Report

on existing situation
in anticipation of the new way of working at the
Polyclinic Cardiology

Process analysis v3.1

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Table of Contents
Chapter 1 Introduction .................................................................................................................................................................... 3
Scope ........................................................................................................................................................................................................ 3
Reading guide ....................................................................................................................................................................................... 3
Chapter 2 Process analysis Polyclinic Cardiology. .............................................................................................................. 4
2.1. Patient Referral ........................................................................................................................................................................... 4
2.1.1. Description of the process .................................................................................................................................................. 4
2.1.2. Description of activities ....................................................................................................................................................... 5
2.1.3. Bottlenecks ................................................................................................................................................................................ 6
2.2. Planning an appointment ........................................................................................................................................................ 7
2.2.1 Description of the process .............................................................................................................................................. 7
2.2.2 Description of activities ................................................................................................................................................... 8
2.2.3. Bottlenecks ................................................................................................................................................................................ 9
2.3. Prepare consultation ............................................................................................................................................................. 12
2.3.1. Description of the process .......................................................................................................................................... 12
2.3.2. Description of activities ............................................................................................................................................... 12
2.3.4. Bottlenecks ............................................................................................................................................................................. 13
2.4. Report for consultation ......................................................................................................................................................... 15
2.4.1 Description of the process ................................................................................................................................................ 15
2.4.2 Description of process activities .................................................................................................................................... 15
2.4.3 Bottlenecks ......................................................................................................................................................................... 16
2.5. Wait ............................................................................................................................................................................................... 17
2.5.1 Description of the process ........................................................................................................................................... 17
2.5.2 Description of activities ................................................................................................................................................ 17
2.5.3 Bottlenecks ......................................................................................................................................................................... 17
2.6. Examine / treat / talk ............................................................................................................................................................ 18
2.6.1 Description of the process ........................................................................................................................................... 18
2.6.2 Description of activities ................................................................................................................................................ 18
2.6.3 Bottlenecks ......................................................................................................................................................................... 19
2.7. Conclude consultation ........................................................................................................................................................... 21
2.7.1 Description of the process ........................................................................................................................................... 21
2.7.2 Description of activities ................................................................................................................................................ 21
2.7.3 Bottlenecks ......................................................................................................................................................................... 21

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Chapter 1 Introduction

Digitization leads to new ways of working, also within the Cardiology Polyclinic. The staff of the polyclinic
cardiology recently was confronted with the implementation of the Electronic Health Record (EHR), the
digital archive and the digital dossier management. In fact, these implementations seem to have
considerable impact on the activities of the staff of the Cardiology Polyclinic.

The Cardiology Polyclinic has an "Appointment and Consultation"-department. In this department, with
the implementation of the EHR, also new IT applications may be taken into consideration, with the goal in
mind to eventually fully convert to a new way of working. This will certainly affect the patient logistics,
the care(-treatment) and the process surrounding the administration / registration process. This
document will provide a description of these processes, "AS-IS".

The underlying questions to be answered in this document are:
• AS-IS: Who does what and when in the polyclinical process - provided the implemented EHR,
digital archive, digital dossier management and existing legacy?
• TO-BE: Where can possible optimization be found -provided the implemented EHR, digital
archive, digital dossier management and existing legacy- dealing with current bottlenecks and
leveraging possible new IT?

Scope

In this document, further use will be made of the following polyclinical process activities.

Patient Planning an Prepare Report for Examine/ Conclude

Referral appointment consultation consultation Wait treat/talk consultation

Process phases within the Cardiology Polyclinic.

Reading guide

As seen in the figure above, the polyclinical process consists of 7 phases. All phases will be explained in
chapter 2. For each phase a description is made on what the goal is, which actors are involved and what
activities are taking place. Also, bottlenecks will be indicated for each process activity. Bottlenecks are
potential obstacles which can have a negative effect on the throughput of the process and/or the quality of
the delivered quality of care.

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Chapter 2 Process analysis Polyclinic Cardiology.

2.1. Patient Referral

Patient Planning an Prepare Report for Examine/ Conclude

Referral appointment consultation consultation Wait treat/talk consultation

Process goal:
Referring a patient to a cardiologist, with the goal of starting or continuing the care treatment.

2.1.1. Description of the process

Ways of referral:

The cardiac patient can be referred to the polyclinic cardiology in the following ways, whereby the
referrer indicates the reason for referral:

− Through an external referrer; this could be a doctor or a medical specialist outside the hospital.

The general practitioner (GP) refers the patient for examination and/or treatment to the cardiologist. This
referral will be received by an employee of the polyclinic in the following ways:

• By phone
• In writing via a letter of referral
• Digitally via CareDomain (CD), an existing computer application

− Through an internal referrer.

• Peer consultation letter (written or digital)
• Telephone (emergency in particular)
• Fax

− Via the emergency room: In addition to the above methods, it is possible that a patient is involved in a
follow-up process at the cardiology polyclinic after treatment in the emergency room. The responsible
physician in the emergency room writes a letter in which the reason of referral is stated; the patient, if
possible, takes initiative to initiate an appointment. In case of a greater urgency, the appointment will
be made by a member of the emergency room.

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2.1.2. Description of activities
Description of action Procedure Operators Recourses
Reception of referral Opening mail. No specific designated employee Polyclinic employee Mailbox
CareDomain (CD) for opening mail. Is performed if time is / doctor’s assistant / polyclinic
available. call center cardiology
employee
Print out CD referral After receiving the referral through mail, the CD Polyclinic employee Blotting-book
referral will be printed and put into the blotting- / doctor’s assistant / CD referrals
book in alphabetical order. The blotting-book Call center
will then be placed in the inbox of cardiologist employee
Dr. Pacer.
Assessment of the CD Based on the referral data, cardiologist Pacer Dr. Pacer Blotting-book
referral (triage) determines the reason of referral, the urgency, to with CD
which cardiologist the patient should be referrals.
appointed, and, if necessary, what kind of Printed CD
diagnostic examination has to take place (ECG, form.
lab, Holter, TTE, etc.). Application
forms diagnostic
Dr. Pacer writes the assessment on the printed examination.
CD form. When the assessment is completed,
Pacer will give the blotting-book to a clinic
employee.
Conclude the referral after A polyclinic visit will be planned based on the Executed by SAP
triage outcome of the triage. polyclinic employee
/ doctor’s assistant
or call center
employee
Informing the patient of the The patient is called to inform when he/she is Executed by SAP
booked consultation expected at the polyclinic. polyclinic employee
/ doctor’s assistant
or call center
employee
Receiving the referral letter The patient visits the counter of the polyclinic Executed by
with the request to make an appointment. The doctor’s assistant
patient presents the letter of referral (in which
the reason of referral is stated) to the doctor’s
assistant.
Processing the referral letter The doctor’s assistant checks in SAP whether Executed by SAP
the patient is known at the cardiology polyclinic. doctor’s assistant

If yes: Make reservation for ‘checkup’

appointment.

If no: ‘Create’ new patient. A comment will be

added into SAP, stating that the referral of the
GP will be handed over by the patient during the
visit.
Note: A patient that is referred this way does not
undergo triage.

Receiving emergency GP calls the polyclinic; employee takes the Executed by call Fax
referral from general urgent request by phone. Emergency request center employee Tray containing
practitioner by telephone must be faxed by the GP. The employee places emergency
the fax into the ‘emergency poly’ tray at the call referrals
center.
Processing the telephonic After receiving the fax, one checks whether Executed by call Fax
emergency referral of the there is an EHR. If not, request/lookup the paper center employee Tray containing
GP medical record, clean up the record and scan it. emergency
referrals
Emergency request/ referral Questions via telephone inquiry of EHR by the Executed by SAP/EHR
cardiologist hospital respective cardiologist. cardiologist
Processing emergency Printing the phone-request of the particular Executed by call SAP/EHR
request cardiologist cardiologist. The print is then put into the center employee Tray containing
‘emergency poly’ tray at the call center. emergency

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 referrals
Emergency request of other Medical specialist fills in the InterCollegual Medical specialist ICC form
specialism within the Contact (ICC-) request form and sends it to the outside the
hospital polyclinic. cardiology
polyclinic.
Processing emergency The polyclinic employee receives the ICC form. Call center or ICC form
request of other specialism After receiving the form, there will be checked polyclinic employee SAP/EHR
within the hospital whether there is a paper medical record. If yes, Paper medical
request/lookup the paper medical record, clean record
up the record and scan it.

Assessment of all Based on the data of the patient and/or the Head of polyclinic ICC form
emergency poly requests emergency poly request for appointment, the (dr. Johnson) Fax
cardiologist Dr. Johnson determines the urgency SAP/EHR
and the time period in which the appointment
will be planned.
The assessment takes place regularly, but not on
a particular time.
Processing the emergency Based on the outcome of the evaluation of the Polyclinic ICC form
poly requests from emergency requests, a polyclinic visit will be employee; restricted Fax
scheduled for the emergency poly. The patient is to certain polyclinic SAP/EHR
informed by telephone about the date and time employees
of the appointment.

2.1.3. Bottlenecks

The table below shows the bottlenecks of the process activity ‘Referral of the patient’. These bottlenecks
are mainly indicated by the employees themselves, but they could also have been observed during the
analysis. For each ‘bottleneck’ a brief advice has been given.

Bottlenecks
What Advice
Receiving and processing of CD request made by the Make this activity a regular part of a sub-activity.
polyclinic employee is not defined by whom, when Assign this business segment to a permanent role.
and in what frequency. Is performed only when time is Connect an indicator: speed in which the CD request
available. has been received, processed, has been evaluated and
resulted in a First Polyclinic Visit (FPV).

The duration of receiving, processing an evaluation of Carry out triage by Nurse Practitioner (NP) or doctor’s
the CD request is long. The output of the triage is assistant according to a decision tree or a strict
dependent on 1 cardiologist. If this cardiologist does protocol. Have triage moments scheduled several
not have the opportunity or is absent, then the CD times a day so that no delays can occur. If possible:
requests will keep floating around. As such, the final make the triage form part of the EHR and build-in a
settlement of a CD request can take weeks. Due to the separate functionality. Connect indicators to the triage
slow handling, a shortcut is eagerly used by the GPs: and regularly measure whether they are achieved.
one does not refer via the CD, but manually write a
letter of referral after which the patient checks-in
himself at the reception desk, the appointment is
scheduled and no triage occurs.

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2.2. Planning an appointment

Patient Planning an Prepare Report for Examine/ Conclude

Referral appointment consultation consultation Wait treat/talk consultation

Process goal:
Scheduling a (follow-up) appointment between patient and cardiologist with the aim to launch or
continue the care(-treatment) process.

2.2.1 Description of the process

There are several methods or channels to be distinguished in which the scheduling of events is executed.
This involves the following:

By telephone

• After completing a triage.
• Request for a regular follow-up appointment and/or continuation of an appointment made by
the patient.
• After hospitalization.
• In case of an emergency


Via the front desk

Patient reports at the front desk with a request for an appointment. This may include the following type of
appointment:

• Follow-up appointment
• First polyclinic appointment
• ECG serving TIA screening, day care, after cardioversion, diagnostic center (GP), or other
medical specialists in the Hospital
• Echo (Ultrasound scan)
• Holter
• Emergency Appointment
• Cardiac Rehabilitation


Consultation Pattern

The following types of polyclinic visits can be distinguished:
• NP = new patient (15 min). Via GP, hospitalization, via the emergency room, or > 2 years since
last polyclinic consultation
• CP = checkup visit > 2, 12 months (10 min)
• CP k = checkup visit, 2 months (10 min)
• CP u = patient comes in for results (5 min)
• CP OK = checkup visit after Operation Room (OK) (10 min)
• CP PTCA = checkup visit after Percutaneous Transluminal Coronary Angioplasty (PTCA) (10
min)
• HR = cardiac rehabilitation
• Echo 1, 2, 3 = concerns NP; gets an ultrasound scan first and then an appointment with the
cardiologist. Analysis period between ultrasound scan and consultation at the clinic takes at least
2 weeks
• Appointments for Holter study: at least 2 weeks of analysis time and up to four patients per day

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2.2.2 Description of activities

Description of action Procedure Operators Recourses
Scheduling an appointment Based on the results of the triage, the polyclinic Doctor’s assistant Handwritten
after completing triage employee adds an appointment in SAP using the triage result on
following codes: Call center CD reference
− NP15 = new patient or patient > 2 years employee SAP
since last polyclinic consult
− CP = patient checkup with a consultation
length of 10 minutes
− HR = consultation on poly cardiac
rehabilitation; consultation length of 15
minutes
− Echo 1, 2 or 3: combi appointment with
echo chamber

Scheduling an appointment After the clinical hospitalization has been Front desk SAP/EHR
after clinical hospitalization finished. The front desk employee of the clinic employee Appointment
makes a request to the call center employee to polyclinic card
book an appointment. The call center employee cardiology
will then schedule the appointment according to
the established appointment types. The front Call center
desk employee and/or the nurse from the employee
polyclinic takes care of informing the patient
about the date and time of the appointment. Nurse polyclinic

Scheduling regular follow- The telephone request comes in at the call center Call center SAP
up appointment and/or of the polyclinic. Call center employee requests employee
rescheduling appointment data (name, date of birth) and plans the visit
by telephonic request from according to the established appointment types.
patient The patient is then informed by phone about the
date and time of an appointment.

Informing the patient after By phone: after completing triage and/or after Doctor’s assistant SAP
completing the triage making a ‘checkup’-appointment about the date Appointment
and time. Call center card
employee
Scheduling an appointment The polyclinic employee requests the name and Doctor’s assistant SAP
at the counter date of birth of the patient. Then opens his/her Appointment
SAP/EHR and opens the card for the front desk card
that is filled in by the cardiologist. Based on the
data of the card, the polyclinic employee
schedules the appointment according to the
established appointment types. Patient will be
informed verbally; appointments will be written
on the appointment card. When applicable, the
patient receives brochures and application forms
(KCHL (Clinical Chemical Hemafological Lab),
radiology, holter, echo).

Scheduling emergency Based on the results of the processing of Doctor’s assistant SAP
appointment emergency department requests, the polyclinic
employee schedules the appointment according
to the established appointment types. The patient
will be informed by the clinic employee about
the date and time of the polyclinic visit by
telephone.

Scheduling ECG ECG’s are scheduled by hand in a paper agenda. Doctor’s assistant Agenda
There are 3 ECG appointment slots; there is a
consultation without appointment for the day
care and geriatrics. ECG images along with the
clinical transaction form are sent to the
secretariat. The ECG will be examined there and

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 sent to the applicant. The transactions form will
be handled by Maria at the policlinic cardiology.

Placing schedule requests in If it is not possible to schedule the consultation Doctor’s assistant SAP
the PA folder of the as requested by the cardiologist, then the Waiting list
Cardiologist. barcode sticker of the patient will be put into the
'waiting list' book (under the tab of the
respective cardiologist). The PA (doctor’s
assistant) of the cardiologist discusses the
possibilities for making the appointment with
the relevant cardiologist and takes care of
making the final reservation and informing the
patient.

2.2.3. Bottlenecks

The table below shows the bottlenecks of the process activity ‘Planning an appointment’. These
bottlenecks are mainly indicated by the employees themselves, but they could also have been observed
during the analysis. For each ‘bottleneck’ a brief advice has been given.


Bottlenecks
What Advice
Patients with a CD request are instructed by their GP See earlier advice regarding triage. In the redesign of
to contact the clinic to make an appointment by the triage procedure a decision has to be made if one
telephone. When a patient calls, and the triage isn't adapts to the general standards of the CD procedure or
completed, the patient is asked not to call but wait for that one goes into dialogue with all the referring GP's
action from the cardiology polyclinic. The patient has to discuss the possibility of making an exception to
a different expectation than the cardiology polyclinic the current procedure of the Cardiology Polyclinic.
is offering and is made highly dependent on action
from the cardiology polyclinic. Therefore the patient
has the tendency to call multiple times if there's no
quick response. The result is a potentially disgruntled
patient and an unnecessary load on the call center.

The scheduling horizon is limited to four months. Adjusting the planning horizon and pattern of
Patients who want to have a follow-up appointment consultation hours; an advisory process with Arnoud
after the schedule horizon call often, resulting in van der Zalm has already been picked up.
unnecessary calls to the call center.

In many cases, after scheduling an appointment, a In the short term, consider sending standard
patient receives information by telephone only. confirmation letters or reminders. On the longer term,
use of text message reminders and/or email
confirmation, if available.

Overcrowded poly calendar, which often results in Revise the planning horizon and pattern of
long waiting lists, patients returning later than desired consultation hours. Also consider new forms of
and consultation hours getting overbooked resulting in consultation hours:
delays. • Consultation by phone
• Intake- and information consultation
• In the future: Online consultation
• More consultation hours to be executed by
other functional levels for e.g. regularcheck-
ups, like by NP’s, doctor’s assistants, etc.
• Place certain categories of patients and/or
consultations with other functional levels
(other than the cardiologist).

Placing the schedule requests in the folder of the PA is Change the planning horizon and pattern of

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a risky and vulnerable process. The patient does not consultation hours in such a way that every patient
get an appointment and remains strongly dependent on immediately receives an appointment.
the action coming from the polyclinic. Not very
patient friendly. Discuss the added value of the PA (doctor's assistant)
role!
Planning the ECG in a paper agenda. The walk-in Plan ECG consultations in SAP, so slots become
policy of geriatrics and day care make it difficult to available which enables walk-in consultations.
supply to demand and to have (human) capacity
available. Vulnerable on billing. Because of this, a more effective use of doctor’s
No transparency of the schedule for the applicant (not assistants is possible, transparency of ECG planning
accessible in SAP) resulting in phone calls: an extra for other specialties (they do not have to call, but can
burden for the call center. consult SAP) and more control for correct billing and
the amount of actions performed.

When making an appointment at the counter, the It is possible to immediately print out the appointment
agreement is written by hand on the appointment card. after this has been created in SAP and then to give it
This is error prone. to the patient. However, a printer has to be facilitated
for behind the counter. If one wants to continue to use
the paper appointment card then make a universal
card. One appointment card for the whole cardiology
polyclinic where all appointments can be found.
Lack of a separate traject of care for patients that need Let intake and/or information consultations be carried
to undergo an intervention. out by nurses. Besides giving information and
instructions, the nurses can also act as a “case
manager” who coordinate the process of the
interventions with the patient and ensure that all
information and planning moves in a timely manner
and according to the established indicators.

By default an ECG is made for all patients who If the future ambition is to actively perform digitized
consult a cardiologist. This is not mentioned as a delay notification then it is advisable to separate the
separate appointment in SAP. The start time of the action for the ECG from the consultation within SAP.
appointment is not the time of consultation, but the
start of the ECG examination. This could arouse false
expectations with patients but may also make the
notification for delay more difficult. Furthermore, it
could also complicate the final invoicing.

Poly visits, blood tests and ultrasound examinations Other nearby hospitals offer a poly model in which
are not scheduled in one day. There is also a (long) the patient receives an initial appointment within 5
duration between the diagnostic testing and follow-up days. On one day they receive an intake, diagnostics
consultation of the patient, for example on Holters and (consisting of blood tests, ECG, bicycle testing and
Echoes. ultrasound), consultation with a cardiologist and a
treatment plan.
Investigate the possibilities of offering such a traject
in the cardiology polyclinic; the way of scheduling
appointments in the echo chamber and analyzing the
echo should also be taken into consideration. In
addition, take a critical look at shortening the time
between the execution of the Holter examination,
analyzing them and providing the results to the
patient.

If there is a dependency with other diagnostic

examination outside the polyclinic: negotiate fixed
slots serving the cardiology (eg MRI, Myoview, etc.)

Evaluation of the ECG made at the polyclinic; is The goal is that an ECG is directly available through
sent to the 4th floor PACS II (image digitizing system). Until that time
consider to do the evaluation of the ECG at the

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 polyclinic. Offer the results of the scan to the
applicant within 24 hours (after scanning).

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2.3. Prepare consultation

Patient Planning an Prepare Report for

Wait
Examine/ Conclude
Referral appointment consultation consultation treat/talk consultation

Process goal:
The consultation will be prepared in order to correctly facilitate the appointment.

2.3.1. Description of the process

The preparation consists of having available the right information, checked for validity.

2.3.2. Description of activities

Description of action Procedure Operators Recourses
‘Consultation lookup’ • Execute at least one week in advance. Doctor’s assistant SAP
• Print the consultation list from SAP. This then who is assigned at
serves as a checklist the counter Paper medical
• Based on the consultation list: record
o Check if paper medical record is scanned and
uploaded into EHR. If not, request/lookup the
paper medical record, clean up the record and
scan it.
o Place the paper medical files in the cabinet at
the secretariat.
o Mark this on the consultation list
o If the consultation hour has been found, mark
this on the list on the cabinet at the secretariat.

General preparation • If still applicable: Taking the stack of paper medical Doctor’s assistant SAP
files in the cabinet. Clean and scan them.
• Printing one consultation list (also called working Paper medical
lists). The letter ‘A’ is mentioned on this list. On record
this list a column is manually drawn onto the list (as
a replacement of the former ‘E’ list).
• Check the following items:
o Is a patient known or not
o A known patient:
§ Check if the dossier has been
scanned. If not, request/lookup,
clean up and scan it.
§ Check scanned documents like
examination reports, etc.
§ Check if the examination has
been executed as stated in the
comment section. If not, then
make a report of this on the
working list and determine if
there are reports and/or check if
examinations are scheduled.
If necessary, call the
departments in question. If
necessary call the patient en
request for a blood examination.
Write down all findings on the
working list.
§ Check on the checkup
appointments (Emergency
Room). If applicable, request

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 the clinical status if there is no
letter of resignation present in
SAP.
o New patient:
§ CareDomain (CD) referral. If
not scanned, find the referral
and scan it.
§ Placing ‘A’ list in the cabinet on
the shelf of the consultation
hour in question. Provided with
the initials of the person
responsible for the preparation.

Checking • 1 day in advance Doctor’s assistant SAP

• Grab the A list from the cabinet
• Print out 3 consultation lists: Paper medical
o List B: For the doctor; on this list the doctor record
can see in an instant which patient comes in
and can report the relevant DTC code during
the consultancy session. The list is placed on
the working desk in the consultancy room
before the start of the consult.
o List C: For the ECG. Is used to see which
patients are coming; Also to record the blood
pressure, weight, etc. The list is placed on the
ECG cart of the particular consulting hour.
o List D: for the bicycle test. Is used to see which
patients care coming; Also to record blood
pressure, weight, etc.
• Verify that scheduled patients are not hospitalized in
the meantime.
• Verify that patients are added during the initial
preparation time. If so, prepare the consulting hour
as described above.
• Verify that missing files have already been scanned.
If not, let them get scanned with urgency.
• Ensure that missing documents/data are available. If
not, make an inquiry and if necessary make an
urgent scan.

2.3.4. Bottlenecks

The table below shows the bottlenecks of the process activity ‘Prepare consultation’. These bottlenecks
are mainly indicated by the employees themselves, but they could also have been observed during the
analysis. For each ‘bottleneck’ a brief advice has been given.

Bottlenecks
What Advice
The working method is rather fragmental. Employees One universal way of execution by all polyclinic staff.
have a tendency to monitor continuously. Thus, the Keep it simple and practical. Preparation has become
impression is raised that a check has to be rechecked a lot easier with the arrival of the EHR, but it can go
and the activity doesn’t get completed because of this. even faster. Employees must gather the courage to let
Printing out the various lists is not necessary. It also go of all the control moments that have been raised
turned out that the preparation was limited to two from a sense of reducing uncertainty.
people. This is a vulnerable.
Printing out the various lists is unnecessary. Data that
is written in the C or D list can be directly entered into
the EHR. In SAP can be seen which patients are
scheduled and in what order; on the basis of the digital
list, the patients can be pulled out of the waiting room.

If necessary, the B list can also expire if the

13

 cardiologist is willing to make the consultation
schedule in SAP and put the corresponding DTCs
directly into SAP. However, this is obviously not a
must.

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2.4. Report for consultation

Patient Planning an Prepare Report for Wait

Examine/ Conclude
Referral appointment consultation consultation treat/talk consultation

Process goal:
The patient reports to the cardiology counter.

2.4.1 Description of the process

The patient enters one of the entrances of the hospital and reports at the counter of the polyclinic
cardiology.

The patient can apply for the following consults:
• Regular, cardiologic consultation
• Holter examination
• Echo examination
• Consultation heart failure
• Pacemaker polyclinic
• ECG consultation

2.4.2 Description of process activities

Description of action Procedure Operators Recourses
The patient checks in at the • Accepting the appointment confirmation Doctor’s assistant SAP
counter and/or appointment card
• Asking for a barcode sticker sheet Appointment
• Changing the status in SAP from planned card
(P) to final (W).
• The patient is referred to the registration Letter of referral
desk if:
o The patient has not yet been Barcode sticker
registered. An ID check and sheet
insurance check will be done at
the registration desk. Barcode
sticker sheets will also be printed
o The patient is registered, but SAP
reports that registration data is
missing
o The patient does not have
barcode stickers
• The patient is referred to the appropriate
waiting room
• For patients who report for Holter - or
(strain) ECG examination:
o The barcode sticker is placed on
the cabinet behind the counter.
This acts as a signal for the
doctor’s assistant (who performs
the examination) that a patient is
present
o Barcode sticker is picked up (or
taken to the doctor’s assistant
who carries out the investigation)
after which the patient will be
called in

No show • Processing the absence of the patient in Doctor’s assistant SAP

15

 SAP

Other activities carried out • Consultation lookup (part of preparing the Doctor’s assistant SAP
by doctor’s assistant at the consultation)
counter • Making follow-up appointments Appointment
• Handling tasks associated with the PA card
(doctor's assistant)
• Scan operations Letter of referral

Barcode sticker
sheet

2.4.3 Bottlenecks
The table below shows the bottlenecks of the process activity ‘Report for consultation’. These bottlenecks
are mainly indicated by the employees themselves, but they could also have been observed during the
analysis. For each ‘bottleneck’ a brief advice has been given.


Bottlenecks
What Advice
No strict separation of front and back office • Is the work restricted to doctor’s assistants? Is it
operations. The doctor's assistant assigned for work possible that this work can be delegated to a
behind the counter is doing (if necessary or possible) lower job level and that this activity can be
work that is not directly related to receiving patients. combined with the counter for the poly ‘lung’?
The doctor's assistant regularly walks away from the • Separate the back and front office operations
workplace; this is not desirable if there is a queue more strictly.
forming. Mixing front and back office operations
doesn’t make the work more efficient.

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2.5. Wait

Patient Planning an Prepare Report for Examine/ Conclude

Referral appointment consultation consultation Wait treat/talk consultation

Process goal:
The patient waits for the consultation proprietor (cardiologist) and/or doctor’s assistant.

2.5.1 Description of the process

After the patient reported at the counter, he/she is referred to the appropriate waiting room.

2.5.2 Description of activities

Description of action Procedure Operators Recourses
Patient waits in the waiting Refer to appropriate waiting room (B, C, D or E) Doctor’s assistant
room.

2.5.3 Bottlenecks

The table below shows the bottlenecks of the process activity ‘Wait’. These bottlenecks are mainly
indicated by the employees themselves, but they could also have been observed during the analysis. For
each ‘bottleneck’ a brief advice has been given.

Bottlenecks
What Advice
Undesirable long waiting times can start to build up Reducing waiting times through optimization of the
poly scheduling (see advice Arnoud van der Zalm)
Patient is not or not sufficiently informed about the • Examine the possibilities regarding
respective waiting periods. implementation of (digital) waiting time
notification
• If not possible: realizing simpler means of waiting
time notification
From a patient perspective, the waiting procedure • Decorate the waiting room (in collaboration with
must be improved. the poly ‘lung’ if possible) according to the
intellectual legacy of PlaneTree/healing
environment. Colors, furniture, info screens,
continuous supply of coffee/tea, etc.)

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2.6. Examine / treat / talk

Patient Planning an Prepare Report for

Wait
Examine/ Conclude
Referral appointment consultation consultation treat/talk consultation

Process goal:
The initiation of the care (treatment) process.
Based on the care demand and the symptoms of the patient, a treatment plan is made and/or continued. A
diagnostic examination is also conducted:
• (exercise) ECG
• Holter examination

2.6.1 Description of the process

The patient is taken from the waiting room by the doctor’s assistant to carry out a (exercise) ECG in the
room provided. After performing the ECG, the patient is referred back to the waiting room. The
cardiologist then calls the patient from the waiting room to carry out the consultation.
During the consultation, the cardiologist can decide, based on the complaints of the patient, to perform an
ECH (if an ECH was not performed yet).
In the case of performing a Holter examination, the patient does not go to the cardiologist directly. The
results of this examination is given during the follow-up appointment with the cardiologist.

2.6.2 Description of activities

Description of action Procedure Operators Recourses
Calling up the patient from Calling up the right patient based on the printed Doctor’s assistant C list
the waiting room poly list (so-called 'C' list).

Performing (exercise) ECG • Request the patient to (partly) undress; Doctor’s assistant C list
assist if necessary
• Measure weight, height, pulse and RR. RR meter
Note the information on the C list under the
name of the individual patient Weight scale
• Entering the personal data of the patient
into ECG equipment SAP
• Do the examination in accordance with
known protocols ECG equipment
• Ask patient to dress; assist if necessary
• Give a copy of the ECG printout or ECG Ergometric
rhythm strip of the exercise to the patient. equipment
• Refer the patient to the appropriate waiting
room
• Enter the vital values into the EHR; in case
of strain ECG: supplemented with general
findings
• Log the actions in SAP
• Call up the next patient and repeat the
activity

Consult • Cardiologist calls in the patient to the Cardiologist SAP

doctor's office based on the printed 'B' list.
• Perform anamnesis, physical examination,
making a (presumptive) diagnosis and
treatment. Findings are directly registered
in the appropriate section in the EHR
• Assessment of (strain) ECG; Register

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 conclusions in EHR
• If not planned but necessary nonetheless:
conduct (strain) ECG. Cardiologist finds
the appropriate doctor’s assistant for this.
• Fill in the front desk card with the required
follow-up: a repeated consultation (with a
specification of desired appointment type
and the duration of the follow-up
appointment), diagnostic examination
and/or referral to other medical specialist or
paramedic
• Placing the ECG, strain ECG strip, and/or
other documents in the Blotting-book so
these can be scanned after the consultation.
• Mark relevant DTC on the B list
• Refer the patient to the counter
• Call in next patient

2.6.3 Bottlenecks
The table below shows the bottlenecks of the process activity ‘Examine / treat / talk’. These bottlenecks
are mainly indicated by the employees themselves, but they could also have been observed during the
analysis. For each ‘bottleneck’ a brief advice has been given.


Bottlenecks
What Advice
The patient has to proceed from one room to the other. • Short term: the patient is offered an OK
The changing room is separate from the room where (Operating Room) jacket or towel that he/she can
the ECG is performed so the patient has to walk wear when walking from the dressing room to the
through the corridor, bare chested. consulting room.
• Adapt the design of the polyclinic building and
design a new environment in which the premise is
that a patient will stay in one office while the
care-providers ‘circle around it’.
Unnecessary actions • C list: not necessary: the doctor’s assistant can
directly see from the consultation list whether a
patient has reported himself and whose turn it is.
• The notation of data on the C list: enter directly
into EHR! This is more efficient, avoids double
work and copying mistakes (overwriting is
always prone to errors)
• B list: not necessary. The cardiologist can see
from the consultation list in SAP if a patient has
reported himself and whose turn it is. However, it
does have a function to write short notes about
DTC which are processed after the consultation.
Activities cardiologist and doctor’s assistant are not • In case of an unplanned strain ECG, the
always aligned to each other cardiologist has to find the appropriate doctor’s
assistant to give the assignment to. This causes
unnecessary loss of time. Equip the doctor’s
assistant, who is assigned to perform the strain
ECG, with a mobile phone so that the assistant
can be reached directly without the cardiologist
having to leave the consultation room.
Acts carried out by the cardiologist that can be • A part of the anamnesis (social anamnesis,
delegated history, medication use, etc.) can be requested
and registered by the doctor’s assistant before the
cardiologist consultation. Letting the patient fill in

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 the questionnaire in advance, which includes
these data, accelerates this process.
• There is a difference in the execution of the
consultation by the different cardiologists.
Physical examination is done by some
cardiologists at each consultation, others only do
it during a first-time poly visit or on indication.
Conducting RR, pulse, weight, length can always
be performed by the doctor’s assistant. Delegating
those activities of the cardiologist saves time and
will have a positive impact on handling efficiency
and delays.

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2.7. Conclude consultation

Patient Planning an Prepare Report for

Wait
Examine/ Conclude
Referral appointment consultation consultation treat/talk consultation

Process goal:
The correct administrative settlement of the consultation.

2.7.1 Description of the process

Processing the requested supplementary diagnosis or treatment diagnostics, processing and/or closing
the DTC and entering the activity into SAP. The referrer will also be informed by letter.

2.7.2 Description of activities

Description of action Procedure Operators Recourses
Processing the requested Filling in the forms and the cardiology team Cardiologist SAP
supplementary admissions discussion if necessary.
or interventions
DTC administration Opening and/or closing the DBC Cardiologist SAP
Processing the DBC’s Administrative
employee
Informing referrers Generate GP letter in EHR. Doctor’s assistant SAP
Authorizing GP letter or ICC Cardiologist
Sending letter (EDIFACT or on paper if
necessary)

Handling telephonic Answering telephone inquiries Doctor’s assistant SAP

inquiries Send the answer of the inquiry to the patient Cardiologist

Scheduling appointments Doctor’s assistant discusses with cardiologist Doctor’s assistant SAP
from waiting list book the possibilities to fit in the patient's Cardiologist
appointment in the already full consultation
schedule. Based on the decision, the patient will
be informed of the date and time of the
appointment.

Inputting activities of ECG, Register the respective actions Doctor’s assistant SAP
strain ECG, Holter
examination
Processing of no-shows Register the no show with the appropriate code Doctor’s assistant SAP

Finish up the scan book Scan patient-related documents and upload them Doctor’s assistant SAP
in SAP

2.7.3 Bottlenecks

The table below shows the bottlenecks of the process activity ‘Conclude consultation’. These bottlenecks
are mainly indicated by the employees themselves, but they could also have been observed during the
analysis. For each ‘bottleneck’ a brief advice has been given.

Bottlenecks
What Advice
The process of the cardiology team discussion is This process is essential for an efficient execution of
unclear and safeguarded insufficiently the treatment for the patient within the Cardiology
Polyclinic. The team discussion should be a clear and

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 planned activity. The case manager previously
suggested, could have an important initiating,
coordinating and guiding role in this process. This role
could also perform the necessary administrative
actions (including EHR records) instead of the
cardiologist.
Increasing number of non-approved GP letters Besides the fact that this occurs due to lack of time of
the cardiologist, a behavioral component could also
play a role here. Enter an indicator relating to the
speed at which a letter is sent and regularly measure
the results. Then discuss the results. This needs to be
further investigated for each cardiologist.
Increasing number of unhandled phone inquiries Process is unclear and not secured. Patients get no or
very late answers to their questions, which causes
them to make unnecessary calls and becoming
dissatisfied. The purpose of the process needs to be
clearer. Many telephone inquiries could also be
handled through a telephonic consultation hour, for
which a transaction can be declared per consultation.

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