Clinic Flow

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Today's Objectives. Understand how data can be collected and the benefits of collecting data to improve clinic efficiencyUnderstand how data-driven decisions were made to adopt the Same Day

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Clinic Flow

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1. Clinic Flow A Performance Improvement Initiative 2005

2. Today’s Objectives Understand how data can be collected and the benefits of collecting data to improve clinic efficiency Understand how data-driven decisions were made to adopt the Same Day – Next Day appointment system & how it contributes to patient satisfaction and clinic efficiency Understand how process mapping helps to identify opportunities for improvement and streamline clinic operations

3. Our Brief History Late 80’s HRS Patient Flow Analysis Clinic Operation team Development of an internal patient flow sheet Development of an internal access database to enhance the reporting system Periodic to daily data collection 1) Initially the patient flow analysis was a major event to accomplish – this was with hqtrs help -- very cumbersome 2) Multidisciplinary involved in clinic process 3) PFA – how client flows through the clinic 4) We’ve tried everything from a utilizing the old PFA to collecting daily data -- to truly look at clinic processes, daily collection of data is needed1) Initially the patient flow analysis was a major event to accomplish – this was with hqtrs help -- very cumbersome 2) Multidisciplinary involved in clinic process 3) PFA – how client flows through the clinic 4) We’ve tried everything from a utilizing the old PFA to collecting daily data -- to truly look at clinic processes, daily collection of data is needed

4. Why collect data?

5. JUMPING TO CONCLUSIONS If no data is collected tend to make temporary fixes If no data is collected tend to make temporary fixes

6. Problem Statement 25% of Bay CHD’s scheduled appointments are being cancelled! Identify the problem with dataIdentify the problem with data

7. The multidisciplinary team gets together to mull over the issue. Anything goes! You just throw it all out there. You’ll need someone to record the responses.The multidisciplinary team gets together to mull over the issue. Anything goes! You just throw it all out there. You’ll need someone to record the responses.

8. Overbooking - We need more nurses! - We need more clerks! - Maybe there’s Not enough space - Appoints scheduled too far in advance - Charts not ready for clinic - Scheduled for the wrong reason - Maybe there’s Not enough space - Appoints scheduled too far in advance - Charts not ready for clinic - Scheduled for the wrong reason

9. LM: How are we going to keep up with all this data? TJ: I’ve got a great power tool for that…Pulls out the computer and says “Hey dude, we’re using a DELL!” TJ: Pulls out clipboards for the other three. NEXT SLIDE SOUND BITE: PANTER.MID FILE (automatically looped for 3 slides)LM: How are we going to keep up with all this data? TJ: I’ve got a great power tool for that…Pulls out the computer and says “Hey dude, we’re using a DELL!” TJ: Pulls out clipboards for the other three. NEXT SLIDE SOUND BITE: PANTER.MID FILE (automatically looped for 3 slides)

10. The fishbone is another valuable tool used in problem-solving. Our analysis showed that it was a people and process problem…The fishbone is another valuable tool used in problem-solving. Our analysis showed that it was a people and process problem…

11. NO BACK-UP for Clinicians After completing the process, we found that the root cause was that we didn’t have a back up for our clinicians!After completing the process, we found that the root cause was that we didn’t have a back up for our clinicians!

12. Five Action Items Were Recommended:

13. PERCENT CANCELLED BEFORE LM: Lets look at what we’ve found so far. CM: “Gosh, in one years time, 22 whole clinic days were cancelled because we didn’t have a clinician!” LM: “Out of 2,300 appointments, almost 572 of those had to be cancelled for the same reason!? SS: “Lets double check out numbers, we need to make sure our figures are right!” NEXT SLIDE LM: Lets look at what we’ve found so far. CM: “Gosh, in one years time, 22 whole clinic days were cancelled because we didn’t have a clinician!” LM: “Out of 2,300 appointments, almost 572 of those had to be cancelled for the same reason!? SS: “Lets double check out numbers, we need to make sure our figures are right!” NEXT SLIDE

14. Same Day – Next Day Always have open appointments for patients to be seen same day or next day Benefits Patient Satisfaction Staff Satisfaction Increased productivity & efficiency Actually, the example shown helped the team decided to modify the open access concept to the Same Day – Next Day appointment system. By implementing out new appointment system we are able to see patients that medically need to be seen and the patients who have the desire to be seen in a two-day turn around.Actually, the example shown helped the team decided to modify the open access concept to the Same Day – Next Day appointment system. By implementing out new appointment system we are able to see patients that medically need to be seen and the patients who have the desire to be seen in a two-day turn around.

15. PERCENT MD APPOINTMENTS CANCELLED BEFORE FOR EXAMPLE, OUR DOCTOR’S CANCELLATIONS WENT DOWN TO 1%! We improved from 25% cancellation rate to 1% We improved 10-15% on no-show rate Which improves productivity of physicians and nurse practitioners FOR EXAMPLE, OUR DOCTOR’S CANCELLATIONS WENT DOWN TO 1%! We improved from 25% cancellation rate to 1% We improved 10-15% on no-show rate Which improves productivity of physicians and nurse practitioners

16. Data Collection Establish a clinic operations team collect & analyze Ways to collect data New HMS will have capability to collect data Develop an internal patient flow sheet Develop an internal database RECAP: Multidisciplinary team We improved from 25% cancellation rate to 1% We improved 10-15% on no-show rate Which improves productivity of physicians and nurse practitioners RECAP: Multidisciplinary team We improved from 25% cancellation rate to 1% We improved 10-15% on no-show rate Which improves productivity of physicians and nurse practitioners

17. Tools we have developed and some graphs we use to analyze our data (has been through various changes) as changes evolve in clinic. Once we have data, we use simple problem-solving tools to get to our root cause and come up with action plans.Tools we have developed and some graphs we use to analyze our data (has been through various changes) as changes evolve in clinic. Once we have data, we use simple problem-solving tools to get to our root cause and come up with action plans.

18. Tools we have developed we use to analyze our data (has been through various changes) as changes evolve in clinic. Once we have data, we use simple problem-solving tools to get to our root cause and come up with action plans.Tools we have developed we use to analyze our data (has been through various changes) as changes evolve in clinic. Once we have data, we use simple problem-solving tools to get to our root cause and come up with action plans.

19. Why Process Map the Clinic Flow? Improve Overall Customer Satisfaction Response to the Patient flow analysis indicating areas for improvement Bottle necks were found Duplication of duties were found Time a patient spent in clinic was too long Average time patients spent in clinic from the Front Reception to Checkout 1.53 minutes Idle times for patients too long Average of 35 minutes

20. Benefits of Improvement Decrease average time patient spends in clinic from two hours to an hour or less Satisfied patients (customers) Eliminate duplicated duties More effective use of staff & resources Increase efficiency Increase quality Satisfied staff

21. WE MAPPED OUR CLINIC PROCESS FROM THE TIME PATIENT PRESENTED TO CHECKIN UNTIL CHECK OUTWE MAPPED OUR CLINIC PROCESS FROM THE TIME PATIENT PRESENTED TO CHECKIN UNTIL CHECK OUT

22. Process Mapping Team A Intake Processes Mapped (Oct. 04) Appointments Front Reception Financial Interview Cashier Record Prep for Appointments Team Members Helen Armstrong, Donna Gregory, Suzi Schomer, Susan Corbin, Marie Barnes, Beth Sanders, Merry Williams, Mary Iffrig, Rhonda Salazar, & Anna Richardson PROCESS MAPPING TEAM A – PATIENT INTAKE PROCESSPROCESS MAPPING TEAM A – PATIENT INTAKE PROCESS

23. Process Mapping Team B Clinic Processes Mapped (June 04) Laboratory HST Clinic Nurses Clinicians Team Members Helen Armstrong, Donna Gregory, Suzi Schomer, Susan Corbin, Adana Ward, Kate Bush, & Doris Barnes. Also input from Kalynn Pressly, Michelle Bautista, Jeanie Chambers, & Dr. Sylvester

24. INTAKE - This process included 3 decision making stepsINTAKE - This process included 3 decision making steps

26. Appointment Process Same Day Next Day appointments Phone appointments Roll over backup Appointment given HCMS updated Walk-In appointments Conducted in a private area Walk-Ins given appointments HCMS updated Call made to MedRec to have record pulled or established and given to Intake We decided that every person to be seen by appointment.We decided that every person to be seen by appointment.

27. Front Intake Process Patient comes to the first available window and writes name and date of birth on the initial contact slip. Patient marks whether visit is for an appointment or immunizations. Appropriate packet is given to patient to complete while standing at window. Appointments for Clinics – record is processed to financial clerk Immunizations- paperwork is processed to the immunization nurse Clinic Walk Ins– sent to appointment clerk to obtain an appointment

28. Other Intake Clerk Duties Medical records are prepared for the next day’s clinics for patients with appointments. By all four ICs via assigned alphabet. A-E, F-K, L-P, Q-Z According to check sheet and placed in appropriate color-coded sleeve for financial status Immunization records are filed daily. By all four ICs via assigned alphabet. A-E, F-K, L-P, Q-Z

29. Financial Interview Clerk Duties All medical records are processed through the Financial Interview Clerk and are placed in the appropriate bin inside the nurse’s station. Color-coded sleeve indicates whether a financial update is needed If financial update is needed, the FC processes patient & record according to new check sheet. If no financial update is needed, FC places record in appropriate bin in nurses station.

30. Intake Process Improvements: Bank Teller-like availability Patient waits for next available Intake Clerk Cross-trained staff for more efficiency Intake Clerk completes paperwork while patient is at window, thus reducing time spent locating patient No incoming phone calls, as nurse calls routed to nursing secretary Assistance provided for obtaining necessary medical records for office visit Initiated check sheets & protocols for record prep, intake packets, & financial interview More privacy for patients, as appointments will be made in private room

31. CLINIC PROCESSES - This process included 8 decision making stepsCLINIC PROCESSES - This process included 8 decision making steps

33. Improved Clinic Process Clinic Nurse (CN): CN picks up record from bin in nursing station CN calls patient back CN obtains vitals CN completes lab request form CN obtains History CN provides C&E

34. If patient needs to see a clinician: CN lays out equipment CN prepares patient CN places medical record in door CN flags room accordingly

35. Clinician (CLN): CLN provides exam CLN writes orders CLN documents in medical record If indicated, CLN reviews specimen(s) CLN flags room accordingly Improved Clinic Process

36. Clinic Nurse: Obtains orders Follows orders C&E patient regarding Rx If patient needs labs drawn, patient and record is taken to the lab. If patient does not need labs or immunizations, the patient, Rx, and encounter form is taken to the cashier. Improved Clinic Process

37. Health Support Tech in Lab (2): HST draws labs according to lab draw sheet. This sheet will be turned into MedRec with the record. HST scan record label into HCMS lab module & verify patient. HST select test(s) ordered in HCMS lab module and generates packing slip. HST records test(s) in lab log(s). HST label and prepare specimens. HST takes patient, Rx, and encounter form to cashier. If patient needs immunizations, drop off the record at the front Intake Window. Turns medical record into MedRec. Improved Clinic Process

38. Immunization Nurse: Provides Immunization service After service is provided, paperwork is turned into front Intake Clerks and/or cashier. Medical record is turned into MedRec Improved Clinic Process THIS IS THE END PIECE OF WHERE OUR PATIENT NEEDS TO GO. WE HAVE IDENTIFIED THIS AREA FOR PROCESSING MAPPINGTHIS IS THE END PIECE OF WHERE OUR PATIENT NEEDS TO GO. WE HAVE IDENTIFIED THIS AREA FOR PROCESSING MAPPING

39. Cashier: Cashier verifies patient name on encounter form with Rx Cashier makes a copy of the Rx Original Rx given to patient Copy placed in box for ordering Cashier receipts out patient If patient needs immunizations, sends patient to Intake Reception window to see the immunization nurse. Improved Clinic Process

40. Clinic Flow Improvements: Nurses station not as crowded More efficient use of staff More efficient flow process Flag System Used on exam doors Record bins used by exam doors Assigned nurse to clinicians / take next chart from bin Less stops for patient because nurse begins with patient Use of duplicate scripts Disposable speculums Extended hours Atomix radio wave clocks

41. Three months later signs of improvement…

42. Note: timing in the deployment stage is very important so that all staff received the same information, tweaks can be made, secondary issues are addressed. Tweaks: Lab check sheet not needed Assigned nurses to providers deleted Note: timing in the deployment stage is very important so that all staff received the same information, tweaks can be made, secondary issues are addressed. Tweaks: Lab check sheet not needed Assigned nurses to providers deleted

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