Hailey James, MHA student Adam Criswell, MD student Improving the quality of free care: An interprofessional approach to quality management at a student-run free clinic Hailey James, MHA student Adam Criswell, MD student

The CARES Clinic Clinic operates Mon., Tues. & Thurs. evenings 6-10 patients/night Offer psychiatry, gynecology & PT/OT services Provide free lab and radiology services and free or reduced referrals Interprofessional board – MD, PT, OT, PA, MHA & Pharmacy students,

Why Quality Improvement? Clinical Education Patient Care Patient satisfaction Patient Safety Quality care Student Learning Interprofessional Opportunity

What is quality? Safe Effective Patient-centered Timely Efficient Equitable Six dimensions of quality as defined by the Institute of Medicine in the Crossing the Quality Chasm report.

How did we decide where to start? We knew we needed to create a system of quality management Started with the results of a previous patient satisfaction study done in 2010. Ellett, JD, Campbell JA, Gonsalves WC. Patient satisfaction in a student-run free medical clinic. Fam Med 2010; 42(1): 16-18. Our aim for this quality improvement project formed in response to the results of the CARES patient satisfaction survey published in January 2010 issue of Family Medicine that found wait times had the poorest rating with a 2.92+/- 1.21 on a 5-point Likert scale. Our bigger objective was to create a system of quality management.

Continuous Quality Improvement What is our Aim? To improve patients’ perception of clinic wait times. And/or to decrease wait times. How will we know change is an improvement? Improved scores on Likert scale survey. Reduction in measured wait times. What changes can we make that will result in improvement? Answers to follow http://www.ihi.org

Data Collection Quantitative data- patient time card Qualitative data- patient focus group

Patient Time Card Data- process flow Patient arrives Patient is let into clinic Patient is taken back to patient room Patient leaves First come, first served- cannot control arrival time Have to wait for day clinic to close

Patient Time Card Data N=30 57% of patient’s time spent in the waiting room is value added. The end of the bar represents two standard deviations from the mean. 95% of patients % value added time was between the range of 29% and 85%. Value added is defined as time spent with someone in the room (a student and/or doctor). N=30

Patient Time Card Data We ran a regression and there were NO correlations between either total wait time (in patient room) or percent value-added time with patient satisfaction. However… No correlations, but very high over all satisfaction. Only 1 patient scored below 3 (or neither satisfied nor dissatisfied).

Patient Time Card Data What does this data mean? Once patients are back in a patient room they are quite satisfied We need to look for room for improvement outside of the patient room What does the qualitative data say? D.A. Thompson and P.R. Yarnold, Relating patient satisfaction to waiting time perceptions and expectations: the disconfirmation paradigm, Academic Emergency Medicine 2 (12) (1995), pp. K. Katz, B. Larson and R. Larson, Prescription for the waiting in line blues: entertain, enlighten and engage, Sloan Manag Rev (1991), pp. 44–53. Maister DH. The psychology of waiting lines. Available at: http://davidmaister.com/articles/5/52/. Accessed July 7, 2009.

Patient Focus Group- Nominal Group Technique Generate Ideas Record Ideas Discuss Ideas Vote on Ideas Immediate participant involvement Option for anonymous participation Equal participation Stimulates conversation

Patient Focus Group Feedback Alert on website on how many doctors are at clinic Ability to call the doctors Provide information of other free services in the area Have clip board outside as a patient sign in Learn more about diabetes and weight loss Expand number of clinic days Open on Saturdays Free eye care Get 3 to 6 months worth of a prescription Provide additional shelter to wait in/under

Patient Focus Group Feedback Alert on website on how many doctors are at clinic Ability to call the doctors Provide information of other free services in the area Have clip board outside as a patient sign in Learn more about diabetes and weight loss Expand number of clinic days Open on Saturdays Free eye care Get 3 to 6 months worth of a prescription Provide additional shelter to wait in/under

Changes for Improvement Create Quality Manager board position Assigned improvements to the appropriate board position Website update on number of doctors available Update CARES pamphlet and print more copies MHA students pass out clip board when they arrive Public health interest group start monthly diabetes/weight management clinic Include free eye clinic information and how to sign up in pamphlet Looking into using neighbor facility as shelter

Looked at what the data tell us Improvement cycle Defined our aims Decided what data is needed Plan Collected wait time data Held patient focus group Do Looked at what the data tell us Study Created MHA position Assigned suggested changes Act

What we learned Quality management is a culture and a way to keep a focus on the patient perspective The structure of the model has allowed us to get an insight into what our patients want. Both the quantitative and qualitative data have pointed to similar conclusions. Perception vs. length of wait times Pawlowski A. Queuing psychology: can waiting in line be fun? CNN website. Available at: http://www.cnn.com/2008/TECH/science/11/20/queuing.psychology/. Accessed July 7, 2009.

Thank you! Questions?