Transcript Improving Patient Visit Times and Satisfaction by Pre-vaccinating in the Outpatient Setting

Improving Patient Visit Times and
Satisfaction by
Pre-vaccinating in the Outpatient
Setting
Rangel QI 2009-2010
Caryn Kerman, Nadia Saldanha, Ron Rice, Jessica
Durst, Hari Narayan, Tolu Onigbanjo, Kate
Avitabile, Rebecca Friedman, Kathleen Brennan,
Dr. Mutnick, Dr. Berger-Jenkins, Dr. Cunningham,
Dr. Winkfield, Sylvia DeJesus, LPN, Wendy Acosta,
MA, Kenia Jones, MA, Clara Paris, RN, Taina
Sanchez, PFA, Betty Reyes, PFA, Juan Rodriguez,
PFA
AIM Statement

At Rangel Clinic we aim to enable faster,
more streamlined well child care visits. By
allowing residents access to their clinic
schedules, we will increase residents'
preparedness for visits. Residents will be
able to review notes on complicated patients
and pre-order routine vaccines. These
changes will create more organized patient
visits with decreased wait time and overall
increased provider and parent satisfaction.
More Specific Aims
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Allow residents "viewer" access to their
clinic schedules via the Epic system
Pre-order vaccines for 2, 4, 6 month
well child care visits by the Monday
evening of the clinic week
Baseline Visit Times
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Visit time for 2, 4, 6 month well child
care visits
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Residents: 129.5 minutes
Attendings: 112.8 minutes
Residents + Attendings: 120.5 minutes
Baseline Provider Satisfaction
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Residents:
 “involving scheduling…there is huge room for
improvement…and would likely increase both patient and
clinician satisfaction.”
 Having “viewing access to our own schedules…can help
identify scheduling mistakes…i.e. pts scheduled on vacation
days or early morning patients when we are ward senior.”
 “we could read up on the patients (especially complicated
ones) beforehand, and help avoid scheduling multiple
complicated patients on the same day.”
 “… we could really improve flow by pre-ordering vaccines
and screens…”
 “…faster, more streamlined visits might improve the no-show
rate, especially for follow up appointments.”
Baseline Nurse Satisfaction

Nurses:
 “It would be great on busy days…to look at the
orders and know which vaccines will need to be
done (before the chart comes to me).”
 “will improve the flow of patients. For example,
rather than getting 2 or 3 charts for vaccines at
once (at the end of the day), patients may be able
to receive vaccines while they are waiting to see
the doctor.”
 “We could take care of patients in a more timely
manner.”
Project Design
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
Brainstorming with PFAs, MAs, and nurses to
design flow chart for pre-vaccination
Initial concerns:
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Making sure appropriate for patient to be prevaccinated
Patients may leave after vaccines but before being
seen by MD
Project Design
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Questionnaire developed to assess
parental feelings regarding prevaccination, wait time and overall visit
satisfaction
Cycle 1
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4 patients were chosen and vaccines
were pre-ordered on the day of the visit
3 patients received vaccines before
seeing the MD (1 patient arrived too late
to be seen by the MD and only vaccines
were given)
Visit time only recorded for 1 patient
All staff felt the afternoon ran smoothly
Cycle 2
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2 patients received vaccines prior to their visit
Wait times: 109 and 74 minutes, significantly
less than the baseline wait times
Barriers:
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MAs had some difficulty determining who would
be eligible for vaccines
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needed to be told by the resident that this patient should
receive vaccines first.
Some parents wanted to talk to the doctor before
having their child vaccinated
Mid-project Improvements
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Prior to patient arrival

Clinicians 
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Review patient schedules
Pre-order vaccines for appropriate patients
With patient arrival

PFA, MA, Nurses
MA,
PFA
Nurse
*Patient registers with PFA
*For child < 1y old, PFA puts chart in CLEAR
takesincluded)
chart as usual
folder (with*MA
survey
*Checks
name,
vitals,
is
child
ill?,
do they
pre-ordered vaccines?
*PFA notes age and time registered
onhave
encounter
*No pre-ordered vaccines or child ill
*Tell nurse the patient is here
*MD with another patient
*MD open for patient
*Chart to nurse’s box
*Vaccines
*Nurse asks parent if they’ve
seen the MD yet.
*Chart to MD’s box in order of time
registered
*MD to give patient satisfaction survey
*Chart to MD’s box in order of time
registered.
*MD to give patient satisfaction survey
*Chart to nurse’s box
*Vaccines
*Nurse asks parent if they’ve
seen the MD yet.
*Chart to PFA to make follow up
appointment
*Patient satisfaction survey to PFA
Mid-project Improvements
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EPIC access
Resident and Attending attendance at
Rangel staff weekly meeting
Reviewed positive feedback with MAs,
Nurses
Mid-Project Improvements
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Patient Satisfication Survey
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Surveys were given without a system to
collect them
Only given to pre-vaccinated families
Changes:
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PFAs place survey in clear folder
RN gives survey to all patients
Red folders throughout clinic to collect survey
Cycle 3
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Patient Satisfaction Survey
Total Completed: 33
Pre-vaccinated: 23
Prefer pre-vaccination 22/23
Felt time was saved: 20/23
5/17 families preferred to see doctor first
Cycle 3
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Patient Satisfaction Survey--not prevaccinated
8/10 (2 did not answer) felt same time
spent in office
Did not want to be pre-vaccinated in
future
Cycle 3
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Chart review of patients between the ages of
2-6 months from Feb 1 to March 31
83 patient charts
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Vaccines were pre-ordered 54% of the time
Residents were more likely to order vaccines than
attendings (68% vs 30% respectively)
60% of our patients were pre-vaccinated if the
vaccines were pre-ordered
Cycle Times
PreNot PreAll
vaccinated vaccinated
Change
Residents
121.2
110.8
114.7 -14.8
Attendings
128.2
94.6
103.0 -9.8
102.3
109.0 -11.5
Residents+ 124
Attendings
Provider Satisfaction/Future
Directions
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19 responded
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42% resident
21% attending
16% nurses
16% PFAs
5% MAs
Provider Satisfaction/Future
Directions
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84% felt pre-vaccinating positive
change
47% easy to fulfill role in project
33% improved time with patients
39% no impact on time with patients
79% continue pre-vaccinating
47% under age 1, 26% all patients
Provider Satisfaction/Future
Directions
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94% improved clinic role
Positive feedback
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I think the entire staff has done a wonderful job
implementing this new change. Everyone got
really excited and it has stood the test of time, so
far.
Even if patients don't leave clinic a whole lot
sooner, they feel as though they are busy when
the are there, as opposed to waiting around.
Has made nurses and families happier.
Provider Satisfaction/Future
Directions
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Negative feedback
 vaccine after visit with provider, pt is able to leave
after being agitated.
 It is hard to pre-vaccinate because of lack of time.
 Nursing should always ask about recent fevers/
illnesses at the pre-vaccination time. Also, slightly
increased frequency of examining very cranky/
crying babies because they are s/p vaccines.
Conclusions
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Pre-vaccination leads to decreased visit
times
Majority of providers feel it is a positive
change and worth continuing
Need to increase consistency for prevaccinating
Successful project because of team
involvement
Previous QI Projects
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2009-2010 Development Screening
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No longer formally screening but Denver
available in all exam rooms and increased
awareness
2008-2009 TB Screening
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Question in Eclypsis