Objective To practice quality improvement tools by applying them to an improvement effort in an ambulatory care setting. Instructions

1. Read the following case study.

2. Follow the instructions at the end of the case.

Case Study Background

You have just been brought in to manage a portfolio of several specialty clinics in a large multi-physician group practice in an academic medical center. The clinics reside in a multi-clinic facility that houses primary care and specialty practices as well as a satellite laboratory and radiology and pharmacy services. The practice provides the following centralized services for each of its clinics: registration, payer interface (e.g., authorization), and billing. The CEO of the practice has asked you to initially devote your attention to Clinic X to improve its efficiency and patient satisfaction. Access Process A primary care physician (or member of the office staff), patient, or family member calls the receptionist at Clinic X to request an appointment. If the receptionist is in the middle of helping a patient in person, the caller is asked to hold. The receptionist then asks the caller, “How may I help you?” If the caller is requesting an appointment within the next month, the appointment date and time is made and given verbally to the caller. If the caller asks additional questions, the receptionist provides answers. The caller is then given the toll-free preregistration phone number and asked to preregister before the date of the scheduled appointment. If the requested appointment is beyond a 30-day period, the caller’s name and address are put in a “future file” because physician availability is given only one month in advance. Every month, the receptionist reviews the future file and schedules an appointment for each person on the list, and a confirmation is automatically mailed to the caller. When a patient preregisters, the financial office is automatically notified and performs the necessary insurance checks and authorizations for the appropriate insurance plan. If the patient does not preregister, when the patient arrives in the clinic on the day of the appointment and checks in with the specialty clinic receptionist, she is asked to first go to the central registration area to register. Any obvious problems with authorization are corrected before the patient returns to the specialty clinic waiting room. Receptionist’s Point of View The receptionist has determined that the best way to not inconvenience the caller is to keep her on the phone for as short an amount of time as possible. The receptionist also expresses frustration with the fact that there are too many things to do at once. Physician’s Point of View The physician thinks too much of his time is spent on paperwork and chasing down authorizations. The physician senses that appointments are always running behind and that patients are frustrated, no matter how nice he is to them. Patient’s Point of View Patients are frustrated when asked to wait in a long line to register, which makes them late for their appointments, and when future appointments are scheduled without their input. As a result of this latter factor, and work or childcare conflicts, patients often do not show up for these scheduled appointments. Office Nurse’s Point of View The office nurse feels that he is playing catch up all day long and explaining delays. The office nurse also wishes there was more time for teaching. Billing Office’s Point of View The billing office thinks some care is given that is not reimbursed because of inaccurate or incomplete insurance or demographic information or that care is denied authorization after the fact. Data On the Picker Institute website (pickerinstitute.org), you find the following patient expectations and dimensions of care for adults and children in their outpatient experiences with a hospital or clinic outpatient appointment:

Respect for patients’ values, preferences, and expressed needs • Coordination and integration of care • Information and education • Physical comfort • Emotional support and alleviation of fear and anxiety • Involvement of family and friends • Transition and continuity • Access to care Your last quarter’s worth of performance data for the clinic is:

Overall satisfaction with visit 82%

Staff is courteous and helpful 90%

Waiting room time is less than 15 minutes 64%

Examination room waiting time is less than 15 minutes 63%

Patient no-show rate 20%

Patient cancellation rate 11%

Provider cancellation rate 10%

Preregistration rate 16%

Average number of patient visits per day 16 Range of patient visits per day 10–23

1. Completely read all of the instructions.

2. Decide which problem you want to focus on as your first priority. Describe the problem and why you chose this problem.

3. State the goal for the improvement effort.

4. Identify the fundamental knowledge that is required on the team to solve this problem. Define the people you will invite to participate on the team and the fundamental knowledge they bring to the team.

5. Document the current process (as it is described in the case narrative) using a process flowchart.

6. Identify your customers and their expectations

7. Explore and prioritize root causes of the problem by doing the following: a. Brainstorm root causes and document the causes on a fishbone diagram. b. Describe how you would collect data about how frequently the root causes contribute to the problem. c. Generate hypothetical data for question 7b. Make a Pareto chart using the hypothetical data for question 7b.

8. Review the following change concepts (Langley et al. 1996). Select and explain the ones that apply to improving your process. Be sure to take into account what you have learned in steps 5 through 7. a. Eliminate waste (e.g., things that are not used, intermediaries, unnecessary duplication) b. Improve workflow (e.g., minimize handoffs, move steps in the process closer together, find and remove bottlenecks, do tasks in parallel, adjust to high and low volumes) c. Manage time (e.g., reduce set-up time and waiting time) d. Manage variation (create standard processes where appropriate) e. Design systems to avoid mistakes (use reminders)

9. Incorporating what you learned in steps 5 through 8, improve the process and document the improved process with a process flowchart or workflow diagram.

10. Decide what you will measure to monitor the voice of the process and briefly describe how you would collect the data.

11. You have completed the “Plan” phase of the Shewhart cycle. Describe briefly how you would complete the rest of the PDCA cycle.

12. Save your answers to each part of this exercise. This will become the documentation of your improvement effort.