May 29, 2009 – Jill Wooldridge P.A.-C.
Boynton Health Service, University of Minnesota, Minneapolis, MN
Topics to be Covered: Define Convenience Care How we came to develop/improve Gopher
Quick Clinic How Gopher Quick Clinic Functions Display data about utilization of GQC Impact on Providers, Primary Care, Urgent
Care Financial Impact Future Considerations and Plans Challenges to the Model
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“CONVENIENCE CARE”WHAT IS IT?
Provides care for Minor Acute Illness (strep throat screens, bladder infections, sinus infections, warts, impetigo etc.), some basic vaccinations and basic testing.
A Walk-in patient centered model usually staffed by Advance Practice Clinicians.
Patients evaluate their own needs and pick care time that is convenient to their schedule.
One Stop Care. Total patient interaction is in one location and usually a single face-to-face interaction with a single Clinician.
Since the first Convenient Care clinics opened in 2000, the industry has grown quickly – today approximately 1,200 such clinics are in operation (many in retail locations)
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HOW WAS THE BOYNTON PROJECT IDENTIFIED?
An effort to support the University’s strategic mission to improve services to the student population.
Community trends and patient expectations for more choice and control over how they access care – and Boynton’s and University Human Resources’ desire to meet these.
An identified internal challenge in our current Urgent Care model to optimally serve acute care patients.
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PURPOSE OF COMMITTEE
October 10, 2006 - Committee charged by COO to evaluate:The benefits of providing a “Convenience Care” model of service.The appeal of “Convenience Care” to our patients and third-party payers.The impact of this service on Urgent and Primary Care.Over-all financial impact.
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COMMITTEE MEMBERS Chair: Mary Alderman - Director Clinic Operations Co-chair: Dave Dorman – Health Promotion Beverly Carpenter – Administrative Assistant Joyce Fortier – Executive Secretary Jill Wooldridge, PA – Provider BJ Anderson, MD - Provider Britt Bakke - Marketing and New Program Development Paula Miller, RN – Student Health Advisory Committee
member Barb Rangel, LPN – Supervisor Patient Assistance and
Information Virginia Tranter, RN – Lead Nurse Immunization Clinic
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QUALITY IMPROVEMENT PROCESS
DMAIC:DMAIC is a basic component of the Six-Sigma methodology (Business Management Strategy) - a way to improve work processes by improving efficiency and eliminating defects.
In its methodology, it asserts that in order to achieve high quality business processes, continued efforts must be made to reduce variations.
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DMAIC MODELDEFINE PHASE:
What are the issues and desires for improvement
MEASURE PHASE:
Data collection to direct improvement efforts
ANALYZE PHASE:
Clarify and identify root cause of issue
IMPROVE PHASE:
List of all potential solutions and their impact with implementation plan and milestones
CONTROL PHASE:
Pilot plan, process control, implementation of solutions and transition control plan
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Define Phase COLLECTING THE VOICE OF THE
CUSTOMER
oConducted informal focus groups with the Student Health Advisory Committee (SHAC).oConducted informal focus groups with Boynton Health Service (BHS) staff: Providers, RNs, Pharmacy, Lab, Front Desk and Support staff.oCreated open message board for comments from BHS staff on shared network drive.
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Measurement Phase
Measured interest in a “Convenience Care” model
•An online survey sent to 4,000 students, with a return rate of 32%, showed 68% were interested.
•An online survey sent to 2,000 faculty and staff, with a return rate of 38%, showed 53% were interested.
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Measurement Phase (continued)PROBLEM: Urgent Care process of dealing with Minor acute illness is inefficient and lengthy for the patient.
Measured current process efficiency for treatment of minor acute illnesses in Urgent Care.
Urgent Care Cycle-time study:Urgent Care Provider Average Cycle Time = 80.5 minutesRN Average Cycle Time = 54.5 minutesRUC Average Cycle Time = 66.0 minutes
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Measurement Phase (continued)Reviewed 12-Month (9/05 - 8/06) Total MinuteClinic® Utilization
U of M Student Benefit Plan (SBP) – 61 visitsU of M Graduate Plan – 75 visitsU of M Staff/Faculty Benefit Plans – 1,885 visitsOf the total Staff/Faculty MinuteClinic® visits, 389 were seen at the Coffman site (just under 50/month).
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Analyze Phase Analyzed results of student, staff and faculty online
surveys. Reviewed list of factors identified in the formal focus
groups. Performed a Root Cause analysis on current model of
care. Consulted with Boynton Health Service Chief
Operating Officer (COO) to examine fiscal implications of implementing a “Convenience Care” model.
Toured the University of Minnesota Duluth QuickCare Clinic.
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Improve Phase In March 2007 the Committee recommended that
BHS provide a “Convenience Care” model service as a pilot, effective fall 2007.
The service was named “Gopher Quick Clinic”.
The hours of service were to be Monday through Friday , 9 a.m. to 5 p.m. with no coverage over the lunch hour (1-2pm).
The service was not offered during holidays/breaks.
Unless year-round fees were approved and a need for summer services was established, the service would not be offered during the summer.
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GQC IMPLEMENTATION TEAM Chair: Mary Alderman - Director Clinic Operations Co-chair: Jill Wooldridge, PA – Provider Britt Bakke - Marketing and New Program Development Margaret Dahl, RN - Nurse Supervisor Primary Care Davin Hedin - Principal Accounts Specialist Sue Jackson - Director Student Health Benefit Plan Amy Murphy – Executive Accounts Specialist Barb Rangel, LPN – Supervisor Patient Assistance and
Information Deb Sandberg, MD – Medical Director Karen Strauman-Raymond, RN – Nursing Director Gina Tran – Supervisor Patient Accounting
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Improve Phase (continued) BHS Marketing Department implemented
the “Marketing Plan” during spring and summer 2007.
During March 2007 through August 2007 the Implementation Committee: • defined flow and location of clinic, • equipped and stocked the clinic, • hired Advanced Practice Clinician providers (to
split time between primary care and GQC) • trained staff on new processes.
On September 4, 2007 the new clinic service was opened.
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Gopher Quick Clinic ServicesGopher Quick Clinic is limited to addressing one of the following concerns per patient visit.
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Common Illnesses:Bladder InfectionBronchitisCold/CoughEar InfectionLaryngitisMononucleosisRespiratory Flu(without vomiting or diarrhea)Seasonal AllergiesSinus InfectionStrep ThroatSwimmer¹s Ear
Skin Conditions:Athlete's FootCold SoresImpetigoMinor SunburnPoison IvyRingwormWarts (three or fewer, does not include genital warts)
Vaccines:Tetanus Vaccines (Td and Tdap)Flu Vaccine (when flu shot clinics not running)
Additional ServicesPregnancy Test
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Boynton Gopher Quick Clinic
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HOW DOES IT WORK?
FRONT DESK STAFF:
Checks in patient, “schedules” them for next available slot (every 15 minutes), tells patient approximate wait time, gives them Short Health History form to fill out.
Handles any co-pay/insurance issues
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HOW DOES IT WORK? GQC PROVIDER (Team of 6 PAs, 2 NPs):
Calls patient from schedule on computer, brings back to room
Interviews patient (uses paper form)Obtains vitals (Spot Vital Signs)Examines patientPerforms any point-of-care labs [Strep, Mono,
Flu, Urine dip, urine pregnancy test; Throat cultures, Urine cultures sent to lab]
Writes any Rx, educates patient, uses pt. education materials
Patient leaves room, provider finishes any documentation
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Boynton Gopher Quick Clinic Exam Room
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HOW DOES IT WORK?
MEDICAL RECORDS:Collects paper encounter forms dailySorts for billing, clinical recordScans the paper visit for our EMR (usually
within 1 day)Abstracts pertinent data directly into our
EMR: Reason for Visit, Vitals, Labs done, Assessment, Medications prescribed (usually within 1-2 days)
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Control Phase (Fall 2007)
The week of October 22-26, 2007 BHS sent a survey to all current Gopher Quick Clinic patients to assess satisfaction with the service.
Katie Lust, PhD, Director of Research and Surveillance, evaluated all surveys
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October 2007 Survey Results
Compare Satisfied vs. Not so SatisfiedSatisfied = Excellent, Very Good and Good
Not so Satisfied = Fair and Poor
81.2% of the patients surveyed rated the entire visit as satisfactory. Target is 90% satisfaction rate.
Patient concerns identified were:1)wait time in the lobby2)time spent with the provider in the exam room3)privacy
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OCTOBER SURVEY PROCESS IMPROVEMENT PLANWAIT TIME : Added appointments over the 1-2 p.m. lunch time Changed marketing material to indicate that GQC was:
1)first-come-first serve and
2)capacity for the clinic may be reached prior to the 5 p.m. closing
TIME SPENT WITH PROVIDER:Changed marketing material to say “Visits last approximately 10 minutes.”
PRIVACY:•Performed a second survey asking more specific privacy questions•Changed location of urine sample drop-off from Lobby to Front Desk
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Control Phase (Winter 2008)On January 22, 2008 BHS sent a 2nd survey to all current Gopher Quick Clinic patients to assess the following:Wait Time expectationsSatisfaction with amount of time spent with the provider in the exam roomLevel of comfort with:
1)check-in procedure
2)location of waiting room
3)location of exam room
Level of comfort with the process for giving a urine sample as it related to:
1)location of restroom
2)privacy of restroom
3)walking from restroom to drop-off box
4)location of drop-of box and overall urine collection procedure
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JANUARY 2008 SURVEY RESULTS
Compared Satisfied vs. Not so SatisfiedSatisfied = Excellent, Very Good and Good
Not so Satisfied = Fair and Poor
89.0% of the patients surveyed rated the entire visit as satisfactory. Target is 90%.
Patient concerns identified were:1) location of lobby in relation to exam room,2) location of restroom in relation to drop-off box and3) wait time
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JANUARY SURVEY PROCESS IMPROVEMENT PLAN
Exam Room Location: Moved exam room from off of Lobby to
interior exam room within Primary Care South (PCS)
Restroom and Drop-off Box Location: Changed restroom and drop-off box
location to be within PCS clinic space
Wait Time: Added second GQC provider in the PM.
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Fall of 2008 – Opened Coffman Satellite Opportunity arose to utilize the Minute Clinic
site across the street in the Union Hired 3 new staff to accommodate new full-
time GQC clinic and have back-up, as well as rotate into primary care to make the position more appealing.
Front desk to be staffed from Patient Assistance Dept
Challenging new workflow to get supplies, equipment (LN2), labs, etc. back and forth
Set up remote access via computer as well Marketing!
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COFFMAN GOPHER QUICK CLINIC Specific Challenges to the satellite site:
Tried to make it as much like the original GQC as possible for provider staff and patients
Had to set up courier drop off in AM, pick up in PM for supplies/labs
Slightly more complicated transfer of patients to Urgent Care if needed – more hassle for patients
Much less privacy, both in the “lobby” and the public restrooms
Had to determine which site to close if providers are absent?
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Visit Statistics for 2007-08 vs. 2008-09
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Cycle Time Statistics for 2007-08 vs. 2008-09
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SUMMARY OF GQC STATISTICS(from previous slides)
From 2007-08 to 2008-09, GQC visits from a comparable period increased from 3787 to 6459.
Average total cycle time decreased from 37 to 29 minutes.
Average wait time in the Lobby decreased from 25 to 18 minutes.
Time with provider remained essentially constant.
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NOVEMBER 2008 SURVEY RESULTS
Compared Satisfied vs. Not so SatisfiedSatisfied = Excellent, Very Good and Good
Not so Satisfied = Fair and Poor
Again, 89.0% of the patients surveyed rated the entire visit as satisfactory. Target is 90%.
Issues identified were:1) wait time satisfaction improved from Spring 082) Significant concerns regarding Privacy/Comfort at Coffman GQC,
especially with regard to waiting area and urine sample collection3) Patients who rated overall visit as fair or poor were expecting or
would have liked to have more time with the provider
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NOVEMBER ‘08 SURVEY PROCESS IMPROVEMENT PLAN
Wait Time: Front Desk staff continue to offer Coffman as an
option if the wait time is > 30 minutes at BHS
Coffman Privacy/Comfort Concerns: In talks now with Coffman Building services about
possible remodeling of the space to allow private waiting area. Unable to change restroom location.
Expectations regarding time with provider: Make sure marketing materials and those
encouraging the service are clear as to its limitations
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IMPACT ON PROVIDERS Gopher Quick Clinic Providers
Simple, easy visits? Or mind-numbingly boring after 25/day?
Mix of GQC time with Family Practice is seen as a job satisfaction issue from a provider perspective, but results in possible “Excess Access” in clinic schedules
Primary Care Providers Initial skepticism regarding continuity of care Concern over loss of quick visits that allow for “make-up”
time for more involved visits. Perception that the complexity of visits has increased in Primary Care, though RVUs via coding has not yet borne that out.
All agree “Quick” must not sacrifice “Quality” – evidence-based guidelines and judicious use of Antibiotics important
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Code Descr CountOfCode
462 ACUTE PHARYNGITIS 2,149
465.9 ACUTE URI NOS 1,815
599.0 URIN TRACT INFECTION NOS 811
461.9 ACUTE SINUSITIS NOS 617
078.10 VIRAL WARTS NOS 404
466.0 ACUTE BRONCHITIS 365
788.1 DYSURIA 249
463 ACUTE TONSILLITIS 244
477.9 ALLERGIC RHINITIS CAUSE UNSPECIFIED 207
034.0 STREP SORE THROAT 179
786.2 COUGH 152
382.00 AC SUPP OTITIS MEDIA NOS 150
381.4 NONSUPP OTITIS MEDIA NOS 131
V72.40 PREGNANCY EXAM/TEST UNCONFIRMED 82
V06.1 VACCIN FOR DTP 80
054.9 HERPES SIMPLEX NOS 78
075 INFECTIOUS MONONUCLEOSIS 69
380.10 INFEC OTITIS EXTERNA NOS 68
919.4 INSECT BITE NEC 62
381.81 DYSFUNCT EUSTACHIAN TUBE 58
Top 20 Diagnoses for 2008-09Gopher Quick Clinic
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IMPACT ON PRIMARY CARE VISITSPercent of minor acute illness was reduced from 18% to 15%
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Top 10 DX for 0607 Top 10 DX for 0708
Screen for Venereal Disease 1838 Screen for Venereal Disease 2236
Routine Medical Exam 1805 Routine Medical Exam 1725
Routine GYN Exam 1548 Routine GYN Exam 1427
Acute Pharyngitis 1517 Acute Pharyngitis 1024
Nonspecific Skin Eruption 833 Pap and Pelvic 1005
Viral Warts 715 Nonspecific Skin Eruption 745
Pap and Pelvic 710 Acne 604
Acne 594 Dysuria 585
Joint Pain – Ankle and Foot 538 Backache 513
Fatigue 538 Viral Warts 513
IMPACT ON URGENT CARE Percentage of visits for minor acute illness was
reduced from 51% to 20%. Target was to reduce the percentage by 50%.
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GOPHER QUICK CLINIC AND URGENT CARE VISITSACADEMIC YEAR 0708 VS. ACADEMIC YEAR 0809
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SUMMARY OF CHANGE IN VISITS(from previous slides)
GQC visits have continually increased in the same ratio as Urgent Care visits have fallen.
Total GQC visits have increased.
Total UC visits have decreased.
Overall total visits to combined departments have increased.
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Financial Impact:Visits and RVUs
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DepartmentVisits
(2006-07)RVUs
(2006-07)RVUs per
VisitPRIMARY CARE 23,778 51,240 2.15URGENT CARE 3,991 9,665 2.42
DepartmentVisits
(2007-08)RVUs
(2007-08)RVUs per
VisitGOPHER QUICK CLINIC 3,822 5,971 1.56PRIMARY CARE 28,150 60,659 2.15URGENT CARE 5,446 11,608 2.13
DepartmentVisits
(2008-09)RVUs
(2008-09)RVUs per
VisitGOPHER QUICK CLINIC 7,770 13,273 1.71PRIMARY CARE 31,390 64,752 2.06URGENT CARE 4,893 10,534 2.15
FINANCIAL MODELING
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GOPHER QUICK CLINIC
PRIMARY CARE
URGENT CARE
Patients per Hour 4 3 2Average Office Revenue per Visit $63 $95 $119Average Ancillary Revenue per Visit * $8 $15 $25Revenue per Hour $284 $329 $287
Average Provider Cost per Hour $51 $67 $95Nursing Support Cost per Hour $0 $23 $63Other Cost per Hour ** $45 $55 $55Total Cost per Hour $96 $145 $214
Margin per Hour (full booking) $188 $184 $74
* Lab, Radiology, Pharmacy** Facility, Med Rec, Billing, Admin, Misc
FINANCIAL ASPECTS
The breakeven point for visits is three visits per hour.
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CONCLUSIONS AND FUTURE CONSIDERATIONS1. We have met our goal of an average cycle time of 30
minutes or less.2. We have met our goal of reducing the percentage of
minor acute visits in Urgent Care by 50%.3. We have not met our goal of reaching an over-all
satisfaction rate of 90% (but so close at 89%!).4. We need to balance access and/or services to
remain financially sound. New Services? How to increase utilization of Coffman site?
5. Anecdotally, there has been a slight shift in acuity in visits in Primary Care, requiring more people staying late.
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Looking Forward – What‘s next? Remodel of Coffman Gopher Quick Clinic
to allow for private waiting area
Move another Gopher Quick Clinic into our St. Paul clinic for ½ day Monday-Friday. (Dropping 2nd PM provider at BHS)
Looking at financial feasibility and/or profitability of adding some preventive services (Cholesterol screen, BP screen)
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CHALLENGES to the CONVENIENCE CARE MODEL
Balancing schedule – having back-up to remain open as advertised, but avoiding excess access
Appropriateness (or not) of self-triage Repeat visits for same issue Higher acuity or complexity than GQC can handle, and
subsequent “re-triage” of patients If desires of patient don’t fit GQC model (wanting more
time, more than one concern, etc.) Getting all information into EMR in a timely way
EMR wasn’t quick enough for pilot, but templates are in development that are more user-friendly, quick-templates – will still likely have to abstract some historical medical information
H1N1 “Swine Flu”…
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Special Thanks to Mary Alderman, Director of Clinic Operations, and Carl Anderson, Chief Operations Officer!
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