to perform.
A questionnaire goes right to the
source; i.e., the physician, in determining
what
improvements would be needed for him to admit more
patients or to keep him from sending patients to other
hospitals.
Another benefit may be the "Hawthorne Effect".
That
is, just by showing that the hospital takes an interest
in the physician's attitude toward outpatient service may
result in the physician admitting more outpatients.
Developing the Questionnaire:
Managers of
Departments which were involved with outpatient services
were asked to submit questions which they would like
18
answered by the physicians.
Administration then added
questions of their own and deleted questions which they
did not want included.
A basic scale of from one to ten
was submitted so that percentages could easily be
determined.
An example of the questionnaire first sub-
mitted to administration is provided in Exhibit 1.
Administration deleted the question about the cost
of outpatient services.
This action eliminated
information which could have been important to the
hospital for present and future pricing policies.
Several physicians mentioned the high cost of outpatient
services in the comment portion of the questionnaire.
this points out that cost does have some importance in a
physician's decision of where to send his patient.
When
one considers that a reference laboratory can do a
complete blood count for $4, while a typical hospital
laboratory may charge $20 or more, it becomes obvious
that cost is an important factor in a physician's
decision of where to send his patient for testing.
The questions about availability and need for other
medical departments were also eliminated.
This facility
does not have obstetrics, maternity, or pediatrics
departments.
This fact may play a significant role in
determining where a physician sends his outpatients.
It
may also play an important role in future expansion
programs.
Nonetheless, it was eliminated from the
questionnaire, at the option of the Administrative Staff.
19
The scaling was also changed from a one-to-ten scale
to a zero-to-ten scale.
This made five the middle of the
scale with an equal number of choices above and below
five.
This could prove to be a liability as it would be
easy for a respondent to choose "5" for all questions.
This, however, did not occur in any of the questionnaires
returned.
Descriptive terms like "poor," "fair," and
"excellent'' were added above the scale and the numbers
were grouped with the terms.
See Exhibit 4.
This
grouping caused some minor problems in scoring as
explained later in this report.
Objectives of Monitoring System:
The immediate
objectives of establishing a system to monitor the
outpatients sent to the facility by the high-percentage
admitters are:
1.
to determine which doctors are the admitters of
a large percentage of outpatients;
2.
to determine the monthly range of numbers of
outpatients admitted by each of the high percentage
admitters;
3.
to flag the results when the range falls below
normal;
4.
to determine the medical specialty to which
they belong.
The information generated by this monitoring system
can later be used by administration to:
1.
indicate the medical specialties which generate
20
1.
indicate the medical specialties which generate
the most outpatient revenue and then allocate
personnel equipment and other resources to keep
these specialties in top form;
2.
determine the mean age of the most active
admitters for deciding when recruitment will be
necessary;
3.
determine the medical specialties responsible
for the most outpatients so that recruitment will
bring in physicians who will also admit many
outpatients. For example, if three OB/Gyns admit 50%
of the outpatients and one was about to retire, a
wise administrator would recruit an OB/Gyn as a
replacement, not a cardiologist, a medical specialty
which routinely admits less than 1% of the
outpatients.
The mean age of the physicians in
these specialties can also be determined.
Sources of Data; Questionnaires:
The questionnaires
which were returned by the physicians provided data which
helped in indicating where physicians see the need for
improvement of outpatient services.
The coding process
begins when the questionnaire is returned.
The
physician's signature determines the identification code.
This, as mentioned, is a three-digit number.
This code
occupies the first three columns of the IBM card.
The
next two columns are coded for the "yes" or "no" answer
to the question of if the physician has a lab in his
21
office. A "yes" response is coded 01, a "no" response is
coded 02, and no response is coded 11.
The next two
columns of the punch card are coded for the next question
and so on.
These cards are coded for each questionnaire
returned, and then keypunched.
The computer program
entitled "Statistical Program for the Social Sciences" or
SPSS is available at the University and by following the
format for instructions to the computer provided in the
SPSS manual, the tabulations were accomplished.
An
example of the program format required and the results
are given in Appendices A. and B. Once the results were
coded and run through the computer, the following
information was made available for each of the variables.
Mean
Standard Deviation
Mode
Skewness
Kurtosis
Median
Coefficient of Variation
Variance
Standard Error
Range
Other statistics are available, however, these shall
be more than sufficient for the uses needed by the study
facility.
A histogram was printed as an aid in examining
each variable.
and B.
These are in Appendices A.
(page 62)
(page 82).
Analysis of Questionnaires:
Of the 705 questionnaires
which were mailed out, 111 were returned.
This figure of
111 served as the total response figure used in the
computer tabulations.
Only 18 of these returns were not
22
signed.
From the pilot study which was done earlier, 12
of these physicians who responded could be identified as
high-percentage admitters of outpatients.
A computer tabulation was performed on the 111 total
physicians who responded and another computer tabulation
was performed on the responses of the 12 high-percentage
admitters.
Sampling Size:
A question arises as to what size
sample to use in determining which physicians are the
high-percentage admitters of outpatients.
A formula for
determining sample size is available but it is based on
estimates and desired confidence intervals.
One must
estimate the standard deviation of the population,
estimate the deviation of the sample mean from the
population mean, and use desired confidence intervals.
This is based on the assumption that the population is
normally distributed.
changing, however.
The population in question is
Some physicians are leaving the staff
and others are joining.
The physician who admits many
outpatients this month may not admit many next month.
The sample size obtained in the formula would be based
only on the universe of a few months.
Rather than apply
a random sampling technique and this formula, all
outpatients for the period of time of the study which was
slightly more than three months were used to determine
the high admitters of outpatients.
outpatient files being used.
This amounted to 2000
This, then, becomes the
23
universe for that particular period of time.
One should
realize that over a period of time this list of highpercentage admitters of outpatients would most certainly
change.
The monitoring system mentioned would then be
most useful in helping the administrator identify who the
new top admitters are.
Sources of Data; Monitoring System:
Data was
obtained from the patient files of this facility.
Analysis was aided with the SPSS programmed computer at
California State University, Northridge.
Analysis; Monitoring System:
were given a code.
The physicians' names
The outpatients admitted for a
particular month shall be totaled and assigned under the
name of the physician who admitted them.
This information shall be added, keypunched, and the
totals fed into a computer.
The range, standard,
deviation, and percentage of total admissions will be
determined for each physician.
From this, a warning
system can be established so that when a physician's
admissions fall below 2 standard deviations, the computer
will print an asterisk.
The administrator can then take
the appropriate action.
Currently the computer is being
reprogrammed for critical financial necessities, and only
the coding of physicians has been achieved.
3.
See Exhibit
(page 3).
The assistant administrator has asked the laboratory
manager to establish a manual system for the time being.
24
He does not expect the system to be as detailed as the
one described.
It is hoped that the clerical staff would
be able to keep a total for each physician who admits
outpatients to the hospital.
A pilot study which was
conducted prior to the proposal for this project showed
that there would be about 180 physicians to keep track
of.
Having the clerical staff keep an accounting of the
number of patients admitted by each of these 180
physicians for each month would not be too formidable of
a task to be accomplished manually.
A more detailed
monitoring system can be established when the computer
programmer finishes his more important tasks.
LIMITATIONS
The main limitation in this or any other type of
scale is that human interpretation is required.
Even
though statistically significant information may be
obtained, it is difficult to pin down either the
theoretical or utilitarian meaning of this information. (5:103)
Limiting Factors (Reproducibility}:
The problem of
measuring reproducibility and validity are another
limiting factor of the results obtained from the
questionnaire.
We do not know if the physicians would
answer in a similar fashion if they were questioned
again.
How factors other than those in the questionnaire
affect the response are not investigated.
For example, a
25
physician may have had very bad impressions of the
radiology department and this may be negatively affecting
his answers toward the laboratory, admitting, and the
hospital.
Because there were no questions about
radiology he may be using his negative responses on the
questionnaire to show his displeasure toward the
radiology department.
Because the questionnaires were not used to draw
attitudinal values of all the physicians for all
hospitals, these limiting factors, although important, do
not rule out the usefulness of the responses.
The
responses were instead used to point out the individual
physicians who had specific answers to specific questions
at this point in time.
It was understood that if the
questionnaires were returned at a different point in
time, the circumstances would produce a different set of
responses.
These results produce measurements of the
type known as judgment scales. (1:67)
The non-response rate of questionnaires is also a
serious limiting factor if one is to draw generalities.
Thus, Kerlinger states the use of the interview is
probably superior to the mailed questionnaire. (6:414)
However, because the target population is physicians,
obtaining their cooperation in granting such interviews
is doubtful. Because the results obtained from only a few
of these high-percentage admitters can be significantly
important the low response rate would not play as
26
important a role as when a sample of the entire population is desired. Thus, the questionnaire may prove to
be a very useful tool when dealing with the opinion of
each individual physician.
It is for this reason that
the questionnaires have a place for the physicians' signatures.
Rate of Returns:
Of the 705 physicians on staff,
those who are considered to be significantly active by
adminitration total only 188.
Thus the 111
questionnaires returned amounts to 59% of the entire
staff, and 15.7% of the active staff.
This figure is
much higher than expected and may be attributed to the
fact that a fellow physician, the pathologist who serves
as director of the laboratory signed the cover letter
which accompanied the questionnaire.
See Exhibit 5.
In
addition, an article about the questionnaire appeared in
the Medical Staff Newsletter approxmately a month after
the questionnaires were sent out.
A later article in the
Medical Staff Newsletter urged physicians to return the
questionnaires if they had not already done so.
The
hospital took on the responsibility and cost involved in
addressing and mailing out the questionnaires to the 705
staff physicians.
Perhaps if a stamped, self-addressed
envelopehad been provided, it may have reduced the
additional effort of the physicians' clerical staff and
increased the rate of returns.
Because physicians are so
busy and their time is so valuable, the response rate was
27
much greater than had been anticipated, even though the
stamped, self-addressed envelopes were not provided.
Questionnaire Design:
Another limiting factor was
the design of the questionnaire which was finally chosen.
Many of the physicians would circle an entire group of
numbers which made it necessary to take the average when
possible.
If the doctor circled two numbers in a
grouping such as zero and one, the lowest number was
arbitrarily chosen for coding into the computer.
Exhibit 4.
(page 54).
See
This slanted the results somewhat
toward the negative end of the scale.
Data Interpretation:
The monitoring system also has
limitations which should be kept in mind.
Here too,
interpretation of data plays an important role.
If a
physician's admission rate falls below his normal monthly
range, it may be due to a vacation rather than dissatisfaction with service. The interpretation of the data
and how to deal with it are left in the hands of administration.
Another limiting factor is the lack of pediatrics/obstetrics or emergency departments at this hospital.
These departments contribute very heavily to the number
of outpatient visits at a hospital.
Their lack makes it
difficult to generalize the findings of this facility to
other hospitals which do have these departments.
One
should be able to conclude that a facility which does
have these specialties should receive even more of its
28
patient revenue from outpatient services.
A facility which does not possess a computer can
still implement this program with manual methods.
However, time sharing could possibly provide a better
alternative.
CHAPTER FOUR - RESULTS
The answers to the questionnaires were coded and
tabulated.
One tabulation included all responses and
another tabulation included only the responses of the 12
most active admitters.
These results were then
summarized and submitted to the department heads and
Administration for their inspection.
The findings of the
computer tabulation as well as a pilot project were
submitted.
The pilot project was conducted in January of /
1981 to find what percentage of the medical staff was
active in admitting patients and if one group of
physicians admitted outpatients while another group admitted inpatients.
The pilot project was also used to
determine which medical specialties were active in
admitting inpatients and outpatients and if one specialty
admitted inpatients while another medical specialty
admitted outpatients.
There were 618 physicians on staff
at that time compared to 705 at the time of the mailing
of the questionnaires.
An example of the results
submitted as well as some brief background information
provided to management is given below.
Evaluations:
The computer tabulations generated
various statistics which could provide different types of
information.
When the computer printouts were shown to
the assistant administrator and the laboratory manager,
they felt that the mean although the most familiar
29
30
statistic to most people could prove to be misleading
with this data. A question which had many low and high
responses could have the same mean as a question which
elicited responses in the center of the scale.
The mean
would not point out in such a case that one question
brought about many low responses from physicians.
could be significant information.
This
For this reason the
median was chosen as the statistic to draw conclusions
and comparisons of the two computer tabulations.
The
median is that point on the scale above and below which
are an equal number of values.
An examination of all the
statistics as well as the histograms generated would be
an even better method provided one had the available
time.
These computer tabulations are provided in the
Appendix.
The histogram is particularly useful in this
study because it would pictorially point out if there
were a large number of low responses.
It is these
responses in the 0, 1, 2, and 3 area of the scale which
may force a physician to send his outpatients to another
facility.
By looking at the distribution displayed by
the histogram with emphasis on the low and high end of
the scale, the researcher can see what areas the
physicians are satisfied with and what areas need
improvement.
31
A REPORT PREPARED FOR ADMINISTRATION
BACKGROUND:
Inpatients:
Hospital statistics for year-ending
1978 from the Journal of the American Hospital
Association showed occupancy and length of stay have
decreased by 0.2% for inpatients nationwide.
Outpatients:
The JAHA notes outpatient visits for
the decade have increased by 120% and now contribute 13%
of the average hospital's total patient revenue.
QUESTIONNAIRES RETURNED:
Out of 705 questionnaires mailed, 111 were returned.
With an active staff of 188, this is an excellent 59%
return rate for active staff and about 16% of total
staff.
FINDINGS:
A pilot study conducted in early 1981 showed the
following:
Inpatients:
4.4% or 27 of the 618 physicians on
staff at the time of the study admitted 43.6% of the
inpatients to the hospital.
Specialties:
The major medical specialties
admitting the largest percentage of inpatients were
general surgeons, ophthalmologists, and
cardiologists.
Outpatients:
3.8% or 24 of the 618 physicians
32
1979-80, this would equal $506,000.
Specialties:
The major medical specialties
admitting the largest percentage of outpatients were
internal medicine, and general practice.
Note:
These findings show that there are two
different populations of physicians, i.e., those that
admit the greatest percentage of inpatients and another
group which admits the greatest percentage of outpatients.
See Table 1.
COMPUTER PROGRAM:
Due to the nature of the computer program being
used, variables which can have more than one answer, or
portions of the questionnaire which invite more than one
comment per question by the physicians are handled
separately to obtain greater accuracy, and are in the
separate tables provided.
Computer Tabulations:
Because a small number of
physicians admit such a large percentage of the outpatients, and because the loss of just one of these
important admitters to a competitive outpatient facility
may result in a loss of as much as 7% of the outpatient
revenue, two computer tabulations were processed.
One
was for all questionnaires returned while the other
tabulation was for questionnaires returned by physicians
who admit a high percentage of outpatients.
See
Appendices A. & B.
Separate tabulations were justified when the pilot
33
study showed that the physician admitting the greatest
number of outpatients had 34 admissions in one month
alone, while the average outpatient admissions for active
staff was 2.6 per month and 0.6 per month for the entire
medical staff.
The pilot study was based on figures
obtained from 2000 outpatient records.
.
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35
TABLE 2.
REFERENCE LABS
Number of
MDs Using Lab
Lab Name
Percentage
of Total
21
Path Associates*
23.9
25
Bio Science
28.4
8
Central Diagnostics
9.1
2
Nichols Institute
2.3
2
Cytology Services
2.3
2
ALS
2.3
4
Cog en Clinical Lab
4.5
5
Midway Hospital
5.7
3
Met path
3.4
16
Other
18.1
100.0%
A total of 19 different laboratories were mentioned.
* Sequencing will be explained in the Evaluation and
Recommendation Section.
36
TABLE 3.
IN-HOUSE TESTS DESIRED
Tests Requested
Number of MDs
Requesting Test
SMA
5
Digoxin
3
Cortisol
1
Quinidine
2
TSH
1
Pronestyl
2
Ferritin
1
ANA
3
Folic Acid Bl2
1
Immunoglobulins
1
Endocrine Studies
1
Thyroid Screening Test
1
Liver Function Test
1
HCG Beta Subunit
1
Theophyllin
1
37
TABLE 4.
COMMENTS
Comment
Number of MDs
Making Comment
Mail and chart results faster,
especially sendouts
6
Send out viral studies
1
Parking is a problem
2
Arterial Blood GAS results
are ridiculous
2
Too costly for most patients
1
Excellent lab, satisfied with
lab, etc.
Resent outpatient procedure,
especially registering
Other
10
2
15
38
EVALUATION OF STUDY FACILITY:
Comparisons:
Comparing the computer tabulation for
the high-percentage outpatient admitters and the tabulation for all questionnaires returned showed the
following:
Office:
Do you have a lab in your office?
Total Responses = 111
Yes, have office lab
=
46 = 42.2% (Adjusted
for non-respondents)
No, do not have lab
=
63 = 57.8% (Adjusted
for non-respondents)
=
12
Yes
=
9
=
75%
No
=
3
=
25%
High admitters
Contrary to what might be expected, the physicians
who admitted the most outpatients to the hospital also
had an office lab.
This may be because they are also
doing a larger volume of work and need the assistance of
a hospital outpatient department.
Parking:
On a scale of zero to ten, parking
received the lowest responses, resulting in a median
of 5.3 for all responses and 2.5 for the high
admitters.
While the histogram reflects the median
pictorially, it also shows the distribution of the
responses. This is, as previously mentioned,
particularly important for answers in the low and
high end of the scale.
The question on parking
showed that there were 17 physicians who responded
~
.
39
in the 0-3 area of the scale and 4 out of 12, or
one-third, were high-percentage admitters.
Routine:
The time for routine tests to be
mailed back received a median of 6.8 for all
responses and 7.0 for the high admitters.
The
histogram showed that 16 of the physicians gave this
question a low rating.
However, only 2 out of 12
were high-percentage admitters.
Admit:
Time a patient spends in admitting
received a median of 7.3 for all responses and 8.0
for the high admitters.
The histogram showed that
14 of the physicians gave this question a low
rating.
Here, however, the tabulation for high-
percentage admitters showed that 4 out of 12 gave
this question a low rating.
In determining the
importance of this question compared to the question
on routine testing, the rating given by highpercentage admitters may play an important role.
Stats:
The required time for stat results to
be completed received a median score of 7.8 for all
responses and 6.0 for the high admitters.
This
question had 14 physicians at the low end of the
scale and 3 of these were high-percentage admitters.
Lab Wait:
The time a patient spends in the lab
received a median of 7.7 for all responses and 8.5
for the high admitters.
This question resulted in 6
physicians responding in the lower area with one of
40
these being a high-percentage admitter.
Quality:
The median was 9.1 for all responses
and 9.7 for the high admitters.
It is very
important to emphasize that none of the physicians
responded in the 0, 1, 2, or 3 area of the scale on
this question of quality of test results.
Call Out:
Do you want all results called to
your office?
Total Responses
=
111
Yes
=
53
=
53.5% (Adjusted)
No
=
46
=
46.5% (Adjusted)
70%
High admitters
=
12
Yes
=
7
=
No
=
3
= 30%
RECOMMENDATIONS FOR THE STUDY FACILITY:
The computer tabulations show most physicians prefer
that:
A.
All outpatient results should be called to the
physician's office.
B.
Routine tests should be mailed back more
frequently. Efforts should be made for sendouts to be
charted faster, with special emphasis on SMA panels.
Several physicians wrote comments about the delay in
receiving results.
C.
Admitting procedure should be simplified and
the time required reduced.
This is especially important
41
because the physician who admits ten times the average
number of outpatients has stated on his questionnaire
that he is sending less and less of his patients to this
facility for this reason.
D.
See Exhibit 4.
Parking will be improved as the construction
process reaches completion.
E.
Quality which received the highest responses
should be maintained at all costs.
Note:
Even when physicians gave low evaluations for
most of the categories, these same physicians gave a
very high evaluation for quality of test results.
This implies that quality of test results is one of
the most important reasons of drawing and keeping a
physician admitting patients to this hospital.
F.
Pathology Associates heads the list of
reference labs in Table 2. because it was the first
reference laboratory mentioned when the returned
physician questionnaires were being coded.
In addition,
the pathologists who direct the laboratory for Midway
Hospital Medical Center are also the owners of Pathology
Associates.
The potential for a conflict of interests is
more pronounced by allowing that reference lab to head
the list eventhough it is the second most actively
utilized lab.
The point is to bring the degree of
competition to the attention of the administrative staff
and allow them to make any necessary decisions with
regard to this potential conflict.
42
RECOMMENDATIONS FOR THE MONITORING SYSTEM:
It may be economically feasible to monitor
admissions for those physicians who admit the greatest
percentage of outpatients, as is currently the practice
for inpatients, because:
A.
Future projections show that a large portion of
a hospital's revenue will be derived from outpatients.
B.
A large percentage of the outpatients are
admitted by a very small percentage of the physicians on
staff.
C.
The physicians admitting the majority of
inpatients are not the same physicians admitting the
majority of outpatients.
The purpose of the monitoring system would be to:
1.
Determine which doctors admit the greatest
percentage of outpatients;
2.
Determine the number of outpatients admitted
per month for each physician;
3.
Establish a range of admissions per month for
-high admitters.
4.
Flag results when the range falls below normal,
so corrective action can be taken.
5.
Detect medical specialty and age for high-
percentage admitters which may be useful in recruitment.
6.
To provide figures to aid in determining if
marketing or other corrective action are producing the
increased admissions desired.
43
FOLLOW-UP:
The results of the computer tabulations and the
recommendations which were submitted to the department
managers and Administration brought about various
changes.
Effective January l, 1982, all outpatient
laboratory results will be telephoned to the doctor's
office.
A special form has been designed to aid the
clerks in the doctor's office in taking these phoned
laboratory results.
See Exhibit 6., page 58.
These
forms will be mailed to all physicians, as well as a new
outpatient admission form.
This admission form can be
given to the patient by the physician.
By filling out
this form prior to admission, the admitting department
estimates it can save the patient thirty minutes of
waiting time. This is a three-part admission form.
The
doctor keeps one for his office records, one copy goes to
admitting and the final copy is for the laboratory.
This
multipart form should simplify some of the paperwork
which certain physicians criticized on the questionnaire.
See Exhibit 7., page 59.
The laboratory manager and pathologist have drafted
a letter which will be sent to the active utilizers of
outpatient services.
See Exhibit 8., page 60.
The
letter thanks these physicians for their usage of the
hospital's outpatient services, describes the laboratory's
accredidations, and mentions the new admission/test
request form which the physician will be receiving.
44
Beginning January 1, 1982, the laboratory will be
doing SMA-12 chemistry panels in-house as had been requested by several physicians in the questionnaire. The
feasibility of doing drug testing is also being investigated.
The Public Relations Department is working on a
brochure which describes the high standards and services
which the laboratory provides.
It will indicate the
improvements which are being introduced as a result of
the physicians' responses to the survey.
Included in the
brochure will be an explanation of the steps in the
simplified admission procedure, lab hours, and a map of
the area.
This brochure will be distributed to all
physicians on staff and left in the hospital lobby and
patient waiting areas.
Currently the computer center is investigating the
amount of time required to implement the outpatient
monitoring system presented in this paper and if it can
be installed within a few months' time.
When the results of the questionnaire and the
marketing strategy were shown to the Administrator he
wanted to know if a similar project could be implemented
for radiology.
Radiology had the option of submitting
questions for the original questionnaire and chose not to
do so.
The liklihood of the returns being as high for a
second survey which only included radiology are not too
good.
Thus a method other than mailing is currently
45
being investigated for the questionnaires.
The practical application of the questionnaire and
monitoring system presented in this paper, and the
resulting improvements which have been initiated by the
study facility have made this project an extremely
rewarding experience.
~
.
CHAPTER FIVE - CONCLUSIONS-RECOMMENDATIONS-SUMMARY
Conclusions:
Economics, governmental, third-party
-~
reimbursers, and other factors are dictating outpatient
services as the method of providing an increasing share
of the country's healthcare.
The limitations caused by
the cost and scarcity of personnel and other resources
necessitates that they are used in the most costefficient manner possible.
For a hospital to remain
viable, it must be competitive.
This means providing the
quality and quantity of service which the customer
desires.
Each facility should establish a method of
evaluating the customer's satisfaction and determining
who its largest customers are.
In the outpatient
facility of the hospital under study, the customers were
physicians and methods of evaluating and monitoring
outpatient services and utilization were established to
meet the needs of these physicians.
Recommendations:
A pilot project conducted prior to
this proposal showed that 3.8% or 24 of the 618 physicians on staff provided 42% of the outpatients for this
hospital.
A wise administrator would want to know who
these physicians were and would want to provide them with
the kind of outpatient service which would keep these
physicians referring their patients to this hospital.
Some kind of evaluation system is highly recommended in a
situation where so few physicians generate such a large
46
47
percentage of outpatients.
In this situation a
questionnaire is a good tool because every one returned
is important when it is returned by one of these highpercentage admitters, or by a physician who has the
potential to admit more patients if the service provided
by the hospital are improved to his satisfaction.
When so few doctors control such a large percentage
of the patients, a monitoring system would be a wise
investment.
This system would alert the monitor if one
of these physicians starts admitting less than his normal
rate, at which point the administrator could take
corrective action.
With such a monitoring system the benefits of programs implemented to induce more physicians to admit more
outpatients can be measured.
One physician doing
outpatient surgeries can easily generate $50,000 per year
in outpatient revenue.
It was estimated that 3.8% or
24 of the physicians generate close to $510,000 per year
in outpatient revenue.
Summary:
If the hospital wants to remain
competitive, he must know the source of revenue.
Knowing
if physicians are referring patients or if the patients
are walk-ins, can be important in directing service to
satisfy the appropriate customer.
When the administrator
has the proper information, decisions can be made which
can help avoid financial disturbances.
The questionnaire
and monitoring system proposed can help the administrator
48
obtain the information necessary to make these decisions.
Currently a standby Emergency Room is under construction at this facility.
This should generate more
walk-in patients for both the Emergency Room and the
hospital.
In this type of situation the patient then
becomes the customer and the opinion of the patient
becomes a much more important factor.
Questions about
the time the patient spent before being treated or about
how courteous the staff were can be submitted to the
patient when he leaves the facility.
These questions and
others can be included in the back of an information
booklet which describes the services of the Emergency
Room.
The questions can be turned in at the Emergency
Room or mailed back at a later date. The same computer
program which handled the physicians' questionnaire can
be easily adjusted to handle the patient questionnaire.
However, rather than a one-time study this survey can be
maintained on a continuing basis thereby warning the
Emergency Room Director of when the department's services
start to deteriorate.
Thus, one can see that with a minimum of cost and
effort, a program can easily be established to evaluate,
improve, and maintain quality services of a department,
be it an outpatient department, a laboratory, or an
emergency room.
This translates directly into monetary
savings which will more than offset the time and
49
financial expenditures required to implement this
program.
50
MIDWAY HOSPITAL MEDICAL CENTER
OUTPATIENT SERVICE EVALUATION BY PHYSICIANS
In an effort to provide the type o~ outpatient laboratory service
which best neets the heeds. of physicians and their patients
we ask for your cooperation in evaluating our outpatient service.
PLEASE CIRCLE ONE:
1.
Usage: Can some thing be. done to in.crease the number of
patients you send in as outpatients?
. or
Yes
No
Please use the following ~u~stio~s to help explain your answers.
Feel free to write on the back to provide us with additional
information not covered.
2.
..
Do you have a laq in your office?
Yes
.
or
No
.
On a scale of ~to 10, please evaluate the areas in outpatient
service which need improvement.
·-1 • No improvement.
10 • Needs a great deal ·of improvement.
PLEASE CIRCLE ONE:
3.
Waiting Time (Admit ti!"l:;j) :
spends in admitting.
l
4.
4
5
6
"7
8
9
IO
2
6
7
8
9
10
•'
Stat Time: The amount of time it takes for stat lab results
to be phoned.back to the office •
.1
6.
3
- .-
Waiting Time (Lab): The amount.of time a patient spenus
waiting to have his/her blood drawn.
l
5.
2
The amount of time a patient
2
3
4
5
6
7
B
g
10
Routine Time: The amount of time it takes for routine
lab tests to be mailed back to your office.
1
2
3
4
5
6
7
8
9
10
..
51
Contiu~e.d .
EXI;liBIT l.
. MIDWAY HOSPITAL MEDICAL CENTER
OUTPATIENT SERVICE EVALUATION BY PHYSICIANS
In an effort to provide tqe type of outpatient laboratory service
which best meets the needs. of physicians and their patients
we ask for your cooperation in evaluating our outpatient service.
PLEASE CIRCLE ONE:
1.
•••
Usage: Can something be. done to in.crease the number of
patients you send in as outpatients?
. or
Yes
.
•
)lo
.
Please use the following q~estions to help explain your answers.
Feel free to write 6n the back to provide us with additional
information not covered.
2.
..
Do you hav~ a laq in your office?
or
Yes
.
No
.
On a scale of 1 to 10, please evaluate the areas in outpatient
service which need improvement.
·-1
. .. • No improvement.
.
10 • Needs a great deal 'of improvement •
;
PLEASE CIRCLE ONE:
3~
Waiting Time (Admitting):
spends in admitting.
1
4.
4
5
6
7
8
9
IO
2
3'
4-5
6
4
6
7
8 ... 9
10
8
10
•'
Stat Time: The amount of time it takes for stat lab results
to be phoned. back to the office.
.1'
6.
3
Waiting Time (Lab): The amount.of time a patient spends
waiting to have his/her blood drawn.
1
s.
2
The amount of time a patient
·- --
2
3
5
7
9
Routine Time: The amount of time it takes for routine
lab tests to be mailed back to your office.
1
2
3
4
5
6
7
8
9
10
•
52
EXHI!HT 2.
It\I
0
•
•
J
•
.•
•.-'
J
•
~
3
••
(
w
I
(
c
•~
t
.
•••
~
'
c:r
~
(
.
~
1---1~--~~
"
1----1~--~0
.,,l.
. .'
0
,,r::
~:
~
0
. 0
c.
~ ~)
..: '
... '~. .
• ..
0
~-
t
..
... . .
.. ,
:
'
(:
l·
0
t
,
0
0
'
(
Q
-..
. •
"
r~
~
(_.
~~
~~ (
. . . .r.:r, .-
L
.
L... - :
0r"T'"'.!~ ."-----;;-""'
r;b
. ..
.'
:.~
e
(-
~
1
.
~
~--1-'---~~
~
~
.
~
•
.
i)
••
,_r.
...
••
I
0
f .. ~
•• 0
1- ,
,:;,l
-
·.. !.
tt:~
~-
• c.
0
~
'
'
QJ
c
..•
..•
.•
0
1-1,
QJo
()~
-.
::J•
>'-• •
I
,...i•
\0~
0~
U\;
0
-·
0
. .'
;.
~:! ~
h·.,~
r.·a:
-
.
I
..
..
'
I~
~
~
.
I
i' :
~ '
~
••
•
'•
•
~
>n::
0
t-
~
ro
0
:s
Physicipn's Name
ADAMS, Andrew, MD
:: ADLER, John, MD ·
ANDERSON, Morris MD
: BAKER, James MD
Code
001
Average
Monthly
Specialty __ _R~nge_Qf AdJ!Ii ts
G.P.
Monthly
Mean
Monthly
Percent
of Total
Total
Admits
This _Month_
2 - 10
5
1;0\
5
002 .
OB/Gyn
10
20
10
2.0\
4
003
Optham ·
10 - 30
20
4.0\
12
004
G.P! .. ·
5 - 15
10
2.0\
3
* •
_Below 2SD
*
*
005
006
007
tr.:l
X
t.L1
. 008
til
H
.,
i
H
8
009
w
010
011
012
. 013
014
!
·•
015
016
017
DAVIS, Edward.MD
018
Surg.
0 -
5
3
0.5\
2
U1
w
~
..,
54
···EXHIBIT 4.
MIDWAY HOSPITAL MEDICAL CENTER
LABORATORY DEPARTMENT-EVALUATION OF
. · OUTPATIENT SERVICES
I
·'""'
In an eff'ort to provide the type of outpatient laboratory services vhich be~t
meet your needs and those of your patients, we would appreciate your cooperation in completing this evaluation form.
PLEASE CIRCLE ONE:
1.
(2).
Do you have a lab in yoc:!:''~ffice?
NO
If no~ what o~tside lab are·:Ytm using?... ·
fJt,t;. ~ ~ 1/.4-d'
/tJ;pW#';(.
..
. .:
/3;&~s··ct'~
...
(
.
••• I
~
I.,.
,.. •
Please indicate your overall evaluation of the Laboratory Department in the
following areas by circling the number which best describes its current
performance.
Very Poor
0 - 1
~·
3.
~
2 - 3
Waiting Time (Admitting):
EV
·Gequa0
4 - 5 - 6
The amount of time a patient spends
7 - 8 - 9'
w~iting
to have his/
10,
4 .- 5 - 6
7 - b - 9
-19
R;utine Time: The amount of time'it takes for routine lab tests to be mailed
· back to your office.
~.
6.
10
STAT Time: The amount.of ti>lla it takes for STAT lab results to be phoned
back to your office.~. 0 - 1
s.
Excellent
10
7.·- 8 - 9
0 - 1
4.
•
1
7 - 8 - 9
The amount of time a patie:'t spends in admitting.
·2-3
Waiting Time (Lab):·
her blood drawn.
-~
Would you like
2-3
ill outpatient
4 - s- 6
lab results
- .. ~.1.-
1-8-9.
10
55
'•
EXHIBIT 4. Continued
.. ::
.... ··.····
:c ...
~--.
·....
Please indicate your overall evaluation of the Laboratory Department in the
following areas by circling the number which best describes its current
: perfot'111f.nce.
.Poor
.--
Very Poor
2 - 3
0 - 1
7.
gualit:z::
4 -
~
2 - 3
The
·----s.---6
ref~rred
5,
out which you think
G
availabil~ty
NO
·
.·
outpati~nts.
7 - 8 ..... 9
Your identify will be useful in tabulating results.
remain anonymous, do not sign.
, fJtYIJ!tV.h
~ :p,
~
7-.8-9
~~~-/Jsn,~
7
.
of parking for
.4-5-6
0 - 1
,I
-·
lJ!C. .1'-~~
~~ ';!~)
Parking:
10
7 - 8 - 9
6
In-house test selection: Ar·e there lab tests
should be performed in-house?
Specify vhich teo<(s)'
9.
s-
Excellent
Good
The quality of test results.
0 - 1
8.
Adequate
~ ~ /1
10
Boweve_r, if you wish to
Clc(f!; rio k
-~~~~
~~~~~rr
~-~~-
~~~
...
~·-
---2:-,. ..
··-
56
'•-
EXHIBIT 5 .
..
~
·:
..
~
ri\fu.t" ldiDWA!t HOSPITAl MEDICAl C~~JTEA
~
5925 San Vicente Boulevard, Los Angeles, Califorf'l;a 90019 • (2131 938-3161
. August 12, 1981
Dear Doctor:
..
Xn an effort to expand and improve our outpatient
laboratory services and mo~e closely identify the
needs of our physicians and your patients, we are
requesting your assistanee in helping us assess
our current level of service and how it might be
improved.
Enclosed is a questionnaire that is being sent to
you and all physicians on staff at Midway Hospital
Medical Center. The questionnaire should be returned
as soon as possibfe.
A self-addressed envelope has been provided for your
convenience. Your cooperation in ~hi~ important
matter is appreciated.
Very truly yours,
P. Kenneth Carter, M.D.
Director, Pathology and
Clinical Laboratory
PKC/pl
Enclosure
.;_
9!!!.!!!!!.
Glucose:
Faotlq
Mur P.P.
........
,.
(70-110 .,,,
UIIC
'""'
(41-Ul 11<1\l
(111-179 ..,,,,
,...... uo ..,,
TIIC
(lJO·JSO aca\)
\ lattantl•
Sodh•
Potassiu.
Chloride
COz (Total)
(20-55\)
(US-141 lll!q/L)
Total Protolo
(6.0-7. 7 Coo\)
(l.S-5.5 IO!q/L)
Albwlln
(1.4-4.6 C.\)
(91-101 oEq/L)
(H-14 IO!q/L}
Allloo Cap
(S-15 IO!q/L)
Jllf
Craatlnlne
(9-19 ••'l
(<.!. 5 .,,,
Ca1cluo
(I. 6·10. 6 aa\}
(l.0-4.0 .,,,
Phosphorus
· (1.5-1.9 aEq/L)
Maaneslua
SCOT
(1·16 1U/L)
SCPT
(l-Jl JU/L)
(56-194 IU/L)
LDII
CPl
-"
CPl heant,...a
Allta .. anl Phosphatase
__u
UFERENCE LAI
Prostatic .Achl Pbos.
(75-200 II<J\)
-Ia
Th•ne•utlc Ran1•
.loolnophyllloo/
Tbeophylllno
(10-20 IC&/01)
t•j
(0.5-l.O na/al)
Dlaolln
Centulcln
:><
......
(4.0-U.o oca/•1)
'"'~
Proneoty1/
Procalnuld•
H
(4.0-1.0 •c&/•1)
NAPA
Qulnl41no
t;1
(l.0-1.0 aca/a1)
H
(l.0-5.0 acafa1)
1-]
(0-202 IU/L)
__u
PATIEIIT !WI!:
(79·251 IU/L)
l(l(JI •
0.26-0.57 IU/L)
Aay1aso
SPEC IMEN DAAWII:
(60-160 u\)
Cho1utoro1
N4
PM
(DATE)
(150-lll •a'l
RESULTS PitcHED:
(M: 1.6-7.4 .,,,
Uric Acid
(F: l.0-5.1 •a\)
Total llllrubln
(O-J.o •a'l
(0-0.5 .,,,
Dl roct 1111 Nbla
.,
-1~if~
~
---
''0"'
(TIME)
N4
(47-ISS oa\)
Trl&lycerldoo
't/"• ...
~·
I
IY:
SICHAnJR£:
_ _ _ _ _ _ _ (DATE)
·-
(LAI) TO:...R!:_
....
(TIME)
""
(TIME)
AM
PM
MIDWAY HOSPITAL MEDICAL CENTER INC.
U1
-...)
I '·
I
--
:j
~
=
~
WIC
!.!.=.LI:rn~!'j:ll_ !,!\!~ g_~!)-~T~
M
(All rttr;ul tu refer to l.olooo lt:vt=lG unletts otheruisc inuicate«.J)
F
~
COAGULATION
1000/• 3 4.1-10.1 4.1-10.1
I
RIC/hpf_ _ _ _ _ _ _ __
m
Flbrlnoren, Quant. _ _ _
Polys
(45-70\)
Throabln Tioe
Stabs
(0-5\)
WSC/hpf_ _- - : - - - - Epl th/lpf_ _ _'_ _ _ _ __
lacterta._ _ _ _ _ _ _ __
(0\)
Cry!tai•----------
Loa-White
Mucous threads _ _ _ _ _ __
P.S.P. (F.D.P.)
Cuu, hyallne/lpf_ _ _ _ __
Fibrin
Cuts, Fino Jrtn/lpf_ _ _ __
tu1lobulln Lyolo
Ly.phocytos
'
(20-45\)
Atypical Ly.ph•
j
"
i
I
(0-2\)
Monocyte•
(0-8\)
Eulnophlh
(0-3\)
luophlh
(0-2\)
Myelocytes
(0\)
Proeyelocytes_ _ _
_(0\)
lh•u
Platolot ht.
(0\)
__}dq. _Inc. _Dec.
Platoht Count_ _(ISD-450 thous/•3)
lotlc. Count
(0-2\)
1•4 lato _ _ _ _ _ _ _ N: 0-1 -.'hr)
P: 0-20-.'hr)
Microscoplc:
Cuu. Coant/lpf,
Specific Grovlty
1.0
Protein (Se•l ~ont) NEG POS
btonu
NEG POS
Glucose Oxidase
NEG POS
--
leduc!na Sublt.
lila (Multlsth)
Uroblllnoaen
•
•
•
_, -.
POS
NEG
.....
r
NEG
1'05
+
....l'j.....
Ivy lloodln& TIM (Te"!'hte) _·(<.1 •In)
::r~
H
(5-IS •In)
(<10 IICJ/•1)
tt1
(N•I)
MonOMrl
H
•·3
(>2 houn)
0'1
Appearance:
Color:
char bur
colorlen
I or lou !U POS _ •
NEG
POll
+
llh (lttotut)
NEG POS
+
SU~
(271-305)
OSI«lLALm, URINE
(50-1200)
bloody
n
unthocl\rotttc
IIC
1•3
\ cnnoud
WIC
/•3
\. 10pented
0
::l
r.
:-J.
- - - ' lywpho
(15-40 •1\)
Protein
•l'
Glucooe _ _
ARTERIAL 11.000
OCCUI.T 11.000, F!C£5:
•J\)
f<60 sec)
+
Occult lloo4
OSI«lLALITT,
iti~
(11-32 ... ,
(~00-400
SPINAL FWID
Morpho I oar:
. I
_ _sec - - '
_ _He
37-47
42-52
Juven1l11
t
Tl ..
--- '
Differential:
i
Patient
Co"tral
4.2-5.4
12-16
"-.tocrlt
l
Prothr~bln
Color: strew yellow .-ber
pH __ c hor huy
cloudy
•111/•l 4.7-6.1
lfuo&lob1n_ _ Goo\ 14-11
IIC
::l
c.
(N: 60\ of bloo4 level)
CA.~ES
pH
Y
A
7.32-7.42
7.35-7.45
{i)
0.
pCO:~___• "•
42-55
34-45
pOz__•H&
40
10- I OOo<SOyr
10-10 .>SOyr
la1e been_ __
TCO.__ _ _ __
U4-,. 'Mq/L)
(-2 to +2)
.~
;
I
MIDWAY HOSPITAL MEDICAL CENTER INC.
~. ":iot"
:.r.. •w~ d ...... ~ooi'J I·;, ............... ,
C~ 90019 r2!Jr CJll! 1161
i
U1
().."\
59
FIRST,.
,. CASE NO.
INITIAL
RH.RATE
RH.HO
1
ADDRESS
PHONE
PREV. AOH.
SSA
RELATIONSHIP .
OCCUPATION
PAT1Wt''s ERI'LDYER
ADDRESS
· PHONE
I
SPOUSE'S EMPLOYER
PHONE
~,,
DEPOSIT ASKED
DIAGNOSIS.
DOCTOR'S NAME
Hidny Hospital
PRE-ADMIT FORM
P Acid Phos
Alk Phos
Amylase
Bun
T. Bilirubin
Calcium
C1
0
,:1.
0
D
,.::~·Creatinine
a
Cholesterol
t=l
CPK
PHBD
.t:liRON
tltJIBC
COAGULATION
BLOOD GASES
OIDIISTRY
0
May 1970.
c
pH
Q PCOz
a POz
l!Xt:TERIOLOGY /Culture
&I LDH
J:l Magnesium
J:lSCOT·
.(] PTI
.Q Ivy Bleeding Time
.d Lee-White Coag. Time
c·.,l'r .. ~HUID - . - - - ~uoncuLII.I••
u Fibrinogen
~THttl
Q;~:·: ~1.-::...~·nv~': b Fibrin Spli~ Products
=U"""'
__.._._~·_•---H~'~..~~,_·;;~~=~·:~: :;~·~·::: Protamine Sulfate
!=-:::."':::."""=""=""":;;;":.'--l!~":..:":.:.:'~:..:.···.:..r:-:::.·•::.;':;;",;,··;::-::..;.."".0 Factors .V VII VIII IX I XIII
D SGPT
l
D Sodium
J:J PotassiUIIl
0 Chloride
0 COz
.
8
Ol .. llil
p
\•?"ICIIO~~
~o:::..-.-.-~::-=-:-..::-,..-. . -.. .-•• -_-11!1"'8"":;;;._,~~
0 SMA. 12
a
C1 Prothrombin
Glucose Tol_ _hrs
t:~atucose
TRANPUSION SERVICE: Tranfusion Date:
HEMATOL(X;Y
0 CBC
11 Hgb/Hct
a Platelet Count
P. SedRate (ESR)
0 Reticulocyte Count·
.ll
Type&Cross; Match._ _ _ _Units
JJ Group/Rh
0 Direct Coombs
o Indirect Coombs
ll Antibody I.D •
Rho GAM
£J Micro GAM
RBCs
Whole Blood
Sal Washed RBCs
.a
OTHER:(please,indicate)
PHYSICIAN:. _ _ _ _ _ _ _ __
''' reverse aide for additional information
60
MIDWAY HOSPITAL MEDICAL CENTER INC.
5g..'~
!>.In Vrcenle Bou.,vdrd. Los Angett.s. Cahlurnra 90019. (213)938·3161
Dear Dr.
Our clinical laboratory records indicate that you have been an active utilizer of
the outpatient services provided·by Midway llospital Medical Center.
We are very
pleased that you have chosen to use our laboratory for outpatient testing.
Midway Hospital Medical Center laboratory is accredited by the Commission on
Inspection
and Accreditation of Laboratories of the College of American Pathologists.
is directed by a board-certified pathologist and has an outstanding m~dical
tec~ologist and clerical staff. Our laboratory service system is designed to make
your dealings with
•
~s
simple and efficient.
We will soon be supplying you with test request forms which we feel will si=plift
ordering and will decrease the amount of time it will take for your patient to be
serviced.
If there are other conveniences that are important to you which we are presentlY
not providinll, please do not hesitate to call the clinical laboratory and speak
to Hr. Herman Beard, Laboratory Manager or P.K. Carter, M.D., Laboratory Dlrectar.
We will be pleased to coordinate arrangements for a laboratory service pr01traa to
meet ycur specific needs.
Very truly yours,
P. Kenneth Carter, M.D.
Director of Clinical Laboratory
61
1.
Duane
~.
2.
~lwin,
Survey DesiGn and Analvsis (Bever:?
Sage Publications, :978), P?· 67-
CR~~fornia,
Hills,
88.
Dona2.d "'•.
Ail~!::irose,
"Pr :!.:nary Care Group ?.r act ice:
a Co:r~1~J~ni t:_t :ros::i tal," IIos~1i ta:. a.n.cl IT~::n:. th
Se:vices Administration 0iinter, l9GO), p. ~2-95.
:r:1?act
0:1
3.
H. r:alor..ey, "~Jhere Does t
~eal Fiscal Conttol of the Outpatient Depa:tnent
Lie?," Hosnitals, 5! (Kay 16, 1977}, pp. 99-107.
4.
Vernon Clover and Howard
:::Zichard :2>er;:1an and.
~:m::as
Bals~e~,
ho
-'~
Busines8 Resea:ch
r:ethodr.; (Colc:mbus, Ohio, Grid, :;:nc., 1974), :s':?· 79-[10.
5.
Handbool~ in He search anc Eva::. uo. t ion
Diego, California, I:aits Publishers, 1980), p.
S tep!1e;1 I sa.c.c,
(Sar.
l03.
6.
?red N. Ker:inger, Foc:ndations of Behavioral ~esearch
(rew York, Holt, ~inehart & Winston, 1973), p. ~l~.
7.
Gary
~'i.
nara.nelJ_,
~:icz:Jin9: A Sourcebook for Beha\riorc-,:1
~llinois, ~ldine Publishing Co.,
Scientists (Chicago,
l97t.1), p.
3.
237.
"Ou~patier.t
Ser~1ices
creased Revenue,
•± 6.
9.
are l\1ajor Contribu'.:ors '.::.o InHospitals, 53 o·~ay 1, 1979), p. 45-
Red nona, "i\p:ply Effective Ji' i sea~ Technique::>
to !@prove Ambulatory Care," Hospit~~s, 50 (~ov. 16,
J ar-:;es I-1.
l976), pp.
iO.
II
~\nne
Cc.re:
A8Der..
T-{.
93-95.
Sor;.1ers a.na. Her1~lan ~1.
S~7 S'c2i:'l
So;:1er-s,
I-Iea]~th
aD.d I{eaJ.-th
in Persyective (Gerr.~ant0\,'!1, :l.ary:.:.nd.,
Cor~)., l977), p. 62.
Po:!_ic~les
62
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r:.::>
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c::-:
a-
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co
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7.
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ct:l*
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......
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~:J<V)
**
**
**
*it
•....
4
..
11'
*
* '****'*'**
COriPU'i:'T::R rOmiliT USED
Of-7700 CM
MAXT~U~
FIELD LENGTH
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Filf ~HIE
N OF CASES
INPUT MEOIU"~
INPUT FORMAT
ACCORDING TO Y(l!JR INPUT FOPMA.T, VARIABLES ARE TO 13E READ AS FOLLOWS
· VARtARLE
10
OFFICE
RE~ER
.OMIT
LABWHT
STATS
ROUTJNf
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OUA.L ITY
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OTHER
FORMAT
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F 2.
F 2.
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0
0
0
0
0
0
0
0
0
0
0
0
2. 0
REC8R~
1
1
1
1
COLUMNS
14-
6-
8-
l
10-
1
1
1
1
14161820-
1
1
26-
1
1
12-
2224-
3
5
7
9
11
13
1'5
17
19
21
23
25
27
13 WILL BE READ.
INPUT FOR~AT PROVIDES FOP 13 VARIABLES.
FOR 1 RECORDS <*CARDS*) PER CASE.
XIMUM OF
27 *COLUMNS* ARE USED ON A RECORD.
VALUE LARELS
OFFICE(OllYES(02)N0(ll)N0 ANSWER
IREFERtOl)PATH A5SOC{02)810SCIENCEl03JC
DTAGNnSTICS(4)NICHOLS INSTITUTEt5lCYTOLOGY SERVICES(&)A L
AN LA8(8lMIOWAY OUTPATIENT LARt9llABORATORY PQOCEDURES(lO)I
CALLOUT(llYES(()NQ(ll)NO 4NSWER/AVA!(l)YES(2)~0(lll~O ANSWI
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PRONESTYLC7)FERRITIN(B)A N A(9)f0LIC ACID B 12(10lOTHERfOTt
AIL·CHART FASTER(2lSENO OUT VIRALS(3)PARKING A PROBLEK(4)U~
~ R G PESULTS(5}T08 COSTLY(6)EXCELLENT LAB(7)BAD OUTPT PRO(
(l0lnTHER
MI S S I N G V H II F. S 0 I= F I C E ( l l ) I Q E F E R ( 11 ) I A D"'~ I T ( 11 ) I l Ail WAI T (ll ) I S T.A TS ( 11 ) IR 0 UTH
,.. ..... _.. ,_ .......
--------·
-----
~ROVIOES
----------~-
0'\
w
IDElJ'J'IF'ICI\'i.'ION
-lW PUYSICJ:AP CODE
CATfGnrn LARS::L
COOt
A~SOLUTf
F9F.O
RELATIVE
FREO
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( PC T)
F RE 0
( PC T)
CUf1
FREQ
(PCT)
117.
1
8. 3
6.3
8.3
185.
1
8.3
8.3
16.7
194,
1
8.3
8.3
25.0
2~4.
1
8.3
8.3
33.3
273.
1
• 8. 3
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41.7
31 5.
1
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8.3
50.0
317.
1
8. 3 .
8.3
58.3
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8.3
8.3
66.7
497,
l
8.~
8.3
75.0
571,
1
8.3
8.3
83.3
613.
1
8.3
8.3
91.7
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1
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8.3
-----100.0
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75.0
7 5. c
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q
3
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- - -
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1.25C
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1.327
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• 96 3
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2.000
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1.167
.205
1.000
15.000
1.537
0
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81109/24.
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(CREATION DATE ,.
81/09/24.)
(HIGH PERCENTAGE OUTPT ADKITTERS)
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.
l
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0
3
2 5. 0
33.3
33.3
2•
1
8.3
11.1
44.4
8•
1
8.3
11. 1
55.6
q.
2
16,7
2 2. 2
77.8
10.
2
16.7
2 2. 2
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11.
3
25.0
MISSING
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12
100.0
10 o. 0
•
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~-----·
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"tf.
....
81/09/Zit.
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Al TUCH!1W
(CQEATION fHTF •
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87.444
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1.555
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4.664
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1. 74 9
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10
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21.750
10.000
48.000
8. 918
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~
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THE AMOUNT OF TlMB A
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8l/09/21t.
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(HIGH PERCENTAGE OUTPT ADHITTERS)
LhR\.iAIT
C~T':GCIPY
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1
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12.5
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12.696
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(CREATION DATE •
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RELATIVE
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1
8.3
11. 1
11.1
2.
1
8.3
11. 1
22.2
3.
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6.3
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3 3. 3
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1
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11.1
44.4
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1
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55.6
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10.
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3 3. 3
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-- -· ----·TOTAL
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66.7
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14.611
10.000
53.000
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