Deaconess Health System definitely had a business imperative on its hands about four years ago.
"We had a problem with physicians and patients complaining, with some frequency, about their inability to get things scheduled in a coordinated fashion," said the Rev. Jerry W. Paul, president of the St. Louis-based system.
The solution came to him when he called a Lands End catalog number at midnight, had his order taken in one call at his convenience and saw the whole order come together on his doorstep not long afterward. "And I thought, why can't we do that with scheduling?"
From that vision, Deaconess Health System proceeded to centralize scheduling and resource management functions. But it wasn't a technology initiative at first.
Following the advice of consultants, Deaconess created a manual system for central scheduling that required a comprehensive redesign of the steps involved in arranging appointments, Paul said.
Automation entered the picture only after the reorganization successfully diverted much of the scheduling routine to a central office, said Pat Brennan, director of systems integration.
The reward for that success was a crush of data and transaction processing that overtaxed the seven schedulers trying to do the job manually.
But by then, the central scheduling concept literally had been worked out on paper, allowing Deaconess to concentrate on computerization.
The initial manual effort put experienced schedulers in charge of setting up and filling out the appointment books of all departments and clinics, Brennan said.
Before that could happen, though, a team of top administrators and 10 department heads worked for about a year to get central scheduling organized and off the ground, with assistance along the way from other department representatives.
Thick manuals of scheduling rules and special instructions were compiled as a result of that effort. Under the supervision of Barbara McEvoy, a registered nurse, the central scheduling office used those manuals as guides to coordinate rooms, resources and routines, such as the correct order of multiple tests among different departments.
The seven schedulers needed all their experience to cope with the demands of the job. The daily routine became a cacophony of phones, faxes and face-to-face conversations, all centering around the contents of dozens of scheduling books arranged on a carousel.
Requests for appointments came in over the phone from physician practices and from a walk-up window serving patients from clinics on the campus of Deaconess Central Campus in St. Louis. The scheduling office was set up near the clinics to handle their patients in person.
In addition to the ringing phones and queued-up patients, schedulers had to field faxes from departments that updated or superseded rules in the manuals on a daily basis.
Other incoming faxes prompted continual changes in the running schedule calendar: notices of physician vacations, changes in available exam rooms, temporary shutdowns for a particular piece of equipment and other daily workplace wrinkles.
On the bright side, McEvoy said, the new scheduling approach started producing efficiencies in short order.
Where departments had built slack into their estimates of procedure time, the central schedulers shortened test cycles and got more done in a day.
Attention to detail also decreased instances where technologists and machines remained idle if a patient didn't show up because of scheduling miscues, she said.
But the addition of two affiliated hospitals a year to the project increased the scheduling load and complicated the scheduling rules.
Rules for the same procedures at Deaconess West Campus in suburban Des Peres and a third campus in northern St. Louis were different from those of the central campus.
Preparation times varied, and even the different models of equipment on hand for diagnostic tests affected the time it took to do the same tests in different locations, McEvoy said.
Phone volume escalated, and schedulers were torn between answering calls and manning the walk-up window. Eventually the window had to be closed in favor of a phone bank just outside the office.
Clinic patients were getting frustrated in line and going home to call. By calling from the phone bank instead, up to three patients at a time could "get in line" with the rest of the phone traffic, and it allowed the office to determine better whom to wait on next, Brennan said.
Some things that should have been simple were anything but. For example, if a patient called about an appointment a doctor's office made, but didn't know what the test or procedure was, the central office had to look through departmental books-more than 50 of them-for the patient's name, McEvoy said.
The logistics of the manual process also made it impossible to schedule more than two months in advance. That tended to cost the system some business because patients would look elsewhere to get elective procedures nailed down even if they weren't planned for several months, she said.
As it was, the office was manually juggling 450 calls a day and scheduling 10,000 events a month. In April 1994, Deaconess decided it had to automate the process, McEvoy said.
It enlisted a computerized scheduling system that could bend to implement the manual system instead of requiring changes to a workable routine, Brennan said.
A St. Louis-based firm, Patriot Healthcare Systems, installed its resource management system at the Deaconess Central Campus in St. Louis, and by October 1994 the first departments were getting their schedules done by computer.
McEvoy said departments were added in groups, the first choices being less complex scheduling situations. Similar departments at Deaconess' central and west campuses were brought in at the same time.
The northern St. Louis campus closed in 1993, shortly after the manual system took effect, but in September 1995 Deaconess merged with Incarnate Word Hospital in St. Louis to create another three-hospital network, Deaconess Incarnate Word Health System.
Computerized scheduling has yet to be expanded to the Incarnate Word campus, Brennan said.
The consulting advice responsible for breaking Deaconess out of the department-centered daily routines added up to about $1.2 million in fees, but Deaconess recouped it during the initial 18-month project period, Paul said.
The continuous-quality-improvement exercise involved in assessing work processes led to the classic "nightmare of discoveries," but those discoveries were converted into operational savings, Paul said.
When all the savings were tallied, he said, they helped offset the consulting fees as well as software development, making the scheduling project a break-even proposition.
Part of the savings came in staff reductions, a half-time position here and there in departments where a clerical person handled scheduling among other duties, McEvoy said.
In other cases, central scheduling replaced work duties that had been performed by registered nurses or other expensive staffers.
In smaller departments, employees who once had to juggle scheduling with other clinical duties were free to administer more patient care, Brennan said.
Physician offices started seeing the difference, Brennan said. Staffers requesting procedures that crossed departments, such as barium administration followed by X-rays, were getting it done in one call instead of being passed between the lab and radiology, he said. "That's just a simple test, but it could take three or four calls to get it right" under the former department-centered situation.
Patients now get a routing slip detailing their progression of appointments and alerting the first department that the patient has two other places to go, McEvoy said.
As for hunting down a doctor-arranged appointment in the Deaconess system, the computer software allows a quick search by patient name instead of a book-by-book process of elimination. "Now we can look it up in a matter of seconds," she said.