Quality improvement report

Losing the wait: improving patient cycle time in principal care

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  1. Jehni Robinson1,
  2. Melody Porterone,
  3. Yara Montalvoone,
  4. Carol J Peden2
  1. one Family unit Medicine, USC Keck School of Medicine, Los Angeles, California, USA
  2. two Gehr Family unit Centre for Health Systems Scientific discipline and Innovation, USC Keck School of Medicine, Los Angeles, California, USA
  1. Correspondence to Dr Jehni Robinson; jehni.robinson{at}med.usc.edu

Abstruse

Inefficient clinic systems leading to prolonged expect times at primary care clinics are a source of frustration for patients, physicians, staff and administration. Measuring and shortening cycle fourth dimension has the potential to improve patient experience, staff satisfaction and patient access past moving more patients through in a shorter cycle time. Limited studies have demonstrated that improvements can be made to cycle time and may result in improved patient satisfaction. Well-nigh of these studies have focused their efforts on improving efficiency at the forepart of the cycle. Our aim was to improve cycle time for the whole visit to less than 60 min within 1 twelvemonth by engaging our squad in brainstorming solutions, presenting regular measurements to our team for review and holding regular meetings to plan rapid improvement cycles. Over the course of 1 year (2017), we were able to reduce cycle fourth dimension by 12% from 71 to 65 min and to amend patient satisfaction with care. Despite the reduction in cycle time, nosotros maintained high satisfaction scores from patients who felt that the doctor spent enough fourth dimension with them. We learnt the value of engaging our team, frequent measurement for reporting, adequate staffing at the beginning of dispensary, and the value of MA staff acting in a flow coordinator role. We have non only maintained this improvement but as well made further small-scale gains over the subsequent 2 years, and by April 2019, our cycle time is at 60 min, despite a marked increase in patient book. Additional work on the fourth dimension after the patient is roomed and waiting for a doctor, and farther analysis of the physician workflow would be important next steps to drive farther comeback.

  • continuous quality improvement
  • teams
  • primary care

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  • continuous quality improvement
  • teams
  • primary care

Problem

Extended patient expect time detracts from patient experience and system productivity. Long cycle times negatively touch on patient, physician and staff satisfaction as clinics run late, and staff have to manage dissatisfied patients and incur overtime and missed breaks. Much of the time the patient spends in the clinic is not spent with the doc merely is spent waiting for them and is therefore non value added and wasteful for the patient. Additionally, inefficient patient flow limits the number of patients that can exist seen each solar day, negatively impacting admission to intendance besides every bit dispensary productivity.

Our family unit medicine clinic is located on the campus of Keck Medical Centre of Academy of Southern California (USC), a large health system affiliated with the Keck School of Medicine at the Academy of Southern California in Los Angeles. Nosotros serve a medically complex and ethnically diverse patient population and provide a wide range of main intendance services, including acute and chronic illness intendance besides every bit preventive services to children and adults. The family medicine dispensary is part of a multispecialty group practice. Our family medicine team consists of physicians, physician administration, nursing staff and registration and discharge staff who see approximately fifteen 000 patient visits per year. The dispensary is managed through a partnership betwixt hospital administration and family medicine kinesthesia leadership and has experienced pregnant growth with an average of 20% new patients per year, which has put force per unit area on the arrangement to improve its efficiency.

Our aim therefore was to decrease cycle time to 60 min or less from a baseline of 71 min inside 12 months of starting our project, and to improve patient satisfaction with await time while maintaining satisfaction with the quality of care provided.

Background

Access to care is a critical measure in determining the chapters of a healthcare system to provide for the needs of new and existing patients. Barriers to access, including inefficiencies that lead to expect times at dispensary visits, are not well studied, and data on quality improvement efforts to improve the efficiency of intendance are minimal. The vast bulk of piece of work in this expanse has been washed on the wait time to get an appointment.ane The few studies that exist on waiting time in the clinic have demonstrated that wait times detract from patient satisfaction and negatively touch on the likelihood that patients volition recommend the practice to others.2 3 A team from a federally qualified health centre4 5 used the Dartmouth microsystem improvement curriculum framework and plan–practice–study–human action (PDSA) cycles to bulldoze change. Their work involved engaging everyone in the clinic (the microsystem) in continuous procedure improvement, using information to track change, and establishing an agreement of positive and productive connections with other parts of the healthcare arrangement, while running rapid improvement cycles. Interventions tried, focused on improving front-end operations associated with registration and showed minimal improvements in wait time with no improvement in patient satisfaction.iv 5 Comprehensive strategies, including optimising scheduling by eliminating overbooking, improving staff communication, patient education and quarterly dr. reports, were tested without significant improvements in turnaround time in a chronic diabetes clinic,vi although patient and staff satisfaction improved. Operational improvements at belch and payment were seen. Lean and Six Sigma procedure flow mapping and spaghetti charts were used to document opportunities for process comeback in a paediatric dispensary with modest gains, showing improvement in cycle time from 113 to 90 min and comeback in patient satisfaction from 88% to 95%.7 The overarching principles of visit planning, colocation of central staff, office design, streamlining check-in, standardising exam rooms, using documentation brusque cuts and streamlining checkouts have been described as areas to work on to improve visit cycle time.8 All of the aforementioned studies plant significant delays at the beginning of the process and during the time with the physician. While minimal improvements were made, sustained comeback over time has not been documented in whatsoever of the previous studies.

Measurement

We measured bike fourth dimension and patient satisfaction and looked at balancing measures every bit we made changes to ensure that improving efficiency did not negatively bear on feel of care. We specifically looked to see if patients felt rushed, or that at that place had been inadequate time spent during the visit.

Wheel time is defined as the fourth dimension from check-in at registration to check-out at discharge and is captured through automatic time stamps documented in our electronic health record when sure tasks are completed. This time was subdivided into 'time from check in completed' to 'seen by nurse' so 'seen by nurse' to 'seen by doc'. We measured patient satisfaction on Group Consumer Cess of Healthcare Providers and Systems' (CGCAPS) surveys: 'run across my provider within xv min' metric. Additionally, and as part of our improvement piece of work, we started to collect self-reported point of care patient satisfaction at checkout, asking patients to rate their overall experience, and more specifically whether or not they felt rushed during the appointment, and their impression that 'my doctor takes fourth dimension to hear what I accept to say'. At baseline in Oct 2016, family medicine total average wheel time was 71 min, comprising 18 min from check-in to seen by nurse, and 53 min from seen past nurse to check-out, as measured for 369 patients. These data were abstracted from the electronic health tape via time stamps when cycle time components were completed. Cycle fourth dimension reports, including the breakdown of components of the time, were delivered monthly to staff for review.

Despite the fact that appointment visits were scheduled for 20 or 40 min, a baseline cycle time of 71 min included boosted not-value-added time spent waiting. Nosotros believed this additional wasted, waiting time contributed to our poor patient feel scores. At baseline, on CGCAPS patient satisfaction surveys, family unit medicine was at the 50th percentile compared with other academic health centres; 82% of patients indicated that they saw their doctor within xv min of appointment time. We believed that our work on reducing bicycle time would improve patient satisfaction scores as measured past CGCAPs surveys.

Design

In 2016–2017, a physician quality and process improvement training was conducted at Keck Medical Centre led by the Heart for Health Organization Innovation and the Value Comeback role. This year-long session aimed to provide physicians with quality improvement skills to support meaningful improvement in quality beyond the healthcare system. Each physician was asked to select a project to meliorate intendance and quality in their respective department. As Vice Chair for Clinical Diplomacy with the Department of Family Medicine, I participated in this programme and was interested in improving bike time for patients seen in the family medicine dispensary.

Within the family medicine clinic, we brought together clinic registration and discharge staff, nursing, physicians and managers and reviewed our baseline data on cycle fourth dimension. Then, nosotros held a brainstorming session to get input from the entire team. Nosotros shared our baseline data and asked the grouping to brainstorm on the possible reasons for delays in clinic cycle time. Each participant wrote down all their ideas on mucilaginous notes and and then nosotros categorised the responses by the component of the patient's journey through our system. Our analysis from this session showed that about of the concerns related to the patient arriving and being registered. Additionally, our hospital'south value comeback office provided masters of health administration (MHA) interns supervised by their squad to shadow patients to create a value stream map, and certificate the steps that take identify from patient check in, to when the physician arrived in the room. Issues and delays in this process were documented, and the fourth dimension was measured for each of these steps. These data were shared with our clinic staff and physicians, and ideas were suggested to improve the processes to decrease the non-value-added time for our patients. Monthly meetings were conducted to plan PDSAs and share data on comeback. Multiple interventions were implemented over the course of several months. Calculation cycle time as a continuing agenda detail on our monthly coming together committed us to connected measurement, results review, assay and planning for boosted interventions.

Strategy

PDSA cycle 1

We hypothesised that our squad of clinic staff, physicians and avant-garde do providers would have important insights into the reasons for patient delays in cycle fourth dimension. Nosotros presented wheel fourth dimension data and brainstormed with our team most barriers to efficient patient flow. Our team had lots of of import input into reasons for delays on which they voted. Of 57 votes, 26 related to check-in; 16 of 57 related to patient care. Nosotros so wanted to get additional information to explain why delays occur during check-in.

PDSA cycle ii

We believed additional particular into why delays occurred during the cheque-in process could help design interventions to address the delays. We used the MHA interns to follow patients and complete a value stream map to identify specific steps in the cheque-in process and to better empathise inefficiencies with this procedure. The check-in process took viii min and several bug were identified, including lengthy reckoner searches for patient names, insurance-related work that was duplicated and lags when the nurse assigned to room the patient was occupied. In add-on, we observed that bank check-in time increased as the mean solar day went on. These data were reviewed with clinic staff and physicians, and several strategies were proposed to accost these concerns.

PDSA wheel 3

We decided to endeavour irresolute our medical banana (MA) schedule to ensure MAs were available to room patients at the starting time of the morning and afternoon clinic sessions. Additionally, front part staff streamlined their processes to improve patient flow. We idea this investment in increased staffing and procedure refinement at the beginning of the clinic session would help reduce cycle time. Cycle time decreased from 74 min in February 2017 to 67 min in March of 2017.

PDSA cycle 4

We held monthly team meetings to review our results and to continue to brainstorm boosted interactions. Reflecting on longer bicycle times in the heart of the day, we decided to change one doctor clinic to begin at 07:00 to decrease the volume of patients toward the end of the morning session.

PDSA cycle 5

During PDSA cycle four, we noted that measuring cycle time was requiring a significant amount of staff time, and an automated measurement was programmed into our electronic health record. This change did non work in August of 2017, then nosotros did not take information for this calendar month. By September 2017, however, cycle fourth dimension had improved to 65 min and the Electronic Health Tape (EHR) report was performance.

At this signal, we completed our initial project and, while we did not run into our goal, nosotros reduced wheel time by 12%. Most of our improvement was in the front end end of the cycle. Over the next year, we began work on reducing the wait fourth dimension after the nurse had finished with the patient. We continued to monitor and report cycle time. We began to work on improving nurse and provider advice, including morning time huddles to prepare and become ready for the day determining who needed vaccinations or other orders. Nosotros reached out to patients ahead of the visit to inquire nearly the reason for the visit to better be prepared. We discussed proactive communication and tried having the nursing staff knock on the door to enquire if anything was needed as a bespeak to permit the dr. know additional patients were waiting. Nosotros empowered the nursing staff to take on the role of flow coordinator and to help united states motility the visit forth if we were getting backside. Nosotros provided the physicians with quarterly reports that included data on their cycle time compared with their peers. These efforts resulted in boosted improvements in our cycle time, and by April 2019 we had achieved our sixty min cycle time.

Results

In October of 2016, our average cycle time was 71 min. By June 2017, we had decreased the cycle time to 63 min, a 12% decrease. This comeback occurred despite an increase in the volume of patients seen from 369 seen in October 2016 to 573 patients seen in June 2017. Our CGCAPS scores for 'See Provider within fifteen min' increased from 82% to 95% in the same time period, 'Recommend this provider role' increased from 92.5% to 100% in May and over again in June of 2017. The affect of the PDSA cycles is shown in figure ane.

Figure 1

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Figure 1

Run nautical chart of full dispensary bicycle time from the start of the project in Oct 2016 to the stop of the first phase in September 2017. PDSAs are shown, total bike time decreased from 71 to 65 min.

We likewise collected point-of-care patient satisfaction data from patients to get immediate feedback on their experience of care and found that patients gave an average score of four.83/v.0 on overall experience today; 4.88/5.0 in response to my medico did not rush me through the appointment; and 4.93/v.0 on my doctor takes the fourth dimension to hear what I have to say.

Staff and providers too responded to daily signal-of-care surveys and rated 4.8/5.0 that 'doctors and nurses work together to provide excellent care', 4.47/five to 'our front desk is calming and friendly' and 4.25/5 'patients rarely feel rushed out the door'. These balancing measures suggest that we succeeded in decreasing wait times without negatively impacting patient and staff satisfaction. As these surveys were created as role of the project, unfortunately, baseline data for these measures were non available.

Lessons and limitations

There were several central learnings from this work. First, coming together with the entire team and brainstorming about the problem and potential solutions were a valuable style to gain a meaning amount of information about our arrangement in a short period of time. It was also important to engage the team in gild to get their participation and commitment to figuring out solutions and determine where they believed the work should brainstorm. Additionally, presenting information back to the team on a monthly footing was important to maintain date and continue working to improve the system. This process also helped squad building and encouraged individuals to think about problems in our arrangement and what they might practise to ameliorate them. I limitation is that we did non include patients to help us brainstorm solutions. Including patients on this team may accept surfaced additional important ideas for improvement. Additionally, we did not have baseline information for the point-of-care patient satisfaction measures. While the responses to questions of feeling rushed and staff working together were potent when measured, we do not know how this compared with baseline before changes were made.

Second, measuring bike time was hard, although time-stamped data could exist extracted from the EHR from check-in at arrival, to check-out at belch, interpretation of these bones data required many conversations and clarifications well-nigh definitions and accurate measurement of dissimilar components of the visit. When does the wheel begin? Is it when the patient arrives or at the date time? How do you account for patients who arrive very early on or very late? To define the components was a time-intensive measurement procedure, and we spent significant time trying to figure out how to measure cycle time reliably from start to end using the electronic health record. When we finally were able to make configurations to our EHR to collect our data more meaningfully, we had a month where we could not collect accurate information (August 2017). Once nosotros had accurate overall cycle time measurement, we were still only able to further delineate into two parts: 'bank check in' to 'seen by nurse' and 'seen by nurse and seen by physician', the end signal of which signified the end of the visit (see figure 2). Additionally, the EHR was non able to distinguish fourth dimension in the exam room waiting for the clinician, from bodily face time spent with the clinician. Anecdotally, we believe there is still significant waiting time in the examination room before the clinician arrives that may be reduced without reducing valuable face-to-face up time with the patient. Going forrad, if we were to add together a further component to the EHR, it would exist a timestamp to be entered by the doctor when they start their actual consultation. Additional analysis of how clinicians spend their time, value-added time spent face-to-confront with patients, versus non-value-added time spent on paperwork or administrative tasks may also help to increase value added fourth dimension with patients. In addition, we realised a meaning number of patients were non stopping at check-out, leading to invalid data for those patients who had to be taken out of our calculations. Nevertheless, nosotros likewise realised that these patients were missing central components of care such equally scheduling follow-upwardly appointments and referrals for specialty care. Taking time to do PDSA cycles on how to accurately measure out cycle time would be advisable for others doing this piece of work. Closely examining the process from starting time to cease can also assistance reveal undetected organisation errors such as patients missing checkout.

Figure 2

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Effigy ii

Cycle time for the second phase of the projection, maintenance and further improvement (September 2017–April 2019). Processes inside the overall cycle time are shown.Total cycle time fell from a mean of 66.75 min in the beginning iv months to be maintained at 60 min in the last iv months to Apr 2019. Fourth dimension spent with provider, nurse and medico vicious from a hateful of 53.5 (first four months) to 48 min. Despite a small-scale reduction in time spent with the provider, patient satisfaction scores remained high and more patients were seen in the clinics.

Third, we recognised that the MAs are a critical component to our flow every bit they are the crucial connexion with front office and with the physicians. They have the potential to play a leadership role in menstruum management. Good advice and interaction with the front office to bring registered patients back and get them set for physicians are important, likewise as communicating with and assisting the md in completion of orders to keep patients moving through the system. Physicians reported that they frequently did not know how many patients were waiting to exist seen and that proactive MAs who alerted them to the arrival of the next patient could assistance to keep them on fourth dimension. This critical period coordinator office was underappreciated. Additionally, overloading the MAs with boosted tasks fabricated information technology difficult for them to fulfil both rooming patients and carrying out orders and moving patients to discharge. Farther training in proactively managing menstruation of patients and ensuring adequate staffing is key to successful clinic period.

Finally, it is interesting to note that the improvements made in our written report and other studies4–7 have largely focused on improving the processes at the offset of clinic related to registration and rooming, and yet, the majority of fourth dimension spent in clinic is waiting for the physician to make it in the room, completing the doctor run across and waiting for orders afterwards to be completed. Our staff and physicians were most interested in working on the delays at the get-go of clinic. There exists some doubt and trepidation well-nigh tackling the time patients are waiting in the examination room for the physician and the time the dr. spends with the patient and on orders. This may be due to the large book of clerical piece of work that physicians are responsible for, and the inherent challenge of managing several complicated medical problems besides as addressing health maintenance issues in a busy primary care practice. The interest in providing comprehensive care may conflict with the interest to provide efficient care.

Conclusion

In the context of increasing demand for chief care, reducing cycle time holds promise of increasing satisfaction for patients and staff, every bit well increased visit efficiency leading to potential for more patients to receive care. This study adds to the small volume of studies that take focused on improving throughput in primary intendance by focusing on improving efficiency at the beginning of the bicycle. Information technology demonstrates the value of engagement of the entire care team and the utilise of frequent measurement and reporting to bulldoze comeback. While the aim of reducing wheel time to less than 60 min was non met during our initial project period, a 12% reduction in time did occur and patient satisfaction increased. Subsequent piece of work edifice on our learning allowed us to reach and sustain our goal over the next year. Balancing measures demonstrated that patients yet felt their physicians spent adequate fourth dimension with them and addressed their concerns. Boosted resources that provided QI training for the lead physician and the apply of MHA interns to help with documenting delays in the process helped to quantify delays and provided additional data on steps that contributed to the delays. This also helped to go some input from patients as well. These resources, provided by the wellness system, were instrumental to the success of this report. While we did not measure out costs or additional revenue, theoretically, the ability to see additional patients based on a more efficient system could generate additional acquirement to pay for these costs or the costs of additional staffing to support improving efficiency. We have also inverse our civilization to include measuring and improving care, as well as empowering our team to come together to create solutions to problems. The meaning impact of primary care exhaustion among staff and physicians with dysfunctional systems, and the move to value-based care argues for additional inquiry and resources towards improving the provision of high-quality, efficient primary care systems. Nosotros intend to continue to mensurate and report on bike fourth dimension and to keep to engage our team on the path to improvement. Further test of the workflow of the physicians, the role of nursing staff and the communication between this team will be important next steps to further amend wheel time.

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© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-employ. Run into rights and permissions. Published by BMJ. http://creativecommons.org/licenses/by-nc/iv.0/ This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC Past-NC 4.0) license, which permits others to distribute, remix, suit, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the employ is non-commercial. See: http://creativecommons.org/licenses/past-nc/4.0/.