Improving Phone Message Follow Up At Keene Family Medicine Clinic Performance Improvement Leader ship Development Program University of Missouri Fall 2010

“90% of all QI work begins after your PI-LDP course is completed” Les Hall, PI-LDP, Fall 2010

Team Members  Rhonda Spooner – Service Coordinator, UP Keene Family Medicine Clinic  Lisa Brockman, L.P.N – Charge Nurse, UP Keene Family Medicine Clinic  Susan Pereira, M.D. – Team Leader, Medical Director UP Keene Family Medicine Clinic  Advisors: Phil Vinyard- MBA, MHA – Asst Manager, Green Meadows & Woodrail Family Medicine Clinics; David Sohl, MHA – Project Manager, Service Excellence  Executive Sponsor: Steve Zweig, M.D., M.S.P.H. – Professor and Chair, University of Missouri Department of Family and Community Medicine

Patient and Family Centered Care How does this project correlate? Improved communication leads to better care Patients deserve timely notification of results, and timely responses to queries. Engaged Staff is palpable to patients/consumers. Satisfied and appropriately cared for patients reflect positively on the institution and the likelihood of increased referrals within the system

Patient Comments Source : Press Ganey Surveys, ; patient exit questionnaires “ I left 3 messages and no one called me back” “ I love this clinic, but getting through on the phone is a nightmare“ “ The phones ring and ring and I never get a chance to leave a message” “ I called 3 times and still haven’t heard about my lab results” “ I took 28 messages off the machine this morning, and 20 of them required call backs for more information”, Cheri, PSR

UP Keene Family Medicine The Players Providers: 4 Physicians ( 3 full time clinical faculty= 7-8 clinics per week; 1 75 % clinical faculty=5 clinics per week), 1 Nurse Practioner (5 acute care clinics per week), 1 Cardiologist ( 1 clinic per week ) Nurses: 4 floor nurses, 1 triage nurse PSR’s: 6

The Scope of the Problem One Tuesday morning in November: 34 messages taken between 8 am and 11:30 am= 340 messages per week 30 % of calls are for medication refills 25 % of calls require gathering of information from patient 40 % of calls are sent to physician/ providers for clinical decision making Time from initiation of message to meaningful patient contact : <1 hour- 4 days Average number of touches per message: 5

Aim Statement By July 1, 2011, 75 % of all phone calls requiring additional clinical decision making will have meaningful patient contact within 4 business hours.

The Real Aim “No Dropped Calls”

Timing of messages, snapshot, November 2010 Phone message total, 8am- 11:30: 34 Time range to resolution/Patient Contact=message completion: Minimum: 12 minutes Maximum: > 3 days 10/20 messages resolved in <4 business hours ( 50%, Goal 75%) 8/20 resolved in 5-10 business hours 2/20 resolved in >10 business hours ( up to 72 hours after message taken).

Pt calls clinic PSR creates message Perfect Process of Phone Refill Message Correct data? Med on protocol? Med called in, EMR updated Message sent to triage nurse Med refill? Message complete Message type appropriate? Yes

Current Phone Message Process PSR takes message Correct message type? Message to Triage Nurse Message sent to provider Yes Provider sends decision/response to triage nurse No Provider checks message? Message stalled No Yes Pt Notified All relevant information present? No

Driver Diagram Reduced time to resolution PowerChart Training of all stakeholders Reduced Volume of calls Incomplete message data Wrong message type Patient call backs excessive Multiple Calls for refills Multiple calls for results Volume of calls increased during peak illness seasons Volume of calls higher depending on day of week Providers inconsistent use of PowerChart tools Providers reply to messages inconsistently Provider service Excellence Appropriate Patient Expectations

Intervention Options Pharmacy Phone Line, E-Script Utilization of tools via PowerChart Phone Message Type Standardization of Message Information Gathering Patient and Provider Education Regarding Follow-up and Results Health-E

Proposed Timeline for Interventions Phone tree (March 2011) Message Inbox standards- Proxies, “out of office” tools, patient communication- Current, In Progress Staff education- Current, In Progress Provider education (Letter templates for results reporting, patient expectations, pro-activity to anticipate follow up)-In Progress Pharmacy routing (E-scripts, EMR updates, Pharmacy Faxing, single staff ownership of refills)- Current Health-E ( Yesterday??- Fall 2011?)

Return On Investment Press Ganey Score Improvement reduced workload for staff and providers Patient satisfaction and increase referral base, recommendation of clinic and providers Better outcomes and better care Staff satisfaction- buy in from changes: efficiency, accuracy

Lessons Learned: Things are not always what they seem… Volume of calls is inconsistent, but consistently numerous Inconsistency of message response from providers Inconsistent message typing Do we need to consider the culture of phone messages? Not all messages are necessary The reasons we think processes break down are often not the reasons they break down To understand a process in order to effect improvement, the process must be understood in all of it’s complexities, as viewed from multiple perspectives and vantage points of all stakeholders

Summary A phone message as an avenue for extended patient care is complex and is influenced by many variables Not all communication with patients in the form of phone messaging is appropriate nor necessary When all participants have clear expectations and adequate support and training, any complex process can, and will likely, improve All team members (clinic, OR, ancillary service) have a part in the patient experience and all members are significant.