Reducing Charting Time at Lakelands Family Health Team Dr. Matt Dumas and Lakelands Family Health Team, September 2017

Overall Vision "Improve efficiency of workflow at our Family Health Team to be able to provide care for more patients"

Baseline Data Data collection started May 8 (Week 1) 2 weekly average times collected: 1) Overall time spent seeing patients, including charting (Median 27 mins) 2) Time spent charting visits (Median 7 mins) First 3 weeks used as baseline because: 1) It's a reasonable estimation of all weeks prior 2) First change made after Week 3 3) n > 100 patients for 1st 3 weeks

5 W and 2 H Root Cause Analysis 1. What is the inefficiency? - Takes too long to chart visits (Baseline Median = 7 mins) 2. Why is it a problem? - 7 mins x 15-20 patients/day = 105-140 minutes 3. Where do we encounter the inefficiency? - Clinic 4. Who is impacted by the inefficiency? - Patients who can't get appointments 5. When did we first encounter the inefficiency? - Every day 6. How did we know there was an inefficiency? - High Third Next Available (20-30 days) 7. How often do we encounter this inefficiency? - At every patient visit

Aim Statement By September 11, 2017, Dr. Matt Dumas will reduce charting time to less than 4 minutes. 3 minutes saved per patient x 20 patients = 1 hour per day.

PSS and OCEAN PSS: Electronic Medical Record (EMR) PSS: Has "Encounter Assistants" (EA's) to speed up data entry OCEAN: Provides > 1000 forms (ie Low Back Pain, Upper Respiratory Infection) OCEAN: Patients can provide a detailed history before the visit on secure tablets that automatically updates the EMR once they tap "Finish" Dr Dumas was underutilizing both resources

OCEAN BPI Preview

Finished BPI (Test Patient)

1. Reduce charting time to < 4 minutes 2. Significantly reduced charting time 3. a) OCEAN forms for all visits 3. b) Use more PSS Encounter Assistants

1. Plan 2. Do (2 changes made) 3. Study 4. Act - Baseline data used to understand source of inefficiency - Planned to reduce charting time via PSS EA's and OCEAN tablets - Also planned to use modified Process Map 2. Do (2 changes made) - Week 3 used EA's for Mental Health and URI's - Week 5 adopted OCEAN, Process Map change and more EA's 3. Study - Significant reduction in Charting Time - Measure = minutes charting per patient 4. Act - Implement changes - Look for next opportunity for continuous improvement

Process Map as of June 16, 2017 (Week 5) 3. Chairs 5. Back Room (PEx) 4. My Desk (History) 6. Back to Desk (Finish Visit ie print prescription) 2. BP Room Baseline median for steps 4-8 = 27 mins Step 8 baseline median: 7 mins 7. Finish visit/Exit office 8. MD Charts Visit 1. Wait Room

Suggested Process Map using OCEAN 3. Chairs 4. Back Room (Pex) - History already reviewed 5. My Desk Finish ie print script 6. Desk (Finish ie print prescription) 2. BP Room OCEAN allows review of history before visit and potentially lowers charting time Duplicate stop at Desk eliminated 6. Finish visit/Exit office 7. MD Charts Visit 1. OCEAN in wait room, ie most of History and MD reviews OCEAN note before visit

Run Chart: Charting Time

Conclusion Project length 16 weeks (May 8 - Aug 15, 2017) Challenge: No industry standard exists to define an optimal Charting Time Significant reduction in charting time achieved Systemic change increases likelihood of sustainability Change did not require extra resources Changes can now be implemented Next search for a continuous improvement target can begin

1) Health Quality Ontario's IDEAS Advanced Learning Program Acknowledgements I gratefully acknowledge the education gained from (no affiliation with either organization): 1) Health Quality Ontario's IDEAS Advanced Learning Program 2) University of Toronto's Rotman School of Management Advanced System Leadership Program