Increasing Provider Productivity at a Homeless Shelter–Based Clinic

Summary

Impact Statement:

The health department was concerned about a falling rate of visits by homeless people to the federally funded Health Care for Homeless project despite an increase in the homeless population. They investigated the causes and made several changes including implementing a process for walk-in service, and were able to increase the number of visits by 30% within a five month period.

Summary:

Hennepin County chose to use a formal quality improvement (QI) project to address a growing concern that while the number of homeless individuals using homeless shelters in Hennepin County increased, the number of clinic visits at Health Care for the Homeless Project (HCHP) clinics decreased. A QI team was identified and chosen based on their knowledge and role within HCHP. The team included not only the full spectrum of operational, clinical, and managerial perspectives; it included seasoned as well as new staff.

The team initiated a QI project with the aim statement to increase by 50% the number of provider and public health nursing (PHN) encounters per clinic hour from

Organization that conducted the QI initiative:

Hennepin County Human Services and Public Health Department

Citation:

Brummel, D. Public Health Quality Improvement Exchange. Increasing Provider Productivity at a Homeless Shelter–Based Clinic. Fri, 11/17/2017 - 11:14. Available at https://www.phqix.org/content/increasing-provider-productivity-homeless-shelter%E2%80%93based-clinic. Accessed December 7, 2023.

Background and Aim

Aim statement:

By December 4, 2010, increase by 50% the number of provider and PHN encounters per clinic hour from <1 per hour/provider to 1.5 per hour/provider.

Need For The QI Initiative:

Despite rising homelessness in Hennepin County, visits to the Health Care for Homeless Project (HCHP) clinic and encounters at the People Serving People (PSP) shelter in Minneapolis were declining. Federal funding guidelines stipulate higher levels of service.

Area for Improvement:

The mission of the Hennepin County’s HCHP is to protect and improve the physical, chemical, mental, and oral health status of homeless individuals. Services are offered at 11 community locations where homeless adults, youth, and children live and receive other services. On-site project services include: acute, preventive, and primary medical care; emergency assessment (triage and linkage); laboratory and pharmaceutical services; case management; health education; outreach and case finding; respite care for clients recuperating from acute illness or injury; chemical and mental health assessment and referral; transportation; client advocacy; and eligibility services. Services are provided by an interdisciplinary team of physicians (paid and volunteer), nurse practitioners, public health nurses, licensed practical nurses, medical assistants, and a financial case aide. In 2009, HCHP served 4,211 homeless men, women, and children through 9,358 encounters. However, despite rising homelessness in Hennepin County, visits to the HCHP clinic and encounters at the PSP shelter, the largest shelter in Minneapolis, were declining. Federal funding guidelines stipulate higher levels of service. A quality improvement (QI) project was initiated to increase by 50% the number of provider and PHN encounters per clinic hour from <1 per hour/per provider to 1.5 per hour/per provider by June 30, 2011.

Root Cause:

The fishbone diagram identified six potential root causes: • electronic medical record (EMR) issues, • staff morale, • internal PSP client outreach, • customer service, • clinic no-show rates, and • external patient referral issues.

Planning and Execution Details

QI Implementation:

The QI team examined the current approach by brainstorming a list of potential problems that might be driving the reduction in clinic encounters and visits at the People Serving People Homeless Shelter (PSP). The brainstorming process began exploration of the connection between the mid-2009 implementation of EPIC, our electronic health record (EHR), and a corresponding decrease in the number of visits and encounters being reported at PSP. Further examination of the current approach was conducted via a staff survey comprised of four questions: 1. How do clients come to you (e.g., walk-in appointment requests, referral from shelter team, outreach)? 2. What do you record in EPIC (e.g., medical appointment information, demographics, helping with transportation, lab results)? 3. What sorts of follow-up do you do with clients (e.g., making future appointments and referrals, providing immunization data, obtaining medical records from other providers)? 4. What ideas do you have to better reflect in EPIC the volume of work that you do? The survey was distributed and completed by eight staff person,; all of whom played key roles in clinic operations. Survey results were compiled, and the results were used to inform a root cause analysis. A fishbone diagram was used to conduct a root-cause analysis and identified a number of key issues. From this, the team went through a nominal group process where issues were ranked and prioritized. The number-one improvement to be tested was in the area of EPIC data issues, specifically clinic no-show rates. Based on currently tracked data, the team determined that provider productivity was the best method to measure changes in the clinic’s no-show rate. The baseline data consist of provider encounters per clinic hour averaged for the 2-month time period of August and September 2010. This analysis demonstrated a baseline encounter of 0.79 encounters per provider per clinic hour. A walk-in service policy was drafted to implement and test at the PSP shelter clinic. All HCHP employees were trained, and the policy was implemented in October 2010. During the check phase of the Plan, Do, Check/Study Act (PDCA) cycle, the QI team discovered the improvement process did not proceed as planned. As a result, the QI team regrouped and worked to develop a new improvement theory that provided more coaching and support to staff to ensure the walk-in service policy was correctly and effectively implemented. The improved implementation strategy was implemented in January 2011, and new measurement data were collected through June 2011.

Focus activities

Administration:

Communications

Organizational effectiveness

Other QI Focus Activities:

Homeless Clinics

Productivity

QI Methods:

PDCA/PDSA Cycle (Plan, Do, Check/Study, Act)

QI Tools:

QI Tool Documentation:

Appendix 2, Henn Co Beta Test Fish Bone Diagram.pdf

Initiative Dates:

7/15/10 to 6/30/11

Initiative Duration:

Between 6-12 months

Methods of evaluation:

The QI team measured provider productivity by calculating the number of medical encounters completed per provider hours worked in a month.

Supplemental Materials:

Quote from partner/participant

Publication (e.g., news story, journal article)

Report

Storyboard

Supplemental Files:

Attachment	Size
Measurable_QI_Outcomes.docx	14.35 KB

Results

Measurable QI Outcomes:

After implementing the new improvement theory, the data collection process went relatively well, and the team was easily able to collect the data needed on appointments, client-specific scheduling histories, completed encounters per clinic hour, and nurse practitioner (NP) hours. However, one issue was discovered in the Do stage; the team learned that PHN data are difficult to capture and analyze because of how and when PHNs document their time. Consequently, results only reflected NP time. Undertaking this QI project brought this issue to light. Efforts are now underway to determine an efficient method of tracking non-NP provider time.

Other QI Outcomes:

The QI project provided HSPHD with an opportunity to explore a problem the department may otherwise have overlooked. Using the PDSA QI framework helped HSPHD shape a meaningful intervention within a defined time period. The QI team found it helpful to have a variety of tools from which to choose from and appreciated the simplicity of the QI reporting process. Overall, HSPHD views this QI project a success as the QI team was able to increase health care access for an underserved and at-risk population. Since the time of this QI project, HSPHD has developed a public health–specific strategic plan that sets organizational objectives at all levels of the service area, defines indicators to measure progress toward achieving objectives, and identifies areas that require focused QI using the PDSA cycle. In addition to achieving measureable outcomes, the project provided a forum for increased team building, developing a better understanding of QI processes and tools, and an opportunity for free and open expression of opinions and ideas. The framework of PDCA ensured that a structured process was followed and that process points and agreements were documented. Collectively, these helped drive policy development and operational change in a way that would be sustainable over time.

Lessons Learned, Observations and Insights:

The Check phase was very helpful in pinpointing what went wrong in the Do phase and giving the QI team an opportunity to address the problems. Without this formal Check phase, the QI team may not have known there was a problem with the implementation of the policy, much less have been able to measure its improvement.

Future Plans:

Training for new employees and ongoing coaching of staff continues in order to ensure the walk-in service policy is effectively implemented. Operational review and monitoring of the process are done formally and informally, and adjustments are made as necessary. Team meetings provide a forum for discussion and may in time serve as a means to address additional issues identified on the root-cause analysis.

Training and Preparation

Information about the Community

Population Size:

1,000,000 +

Population Characteristics:

Hennepin County, the largest county in Minnesota, comprises 46 municipalities, including Minneapolis, Minnesota’s most populous city. The county encompasses 611 square miles, with an estimated population of 1.1 million. Hennepin County was established by the Territorial Legislature of Minnesota in 1852, which was 6 years before Minnesota became a state. It forms part of one of the nation's major metropolitan areas, which ranks sixteenth in the nation in population, and it is the largest of Minnesota's 87 counties in budget, estimated market value, and population, with almost a quarter of the state's population. The City of Minneapolis is its largest city and the county seat. Hennepin has a broad-based economy with sizable manufacturing, financial, governmental, trade, health care, and entertainment sectors. The diversity of this base has typically provided some level of insulation against economic downturns. Many major corporations are headquartered in the county. Income levels tend to exceed the national average, and the county's tax-base growth continues to be strong. Employment remains relatively stable, and the unemployment rate has typically remained below the national average. The citizenry in Hennepin is well educated: more than 88% of Hennepin County residents over age 25 are high school graduates—but not across all racial and ethnic groups. The population is aging, with a large swell of 45–65-year-olds approaching retirement and the life changes associated with aging. The community is fortunate to have an almost equal number of younger adults following behind that will continue to keep this community strong and our elders supported. The population is growing more diverse and is home to Minnesota’s largest foreign-born population: one in eight Hennepin residents were born in a different country. The largest number of Somali refugees in Minnesota lives in the county. Hennepin is a highly linguistically diverse county, with 90 different languages spoken. This is the eighteenth-highest number recorded in any county in the United States.

Information about the Health Department

QI Staff Information

Total number of Staff on QI Team:

12

Total number of FTEs on QI Team:

1.90

QI team members:

Role in the Initiative:

Responsible for reporting and productivity monitoring. Oversaw implementation of measures.

Role in Organization:

Clinic Manager

FTE:

0.20

Role in the Initiative:

Subject matter expert who brought a historical overview and broad perspective to QI project.

Role in Organization:

Nurse Practitioner

FTE:

0.10

Role in the Initiative:

Implementation and communication on-site at homeless shelter.

Role in Organization:

Nurse Manager

FTE:

0.20

Role in the Initiative:

QI technical assistance and overall responsibility for PHAB Beta Test project.

Role in Organization:

PHAB Coordinator

FTE:

0.10

Role in the Initiative:

Provided background on shelter needs and expectations. Provided broad understanding and insight into homeless issues and trends (nominal).

Role in Organization:

Shelter Site Liaison

Role in the Initiative:

Knowledge and expertise in EMRs and how registration and scheduling practices impact billing operations.

Role in Organization:

EMR "Super User"

FTE:

0.20

Role in the Initiative:

Responsible for clinic flow for client registration and scheduling.

Role in Organization:

LPN

FTE:

0.20

Role in the Initiative:

Common-sense expert, historical perspective, previously responsible for pre-EMR productivity reporting.

Role in Organization:

Financial Case Aide

FTE:

0.20

Role in the Initiative:

QI Project Manager

Role in Organization:

Managed project, documentarian, and process facilitator.

FTE:

0.30

Role in the Initiative:

Questioned assumptions. Also, was new to her role, which added a level of objectivity to the process.

Role in Organization:

Program Manager

FTE:

0.10

Role in the Initiative:

Oversaw registration and scheduling processes; knew what systems worked in other public health clinics; provided overall communication on new policies and procedures; had broad knowledge of EMRs.

Role in Organization:

Administrative Supervisor

FTE:

0.20

Role in the Initiative:

Role spanned clinical duties and also registration and scheduling; broad understanding of impact of new policy from both perspectives.

Role in Organization:

PHN

FTE:

0.10

Increasing Provider Productivity at a Homeless Shelter–Based Clinic

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

Comments

Additional interventions

QI Spotlight

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Increasing Provider Productivity at a Homeless Shelter–Based Clinic

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

Comments

QI Spotlight