Improving Whatcom County Health Department's WIC Scheduling Efficiencies Using Quality Improvement Techniques

The team chose the Plan, Do, Check, Act (PDCA) cycle for creating and implementing change and used brainstorming, fishbone diagrams, Pareto charts, and process flowcharts. The overall goal was to increase the number of WIC-eligible clients served by maximizing use of available appointment time. WCHD assembled a diverse team that included WIC and Parent-Child Health supervisory staff, a WIC certifier, and the QI facilitator. The team received monthly technical support (via a 30-minute conference call) from the Washington State Performance Management Centers for Excellence as part of a $10,000 QI grant. The team examined the current approach and focused efforts on process improvements to increase scheduling efficiencies and improve customer satisfaction. The team identified the root cause of missed client appointments: 52% of clients forgot their appointments (13 of 25), and of all clients, those making a 2C had the highest no-show rate: 32%. Potential solutions were identified, and the following potential changes were identified: • Improve the client appointment reminder system by calling 2 days before the appointment rather than continuing the current practice of calling 1 day before. • Provide 2C clients with additional options for nutrition education that do not require a formal one-on-one appointment with a WIC certifier. The team then identified an improvement theory: If the team reduces no-show appointments, then the overall caseload will go up. If fewer 2C clients need 15-minute one-on-one appointments with a WIC certifier, then additional appointment time will be available for new clients. The team tested the theory for 3 weeks by having the clerk call clients 2 days before their appointments as a reminder. The team created a client Education Room to accommodate clients who prefer this option to a 15-minute in-person meeting. Clients were surveyed regarding their experience. The team studied the results and found the following: • Calling clients 2 days before an appointment did not improve no-show rates. Unfilled time increased for certifiers from 11% to 15%. • After piloting the Education Room, the team now estimates that between 360 and 720 clients will use the Education Room annually (with 15 minutes of certifier time saved per client) for an annual cost savings in the range of $3,500–$7,000. • Of the clients surveyed, 61% appreciated the convenience of the Education Room option. The team standardized the improvement by expanding the Education Room option to serve WIC clients who have missed their appointments and scheduled 2Cs. An at-home online education option will also be offered. The following future plans were established: • Improve the accuracy and efficiency of WIC data collection:In October 2013 we submitted some of our data concerns to Washington Department of Health and they agreed to consider these concerns as they are in the process of redesigning their statewide WIC data collection system. • Explore the feasibility of text messaging appointment reminders to clients: In November 2013 we began a text and email pilot project and continue to collect data through February 2014 to determine if texting and emailing appointment reminders would decrease the client no show rate. • Create an effective marketing plan to attract new WIC-eligible clients: In January 2014 we convened a WIC Community Outreach group consisting of all four local WIC agencies in the community to develop the marketing plan. Our next meeting is in April 2014. WIC clients are positively affected by this initiative in that they now have more flexibility in how they schedule and receive their required nutrition education. The initiative also has a positive impact on the WIC schedule. Because the team removed some of the 2Cs from the schedule, more time is open in the appointment book to schedule more new WIC certifications and recertifications, which are longer appointments and often more difficult to reschedule.

The team is still evaluating the effectiveness of the new 2C options on appointment completion rates and will continue to evaluate this over time. The team identified data collection system problems (e.g., inaccuracies in the number of missed and rescheduled appointments and unfilled appointment slots; and lack of automated data collection) and have modified the data collection system to more accurately evaluate missed and rescheduled appointments and unfilled appointment slots. The team evaluated client satisfaction with the new 2C options, and 61% of the clients surveyed appreciated the convenience of the Education Room option.