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Adult Health Clinic Patient Services
Summary
Impact Statement:
Cumberland County Health Department achieved dramatic improvements in the quality of services offered by their Adult Health Clinic through a Kaizen event. Prescription refill wait times decreased from as long as 6 weeks to less than 72 hours, and referrals to specialists, many of which had lengthy delays or were ignored altogether until the next appointment, are now promptly processed and tracked. Additional improvements included modifying job assignments to make better use of registered nurses and medical assistants/nursing assistants, more organized medical records storage, enhanced signage, enhanced patient satisfaction, a new “patient-first” mentality among agency staff, and a greatly improved patient show rate.
Summary:
The Adult Health Clinic (AHC) patient services quality improvement (QI) project aimed to increase effectiveness, efficiency, and timeliness of provision of medical services.
Organization that conducted the QI initiative:
Cumberland County Health Department
Citation:
Tran-Phu, L. Public Health Quality Improvement Exchange. Adult Health Clinic Patient Services. Wed, 05/28/2014 - 22:11. Available at https://www.phqix.org/content/adult-health-clinic-patient-services. Accessed November 11, 2024.
Background and Aim
Aim statement:
Cumberland County Health Department's QI project aim was to increase the effectiveness, efficiency, and timeliness of provision of medical services in the AHC.
The patient population affected by this QI Initiative was the AHC patients who were uninsured and affected by chronic diseases. They could not obtain medical services from anyone else except from the local health department safety-net providers.
Cumberland County Health Department's goals were the following:
(1) Decrease AHC patients’ prescription refill wait time from 6 weeks to 48–72 hours.
(2) Decrease patient in-clinic time from 4 hours to 2 hours.
(3) Increase patient satisfaction with the AHC from 25% to 90%.
(4) Increase the patient-first culture of service excellence within the agency from 25% of the staff to 95% of the staff.
We expect that the increase of the patient-first culture of service excellence within the agency staff will be a byproduct of our QI efforts.
Need For The QI Initiative:
The concerned managers called for repeated meetings to assign more tasks to staff, but there was no buy-in from staff and backlogs of work accumulated. To minimize liabilities, managers had to call upon the other clinics'/programs’ staff to do the work that was left unfinished by the AHC staff, which caused generalized resentment.
Due to the multiple complaints of dissatisfaction both from patients and staff, the Health Director and the Leadership Team decided that the agency’s first QI efforts should focus on improving services provided by this clinic. The North Carolina Center for Public Health Quality supported the agency's efforts throughout this QI project.
Area for Improvement:
The AHC was the one clinical area where most of the patients’ and staff members' complaints about the poor services were generated. The complaints reached the Health Director daily. Patients could not obtain their prescription refills in a timely manner. Many referrals to outside agencies were neither carried through, nor did staff follow up on them. Hundreds of medical records were kept in the clinic awaiting completion, creating confusion and delay during the registration process whenever patients returned to any of the agency’s clinics. Duplicate medical records were created because the patients’ current records could not be located promptly for the patients’ return visits.
The AHC work environment was very dysfunctional and difficult for all staff because no one was accountable for the backlogs of work undone, and all were blaming the others. There was no teamwork and staff’s morale was extremely low, with very high turnover. The medical providers were very concerned about liabilities.
Root Cause:
- Long wait time for prescription refills:
Patients’ requests for prescription refills were recorded on loose paper by different staff members who received the phone calls. The loose paper was clipped on the patients’ medical records and placed in a closet awaiting the providers’ attention. If the loose paper got lost, there was no evidence or documentation of the prescription refill requests. There was neither accountability nor ownership for this task from any staff member.
- Ill-defined staff responsibilities and accountability:
Prior to the Kaizen event, staff’s responsibilities and accountability were ill-defined, creating confusion, resentment, and blame among staff and also overwhelming backlogs of work.
Registered nurses were assigned to perform only administrative tasks (e.g., making referral phone calls to outside agencies or specialists), collecting prescription refill requests and matching them with medical records.
MOA/CNAs, on the other hand, were assigned to work alongside medical providers and thus provided “medical work” to patients. This arrangement created incomplete patient interviews, incomplete medical histories, and incomplete review of systems, thus causing the medical providers to do extra “nursing” work in addition to their medical work.
- Pending referrals:
Most of the AHC indigent patients are diagnosed with multiple chronic diseases. Previously, AHC medical services were provided by two mid-level providers who ordered a large number of referrals to specialists. Because the supporting staff’s responsibilities were ill-defined, they carried out the referral orders only after they are finished with the other, more urgent tasks. There was no uniform referral tracking system for the AHC because staff did not want to use the tracking systems created by their supervisors. Providers and nurses could not retrieve any information about the status of any given referral from the time the order was written and until the return correspondence from the specialist had been placed in the chart. In many instances, it was only when the patients returned for their 3-month follow-up that the medical providers found out that the referral orders written 3 months prior were never carried out by the clinic’s support staff.
- HIPAA compliance and medical records management:
Prior to the QI process, on any given day, about 600 incomplete medical records were kept in the AHC’s offices and closets, awaiting prescriptions to be refilled, referrals to be made, medical notes to be recorded, correspondences, laboratory and X-ray results to be reviewed, etc.
The other agency clinics or programs could not again access to the medical records kept in the AHC, and duplicate records were created throughout the agency.
Patients had to wait a long time for their medical records to be located before being registered for their AHC’s visit.
- Incoherent and inefficient patient flow:
The previous AHC patient schedules began at 7:45 AM, although there were no support staff to process the patients until 8:10 AM. The clinic profiles did not allow adequate time for the providers or the nurses to provide quality patient services to complex patients.
The registration desk was not well organized, and there were many waste steps in the process of registration of both new and established patients; the registration staff had to leave their work areas to find the appropriate flow sheet and forms for each patient’s type of visit. For established patients, the registration staff had to search repeatedly for the patient’s medical records among the hundreds of medical records lying around in the clinic areas, while the patients were waiting.
Staff roles were not clearly defined, and the same tasks must be duplicated or repeated by several staff, creating confusion and redundancy of work. There was no “teamwork” spirit.
Patients would arrive at the clinic with unscheduled labs or blood pressure check visits.
Confused patients were lost in hallways or forgotten in waiting areas, due to lack of signage and to a total communication breakdown between staff and patients, as well as between staff of different specialties.
Planning and Execution Details
QI Implementation:
The North Carolina Center for Quality Improvement provided assistance to the agency with the QI processes and tools training and also provided the agency with the North Carolina State University (NCSU) QI experts’ technical education and local support. Specific methods and tools as described below were used during the Kaizen event to determine problem areas that could be improved with specific time constraints.
This QI initiative was the agency’s first QI project after years of trying unsuccessfully to improve the AHC patient services and patient flow. After the QI team received QI training from the North Carolina Center for Quality Improvement, Cumberland County Health Department decided to apply the methods and tools to this clinic. The QI team that received formal training in turn trained QI methods and tools to the frontline staff so they could make successful small changes by applying the model for improvement.
Describe how the QI initiative was implemented, including where and when it took place and how it addressed the problem.
- Long wait time for prescription refills:
The AHC staff addressed the prescription refill requests delay by assigning this responsibility to one specific staff member. All phone calls and prescription refill requests are now directed to that staff member, who will match the prescription refill request with the patient’s medical record and bring both the request and the medical record to the medical provider, who will approve the refill and sign. When the prescription refill is authorized and signed, she will give the authorized prescription refill to the registered nurse who will notify both the pharmacy and the patient.
This process now takes between 48 and 72 hours to be completed and patients are satisfied.
- Ill-defined staff responsibilities and accountability:
The Kaizen lean tools helped eliminate waste activities. Responsibilities for specific tasks are now shifted and reassigned to the best trained staff to ensure effectiveness, efficiency, and quality of the medical services provided to patients.
Registered nurses are now assigned to work one-on-one alongside medical providers, to be part of an efficient medical team providing quality medical care for each patient while optimizing the use of the medical providers’ time.
Medical office assistants (MOAs)/certified nursing assistants (CNAs) are now assigned to handle administrative tasks, such as recording prescription refill requests and matching them with medical records, placing faxes of correspondences and laboratory and x-ray results in medical records for providers to review, and following up on referrals. MOA/CNAs can also do electrocardiograms (EKGs) and breathing treatments, but they no longer work one-on-one with physicians.
The Kaizen lean tools also helped the AHC determine the need for additional qualified nursing staff to perform more specialized patient services. Therefore, two additional registered nurse positions were created after the Kaizen event.
Similarly, a new medical doctor position was created for the AHC to address the high complexity of the AHC patients' medical conditions. This physician sees the AHC patients alongside the mid-level practitioner and also provides this practitioner with guidance and supervision to ensure that patients receive the highest quality of medical services.
Cross-training is provided for all positions to ensure for cross-coverage during staff member’s leave of absence. With the new positions filled, the patient flow has greatly improved and there are no more backlogs of work.
- Pending referrals:
To ensure that all referral orders are carried out properly, the AHC QI team had assigned the specific referral task to one MOA who assumes the responsibility of doing the referral on the same day of the patient’s visit, then tracks its follow-up and places the specialists’ reports on the patient’s medical records in a timely fashion. A uniform referral tracking system was created on a Microsoft Excel spreadsheet and is now placed on the in-house share drive for easy access for consultation and update from any in-house computer. The new AHC physician, working alongside the mid-level provider, helps decrease the number of referrals to outside practitioners and specialists.
- Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliance and medical records management:
After eliminating waste areas and all non-value-added activities, to increase staff’s efficiency and to decrease liabilities, the AHC QI staff had assigned specific tasks to each team member.
Prescription refill requests, referrals orders, laboratory, and x-ray results are now addressed daily, and patients’ medical records are being returned to the Medical Records Department promptly after the patient’s visit. “Out cards” are being used whenever medical records are pulled from one clinic to another to ensure better continuity of care. There are currently less than 20 incomplete medical records in the clinic on any given day.
The training on HIPAA requirements and medical records management is provided by the HIPAA officer and is ongoing for all clinical staff and mandatory for new hires.
- Incoherent and inefficient patient flow:
The QI team helped the AHC staff reset their mindset, which is now oriented toward the patient-first culture, in order to help the clinic improve the quality of its patient services.
The registration process is now streamlined, with improved patient sign-in and staff work stations. Forms are conveniently placed within staff’s reach within their work stations.
Medical records are available at the registration desk on the afternoon prior to the patient’s appointment.
The receptionist will ask the patient about any changes in their demographics and/or financial status at check-in time. If there are no changes, then the patient can be directed to the nurse.
Visible signage (“Discharge,” “Lab,” “Restroom,” “Waiting area,” etc.) helps improve patient directional instructions.
The workflow for the providers is now streamlined with computers conveniently installed in their working stations, and providers no longer have to return to their offices each time they need to look up medical information.
Patients' medical flow sheets were redesigned to better fit the more complex Internal Medicine AHC patients' needs.
Knowledgeable nurses are assigned to work alongside the providers to ensure higher efficiency and accuracy in patient care.
The physician is always available within the clinic for effective guidance for the mid-level provider so as to ensure consistent quality medical care and promptness of care delivery.
The AHC appointment schedules were improved with the NCSU Kaizen team’s expertise and guidance to allow adequate time flexibility for the providers to handle new or more complex established patients. To better control the patient flow, all services must have an appointment (including labs, blood pressure checks).
The agency is working on installing an efficient Electronic Health Record (EHR) system to streamline the entire process of patient care. The EHR will also permanently eliminate the issue of incomplete medical records lying around in various clinic areas.
Brief daily morning reports keep everyone informed of staffing status and maintain essential communication between the clinic’s staff for practicality and efficiency of operations.
Cross-training of staff and back-up protocols for daily services are provided consistently to ensure clinic coverage in case of staff absences.
Stakeholders: all clinic staff and their patients. Satisfaction surveys were sent out before and after the QI Initiative. The post-QI initiative satisfaction rates were higher than expected.
QI Methods:
QI Tools:
Other QI tools:
Waste worksheet
Newspaper report
Value stream map
Gemba walk
Time study and comparison graphs
Spaghetti diagram
Initiative Dates:
4/1/11 to 10/1/11
Initiative Duration:
Less than 6 months
Methods of evaluation:
To measure its QI success, Cumberland County Health Department used patient and staff satisfaction surveys, measured and compared patient in-clinic time studies, and performed daily counts of the amount of work that was left incomplete.
Direct observation and counting of the number of referrals and prescription refills made on time. The daily count of the number of patients served.
Other Information:
(1) Change is inevitable. The more that staff resist change, the more painful the change will become.
(2) The implementation of changes must be built up from the enthusiastic frontline staff and not forced down by the leadership to resistant and fearful frontline staff.
(3) Communication is key.
(4) Teamwork and buy-in from all levels of staff are indispensable to the success of the QI initiative and sustenance of the improvements. Coaching collaboration between staff to facilitate change is more desirable than forcing changes to happen among fearful and resistant staff.
(5) Leadership must support and facilitate changes at all times to decrease staff confusion.
Supplemental Materials:
Client Time Comparison Graph
Supplemental Files:
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Results
Measurable QI Outcomes:
See attachment: Client comparison graph
Quality medical care:
With the new schedules allowing more time flexibility for the medical providers to provide quality medical care to complex patients burdened with chronic diseases, both patients and staff voice satisfaction when surveyed.
Patient satisfaction:
Patients are now thrilled with the increased time spent with their providers and the improved quality of their medical care. They are pleased with the decreased wait time, both in-clinic and for their prescription refills. The AHC had recently received “cheers” from satisfied patients in the newspaper.
Staff satisfaction:
With an adequate number of specialized staff to ensure that the work is completed daily, the AHC staff stated in a recent survey that they now really love to come to work in the AHC. After witnessing the drastic change in the AHC work environment, a previously temporary registered nurse had chosen to apply for the new permanent registered nurse position.
QI culture spread:
With patients' and staff members' much higher satisfaction, 98% of the surveyed staff now choose to adopt, cultivate, and spread the excellent customer services and patient-first mentality. QI is not just a method or strategy; it is gradually becoming a culture and lifestyle within the agency.
Prescription refills:
The prescription refills turnaround time is now less than 72 hours. The show rate for appointments has greatly improved.
Pending referrals:
All referrals to specialists are now promptly processed and tracked. The specialists’ reports are now placed in the patient’s medical record prior to the patient’s return visit. With a full-time physician working in the AHC and serving as a consultant for the patients, the mid-level provider no longer needs to order as many referrals to specialists.
HIPAA compliance:
Most of the patients’ medical records are now being returned to the Medical Records Department at the close of each business day, and HIPAA compliance is observed.
Other QI Outcomes:
Empowerment of frontline staff:
Empowerment makes staff feel good and trusted and brings out the best performance in each team member. Empowerment builds staff members' loyalty and fosters their passion for the quality of their daily work. Being recognized for their efforts and empowered to claim their own success, staff now proudly share their success stories and show off their accomplishments with coworkers in other departments, thus inspiring and spreading the QI lifestyle and culture throughout the agency.
Morale boost:
Through empowerment of the AHC frontline staff, staff morale is currently at its highest, and staff from other clinics had been visiting the AHC to inquire and learn about the wonders of QI from their happy colleagues. The different areas are now asking the QI team when their areas can receive the QI experience.
Teamwork success:
The AHC work environment is now greatly improved. With their new roles clearly defined and with a predetermined back-up cross-coverage plan, staff members work very well together and demonstrate very strong teamwork spirit. Each team member now participates in teamwork, diligently assuming the responsibility and the accountability for the entire clinic’s performance. They finish their own work and help each other succeed. Teamwork further increases the clinic’s performance. The AHC staff members now describe their “new” team as a very efficient and unified team that works together harmoniously. They describe their “team spirit” with words such as "efficiency," "unity," "consistency," "harmony," "positivity," "support," and "accountability." The successful work environment is now very positive, and the harmony of the AHC teamwork spirit is contagious to other areas.
Patient, staff, and leadership’s confidence in and trust and support of QI:
Staff had learned very useful new skills, such as eliminating non-value-added activities and employing Plan-Do-Study-Act (PDSA) cycles to implement small, feasible changes. Their continued success builds their trust both in their own abilities to create change and in their coworkers’ ability to do so, and this in turn fosters their team spirit.
Served efficiently by effective staff, patients become more satisfied and readily express their appreciation and gratitude toward staff. The patient surveys show that the AHC’s patient satisfaction rate had increased exponentially from the poor 25% before to the outstanding 98% after the QI process. The QI project was presented during a Board of Health (BOH) meeting. The BOH members were impressed and most pleased with the agency’s efforts at improving its patient services and with its success. The patients’ “cheers” in the local newspaper and also the “Most Improved” award were shared with all staff and the BOH. This further boosts AHC staff members' morale and increases their performance.
Via the County Connection newsletter, the QI success story will be shared with the rest of the county coworkers with the hope that the agency's success becomes a source of inspiration for QI for other county programs.
Lessons Learned, Observations and Insights:
Change is inevitable. At a time of economic downturn, when budgets are cut and the costs of medical services to the uninsured citizens rise sharply, services from the safety-net public health agency are expected to increase with decreasing number of staff. Thus, the agency is preparing to embrace the increased workload with leaner budgets by becoming more effective and more efficient and by eliminating all non-value-added activities.
The first QI experience had taught the Cumberland County Health Department how to perform at newer levels of efficiency and efficacy. Lean skills bring about savings on staff time and service costs for the entire agency while also providing better quality services for clients and patients. When each department is trained to apply the Lean tools and the QI’s Model for Improvement effectively, then the entire agency will perform at newer levels of efficiency and efficacy. The bonus is the increased staff morale.
The change process is more effective and encounters less resistance when led by the frontline staff, who are desirous to improve their own work environment and conditions. Empowering the frontline staff with the authority to create small and feasible improvements for themselves is paramount for long-lasting success.
Staff involved in the QI process must be allowed adequate time off to learn the QI tools and to apply the QI skills in their area judiciously. All disciplines of staff in the targeted area must be included in the QI project, and their buy-in must be earned. Feedback from everyone, including patients/clients and staff, must be diligently sought, solicited, and encouraged, whether in person, in writing, using surveys or suggestion boxes, anonymously, or in public.
The QI team must ensure that the area QI staff continue to use their QI skills to sustain the positive changes and to maintain the high level of staff morale.
The QI team must provide continuous QI skills training to staff from different programs and areas to sustain the newly achieved improvements, foster the agency’s desires for further improvements, and spread the QI lifestyle and culture throughout the entire agency.
Communication is paramount:
To lessen staff resistance and ensure buy-in for success, the QI team must reassure all staff that the focus of the QI process is to change the service processes and not the people providing the services.
To prepare everyone for the upcoming changes—prior to any actual changes—the QI team must continuously and effectively communicate with staff and management and diligently explain why, when, and what will change. The QI team must communicate with Senior Management regularly to report results, impacts, and outcomes to ensure the Senior Leadership’s continuous and enthusiastic support for each QI project.
In times of doubt and when facing challenges and adversity, the QI team members must communicate with each other daily and must stand firm together and resist falling apart. The QI team must be prepared to endure and overcome indifference, resistance, criticism, and/or negativity from many sources, from staff to managers, and have strong faith in the evidence-based QI tools and in the ultimate upcoming success of the QI process.
In the agency's experiences, because this was the first QI project, the agency's initial expectations were low and its doubts high. Therefore, the successful results were unexpected and above the agency's hope and expectations. Everything went as planned and only when appropriately planned.
The QI team is composed mostly of managers who are in charge of several programs and clinics simultaneously and who at the same time provide services as frontline staff in certain areas. Due to lack of planned time devoted for the QI project, the team had failed to plan for timely data collection prior to the QI project and the Kaizen event. Therefore, for the AHC QI project, except for the daily patient complaints about the AHC’s services received by the Health Director, the pre-QI data are much weaker than the post-QI data. Staff have now learned that solid pre- and post-QI data are necessary for accurate measurements of the agency's success as well as to share its success stories. Therefore, for the next QI project, the agency will diligently collect adequate pre-QI data prior to any PDSA implementation.
Cumberland County Health Department had also failed to provide appropriate leave time for the QI staff, both for the clinic frontline staff and for the QI team members, thus creating undue stress to staff who must carry out their daily tasks in addition to the QI activities. For our next QI project, the department will make sure that everyone participating in the QI project will have adequate leave time from their areas to learn the QI tools effectively and fruitfully implement the QI skills in their areas.
Cumberland County Health Department wished it had known before beginning this project that data collection and documentation are of utmost importance.
As stated above, the department wishes it had known that all data, pre-, during, and post-QI are of utmost importance so that staff could have prepared and collected more solid data to share in the department's success story.
The department has now learned the importance of designing measurement tools and of documenting all data, especially outcomes measurements to ensure the sustainability of the QI efforts.
Adversity:
In the beginning of the QI project, Cumberland County Health Department had allowed indifference, doubt, resistance, and negativity from many sources, at many levels, with accusations of being another new-and-improved fad or gimmick to depress staff morale, discourage their spirit, and erode their hope and faith.
Now that the first QI project has turned out to be a huge, unexpected success, together as a team, staff have learned that their trust in the evidence-based QI magic prowess is solid and indestructible.
Future Plans:
Cumberland County Health Department assigned the frontline staff to monitor and to sustain the improvements made. One qualified staff member was designated as the “Clinic Operation Manager,” whose duties are to ensure overall staff and patient satisfaction as well as timeliness and quality of services.
A QI Policy and Procedures Manual has been written for the entire agency. However, the implementation of the QI process in other clinics has been modified to adjust to the respective clinics’ needs and capacity.
Staff continued to be trained in QI methods and tools.
Training and Preparation
QI Related Training Received:
Lean training and Kaizen event from the NCSU Lean experts. The core QI team consists of the Medical Director, Assistant Nursing Director, Management Support Supervisor, Medical Records Department Supervisor, and Environmental Health Specialist and received QI training from the North Carolina Center for Quality Improvement as well as from the QI and Lean experts from NCSU.
Information about the Community
Population Characteristics:
In 2009, Cumberland County had an estimated population of 315,207 persons, with 55.5% Caucasians, 37.5% black/African Americans, and 6.3% Hispanic or Latino.
In 2008, there were 15.8% of the population in Cumberland County living below the poverty level, with 9.0% unemployment rate; 16.8% of Cumberland adults under 65 years of age are uninsured; 5.8% stated that they had poor health; and 13.6% needed to see a doctor during the previous year but could not because of the high costs.
Financially Needy Percentage:
92% of the AHC are uninsured, and 45% of the AHC live below the poverty level.
15.8% of the population in Cumberland County live below the poverty level.
16.8% of the population is uninsured.
Information about the Health Department
Local Health Department Governance:
Local Governance - all LHDs in the state are units of local government
PHAB Accreditation Status:
Planning to submit application for accreditation in the next year
Annual QI Initiative Frequency:
QI activity level:
Organization Type:
QI Staff Information
Total number of Staff on QI Team:
6
Total number of FTEs on QI Team:
0.60
QI team members:
Role in Organization:
Medical Director
FTE:
0.10
Role in Organization:
Assistant Director of Nursing
FTE:
0.10
Role in Organization:
Management Support Supervisor
FTE:
0.10
Role in Organization:
Medical Record Department Supervisor
FTE:
0.10
Role in Organization:
Environmental Health Specialist
FTE:
0.10
Role in Organization:
State Consultant Nurse
FTE:
0.10
Accreditation Details
Collaborations
Partner Organizations:
NC Center for Public Health Quality
Contact Information of the Submitter
First Name:
Lan
Last Name:
Tran-Phu
Organization:
Cumberland County Health Department
Submission Status:
Completed
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