Reducing Client Cycle Times for Clinical Visits

Summary

Impact Statement:

Client complaints and staff dissatisfaction with prenatal clinic wait times led the Seminole County DOH to use QI to decrease their client visit times. Focusing on modifying the prenatal scheduling matrix, eliminating duplicate charts, and decreasing the physical distance traveled between check-in and the clinic helped the team decrease wait times by 21%.

Summary:

Using the Lean Six Sigma Define, Measure, Analyze, Improve, Control (DMAIC) approach to quality improvement (QI), the Florida Department of Health in Seminole County decreased the average client cycle time for short clinical visits by 48%. On the basis of client complaints and staff dissatisfaction with shifts ending after business hours, the executive leadership requested that the quality council examine the clinical service process flow. After evaluating several clinical process components, the quality council selected client cycle time for an agency and Lean Six Sigma Green Belt certification improvement project. The multidepartmental team used client router forms to document wait and process times for clients seen for clinical services between September and October 2014 and determined the average cycle time to be 67 minutes. A benchmark of 45 minutes was obtained from state QI data.

A careful analysis of the stratified data was used to identify potential root causes and to statistically verify three contributing causes to increased client wait and processing times. These causes included duplication of charting, inadequate assigned appointment length, and the physical distance and separation of the check-in area from the clinic. The team then determined the most feasible countermeasures and implemented an action plan consisting of educating employees, eliminating redundancies, consolidating registration practices, and modifying the appointment scheduling matrix over a 3-week pilot period. Patient routers were again used to collect client cycle time data. Results showed an average cycle time of 47 minutes for short visits, a 21% decrease since implementing the countermeasures.

Organization that conducted the QI initiative:

Florida Department of Health in Seminole County

Citation:

Warren, S. Public Health Quality Improvement Exchange. Reducing Client Cycle Times for Clinical Visits. Tue, 05/05/2015 - 09:35. Available at http://phqix.org/content/reducing-client-cycle-times-clinical-visits. Accessed April 19, 2024.

Background and Aim

Aim statement:

The goal of this project was to reduce client cycle times through the clinic for short visits to the identified benchmark of 45 minutes by March 20, 2015. Project objectives included integrating client registration into the clinical area, eliminating duplicate charting by establishing electronic-only charting, and modifying the clinical schedule to allow all programs to be seen Monday through Friday.

Need For The QI Initiative:

The need for this initiative was based on the current organizational strategic plan and directive by the executive leadership team to review clinical service processes. Based on the selection matrix completed by quality council members, client cycle time for clinical services was identified as needing the most improvement and having the biggest impact on stakeholder groups.

Area for Improvement:

The Florida Department of Health in Seminole County serves roughly 60 clients per day who seek clinical services under the family planning, sexually transmitted disease (STD)/HIV, prenatal, adult, and child health programs. The agency had received several customer complaints that clinical visits exceeded their time expectations, along with internal complaints regarding staff working past normal business hours in completing scheduled client visits. A 2-month review of cycle times was conducted using client routers. Results from the review identified that the average time from check-in to check-out for all short client visits was 67 minutes. This cycle time far exceeded the recommended average of 45 minutes provided by the state Practice Management Institute. The purpose of this project was to reduce client cycle times through the clinic.

Root Cause:

As part of the Analyze step of the DMAIC model, a cause-and-effect diagram was completed. The team identified three root causes. First, client cycle time was increased because of the physical separation between the client registration area and the clinic. To confirm this root cause, registration representatives were asked to wear pedometers while completing the tasks required to register a client and provide required documentation to the clinical team. Results showed that on average, registration representatives were walking 2.5 miles per day (110 steps per client) to provide this information. These steps and procedures were adding 10 minutes to each clinical appointment. Second, client cycle time was increased because of the duplication of charting. Current practices required clinical representatives to provide both electronic and manual documentation for the medical record related to the client’s visit. Through data collected on completed client routers, it was shown that duplicating work added an average of 20 minutes to a clinical visit. Third, inadequate appointment lengths assigned for certain types of visits caused an increase in cycle time. Router information identified that although established prenatal appointments were available/scheduled every 10 minutes, the average time a provider and nurse spent for an established prenatal appointment was 20 minutes. Staff discovered that on days when established prenatal appointments were booked back to back, wait and processing times were significantly higher than on days when prenatal appointments were not booked back to back.

Planning and Execution Details

QI Implementation:

After stratifying and comparing various client information collected via routers for a 2-month time span, operational and clinical staff engaged in a brainstorming session to identify potential root causes affecting client cycle times. The QI project team then reviewed suggestions to determine which ideas could be validated through the collected client information and to what statistical level of value was the issue affecting overall client cycle times. Three validated root causes were identified, and each added a minimum of 10 non-value-added minutes to every cycle time. A countermeasure matrix was generated to show the most feasible and effective practical methods for reducing waste and overcoming the root causes. Next, a barriers and aids analysis was completed to see what potential concerns could arise while implementing the countermeasures and what tools and aids were available to overcome those issues. An action plan was developed to handle the remaining barriers. The action plan included the person responsible for completing the action and the steps that needed to be completed and by when. Once these barriers were identified and an action plan was in place, the countermeasures were implemented. First, appointment length and availability were changed for established prenatal clients. Responsibility for completing this change and ensuring staff awareness was given to the operational manager, who ensured that training was completed 1 week before the new schedule rollout, with many electronic and posted follow-up education notifications provided to all affected employees. Next, manual charting in the client records was stopped for the family planning, child health, and STD/HIV programs, in which charting was completely available online and approved by the local medical director and state office. The nursing director and medical director completed countermeasure implementation. Finally, client registration and check-in were moved to the clinical area. The operations manager identified a new location and conducted setup and staff education regarding the new clinical flow and training. These countermeasures were enacted on February 9, 2015. From February 16 to March 6, 2015, client routers were again used to collect client information and cycle times. Results from these routers showed a 21% reduction in client cycle time for short visits.

Focus activities

Screening for diseases and conditions:

Other STDs

Maternal and Child Health Services:

Family planning

Prenatal care

Other Public Health Services:

Access to care

QI Methods:

Lean/Six Sigma

Other QI Methods:

Barriers and aids analysis,

countermeasure matrix,

time studies,

prioritized action plan

QI Tools:

Brainstorming

Cause and Effect Diagrams

QI Tool Documentation:

DOH-Seminole Right on Time Presentation.pptx

Initiative Dates:

9/1/14 to 3/20/15

Methods of evaluation:

Various forms of qualitative and quantitative data were used to evaluate the process and outcome measures for the QI initiative. Client routers were used both before and after the initiative to determine what type of effect the implemented countermeasures had on the overall client cycle time and project outcome. Router information was stratified to identify any commonalities or visit similarities that increased cycle time. Internal stakeholder meetings were held routinely to gauge employees' understanding and engagement in current process measures. An action plan was developed with established target dates to keep the project on track and to ensure that milestones were met in a timely fashion. To ensure the continuation of project goals, suggestion boards were placed in the clinical staff room to request recommendations or suggestions on other potential root causes to investigate related to client cycle time. Weekly, 10% of all clients seen for short clinical visits have their cycle times documented to determine whether wait and process times are remaining at the current level, increasing, or decreasing. Sampling results are posted in the clinical area to support accountability and promote employee engagement.

Supplemental Materials:

Sample of materials produced

Report

Results

Measurable QI Outcomes:

Client routers completed during the 3-week pilot period after implementing the identified countermeasures showed a 21% reduction in overall client cycle time for short clinical visits. The average time for clients from check-in to check-out went from 67 minutes before the project to 47 minutes after the project. In the months since implementation of this project, staff work beyond normal business hours has been reduced from 26% to 0%. No client complaints have been received regarding cycle time for clinical services. Random client cycle time audits since implementation have shown a continuation of an average 47-minute cycle time. As of April 1, 2015, implemented countermeasures have supported a current clinical cycle time of 46 minutes.

Other QI Outcomes:

Employee engagement regarding clinical process initiatives has increased based on the results obtained from this project. Staff education and awareness of QI practices and methods have increased to support a QI culture.

Lessons Learned, Observations and Insights:

Lessons learned and future plans are as follows: 1. Clinical services and the scope of the health department continue to change as the community's needs change. It is imperative to keep updated data to ensure understanding of clinical flow. 2. Identification of changes regarding the prenatal program may affect future clinic flow. It is now anticipated that prenatal clinical services will end within the year, which will affect cycle times. 3. The decreased need for physical charts has generated a cost savings for the organization estimated at $5,000 yearly.

Future Plans:

Project information and results have been and are anticipated to be presented locally (via a town hall event), statewide (via the Office for Quality Improvement), and nationally during the upcoming Annual Sterling Conference. The continuation of client routers and posted cycle time results support the likelihood of project continuation. Future plans for monitoring and maintaining the improvements have been addressed in the current action plan, over which the quality council maintains responsibility.

Reducing Client Cycle Times for Clinical Visits

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Collaborations

Contact Information of the Submitter

QI Spotlight

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Reducing Client Cycle Times for Clinical Visits

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Collaborations

Contact Information of the Submitter

QI Spotlight