Quality Improvement

in Action

Reducing patient turn away at a NC County STI Clinic

Samantha Charm, Jennifer Hill, Ashley Marshall, Eva Fernández, Brianne Kallam, and Jaimie Lea

Presentation Objectives

• Overview of approach

• Data collection and baseline data

• Changes

• Results

• Next steps

MODEL FOR IMPROVEMENT

Image: http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx

Plan-Do-Study-Act (PDSA) Cycle

Three Fundamental Questions

Set aims Established measures Selected changes

Planned the change Tried the change Observed the results Acted on what we learned

PDSA Cycles

Small scale changes that are refined through multiple rounds of testing.

Image: http://sisep.fpg.unc.edu/news/sisep-enotes-july-2012

Aim for Our Project

Reduce the weekly number of patients turned away from the NC County STI Clinic.

Understanding the Clinic

• Observations and shadowing

• Patient and staff interviews

• Mapping work flows

• Timing steps of work flow

What We Observed

Observations: • Busy staff with varied responsibilities • Reliance on verbal communication • Long wait times at registration

Hypotheses: • Bottlenecks → Longer patient wait times → Turn away • Potential to see more patients

Data Collection

Data Collection Methods

Returning Client Tickets

Clinic Volume

Wait Time of Registration

Definitions of Turn Away

NC HHS Definition: Patient who is unable to be seen within 24 hours of first attempt at seeing a provider.

Project Definition: Patient who is told they cannot be seen during that clinic and will need to return at a later time.

Measuring Turn Away

Measuring Clinic Volume

The weekly number of patients seen by a clinic provider.

Measuring Wait Time

Complete Intake Process

Place the Chart in the box for

provider use

Give patient number or add

them to the wait list

= Time recorded

The amount of time it takes after a patient is given a number to when their chart is ready for provider use.

Complete Registration

Baseline Results

Patients Turned Away at Baseline

State Definition

21 Patients turned away

= 10% 214 Patients who walked

in the door

Alternate Definition

29 Patients turned away

= 14% 214 Patients who walked

in the door

Wait Time in Minutes at Baseline

0

1

2

3

4

5

6

7

8

9

10

0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 91-100 101-110 111-120 121-130 131-140

Fre

qu

en

cy

Wait time between registration and chart up (minutes)

Under 1 hour: 59% 1-1.5 hours: 19% Over 1.5 hours: 22%

Changes

Implemented Package of Changes

Intake and Registration Process

• Expedited registration for first two patients

• Clipboard for patient information collection

Appointments and Scheduling

• Chart of initial number of walk-in appointments

• Same/next day appointments for patients turned away

Staff Communication

• Communication board

Expedited Registration Process

Image credit: Eva Fernandez

Clipboard for Patient Information Collection

Same Day & Next Day Appointments

Staff Communication Board

Image credit: Samantha Charm

What We Learned

Percent of Patients Turned Away After Changes

13.6%

9.8%

3.5%

0.0%

Project Defintion State Defintion

Before

After

• An increase in the number of patients seen • 185 at baseline compared to 217 at follow up

• One less intake staff member

Patient Turn Away Decreased Despite...

Patient Wait Time After Changes

0

2

4

6

8

10

12

14F

requ

en

cy

Wait time between registration and chart up (minutes)

Before

After

Limitations of Data

• Problem with first set of outcome data

• Biases towards time of data collection

What to do next

Initial Changes

• Continue using implemented changes

• Refine initial changes

• Registration forms included on clipboards

• Timing of collection of registration forms

• Consider the sustainability of these changes

Reduce Interruptions to Flow

• Changes in outgoing message • Internal Instant Messaging system

Technology to Reduce Steps Reduce Steps Through Technology

• Different avenues for chart requests • Use of new EMR system

What Else?