Sei sulla pagina 1di 18

BAB034

Revised June 17, 2004

West Coast University Student Health Services Primary Care Clinic


We have a real opportunity to make some meaningful changes in the way things are done around here. With the move to the new facility, we are looking at how we can transform the process to make our patients much more satisfied with the service they are getting. Now they are seeing the doctor they have chosen for primary care more often than not, but the waiting times can be just too long. I am hoping that this new team approach will do the trick! Joan Carwin Director Primary Care Clinic WCU Student Health Services

The West Coast University Student Health Services


The West Coast University Student Health Service (SHS) served the medical needs of the 34,700 students who attended the West Coast University (WCU). All undergraduate students (23,769) were required to be enrolled in the medical plan, while it was optional for, but usually chosen by, graduate students. Almost half of the total student population used the SHS in any given year. The Student Health Services (SHS) offered care in a primary care clinic and several other specialty clinics. SHS had its own laboratory and performed most routine lab procedures inhouse. In addition, the SHS had its own pharmacy and offered dental services, HIV testing, and a broad menu of social services. SHS was principally funded by registration fees, so many services were available at no additional charge to registered students such as office visits, routine procedures, some lab tests, xrays performed in SHS and fitness exams. Other services such as pharmaceuticals, immunizations, more extensive physicals or more specialized lab tests were available for a minimal fee.

David Wylie, Director of Babson College Case Publishing, worked with Professors Ashok Rao, Jay Rao and Ivor Morgan, Babson College, to prepare this case as a basis for class discussion rather than to illustrate either effective or ineffective handling of an administrative situation. Copyright by Babson College 2000 and licensed for publication to Harvard Business School Publishing. To order copies or request permission to reproduce materials, call (800) 545-7685 or write Harvard Business School Publishing, Boston, MA 02163. No part of this publication may be reproduced, stored in a retrieval system, used in a spreadsheet, or transmitted in any form or by any means electronic, mechanical, photocopying, recording, or otherwise without the permission of copyright holders.

West Coast University Student Health Services Primary Care Clinic

BAB034

The Primary Care Clinic (PCC) served most medical needs. As elsewhere in SHS, physicians, nurses and nurse practitioners provided care. For continuity of care, patients were encouraged to choose a primary care clinician to act as a principal health care provider. In addition to meeting basic health needs, this clinician could act as an excellent resource for other health concerns. The PCC also offered walk-in care that did not require an appointment. It was geared toward the diagnosis and treatment of minor medical problems. Because of the demand for the limited walk-in spaces, patients were sometimes asked, after having a condition assessed by a triage nurse, to return at another time especially when a particular doctor or nurse practitioner was scheduled to be on duty. Usually clinicians would set separate appointments for follow up care directly with the patient, thus circumventing triage nurses. Time was scheduled every week for clinicians to devote to such appointments. Referral appointments were also available to the specialty clinics. Specialty Clinics provided specialized care when referred by another SHS clinician. Services included immunization, dermatology, orthopedics, surgery, internal medicine, allergy, head and neck, ophthalmology, urology and neurology.

The Primary Care Clinic


The PCC was the only walk-in clinic among the three. Patients could walk-in without appointments on a first-come-first-serve basis. The SHS was open Monday through Friday, 8 a.m. to 5 p.m. The facility was closed during noon to 1 p.m. when the clinicians would take a lunch break. Students visited the PCC for treatment of problems ranging from common colds, fever, nausea, warts to more serious problems like chest pains, hepatitis and emergencies. The PCC was staffed, five full-time and three part-time nurse practitioners (NP), five full-time and four part-time physicians (MD), six medical assistants (MA), and support staff personnel. (See Table 1 for information on staffing levels and cost and Table 2 for Staffing Levels at the Walk-in Clinic). One of the NPs was always on duty as triage. However, NPs would take turns at performing this function. The staffing was assigned in cohorts of 2 MDs, 1 NP and 1 MA. Doctors were either scheduled to staff the walk-in clinic or to see appointments (see Exhibit 1 for the staffing schedule). Nurses when not assigned to walk-in were assigned to handle appointments as well as a variety of other activities such as fitness tests and immunizations. They were helped in this by the MAs. Staffing assignments were arrived at by considering the demand during different times of the day and different days of the week, and the times clinicians felt was needed to set aside for appointments.

Table 1 Yearly Clinical Staffing Costs - Primary Care Clinic


Physicians Nurse Practitioners Medical Assistants TOTAL
* Full time equivalents

7.0 6.5 6.0

$722,375 351,661 173,343 $1,147,279

West Coast University Student Health Services Primary Care Clinic

BAB034

Table 2 Staffing Levels in the Primary Care Clinic


Dr. Able Dr. Babson Dr. Carwin Dr. Davidson Dr. Epstein Dr. Franck Dr. Good Dr. Heather Dr. Ito Total Hours 28 32 20 40 36 32 28 32 20 268 Nurse Juan Nurse Kaplan Nurse Llowe Nurse Merlin Nurse Nelson Nurse Olin Nurse Plather Nurse Quin Total Hours 40 40 40 40 12 16 40 24 252

Note: Staff members were considered to be full time if they worked more than 30 hours per week.

Joan Carwin was director of the PCC, reporting directly to the Director of the Student Health Services. (See Exhibit 2, Organizational Chart). She was a doctor and held a masters degree in public health. Her responsibilities as director of the PCC, however, precluded a fulltime medical practice. She split her time evenly between her role as an administrator and a physician. She had been working at the clinic for twelve years, and at her current position for six years. In the fall of 1997, the PCC was scheduled to move out of its current location in the basement of the Student Health Center facility into a new building specifically designed for the clinic. While there was a high level of excitement coupled with the usual degree of apprehension associated with such a move, Carwin and her colleagues saw this imminent move as an opportunity to review and improve the way in which services were being delivered to the students. Several factors had prompted this self-examination. First, the opening of the new WCU Medical Plaza within the university campus offered students easy access to qualified WCU physicians private practices, posing a direct threat to the SHS customer base, and ultimately to its funding. Second of all, an independent study in 1995 of patient satisfaction, by a WCU student, as detailed below, suggested that there was room for improvement. Some of the students interviewed commented as follows: ...every time I come in I become very frustrated. I usually have to wait about 30 minutes before being seen. However, once I am seen I am very satisfied. The doctors and nurses are great - it just takes patience to get a chance to see them.... ...highly satisfying - excellent care and counseling from my primary care physician...the only bad thing is trying to schedule the time to see her on a student's schedule....

West Coast University Student Health Services Primary Care Clinic

BAB034

...its just very frustrating and nerve-wracking until you've been to student health a few times and understand how it works (complicated - going to several different stations for a simple visit).... ...other than lengthy waiting times (45 minutes - 1 hr), the people have been very helpful, courteous, cheerful.... ...I have used the system a lot over the past 6 years...mainly because of my physician...for many years I refused to see anyone but him because he is very thorough.... ...I chose my doctor. He became my primary physician even though that's not how things are run here.... The combination of the threat of decreased usage and the promise of improvement prompted an examination of the systems and procedures being used at the PCC. As the move into the new facility loomed, Carwin knew that she would have to make some definitive recommendations.

Patient Satisfaction Survey


In May of 1995, 2,100 randomly selected users of the SHS were surveyed to elicit their perceptions along ten dimensions of service, from which 775 responses were gathered (see Table 3). While those service dimensions that were directly related to quality of health care were rated quite highly, those related to organizational operations and procedures clearly showed room for improvement. The fact that non-users perceived the service provided by the clinic as unfavorable was of great concern to Carwin, in particular the variance between user and non-user ratings of waiting times both to get an appointment and at the walk-in clinic. In a further study using conjoint analysis1, it was determined that while students preferred to see particular clinicians, reducing waiting times were more important than the choice of clinician. The importance of the choice of clinician, however, increased if the patients perceived the medical condition to be more serious. The study also revealed that there were several classes of patients at the PCC: those who preferred to have a physician as their primary care provider, those who wanted a primary care provider but were indifferent among clinicians, and finally those who did not want a primary care clinician at all. Indeed, those patients who had chosen primary care physicians and visited them regularly had significantly higher satisfaction with the PCC than the other respondents.

Conjoint analysis is a research technique which requires respondents to make choices between competing combinations of attributes and which provides an understanding of preferences.

West Coast University Student Health Services Primary Care Clinic

BAB034

Table 3 Results of Student Survey


Service Dimension Cost of Services Quality of Medical Care SHS Staff Attitudes Physical Environment of SHS SHS Hours of Operation Campus Location Admin. Paperwork and Procedures Waiting Time to Get an Appointment Waiting Time in Walk-in Clinic Confidentiality Percent Favorable Ratings* Non-user 74.8 78.1 72.2 73.1 71.9 60.1 46.0 42.7 29.4 93.9 User 88.0 83.7 81.5 77.6 70.1 64.5 63.8 57.3 52.3 93.5 Total 83.5 81.8 78.4 76.1 70.7 62.9 57.8 52.2 44.6 93.6

* The survey was conducted using a four-point scale: very satisfied, somewhat satisfied, somewhat dissatisfied, and very dissatisfied. Percent Favorable Ratings referred to the percent of ratings that fell into the two positive categories. No neutral category was included.

In a follow-up study, 26.5% of the respondents noted excessive waiting times, 14% difficulty in obtaining appointments in a timely fashion, and 6.7% facility problems. After meeting with members of her staff, Carwin formulated three broad objectives for improving the operations and service at the PCC: x x x Reduce the waiting time for seeing a healthcare provider. Transform the perception of the clinic as an impersonal bureaucracy. Improve student perceptions (especially non-users) about the performance and effectiveness of the PCC.

Carwins concern for waiting times was expressed in a recent memo to all the clinicians, In order to accomplish PCCs objectives, we will need to use all of our skills and experience thoughtfully and in a timely manner. That includes being present and on time, especially for that first appointment of each day. Tardiness at the beginning of the day will no longer be tolerated as before. If it occurs, patients will be shifted to other staff, and the tardy staff member will be held accountable. Frequent tardiness will be dealt with in the context of the performance evaluation.

The Current System


In an effort to make SHS more personalized and pro-active, students were encouraged to choose a primary-care clinician. Doctors supported this initiative since they also wanted their patients to see only them. They felt strongly that it contributed to the quality of health care they could provide. In addition to being able to monitor their patients progress several eminent doctors argued that medical care involved more than just treatment, and that personal relationships added to both the quality of health care and the patients perception of good service. Many patients therefore had the attitude of wanting to see my doctor.

West Coast University Student Health Services Primary Care Clinic

BAB034

Upon arriving at the PCC, each patient registered at the front desk and was asked to complete a short form indicating the nature of the medical problem (see Exhibit 3). While the student waited in a central waiting room, the staff at the front desk reviewed this form and requested that the students medical record be pulled from the central files and given to a triage nurse. Only a few patients ever required urgent care. These patients were taken immediately to the first available nurse practitioner or doctor. The staff at the front desk was also in charge of checking student identification, entering account information, identifying no-shows, scheduling staff, rotating nursing and medical students, and reconciling billing disputes. Every walk-in patient who did not require emergency care had to see the triage nurse. The triage nurse would make an assessment of the patients condition to determine if either an NP or an MD should see him or her. (See Exhibit 4 for a list of conditions requiring the attention of a doctor). Whenever possible, the patient was scheduled to see his or her chosen primary care physician. Often, however, that clinician was not on duty in the walk-in clinic and the patient would have to return when he or she was on duty. The triage nurse therefore screened the walkin patients and directed the patients to the clinicians. The screening was influenced by the medical condition of the patient, the patients request to see a particular provider, if any, and each clinicians commitment for pre-scheduled appointments. If the triage nurse determined that a clinician should see a patient, the patient took the medical file to the MA (who served three clinicians) located just outside the clinicians office. All the full time clinicians had their own offices. The part-timers shared offices. Carwin and the head NP, who were part-time administrators and part-time clinicians, had their own offices. The clinician offices served as examination rooms as well. The PCC had 15 offices (See Exhibit 5 for PCC Layout). The MA checked vital signs (temperature and blood pressure) and was responsible for paperwork, requesting lab tests, updating charts as noted by clinicians, returning charts to the filing area, and gathering charts for those who had appointments. They also filled out lab slips, performed various routine tests, fitted ortho devices, and washed wounds and ears. The actual attention given by the MA to each patient only took on average 3.5 minutes. Then they waited for the clinician to become available at which point they would meet in the clinicians office. Typically the clinician was with the patient for about 20 minutes. Then as the patient left the clinician would take 5 minutes to make notes and add to the patients file. Those patients who had come earlier but who had chosen to return when their clinician was on duty also checked in at the front desk. They then went directly to the medical assistant assigned to the clinician they wanted to see. During the previous six months, physicians had treated 9,005 patients and nurse practitioners 6,760 patients. Sixty percent of patients were walk-ins, while the rest had appointments directly with clinicians. Twenty-one percent of all patients had a specific clinician. If a walk-in patient had a specific clinician they would request that person. If that person was not available, the patient would ask when the person would be available and plan to return at that time. Sometimes they had to wait two or even three days before their clinician would be available. If the triage nurse felt the patient should be seen earlier, he or she would try to persuade the patient to see one of the clinicians present. Usually, however, the patient would

West Coast University Student Health Services Primary Care Clinic

BAB034

simply return when their clinician was available. On a typical day forty-five percent of the patients coming for walk-in care were returning to see their specific clinician. Twenty-two percent of the meetings with MDs could have been treated by NPs, but were not due to patient preference for single clinician care. The mix of patients requiring MD versus NP attention did not vary meaningfully at different times of the day or the week. Overall traffic at the clinic did, however, change substantially both by the day and the day of the week. This system worked, but waiting times were excessive. (See Exhibit 6 for process flow diagram of the current system, Exhibit 7 for that of the new system, Exhibit 8 for a summary of arrivals and Exhibit 9 for the schedule of individual clinicians).

The Proposed Team System


Carwin had been working with her staff to devise a plan which she hoped would provide a suitable compromise to allow patients to still receive personalized medical attention yet avoid the long waiting times. The basic structure of the plan was to assign all patients to teams comprised of MDs and NPs, regardless of their desire for personalized service. They would therefore no longer be able to request a certain clinician, but only a team. Patients would be assigned to teams so that each team had a patient load proportionate to its size. The teams would be scheduled so that there were always members of each team scheduled to be on hand to treat patients in their group. For example, if a team were composed of one MD and one NP, at least one clinician would always be available to see walk-ins. So, if a patient had requested the specific team, they might sometimes see the MD and on other occasions see the NP. An incoming patient would still go to the front desk to fill out the short registration form. The form would be used to trigger pulling the medical record. The records would then be transferred to a triage nurse. The patient would wait in the front waiting area until the triage nurse could assess the need to see an MD or a NP, whether the patient should or could return for an appointment, and make an appointment if needed. The records would then be given to a pool of medical assistants who would take the vital signs and enter the information on the forms. Carwin estimated that at any time there could be an equivalent of up to 4 medical assistants in the pool. The records would then be put into a rack according to each patients chosen or assigned medical team. When the appropriate clinician was free, the patient would be directed to an examination room. The new facility was centrally located near the busy campus open-air theater. The PCC was to be on the first floor of this four-floor facility, with an attractive lobby facing the triage center and a comfortable waiting room with a full bank of windows near the central medical assistants station. The ten examination rooms were arranged around this station, each shared by two clinicians. The remaining three upper floors housed administrative and clinicians offices, the pharmacy, specialty clinics, a physical therapy center, and record storage. A dumb waiter would transport medical records between the fourth floor and the first floor. The clinicians would be sharing offices as well under he proposed plan, two per room, however these offices would no longer be used as examination rooms. All staff lockers would be located on the fourth floor.

West Coast University Student Health Services Primary Care Clinic

BAB034

Most of the NPs were enthusiastic about the move, realizing that the new facility would create a more pleasant work and treatment environment. As with any design, however, they also had some concerns. The examination rooms and clinician offices had little natural light, for example, and the only elevator seemed to be very slow. The clinicians had signed up for one or more groups to work on operational issues for the move. These relocation work groups dealt with inventory, displays, security, waste disposal, space assignments, emergency and patient flow issues. The operations coordinator, Jean Sarti, described the response from the NPs and staff to be very positive. Even though the MDs had signed up for these teams, they were described as apathetic and silent during team meetings. In fact MDs chose not to participate on 1/3 of the teams. Reactions to the formation of the proposed clinician provider teams were not too different. The RNs and MAs were enthusiastic and up beat about the proposed changes. Some thought that the team approach was a great way to improve communications among providers and between patients and the PCC. Some noted as long as we have to share offices, we might as well belong to teams," "I have always felt the need for a mentor," "Ive heard that the team structure is working great at the WCU internal medicine division." Most of the MDs, however, were taciturn. Carwin thought that they actually were distressed but reluctant to express their opinions. She was unsure how to convince them of the benefits of the program and thus get their support. While Carwin knew the new system would provide some improvement, she had not yet determined how many medical assistants should be assigned to the pool at various times, nor did she know the composition of the clinical teams. She felt the composition of the clinical teams was of utmost importance. If structured properly it would reduce the waiting times as well as reduce the number of returns. The present system was effectively a team of one. So, if the clinician were not available the patient requesting that clinician would have to return. She knew that sometimes this meant the patient would have to return as much as three days later. She was also acutely aware that this contributed significantly to the poor perception of the services offered. However, if she went to the other extreme and said that everyone belonged to the same team, then in effect the patient would no longer have the choice to choose a specific clinician. She knew that this extreme would be unsatisfactory to patients. She was also well aware that many of the clinicians would criticize this approach as being too impersonal and detract from the quality of care. This was an argument to which she was sympathetic.

Guidelines
As Carwin considered the problem she realized she would need some help. Having used a WCU student before, she wondered if another would be available to help with this problem. As a first step she called some of the senior clinicians together for the purpose of outlining some concrete goals. The group came up with the following guidelines: xTotal waiting time of 20 minutes or less. xLess than five percent of patients unable to see their specific team when they came to the walk-in clinic.
8

West Coast University Student Health Services Primary Care Clinic

BAB034

xThe maximum delay for seeing a team clinician should be one day. The ultimate goal was to improve the level of service to the patients. She also realized that one key to making the transformation smooth and effective was to gain the full support of the clinical staff.

West Coast University Student Health Services Primary Care Clinic

BAB034

Exhibit 1 Staffing Schedule Walk-in Clinic2

8-9 9 - 10 10 11 11 12 12 - 1 1-2 2-3 3-4 4-5

Monday MD NP MA 2 1 1 2 1 1 2 1 1 2 0 4 4 4 2 1 0 2 2 2 1 1 0 2 2 2 1

Tuesday Wednesday Thursday Friday MD NP MA MD NP MA MD NP MA MD NP MA 0 0 1 2 1 1 2 1 1 2 1 1 2 1 1 2 1 1 2 1 1 2 1 1 2 1 1 2 1 1 2 1 1 2 1 1 2 0 2 2 2 2 1 0 1 1 1 1 1 0 1 1 1 1 2 0 4 4 4 2 1 0 2 2 2 1 1 0 2 2 2 1 2 0 2 2 2 2 1 0 1 1 1 1 1 0 1 1 1 1 4 0 4 4 4 4 2 0 2 2 2 2 1 0 2 2 2 2

Appointment Coverage
Monday MD NP 4 4 4 4 5 6 5 6 0 0 4 4 4 4 4 4 6 5 Tuesday MD NP 0 0 4 4 4 4 4 4 0 0 4 4 4 4 4 4 4 4 Wednesday MD NP 3 1 5 1 5 3 5 3 0 0 1 2 1 2 1 2 3 2 Thursday MD NP 5 3 5 3 6 5 6 5 0 0 5 4 5 4 5 4 5 4 Friday MD NP 4 4 4 4 4 4 2 3 0 0 4 3 4 3 4 3 4 3

8-9 9 - 10 10 - 11 11 - 12 12 - 1 1-2 2-3 3-4 4-5

2 MD - Doctors, NP Nurse Practitioners, MA - Medical Assistants. The NPs took turns at the triage function so one was always on duty.

10

West Coast University Student Health Services Primary Care Clinic

BAB034

Exhibit 2 Organizational Chart


SHS Board of Directors

Director, Womens Care Clinic Dr. Connie Wu

Director, Primary Care Clinic Dr. Joan Carwin

Director, Specialty Care Dr. Al Pearson

Operations Coordinator Jean Sarti

Head Nurse Practitioner Millie Nelson

Doctors / Physicians

Clinic Assts., Student Assts., and Staff

Nurse Practitioners & Triage Nurses

11

West Coast University Student Health Services Primary Care Clinic

BAB034

Exhibit 3 Registration Form WCU STUDENT HEALTH SERVICE - REQUEST FOR SERVICE
Present this card with your current registration or optional health card and photo ID to the eligibility screener desk. REGISTRATION # LAST NAME FIRST DATE OF BIRTH MIDDLE

LOCAL ADDRESS, CITY, AND ZIP CODE PHONE NUMBER

STATE REASON FOR VISIT (YOU MAY STATE PERSONAL PROBLEM)

SHS 800 Revised 11/87 RECORD

1-OUTCARD 2-ACCOMPANY

12

West Coast University Student Health Services Primary Care Clinic

BAB034

Exhibit 4 Conditions Requiring the Attention of a Doctor


(add those for NPs, adding frequency for each kind of condition) Accident check Acute body pain Acute or chronic fatigue Back pain Blacking out or dizziness Blood in stools, urine, or cough Blurred vision, change in vision, double vision Changing scar Chest pain Heart murmur Hepatitis exposure High blood pressure or rapid heart beat Hypoglycemia Inability to urinate Irregular menstruation Joint pains Migraine headaches Pneumonia Testicular pain Thyroid problems Tremors or shaking Trouble breathing or swallowing Yellow skin coloration

13

West Coast University Student Health Services Primary Care Clinic

BAB034

Exhibit 5 PCC Layout


CLINICIAN OFFICE CLINICIAN OFFICE CLINICIAN OFFICE CLINICIAN OFFICE CLINICIAN OFFICE

CLINIC ASST.

CLINIC ASST.

CLINICIAN OFFICE CLINIC ASST. CLINIC ASSISTANTS STATION & SUPPLIES

CLINICIAN OFFICE

BOOK SHELF

CLINICIAN OFFICE

CLINICIAN OFFICE CLINICIAN OFFICE WASH ROOM BATH ROOM CLINICIAN OFFICE

SUPPLY ROOM

CLINIC ASST.

CLINICIAN OFFICE RECOVERY ROOMS OFFICE MAG. TABLE ATRIUM BOOK SHELF

CLINICIAN OFFICE

CLINIC ASST.

JOANS OFFICE

CLINICIAN OFFICE

STUDENT ASST.S OFFICE

STUDENT ASST.

TRIAGE NURSE ROOM FRONT DESK RECORDS SHELVES

MAGAZINE TABLE

WRITING DESK

PHARMACY

INFO. ROOM

ENTRY / EXIT

14

West Coast University Student Health Services Primary Care Clinic

BAB034

Exhibit 6 Process Flow Diagram - Current System Walk-in Patients

Front Desk

Triage Returning Patients

Dont care which doctor

Want specific doctor

Return to see specific clinician during walk-in

Clinical Assistant

Clinical Assistant

NP

MD

NP

MD

15

West Coast University Student Health Services Primary Care Clinic

BAB034

Exhibit 7 Process Flow Diagram - New System


Walk-in Patients

Front Desk

Triage Returning Patients

Dont care which team

y
Want specific team

Return to see specific clinician during walk-in

Clinical Assistants

NP NP NP

MD MD MD MD

NP NP NP

MD MD MD MD

Team

Team

16

West Coast University Student Health Services Primary Care Clinic

BAB034

Exhibit 8 Summary of Arrival and Waiting Times Average Patient Arrival Times for Walk-in Clinic
8-9 9 - 10 10 - 11 11 - 12 12 - 1 1-2 2-3 3-4 4-5 Total 13 12 12 12 Closed 13 12 8 3 85 13 12 12 12 Closed 12 12 8 3 84 12 11 10 11 Closed 11 10 7 3 75 11 10 9 10 Closed 10 10 7 2 69 10 9 8 9 Closed 10 9 7 2 64

17

West Coast University Student Health Services Primary Care Clinic

BAB034

Exhibit 9 - Schedule of Individual Clinicians


Mon A-MD B-MD C-MD D-MD E-MD F-MD G-MD H-MD I-MD J-NP K-NP L-NP M-NP N-NP O-NP P-NP Q-NP Tue A-MD B-MD C-MD D-MD E-MD F-MD G-MD H-MD I-MD J-NP K-NP L-NP M-NP N-NP O-NP P-NP Q-NP Wed A-MD B-MD C-MD D-MD E-MD F-MD G-MD H-MD I-MD J-NP K-NP L-NP M-NP N-NP O-NP P-NP Q-NP 8-9 -A W W E -A A A A W A A H E A T 8-9 -----------------8-9 P A P A W A --W W P P T --A -9-10 -A W W E -A A A A W A A H E A T 9-10 -A -A A W A W -A A A W -T A H 9-10 A A A A W A --W W P P T --A -10-11 -A W W A -A A A A W A A A A A T 10-11 -A -A A W A W -A A A W -T A H 10-11 A A A A W A --W W A A T --A -11-12 -A W W A -A A A A W A A A A A T 11-12 -A -A A W A W -A A A W -T A H 11-12 A A A A W A --W W A A T --A -1-2 A W W A A -W W A A A W A W -A T 1-2 -W -W A A A A -A A A A --W T 1-2 W A -W W W ---A W W A --T -2-3 A W W A A -W W A A A W A W -A T 2-3 -W -W A A A A -A A A A --W T 2-3 W A -W W W ---A W W A --T -3-4 A W W A A -W W A A A W A W -A T 3-4 -W -W A A A A -A A A A --W T 3-4 W A -W W W ---A W W A --T -4-5 A A W A A -A W A A A W A A -A T 4-5 -W -W A A A A -A A A A --W T 4-5 W A -A A W ---A A W A --T -Thur A-MD B-MD C-MD D-MD E-MD F-MD G-MD H-MD I-MD J-NP K-NP L-NP M-NP N-NP O-NP P-NP Q-NP Fri A-MD B-MD C-MD D-MD E-MD F-MD G-MD H-MD I-MD J-NP K-NP L-NP M-NP N-NP O-NP P-NP Q-NP 8-9 A A A H -A A W W H A W A -A H T 8-9 A A -W W A -A -T W A A -A A -9-10 A A A H -A A W W H A W A -A H T 9-10 A A -W W A -A -T W A A -A A -10-11 A A A A -A A W W A A W A -A A T 10-11 A A -W W A -A -T W A A -A A -11-12 A A A A -A A W W A A W A -A A T 11-12 W W -W W A -A -T W A W -A A -1-2 W --W A A A A A A A A A --W T 1-2 W W A W W A A A -A A W W A -T -2-3 W --W A A A A A A A A A --W T 2-3 W W A W W A A A -A A W W A -T -3-4 W --W A A A A A A A A A --W T 3-4 W W A W W A A A -A A W W A -T -4-5 W --W A A A A A A A A A --W T 4-5 W W A W W A A A -A A W W A -T --

P - Physical W - Walk-in A - Appointments T - Triage

18