Case Study Background You have just been brought in to manage several specialty clinics in a large multi-physician group practice in an academic medical center. The clinics reside in a multi-clinic facility that houses primary care and specialty practices, as well as a satellite laboratory and radiology and pharmacy services. The practice provides the following centralized services for each of its clinics: registration, payer interface (e.g., authorization), and billing. The CEO of the practice has asked you to initially devote your attention to Clinic X to improve efficiency and patient satisfaction. Current Process A primary care physician (or member of the office staff), patient, or family member calls the receptionist at Clinic X to request an appointment. If the receptionist is in the middle of helping a patient in person, the caller is asked to hold. The receptionist then asks the caller, How may I help you? If the caller is requesting an appointment within the next month, the appointment date and time are made and given verbally to the caller. If the caller asks additional questions, the receptionist provides answers. The caller is then given the toll-free preregistration phone number and asked to preregister before the date of the scheduled appointment. If the requested appointment is beyond a 30-day period, the callers name and address are put in a future file because physician availability is given only one month in advance. Every month, the receptionist reviews the future file and schedules an appointment for each person on the list, and a confirmation is automatically mailed to the caller. When a patient preregisters, the financial office is automatically notified and performs the necessary insurance checks and authorizations for the appropriate insurance plan. If the patient does not preregister, when the patient arrives at the clinic on the day of the appointment and checks in with the specialty clinic receptionist, she is asked to first go to the central registration area to register. Any obvious problems with authorization are corrected before the patient returns to the specialty clinic waiting room. Receptionists Point of View The receptionist has determined that the best way not to inconvenience the caller is to keep her on the phone for the shortest period possible. The receptionist expresses frustration with the fact that there are too many tasks in the office to do at once. Physicians Point of View The physician thinks too much of his time is spent on paperwork and chasing down authorizations. The physician senses that appointments are always running behind and that patients are frustrated, no matter how nice he is to them. Patients Point of View Patients are frustrated when asked to wait in a long line to register, which makes them late for their appointments, and when future appointments are scheduled without their input. As a result of this latter factor, and work or childcare conflicts, patients often do not show up for these scheduled appointments. Office Nurses Point of View The office nurse feels that he is playing catch up all day long and explaining delays. The office nurse also wishes there was more time for teaching. Billing Offices Point of View The billing office thinks that physicians are giving some care that is not reimbursed because of inaccurate or incomplete insurance or demographic information, and observes that some care is denied authorization after the fact. Patient Satisfaction Measures All clinics in the multi-physician group contract with a customer satisfaction measurement firm that administers customer surveys. This survey is sent to the random sample of patients at each clinic to determine their satisfaction ratings for eight dimensions of outpatient and inpatient care for adults and children: Respect for patients values, preferences, and expressed needs Coordination and integration of care Information and education Physical comfort Emotional support and alleviation of fear and anxiety Involvement of family and friends Transition and continuity Access to care Here are the results of 200 customers ranking these eight items from most important to least important: Topic 1. Respect for patients values, preferences, and expressed needs 2. Coordination and integration of care 3. Information and education 4. Physical comfort 5. Emotional support and alleviation of fear and anxiety 6. Involvement of family and friends 7. Transition and continuity 8. Access to care Performance Data The last quarters worth of performance data for Clinic X are found in the following table: Overall satisfaction with visit rated as very good or excellent 82% Staff courtesy and helpfulness rated as very good or excellent 90% Waiting room time for patients is less than 15 minutes 64% Examination room waiting time is less than 15 minutes 63% Patient no-show rate 20% Patient appointment cancellation rate 11% Provider appointment cancellation rate 10% Rate of initial insurance claim rejections because of inaccurate or incomplete patient record documentation 4% Patient preregistration rate 16% Average number of patient visits per day 16 Range of patient visits per day 10-23 1.How would the use of a flow chart (quality improvement tool) help you document the current process? Explain. 2. Identify the customer(s) of the process you chose to be improved and their expectations. 3. Once you have designed a change for your process, would a flowchart or work flow diagram (maybe both) help you describe the change to your process? (You do not have to draw one out, just explain). Explain your answer. 4. Decide what you will measure to monitor process performance to be sure your changes were effective and briefly describe how you would collect the data. Explain your answer. 5. You have completed the Plan phase of the Shewhart cycle (PDSA). Why is using a performance improvement model such as the PDSA or FADE important in your quality improvement efforts