SFGH Children’s Health Center Quarterly Report # 2, September 2011

1. SFGH Children’s Health CenterQuarterly Report # 2, September 2011 The Children’s Health Fairies • Lannie Adelman, RN, MS, MBA • Shonul Jain, MD • Shannon Thyne, MD • Katie McPeak, MD • Mabel Chan, MD • Jennie Trinh

2. Aim Statement • Original AIM Statement “For primary care patients, decrease total patient time at clinic visits (including registration, clinician time, immunizations, and labs) to <90 minutes per patient by January 1, 2012.” • Ultimate goal of increasing patient visits and therefore improving access • Route to improvement is through streamlining/shortening the patient visit • Focus on improving communication/efficiency through use of huddles & pre-visit preparation (checklists)

3. Achieving AIM

4. Changes tested or implemented this Quarter • Multiple PDSAs refining a checklist as tool for huddle • Feedback from MEA and MDs leading to simplified check list (see next slide) • Multiple PDSAs refining Huddle process • Process is not empowering the whole team – maintaining MD-centered care • Huddles don’t work when “we don’t have enough hands” • “When I arrive, there is not someone there who is assigned to me. I would like to have the same person throughout the entire clinic.” • Schedule variations are impeding huddle capacity • Learnings from PDSAs • Our original concept of a huddle may not work. • The checklist is a helpful tool, but the most important part of team “huddle” is the preparation and open communication between providers and staff. • Need to continue to facilitate “prepping” prior to clinic. • Need to facilitate the ability to have a time in the beginning of clinic to communicate with each other.

5. Pre-visit Checklist

6. Changes tested or implemented this Quarter • Other Changes Implemented • Modified MEA schedules to improve staff ratios • Added “RN leader” to group of primary care MEAs to help problem-solving and team efficiency • Charts being available the day prior to clinic for “prepping” • Focus on communication: • Created posted schedule display to help anticipate busy clinic days • Increased frequency of staff meetings & check-ins to disseminate information and solicit feedback • Created clinic “face sheet” to help with name recognition and staff communication • Data Wall to show progress

8. Data – Access Measures # of days # of days

9. Data - Empanelment Total % of Patients Unassigned to PCPs Total % of Patients Unassigned, by Age

10. Data – Cycle Time Average time from arrival to departure whole clinic Time for Each Component of Patient Visit GOAL minutes

11. Challenges • Difficult to communicate change • Continued problems with morale and buy-in • Short staffed • Resistance to change • Providers not arriving on time; people still doing things their own way • Unique aspects of our clinic • Busy drop-in urgent care • Academic site with trainees • Some issues more difficult to fix • SPACE • Limited budget to hire new staff

12. Action Plan for Next 6 Months • Where we hope to be: • Revised immunization form to streamline vaccine ordering • Hiring data coordinator to help with collection/dissemination • Panel manager • Schedules modified to allow providers to attend teaching conference; have all the MEA’s present at the start of clinic and having designated time for group “huddle” prior to seeing patients. • Regular all-staff meetings • Annual all staff retreat

13. Lessons Learned • Original concepts aren’t always right. • Large changes can require multiple smaller adjustments prior to achieving the ultimate goal. • A lot can be learned from doing small tests of change. • Input and involvement from all staff is important. • We realize the importance of accountability. • Communication is the key! • Change is good but it takes time and energy.

14. Team Growth • We function better as a core team in the following ways… • We all share a common goal and vision. • We have realized each others strengths and assigned task appropriately. • We communicate better.