1. Quality Improvement in Efficiency and Patient Wait Time
Primary Care Clinic
Efficiency and Patient Wait Time
DD Villarreal; A Phan; J Banales; ML Harline; D Ramirez; RC Stepp; J Vasquez; C Cardiel; R Kaushik; R Huston; R Wayne; M Barajaz; C Davenport
Department of Pediatrics. Baylor College of Medicine.
The Children’s Hospital of San Antonio. San Antonio, TX
ABSTRACT
In an effort to reduce the wait time in our primary care clinic, we set out to implement small changes throughout our intern year to improve efficiency. Our primary aim was to reduce the wait time from patient arrival to being seen by a provider by 25% within 6 months in the primary care clinic. We utilized the Institute for Healthcare Improvement model for improvement and completed 4 PDSA cycles. Within 6 months, we have reduced time from arrival to being seen by a provider from 68 minutes to 45 minutes, a reduction of 34% (Figure 1B).
Aim:
To reduce clinic wait time from check-in to seeing the provider by 25% within 6 months
INTERVENTIONS
A series of PDSA cycles were utilized to optimize the timing and flow of our clinic with continuous feedback from our stakeholders.
(1) A pre-clinic huddle was instituted between providers, medical assistants, and front desk staff.
(2) Medical assistants participated in cross-training to learn how to perform each task in the clinic and one de-centralized scheduler was designated to our clinic.
(3) Computers were turned on in the patient rooms early in the morning, medical assistants began providing the immunization records for every patient being seen that day to the providers at the beginning of their clinic day for review, and providers began ordering vaccines at the beginning of each patient visit.
(4) A second de-centralized scheduler was designated to our clinic.
EVERYTHING FOR OUR CHILDRENTM
BACKGROUND
Patient satisfaction has been shown in many studies to be directly linked to patient wait time [1]. The value of time becomes even more apparent when the patient is a hungry toddler whose parent has taken time off work for the clinic visit.
As interns, we decided to try to improve our clinic wait times over several months. We observed how the clinic system worked as we followed patients through check-in, intake, exam, and check-out. We stratified all the key players in the clinic by high and low influence, and high and low involvement. We sought input and encouraged discussion among clinic staff and providers when creating interventions.
DATA ANALYSIS
Data was obtained using the Athena Electronic Medical Records (EMR) reports feature. We analyzed the Wait Time for Provider as the interval from check-in start time to exam start time. We analyzed the Total Visit Time as the interval from check-in start time to check-out start time. After taking a mean and standard deviation (SD) for both of those time intervals, the patient encounter was considered an outlier and excluded from further analysis if one of those time intervals was outside of 2 SD of the mean. These outliers occurred from operator error in the Athena EMR or were often explained by having patients sent off to perform urgent lab work or imaging inside the hospital, and then returning to the primary care clinic to complete their appointment.
RESULTS
Figure 1. As a clinic, we saw about the same number of average patients per day during the 5 cycle time periods (42.2, 48.3, 47.8, 47.0, and 45.6 patients per day, in chronological order). We decreased Total Clinic Visit Time from 107 minutes to 80 minutes (25%) (A). We decreased Wait Time for Provider from 68 minutes to 45 minutes (34%) (B). A B
Baseline
Pre-Clinic Huddle
Baseline
Pre-Clinic Huddle
MA cross-training &
1st de-centralized scheduler
MA cross-training &
1st de-centralized scheduler
Computer prep, vaccine records available for review in advance, & vaccine orders placed earlier
2nd
de-centralized scheduler
Computer prep, vaccine records available for review in advance, & vaccine orders placed earlier
2nd
de-centralized scheduler
CONCLUSIONS
Following the implementation of the above interventions, both wait time to be seen by a provider and total clinic visit time were substantially reduced. Complex variables outside of the control of providers (such as insufficient number of staff or outdated technologies) may prove challenging, so it is imperative that clinic teams work together to implement practical changes. These changes led to dramatic improvements despite immediate inability to incorporate broader, more costly system changes. Our hope is that these results may encourage others involved in ambulatory care to realize the effect of small, simple changes on the very important metric of patient wait time.
ACKNOWLEDGEMENTS
Special thanks to all of the third floor clinic staff who effectively implemented all of the interventions discussed above: Jackie Aguirre, Caroline Campacos, Samantha Castillo, Stephanie Escalera, Vangie Martinez, Joyce Medina, Melissa Mejia, Mireya Muniz, Natalie Nava, Christina Pantoja, Mark Riojas, Rose Suarez, Tanya Valdez, and Sandra Vargas.
REFERENCES
Michael, M., S. D. Schaffer, et al. Improving wait times and patient satisfaction in primary care. Journal for Healthcare Quality: official publication of the National Association for Healthcare Quality, (2):
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