EXERCISE 8: IMPROVEMENT CASE STUDY

Objective

To practice quality improvement tools by applying them to an improvement effort in an ambulatory care setting.

Instructions

1. Read the following case study.

2. Follow the instructions at the end of the case.

Case Study

Background

You have just been brought in to manage a portfolio of 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 its efficiency and patient satisfaction.

Access 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 is 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 in 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 to not inconvenience the caller is to keep her on the phone for as short an amount of time as possible. The receptionist also expresses frustration with the fact that there are too many things 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 some care is given that is not reimbursed because of inaccurate or incomplete insurance or demographic information or that care is denied authorization after the fact.

Data

On the Picker Institute website (pickerinstitute.org), you find the following aptient expectations and dimensions of care for adults and children in their outpatient experiences with a hospital or clinic outpatient appointment:

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

Your last quarters worth of performance data for the clinic is:

Overall satisfaction with visit	82%
Staff is courteous and helpful	90%
Waiting room time is less than 15 minutes	64%
Examination room waiting time is less than 15 minutes	63%
Patient no-show rate	20%
Patient cancellation rate	11%
Provider cancellation rate	10%
Preregistration rate	16%
Average number of patient visits per day	16
Range of patient visits per day	1023

Explore and prioritize root causes of the problem by doing the following:

a. Brainstorm root causes and document the causes on a fishbone diagram.

b. Describe how you would collect data about how frequently the root causes contribute to the problem.

c. Generate hypothetical data for question

7b. Make a Pareto chart using the hypothetical data for question 7b.

8. Review the following change concepts (Langley et al. 1996). Select and explain the ones that apply to improving your process. Be sure to take into account what you have learned in steps 5 through 7.

a. Eliminate waste (e.g., things that are not used, intermediaries, unnecessary duplication)

b. Improve workflow (e.g., minimize handoffs, move steps in the process closer together, find and remove bottlenecks, do tasks in parallel, adjust to high and low volumes)

c. Manage time (e.g., reduce set-up time and waiting time)

d. Manage variation (create standard processes where appropriate)

e. Design systems to avoid mistakes (use reminders)

9. Incorporating what you learned in steps 5 through 8, improve the process, and document the improved process with a process flowchart or workflow diagram.

10. Decide what you will measure to monitor the voice of the process and briefly describe how you would collect the data.

11. You have completed the Plan phase of the Shewhart cycle. Describe briefly how you would complete the rest of the PDCA cycle.