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Case Study 1 - Improving Clinic Flow with Continuous Improvement

Case Study

I. Initial Project Topics for Improving Clinic Flow

Project Goal

The goal of this project was to begin implementing Continuous Improvement (CI) processes to improve clinic flow to be able to:

  • Improve productivity of providers, medical assistants and clinic staff.
  • Support people so they work at the top of his or her license.
  • Reduce waste from confusion (activities requiring clarification), waiting (for procedures and medications) and defects (errors, misunderstandings and incorrect acts).


The scope of this project was limited to front desk and back office processes with patients.


The approach used for this project focused on two major topics:

  • Identifying improvements with an initial CI clinic flow project (Exhibits 1 and 2).
  • Identifying future CI projects to improve clinic performance.

Results and Recommendations from Initial Continuous Improvement Clinic Flow Project

Front Desk - Check-in, Check-out and Telephone Calls

1. Improve management of incoming telephone calls.
Incoming telephone calls are handled by three front-desk people who also handle check-in and check-out of patients. Until recently, calls that could not be answered immediately rolled to voice mail and were returned between working with patients arriving at the front desk.

Add an automatic call distributor (ACD) to the telephone system to provide a holding queue and call statistics to determine call arrivals by hour of day and staffing needed to minimize delays on incoming calls. [ACD has been installed]

2. Reduce defects from incorrect patient information and inconsistent appointment types.
Patient information that is not correct at check-in impacts information on prescriptions, lab work, imaging and referrals. Defects in patient information delay patients from receiving needed support and the Clinic from effectively billing insurance companies.

Use the Aim-Measure-Change Model for Accelerating Change (Exhibit 3) to make changes that will result in reducing incorrect patient information defects. Standardize appointment types, implement training on types of appointments to use and measure performance to standards.

Back Office - Medical examinations, laboratory work and patient medical support

1. Ensure timely completion of medical records.
Timely completion of medical records is an important standard of patient care and is required by payers and accrediting organizations. A plan has been developed to ensure timely completion of medical records at the Clinic. Recently, a problem has been identified with the EMR where locked charts (complete) are designated as unlocked (not complete).

Implement the plan that has been developed to ensure medical records are closed timely for each provider. Work with the EMR vendor to resolve the problem of identification of locked and unlocked charts.

2. Implement a Team Leader to coordinate the work of medical assistants.
Medical assistants have a significant impact on the flow of work to and from providers. Provider workloads vary during the day depending on patient schedules, patient needs, no shows and other provider commitments. This can overload some medical assistants with work.

Implement a team leader position to ensure effective clinic flow and reduce delays and bottlenecks by focusing medical assistant resources where they are most needed during the day. Additionally, the team leader can document problems and errors, maintain the quality improvement focus, develop standardized work and visual controls showing clinic progress.

3. Reduce delays and defects working with patients and providers.
Several issues impact the effectiveness and efficiency of the providers and the medical assistants, including translation, lost lab specimens, medication refill processes and reminder and appointment cards. Each of these processes has delays and defects that slow the work in the back.

Use the Aim-Measure-Change Model for Accelerating Change (Exhibit 3) to reduce delays and defects in these areas:

  • Translation: Improve the efficiency and effectiveness of the translation process.
  • Lost labs: Reduce lost or misplaced labs for RML and lab results that are not returned.
  • Medication refills: Define processes for e-prescribing and reducing medication errors.
  • Reminder and appointment cards: Automate processes to minimize MA time.

II. Future Projects Topics to Improve Clinic Flow

1. Improve the Effectiveness of the EMR.

  • Develop a plan to assess strengths and weaknesses of the EMR.
  • Implement the Nursing Guide for the EMR that a provider is creating.
  • Develop guides for providers to speed use of the EMR.

2. Focus on Waste Reduction.

  • Define value from the patient’s point of view.
  • Continue improving processes to eliminate waste.
  • Standardize everyone's work in the clinic.
  • Focus on preventing errors at the source and continually track errors.
  • Modify scheduling templates to expand the number of patients seen by provider.

3. Implement Visual Controls and Measurement

  • Implement visual management tools to improve patient flow.
  • Create "Glass Wall Measures" of Performance for each provider for each day. [Clinic end times, problems and errors, patients by types and more]
  • Measure errors and problems every day throughout the clinic and evaluate them weekly.
  • Implement 5S [Sort, Set in Order, Shine, Standardize and Sustain] to smooth clinic flow.

4. Build Skills in Continuous Improvement (CI).

  • Develop skills in Lean and Six Sigma for health care.
  • Select one person to teach and coach in CI.
  • Use Kaizen events (rapid improvement events) to enhance Continuous Improvement.

5. Set Priorities for Other Topics to Improve Clinic Flow.

  • Review options on patient scheduling to maximize patients seen and ensure there are sufficient appointment times for patients.
  • Ensure inventory is correct for supplies and vaccines (especially for well-child checkups)
  • Assess traffic load and requirements for fax lines.
  • Determine how to more effectively manage no-shows by provider.
  • Ensure 90 days of e-prescribing of 40 percent of prescriptions.

Exhibit 1

Exhibit 2

Exhibit 3

Case Study 2 - Summary of Hospital Discharge Continuous Improvement Project

Case Study

The discharge process at the Hospital is complex and requires teamwork to be effective. Doctors, nurses, managers, case workers, unit clerks and others encounter delays and defects in discharging patients. This case study describes the discharge processes and needed changes to make discharge safer and more effective for patients and those who care for them.

This case study gives a brief overview of the project that focused on improving the discharge processes, including:

  • Project Goal, Scope and Approach
  • Team Participation and Acknowledgement
  • Discharge Process and Improvements Needed
  • Next Steps in Improving the Discharge Process

A. Project Goal, Scope and Approach

Project Goal
The goal of this project was to improve patient safety and the quality of discharges by reducing delays and defects and changing processes so 85 percent of patients are discharged by 2:00 p.m. each day. Patient safety issues occur at discharge when communication and instructions are not clear or when there is a problem with a prescription or the prescription is not given to the patient. Additionally, delays in discharging patients impact patient satisfaction. Other defects and delays occur during discharge that impact doctors, nurses, case managers and unit clerks.

Project Scope
The scope of this project was limited to the workflow and productivity issues related to the patient discharge process. Workflow and discharge processes were examined on two nursing units on the East floor and one the West floor working with doctors, nurses, managers, staff nurses, case managers and unit clerks.

Project Approach
The approach used for this project included these major steps:

  1. Selected nursing units of the hospital to begin analyzing the discharge process.
  2. Observed and documented workflow process of staff nurses, case managers, residents, unit clerks to define discharge process.
  3. Obtained input on defects and delays in the discharge process from patients, doctors, case managers, staff nurses.
  4. Interviewed and documented workflow processes in testing and support departments that provide services for the discharge process, including Radiology, OT/PT, Echo and Reference Lab.
  5. Worked with physicians to obtain input on project approach and assessment of results.

B. Team Participation and Acknowledgement

This project was a team effort with many people who participated in defining workflows, identifying defects and delays, describing opportunities for improvement and providing insights and perspective on discharge processes. We particularly appreciate the inputs and ideas for improvement from the nurse managers, staff nurses, case managers and unit clerks on each of the three floors.

During this project we met with a physician advisory team that included: Dr. B, Dr. C and Dr. H. We appreciate their insight and perspective on setting priorities that have significant impact on improving discharge processes.

The project team for this project included seven nurses from the quality department l. Each brought insight and perspective to make the discharge process better for patients. We particularly thank the manager in the Quality Department for her enthusiasm for improving quality and management skills in working with others.

C. Discharge Processes and Recommended Changes

These are the recommended changes from this project:

Recommendation - 1 - Improving Communication at Discharge
Design and implement an education guide for medical students and residents describing what should be said and not said regarding patient discharge and implement methods to track compliance. An education guide has been developed for attending physicians to use with medical students and residents to improve communication at discharge.

Recommendation - 2 - Early Communication on Discharge
Develop standardized work for residents to communicate bed number and patient name for patients who will be discharged to case managers early in the day, typically before 9:00 a.m. This communication should define any long lead time issues that may delay discharge and will require research by the case managers.

Recommendation - 3 - Testing Delays that Slow Discharge
Examine testing and OT/PT processes beginning in microbiology and radiology to determine changes that will produce the most significant reduction in discharge delays and defects and implement needed changes.

Recommendation - 4 - Physician Rounding Early in the Day
Work with physicians to review schedules and evaluate alternatives for rounding early each day.

Recommendation - 5 - Seeing Discharge Patients Early and Writing Orders Early
Change the rounding process so discharge patients are seen early in rounding and discharge orders are written early.

Recommendation - 6 - Adding Staff Nurse to Rounding Team
Add staff nurses to the rounding team to improve communication among Attendings, residents and staff nurses to enhance the effectiveness of the discharge process.

Recommendation - 7 - Discharge Documents and Processes at Discharge
Review and revise documents and processes used by staff nurses at discharge.

Recommendation - 8 - Standardized Work for Discharge Processes
Develop standardized work on the best methods for the staff nurse discharge process and train nurses on the new standardized work processes.

Recommendation - 9 - Gracious and Compassionate Goodbye for Patients
Implement new processes so each patient is escorted to the exit of the hospital in a wheelchair and given a gracious goodbye from a person who demonstrates genuine compassion.

Recommendation - 10 - Transportation Processes to Next Destination
Evaluate and improve transportation processes used to schedule patient transportation with family members and with other transportation services.

D. Next Steps in Improving the Discharge Process

We have developed an implementation plan that describes the priorities and resources required to continue improving the discharge process, as described in final report. Implementation Plans and Resources Required. We believe the plan will require 1024 hours of Quality Department and consulting time over 16 weeks. We believe these priorities should be used implementing the recommendation from this project:

First Priority Changes [Complete by July 20, 2012]

  1. Improve Discharge Process Used by Staff Nurses.
    • (1) Recommendation III-7 - Discharge Documents and Processes at Discharge
    • (2) Recommendation III-8 - Standardized Work for Discharge Processes
  2. Reduce Waiting Time for Test Results.
    • (1) Recommendation III-3: - Testing Delays that Slow Discharge
      Initial Focus: Radiology and Microbiology
  3. Improving Communication at Discharge (Recommendation III-1)
  4. Early communication on discharge (Recommendation III-2)
  5. Physician Rounding Early in the Day (Recommendation III-4)
  6. Adding Staff Nurse to Rounding Team (Recommendation III-6)
  7. Gracious and Compassionate Goodbye for Patients (Recommendation III-9)

Second Priority Changes [Complete by August 31, 2012]

  1. Reduce Waiting Time for Test Results.
    • (1) Recommendation III-3: - Testing Delays that Slow Discharge Second Focus: Stress Echo and Echo; OT and PT
  2. Transportation Processes to Next Destination (Recommendation III-10)

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