Healthcare faculty/staff #

Physicians 8

PA (Physician Assistant) 1

NP (Nurse Practitioner) 5

RN (Registered Nurse) 3

MOA (Medical Office Assistant)* 6

CSA (Clinical Staff Assistant)* 5

Background

• Outpatient clinics care for patients through scheduled appointments • Clinics need to optimize timeliness, interacting workflows of multiple staff and

health professionals to accommodate multiple patient visits Opportunity Decrease the time patients spend waiting during each visit in order to increase

patient access to care via increased clinic efficiency and improve patient satisfaction

Scope The ambulatory endocrinology clinic at University of Texas Southwestern (UTSW)

The UT Southwestern Endocrinology Clinic

Improving Access and Wait Time in an

Ambulatory Endocrinology Clinic Eric Kuo, Benjamin Weia, Eleanor Phelps, BSN, MA, RN, Chanhaeng Rhee, MD, MBA

Multi-disciplinary team: Gary Reed, M.D., Perry Bickel, M.D. Alex Tessnow, M.D., Gregory Sees, RN, CMPE, Hilary Trevino, NP, Bobbie Joe Martell

Aim

From June 15, 2015 to August, 2015, derive implementations to: (1) Improve monthly access of patients to endocrinologists, measured by days

until third appointment, by 10% (2) Increase Press-Ganey patient satisfaction score rankings of “Access” and

“Moving Through Visit” by 10 percentile points each

Defined project with stakeholders of the clinic. Shadowed clinic to construct a detailed process map.

Next Steps • Await approval and support from

clinic managers • Selected changes will be made in

the endocrinology clinic • Data from changes will be

collected over the span of a year

Total processes: 113

Green: Check-in Purple: CSA

Orange: Physician

Navy: Valet

Green: Check-out

Yellow: MOA

Allowed identification of “wasteful” processes in the clinic that do not add value to the patients’ experience.

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it fo

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pto

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qu

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en

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No

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om

0%

20%

40%

60%

80%

100%

0

2

4

6

8

10

12

14

16

Cu

mu

lati

ve %

Tim

e

Causes

Patient Time Outside Visit - Average

Vital Few Useful Many Cumulative% Cut Off % [42]

Total after Check-in = 35.25 min

Appt. Type 20-min 30-min 40-min 60-min

Median Time Outside Appt. (min.)

36

37

25

14

20 Min Appointments

Duration

Fre

qu

en

cy

25 75 125 175 225 275 325 375 425 475

03

06

09

01

20

30 Min Appointments

Duration

Fre

qu

en

cy

25 75 125 175 225 275 325 375 425 475

03

07

01

10

40 Min Appointments

Duration

Fre

qu

en

cy

0 50 100 175 250 325 400 475

01

03

05

0

60 Min Appointments

Duration

Fre

qu

en

cy

0 50 100 150 200 250 300 350 400 450 500

03

06

09

01

20

Duration Duration Duration Duration

Appt. Type: 20 min 30 min 40 min 60 min

(A) Breakdown of patients’ wait time during a patient’s clinic visit outside of the physician’s exam room. • Average total observed time

outside of physician’s exam room was estimate to be 35 min.

• Total time ranged from 15 min. during “slow” mornings to 90+ min. on “busy” days. (data not shown) n<10

(B) Appointment times were pulled from EPIC based on subtracting check-in time from check-out time. • Time outside appointment for 20

and 30 min. appointments was close to average duration in pareto chart

• While time outside appointment for 40 and 60 min. appointments was lower than average estimated length in (A).

Endocrinology Clinic Other Subspecialty Clinics

Project Design

Measures of Clinic

Sky Blue: Patient

Pink: RN

Breakdown of Wait Time During Visit

Criteria Weight Measurement

Impact 30% Total staff and wait time (min.)

Risk Priority Number

25% Calculated risk

Ease of Implementation

15% # of start up changes

Maintenance Cost 15% USD

Start-up Cost 10% USD

Adaptability to other clinics

5% # of clinics implementation can be applied to

From quality tools, identified 28 potential

implementations for the clinic.

Ranked recommendations according to

Priorization Matrix with weighted criteria:

A

B

Mapped Workflows of Clinic Staff

Changes to Be Made

Workflow: Problem/ Improvement Opportunity

(Rank) Recommended Implementation

Pre-Arrival: Patient does not know how long from parking lot to clinic

(1) Information for patient clearly stating how many minutes in advance to arrive

Check-In: Clerks need to navigate to multiple areas in system repetitively to print & scan forms for pts

(3) Design “megaprint“ and “megascan” buttons that are a one-stop click that handles routine info for each patient

Pre-Arrival: Patient does not know how long from parking lot to clinic

(1) Information for patient clearly stating how many minutes in advance to arrive

MOA: ROS not finished online before visit

(2) Give patients ROS form at checkout

Nurse: Physician/Nurse not documenting samples

(4) Inventory of lot numbers that can be checked off.

Top Ranking Recommendations

Starred (*) means staff shared with other General Internal Medicine Subspecialties clinics.

Applied DMAIC methodology to improve the clinic’s processes:

Define Measure Pending Implementation Analyze

Utilized multiple tools to capture wait time and its specific components. Collected archived patient satisfaction survey results and considered problems voiced by patients.

Analyzed measured waiting times and patient satisfaction results for trends with Pareto diagrams and histograms. Applied root cause analysis.

From analysis, brainstormed a list of possible solutions. Ranked ideas according to prioritization matrix, incorporating failure modes effect analysis (FMEA). Presented highest-ranking implementations to clinic managers.

Lessons Learned • Medical students can apply QI

methodology to an operating clinic to design implementations for improvement

• 3 months of a summer is enough time for full-time medical students to progress to the implementation phase of DMAIC