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

1. Improving Patient Visit Times and Satisfaction byPre-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

2. 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. 

3. More Specific Aims • 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  

4. Baseline Visit Times • Visit time for 2, 4, 6 month well child care visits  • Residents: 129.5 minutes • Attendings: 112.8 minutes • Residents + Attendings: 120.5 minutes

5. Baseline Provider Satisfaction • 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.”

6. 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.”

7. Project Design • Brainstorming with PFAs, MAs, and nurses to design flow chart for pre-vaccination • Initial concerns: • Making sure appropriate for patient to be pre-vaccinated • Patients may leave after vaccines but before being seen by MD

8. Project Design • Questionnaire developed to assess parental feelings regarding pre-vaccination, wait time and overall visit satisfaction

9. Cycle 1 • 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

10. Cycle 2 • 2 patients received vaccines prior to their visit • Wait times: 109 and 74 minutes, significantly less than the baseline wait times • Barriers: • MAs had some difficulty determining who would be eligible for vaccines • 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

11. Mid-project Improvements • Prior to patient arrival • Clinicians - • Review patient schedules • Pre-order vaccines for appropriate patients • With patient arrival • PFA, MA, Nurses

13. MA, Nurse *MA takes chart as usual *Checks name, vitals, is child ill?, do they have pre-ordered vaccines? *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 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 PFA *Patient registers with PFA *For child < 1y old, PFA puts chart in CLEAR folder (with survey included) *PFA notes age and time registered on encounter *Chart to PFA to make follow up appointment *Patient satisfaction survey to PFA

14. Mid-project Improvements • EPIC access • Resident and Attending attendance at Rangel staff weekly meeting • Reviewed positive feedback with MAs, Nurses

15. Mid-Project Improvements • Patient Satisfication Survey • Surveys were given without a system to collect them • Only given to pre-vaccinated families • Changes: • PFAs place survey in clear folder • RN gives survey to all patients • Red folders throughout clinic to collect survey

17. Cycle 3 • 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

18. Cycle 3 • Patient Satisfaction Survey--not pre-vaccinated • 8/10 (2 did not answer) felt same time spent in office • Did not want to be pre-vaccinated in future

19. Cycle 3 • Chart review of patients between the ages of 2-6 months from Feb 1 to March 31 • 83 patient charts • 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

20. Cycle Times

21. 19 responded 42% resident 21% attending 16% nurses 16% PFAs 5% MAs Provider Satisfaction/Future Directions

22. Provider Satisfaction/Future Directions • 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

23. Provider Satisfaction/Future Directions • 94% improved clinic role • Positive feedback • 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.

24. Provider Satisfaction/Future Directions • 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.

25. Conclusions • Pre-vaccination leads to decreased visit times • Majority of providers feel it is a positive change and worth continuing • Need to increase consistency for pre-vaccinating • Successful project because of team involvement

26. 2009-2010 Development Screening No longer formally screening but Denver available in all exam rooms and increased awareness 2008-2009 TB Screening Question in Eclypsis Previous QI Projects