Adult Health Clinic Patient Services

The North Carolina Center for Quality Improvement provided assistance to the agency with the QI processes and tools training and also provided the agency with the North Carolina State University (NCSU) QI experts’ technical education and local support. Specific methods and tools as described below were used during the Kaizen event to determine problem areas that could be improved with specific time constraints. This QI initiative was the agency’s first QI project after years of trying unsuccessfully to improve the AHC patient services and patient flow. After the QI team received QI training from the North Carolina Center for Quality Improvement, Cumberland County Health Department decided to apply the methods and tools to this clinic. The QI team that received formal training in turn trained QI methods and tools to the frontline staff so they could make successful small changes by applying the model for improvement. Describe how the QI initiative was implemented, including where and when it took place and how it addressed the problem. - Long wait time for prescription refills: The AHC staff addressed the prescription refill requests delay by assigning this responsibility to one specific staff member. All phone calls and prescription refill requests are now directed to that staff member, who will match the prescription refill request with the patient’s medical record and bring both the request and the medical record to the medical provider, who will approve the refill and sign. When the prescription refill is authorized and signed, she will give the authorized prescription refill to the registered nurse who will notify both the pharmacy and the patient. This process now takes between 48 and 72 hours to be completed and patients are satisfied. - Ill-defined staff responsibilities and accountability: The Kaizen lean tools helped eliminate waste activities. Responsibilities for specific tasks are now shifted and reassigned to the best trained staff to ensure effectiveness, efficiency, and quality of the medical services provided to patients. Registered nurses are now assigned to work one-on-one alongside medical providers, to be part of an efficient medical team providing quality medical care for each patient while optimizing the use of the medical providers’ time. Medical office assistants (MOAs)/certified nursing assistants (CNAs) are now assigned to handle administrative tasks, such as recording prescription refill requests and matching them with medical records, placing faxes of correspondences and laboratory and x-ray results in medical records for providers to review, and following up on referrals. MOA/CNAs can also do electrocardiograms (EKGs) and breathing treatments, but they no longer work one-on-one with physicians. The Kaizen lean tools also helped the AHC determine the need for additional qualified nursing staff to perform more specialized patient services. Therefore, two additional registered nurse positions were created after the Kaizen event. Similarly, a new medical doctor position was created for the AHC to address the high complexity of the AHC patients' medical conditions. This physician sees the AHC patients alongside the mid-level practitioner and also provides this practitioner with guidance and supervision to ensure that patients receive the highest quality of medical services. Cross-training is provided for all positions to ensure for cross-coverage during staff member’s leave of absence. With the new positions filled, the patient flow has greatly improved and there are no more backlogs of work. - Pending referrals: To ensure that all referral orders are carried out properly, the AHC QI team had assigned the specific referral task to one MOA who assumes the responsibility of doing the referral on the same day of the patient’s visit, then tracks its follow-up and places the specialists’ reports on the patient’s medical records in a timely fashion. A uniform referral tracking system was created on a Microsoft Excel spreadsheet and is now placed on the in-house share drive for easy access for consultation and update from any in-house computer. The new AHC physician, working alongside the mid-level provider, helps decrease the number of referrals to outside practitioners and specialists. - Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliance and medical records management: After eliminating waste areas and all non-value-added activities, to increase staff’s efficiency and to decrease liabilities, the AHC QI staff had assigned specific tasks to each team member. Prescription refill requests, referrals orders, laboratory, and x-ray results are now addressed daily, and patients’ medical records are being returned to the Medical Records Department promptly after the patient’s visit. “Out cards” are being used whenever medical records are pulled from one clinic to another to ensure better continuity of care. There are currently less than 20 incomplete medical records in the clinic on any given day. The training on HIPAA requirements and medical records management is provided by the HIPAA officer and is ongoing for all clinical staff and mandatory for new hires. - Incoherent and inefficient patient flow: The QI team helped the AHC staff reset their mindset, which is now oriented toward the patient-first culture, in order to help the clinic improve the quality of its patient services. The registration process is now streamlined, with improved patient sign-in and staff work stations. Forms are conveniently placed within staff’s reach within their work stations. Medical records are available at the registration desk on the afternoon prior to the patient’s appointment. The receptionist will ask the patient about any changes in their demographics and/or financial status at check-in time. If there are no changes, then the patient can be directed to the nurse. Visible signage (“Discharge,” “Lab,” “Restroom,” “Waiting area,” etc.) helps improve patient directional instructions. The workflow for the providers is now streamlined with computers conveniently installed in their working stations, and providers no longer have to return to their offices each time they need to look up medical information. Patients' medical flow sheets were redesigned to better fit the more complex Internal Medicine AHC patients' needs. Knowledgeable nurses are assigned to work alongside the providers to ensure higher efficiency and accuracy in patient care. The physician is always available within the clinic for effective guidance for the mid-level provider so as to ensure consistent quality medical care and promptness of care delivery. The AHC appointment schedules were improved with the NCSU Kaizen team’s expertise and guidance to allow adequate time flexibility for the providers to handle new or more complex established patients. To better control the patient flow, all services must have an appointment (including labs, blood pressure checks). The agency is working on installing an efficient Electronic Health Record (EHR) system to streamline the entire process of patient care. The EHR will also permanently eliminate the issue of incomplete medical records lying around in various clinic areas. Brief daily morning reports keep everyone informed of staffing status and maintain essential communication between the clinic’s staff for practicality and efficiency of operations. Cross-training of staff and back-up protocols for daily services are provided consistently to ensure clinic coverage in case of staff absences. Stakeholders: all clinic staff and their patients. Satisfaction surveys were sent out before and after the QI Initiative. The post-QI initiative satisfaction rates were higher than expected.

To measure its QI success, Cumberland County Health Department used patient and staff satisfaction surveys, measured and compared patient in-clinic time studies, and performed daily counts of the amount of work that was left incomplete. Direct observation and counting of the number of referrals and prescription refills made on time. The daily count of the number of patients served.