Clinical Safety & Effectiveness Cohortcme.uthscsa.edu/CSEProject/Cohort15/Group15.pdf · process. The desired centering index is a Cpk of > 1.33. The histogram shows a Cpk of 0.56,

Clinical Safety & Effectiveness Cohort 15 Team 15

1

MARC Primary Care Clinic Workflow Improvement

DATE Educating for Quality Improvement & Patient Safety

Meet The Team

Chandana Tripathy M.D. Team Lead

Muhammad Akram M.D Co-Team Lead

Azeneth Gonzalez LVN CS&E Participant

Cynthia Craig LVN CS&E Participant

Francisco Rodriguez MA Team member

Krystal Garza MA Team member

Crystal Cruz Front Desk Team member

Margaret Aguilar MA Team member

Edna Cruz, M.Sc., RN, CPHQ Facilitator

Sponsor Department: Dr. Sara Pastoor, Director Primary Care Center UTHSCSA

2

AIM STATEMENT

To reduce patient cycle time (Patient arrival to discharge by MD) at the MARC Primary Care clinic by 50% by December 2014.

3

Background Problem - Patient cycle time/turn around time is typically 90-120 minutes industry-wide

Several studies have documented that long wait times are associated with decreased patient satisfaction.

As MARC Primary Care center evolves towards the Patient Centered Medical Home model, keeping the patient as the center of care delivery and improving patient experience and satisfaction is critical. Reducing patient cycle time by 50% will help us improve patient satisfaction.

4

5

Patient Arrives

Patient Registers

Nurse Available?

Triage Room

Wait Room

MD Exam Room Available?

Room Patient

Physician Exam RoomIncomplete V/S Equipment

YES

YESMD

Office VisitYES

NO

NO

MD Exam Room Available?

YES

NO

Primary Care MARC Clinic Flow

Intervention Implemented starting 8/15/14

1) Clinic staff was divided into 2 groups Intake team helping with face to face visits and LVN assigned to assist with back office work - Messaging and refills

2) Intake team assigned 1 :1 to MD with clear instructions to buddy up and help each other when necessary

3) Intake team was trained to use Intake Checklist

4) Pre-visit Preparation time allotted to Intake staff in order to Scrub schedules- make notes of overdue health maintenance items, proactively administer immunizations or point of care tests such as A1c, and complete Medicare Wellness Questionnaire before MD evaluation.

5) Physicians schedules were rearranged so that on a given session no more than 11 providers were in clinic as we have only 22 exam rooms thus 2 exam rooms /provider.

Data source /Collection Method

• Data will be obtained from EPIC – chart review for below time stamps:

– Pre-intervention data from 7/15/14-8/14/14

– Post-intervention data from 8/15/14 -11/15/14

• Proxy time points were used

- Appointment time to check in/arrival time

- Time nurse logs in to EPIC to start intake process – Intake start time

- Time M.D. logs into EPIC – MD start time

- Visit Completion - After visit summary printed by MD

Patient cycle time: Appointment check in to AVS print time

The histogram determines if a process will deliver a product or service that meets the customer requirements. Customer requirements are defined using the Upper Specification Limit (USL=0:15) and a Lower Specification Limit (LSL=0:00). The clinic Appointment to Check-In process based on the previous SPC is stable, so we can now assess the centering capability of the process. The desired centering index is a Cpk of > 1.33. The histogram shows a Cpk of 0.56, demonstrating room for improvement. The histogram is highly asymmetrical and positively skewed = 7.43 to the right.

USL 0:15

LSL 0:00

Average 0.20

Cp - Used w/Samples 12.25

Cpk- Used w/Total Population 0.56

Pp 4.33

Ppk 0.20

Skewness 7.43

Performance Indices

Centering Index

Capability Index

MARC Primary Care Clinic Workflow Improvement

Box & Whiskers Plot of median Check-In - AVS CYCLE-TIME by Week

Analysis of Appointment to Check-In Time

Time Analysis by CategoriesDistribution by

Time Categories% by Time Categories

Sum of:

Appt Time to Checkin

Average of:

Appt Time to Checkin

W/I 15 Min Pre/Appt Time 449 41.2% Early Arrivals 59:51:37 0:08:00

>15 Min Pre/Appt Time 402 36.9% Early Arrivals 259:45:15 0:38:46

W/I 15 Min Post/Appt Time 230 Opportunity 21.1% Late Arrivals 47:59:18 0:12:31

>15 Min Post/Appt Time 8 to improve 00.7% Late Arrivals 3:00:37 0:22:35

Grand Total 1089 100% 370:36:47 0:20:25

Time Analysis by Categories Distribution by Time Categories Average of CheckIn to Triage Cycle Time

W/I 15 Min Pre/Appt Time 445 0:27:09

>15 Min Pre/Appt Time 399 0:32:41

W/I 15 Min Post/Appt Time 223 0:22:27

>15 Min Post/Appt Time 8 0:24:48

Grand Total 1075 0:28:13

Analysis of Patient Check-In to Triage Time

* Totals in the distribution columns are different, as the triage time was in some cases recorded prior to the patient check-in.

Intervention - continued

Additional interventions proposed 11/12/14 to be implemented

Screen shots of incorrect Medication Reconciliation before and after MD review and correction with immediate feedback to staff.

Goal - Improve the accuracy of medication reconciliation by intake team thus allowing MD to focus more on disease management, counselling and care coordination.

UCL 0.0477 0.0473

0.0532

CL 0.0376

0.0350

0.0435

LCL 0.0274

0.0226

0.0338

0:26:38

0:33:50

0:41:02

0:48:14

0:55:26

1:02:38

1:09:50

1:17:02

1:24:149

/29

/20

13

10

/13

/20

13

10

/27

/20

13

11

/10

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11

/24

/20

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/8/2

013

12

/15

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12

/29

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13

1/1

9/2

014

2/2

/20

14

2/1

6/2

014

3/2

/20

14

3/2

3/2

014

4/6

/20

14

4/2

0/2

014

5/4

/20

14

5/1

8/2

014

6/1

/20

14

6/1

5/2

014

6/2

9/2

014

7/1

3/2

014

7/2

0/2

014

8/1

0/2

014

8/2

4/2

014

9/7

/20

14

9/2

1/2

014

10

/5/2

014

10

/19

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14

11

/2/2

014

11

/16

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14

12

/5/2

014

Ave

rage

of

Ch

eck

In -

AV

S C

YCLE

-TIM

E

Appointment Week

MARC Primary Check In Clinic Workflow Improvement

Xbar R Chart Average of Check-In - AVS CYCLE-TIME by Week

CL 0.326 0.314

0.442 UCL 0.463 0.470

0.775

LCL 0.189

0.159

0.109

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

9/2

9/2

01

31

0/6

/20

13

10

/13

/20

13

10

/20

/20

13

10

/27

/20

13

11

/3/2

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31

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/20

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12

/15

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12

/22

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12

/29

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13

1/1

2/2

01

41

/19

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14

1/2

6/2

01

42

/2/2

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42

/9/2

01

42

/16

/20

14

2/2

3/2

01

43

/2/2

01

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/16

/20

14

3/2

3/2

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43

/30

/20

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4/6

/20

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4/1

3/2

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44

/20

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4/2

7/2

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45

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5/1

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/25

/20

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6/1

/20

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6/8

/20

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6/1

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46

/22

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6/2

9/2

01

47

/6/2

01

47

/13

/20

14

7/2

0/2

01

48

/3/2

01

48

/10

/20

14

8/1

7/2

01

48

/24

/20

14

8/3

1/2

01

49

/7/2

01

49

/14

/20

14

9/2

1/2

01

49

/28

/20

14

10

/5/2

01

41

0/1

2/2

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41

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9/2

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0/2

6/2

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/20

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11

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Appointment Week

MARC Check In Care Clinic Workflow Improvement

p-Chart of Check-In to AVS > 60 Minutes by Week

Intervention – continued Future Intervention

1) Patient Late for appointment was noted as frequent cause for

delay and longer cycle time. In near future we plan to edit Televox reminder notifications and appointment slips to say patient must arrive 15 minutes before MD appointment time to complete a nurse visit that involves Updating health history, medications, Immunization records and other Health maintenance items. For example script will say “Please arrive for Nurse visit at 8:45 am in preparation for your MD appointment at 9 am.”

2) Increase triage spots and purchase additional triage equipment.

Return on Investment

Soft Gains or Returns (Benefits derived or potential costs avoided) • Increased patient throughput • Timely in-basket management • Increased delivery of non face-to-face patient care • Reduced physician burn out • Improved patient experience • Reduced overtime pay • Reduced vacancies and turnover rates

Investment Costs

• Scale • Vital sign machine • Vital sign stand • Staff time for data monitoring

Return on Investment

Annual GainIncreased Capacity (*1 additional patients/day @ $105) $25,200

*Conservative estimate of increased productivity

Cost Ranges Lowest Costs Highest CostsVital Sign Machines 500.00$ 2,850.00$

Vital Sign Stand 150.00$ 800.00$

Scale 500.00$ 500.00$

Data Analyst Annual salary ($55k)

Data Analyst Benefits (28% of annual salary or $15,400)

Data Analyst time (4 Hrs @ 33.84 or $135/month x12) 1,620.00$ 1,620.00$

TOTAL COSTS 2,770.00$ 5,770.00$

** ROI: Numerator divided by Denominator 9.1 4.4

** for every one dollar spent there is a maximum return of $9.10 or a minimum return of $4.40.

Denominator or Investment Costs

Numerator or Net Gains

47%

56%

47%

35%

69%

64%

47%

56%

47%

35%

69%

64%

0%

10%

20%

30%

40%

50%

60%

70%

80%

7/1/2014 8/1/2014 9/1/2014 10/1/2014 11/1/2014 12/1/2014

Health maintenance items addressed %

Clinic Average (Multiple Items)

$0

$50,000

$100,000

$150,000

$200,000

$250,000

$300,000

Medicare Wellness Charges

Charges

Summary Lessons learnt from this Project

- MARC Primary Care Clinic has a reasonable cycle time (Patient check in to

MD discharge time) approximate 60 minutes +/- few seconds

- There are areas of inefficiency/wasted time counted to this cycle time

“time spent waiting for nurse to triage”. We plan to target future

interventions as outlined in previous slides to reduce wasted time

- Marginal increased Intake time after 8/15/14 can be attributed to

comprehensive Intake questionnaire and as a result a 20% increase in

completion of overdue health Maintenance item was noted clinic wide.

- As a result patient can spend unrushed quality time with the physician

focusing more on disease management, counselling and care coordination

ultimately improving health outcomes and patient satisfaction.

Thank You !