1. SFGH Childrens Health Center Quarterly Report # 2, September 2011 The Childrens Health Fairies Lannie Adelman, RN, MS, MBA Shonul Jain, MD Shannon Thyne, MD Katie McPeak, MD Mabel Chan, MD Jennie Trinh

2. Aim Statement Original AIM Statement For primary care patients, decrease total patient time at clinic visits (including registration, clinician time, immunizations, and labs) to <90 minutes per patient by January 1, 2012. –Ultimate goal of increasing patient visits and therefore improving access –Route to improvement is through streamlining/shortening the patient visit –Focus on improving communication/efficiency through use of huddles & pre-visit preparation (checklists)

3. Achieving AIM

4. Changes tested or implemented this Quarter Multiple PDSAs refining a checklist as tool for huddle Feedback from MEA and MDs leading to simplified check list (see next slide) Multiple PDSAs refining Huddle process –Process is not empowering the whole team – maintaining MD-centered care –Huddles dont work when we dont have enough hands –When I arrive, there is not someone there who is assigned to me. I would like to have the same person throughout the entire clinic. –Schedule variations are impeding huddle capacity Learnings from PDSAs –Our original concept of a huddle may not work. –The checklist is a helpful tool, but the most important part of team huddle is the preparation and open communication between providers and staff. –Need to continue to facilitate prepping prior to clinic. –Need to facilitate the ability to have a time in the beginning of clinic to communicate with each other.

5. Pre-visit Checklist

6. Changes tested or implemented this Quarter Other Changes Implemented Modified MEA schedules to improve staff ratios Added RN leader to group of primary care MEAs to help problem-solving and team efficiency Charts being available the day prior to clinic for prepping Focus on communication: Created posted schedule display to help anticipate busy clinic days Increased frequency of staff meetings & check-ins to disseminate information and solicit feedback Created clinic face sheet to help with name recognition and staff communication Data Wall to show progress

8. Data – Access Measures # of days

9. Data - Empanelment Total % of Patients Unassigned, by AgeTotal % of Patients Unassigned to PCPs

10. Data – Cycle Time Average time from arrival to departure whole clinic minutes GOAL Time for Each Component of Patient Visit

11. Challenges Difficult to communicate change Continued problems with morale and buy-in –Short staffed –Resistance to change –Providers not arriving on time; people still doing things their own way Unique aspects of our clinic –Busy drop-in urgent care –Academic site with trainees Some issues more difficult to fix –SPACE –Limited budget to hire new staff

12. Action Plan for Next 6 Months Where we hope to be: –Revised immunization form to streamline vaccine ordering –Hiring data coordinator to help with collection/dissemination –Panel manager –Schedules modified to allow providers to attend teaching conference; have all the MEAs present at the start of clinic and having designated time for group huddle prior to seeing patients. –Regular all-staff meetings Annual all staff retreat

13. Original concepts arent always right. Large changes can require multiple smaller adjustments prior to achieving the ultimate goal. A lot can be learned from doing small tests of change. Input and involvement from all staff is important. We realize the importance of accountability. Communication is the key! Change is good but it takes time and energy. Lessons Learned

14. We function better as a core team in the following ways… –We all share a common goal and vision. –We have realized each others strengths and assigned task appropriately. –We communicate better. Team Growth