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May 29, 2009 – Jill Wooldridge P.A.-C. Boynton Health Service, University of Minnesota, Minneapolis, MN.

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Presentation on theme: "May 29, 2009 – Jill Wooldridge P.A.-C. Boynton Health Service, University of Minnesota, Minneapolis, MN."— Presentation transcript:

1 May 29, 2009 – Jill Wooldridge P.A.-C. Boynton Health Service, University of Minnesota, Minneapolis, MN

2 Topics to be Covered: Define Convenience Care How we came to develop/improve Gopher Quick Clinic How Gopher Quick Clinic Functions Display data about utilization of GQC Impact on Providers, Primary Care, Urgent Care Financial Impact Future Considerations and Plans Challenges to the Model 2

3 CONVENIENCE CARE WHAT IS IT? Provides care for Minor Acute Illness (strep throat screens, bladder infections, sinus infections, warts, impetigo etc.), some basic vaccinations and basic testing. A Walk-in patient centered model usually staffed by Advance Practice Clinicians. Patients evaluate their own needs and pick care time that is convenient to their schedule. One Stop Care. Total patient interaction is in one location and usually a single face-to-face interaction with a single Clinician. Since the first Convenient Care clinics opened in 2000, the industry has grown quickly – today approximately 1,200 such clinics are in operation (many in retail locations) 3

4 HOW WAS THE BOYNTON PROJECT IDENTIFIED? An effort to support the Universitys strategic mission to improve services to the student population. Community trends and patient expectations for more choice and control over how they access care – and Boyntons and University Human Resources desire to meet these. An identified internal challenge in our current Urgent Care model to optimally serve acute care patients. 4

5 PURPOSE OF COMMITTEE October 10, Committee charged by COO to evaluate: The benefits of providing a Convenience Care model of service. The appeal of Convenience Care to our patients and third-party payers. The impact of this service on Urgent and Primary Care. Over-all financial impact. 5

6 COMMITTEE MEMBERS Chair: Mary Alderman - Director Clinic Operations Co-chair: Dave Dorman – Health Promotion Beverly Carpenter – Administrative Assistant Joyce Fortier – Executive Secretary Jill Wooldridge, PA – Provider BJ Anderson, MD - Provider Britt Bakke - Marketing and New Program Development Paula Miller, RN – Student Health Advisory Committee member Barb Rangel, LPN – Supervisor Patient Assistance and Information Virginia Tranter, RN – Lead Nurse Immunization Clinic 6

7 QUALITY IMPROVEMENT PROCESS DMAIC: DMAIC is a basic component of the Six- Sigma methodology (Business Management Strategy) - a way to improve work processes by improving efficiency and eliminating defects. In its methodology, it asserts that in order to achieve high quality business processes, continued efforts must be made to reduce variations. 7

8 DMAIC MODEL DEFINE PHASE: What are the issues and desires for improvement MEASURE PHASE: Data collection to direct improvement efforts ANALYZE PHASE: Clarify and identify root cause of issue IMPROVE PHASE: List of all potential solutions and their impact with implementation plan and milestones CONTROL PHASE: Pilot plan, process control, implementation of solutions and transition control plan 8

9 Define Phase COLLECTING THE VOICE OF THE CUSTOMER o Conducted informal focus groups with the Student Health Advisory Committee (SHAC). o Conducted informal focus groups with Boynton Health Service (BHS) staff: Providers, RNs, Pharmacy, Lab, Front Desk and Support staff. o Created open message board for comments from BHS staff on shared network drive. 9

10 Measurement Phase Measured interest in a Convenience Care model An online survey sent to 4,000 students, with a return rate of 32%, showed 68% were interested. An online survey sent to 2,000 faculty and staff, with a return rate of 38%, showed 53% were interested. 10

11 Measurement Phase (continued) PROBLEM: Urgent Care process of dealing with Minor acute illness is inefficient and lengthy for the patient. Measured current process efficiency for treatment of minor acute illnesses in Urgent Care. Urgent Care Cycle-time study: Urgent Care Provider Average Cycle Time = 80.5 minutes RN Average Cycle Time = 54.5 minutes RUC Average Cycle Time = 66.0 minutes 11

12 Measurement Phase (continued) Reviewed 12-Month (9/05 - 8/06) Total MinuteClinic® Utilization U of M Student Benefit Plan (SBP) – 61 visits U of M Graduate Plan – 75 visits U of M Staff/Faculty Benefit Plans – 1,885 visits Of the total Staff/Faculty MinuteClinic® visits, 389 were seen at the Coffman site (just under 50/month). 12

13 Analyze Phase Analyzed results of student, staff and faculty online surveys. Reviewed list of factors identified in the formal focus groups. Performed a Root Cause analysis on current model of care. Consulted with Boynton Health Service Chief Operating Officer (COO) to examine fiscal implications of implementing a Convenience Care model. Toured the University of Minnesota Duluth QuickCare Clinic. 13

14 Improve Phase In March 2007 the Committee recommended that BHS provide a Convenience Care model service as a pilot, effective fall The service was named Gopher Quick Clinic. The hours of service were to be Monday through Friday, 9 a.m. to 5 p.m. with no coverage over the lunch hour (1-2pm). The service was not offered during holidays/breaks. Unless year-round fees were approved and a need for summer services was established, the service would not be offered during the summer. 14

15 GQC IMPLEMENTATION TEAM Chair: Mary Alderman - Director Clinic Operations Co-chair: Jill Wooldridge, PA – Provider Britt Bakke - Marketing and New Program Development Margaret Dahl, RN - Nurse Supervisor Primary Care Davin Hedin - Principal Accounts Specialist Sue Jackson - Director Student Health Benefit Plan Amy Murphy – Executive Accounts Specialist Barb Rangel, LPN – Supervisor Patient Assistance and Information Deb Sandberg, MD – Medical Director Karen Strauman-Raymond, RN – Nursing Director Gina Tran – Supervisor Patient Accounting 15

16 Improve Phase (continued) BHS Marketing Department implemented the Marketing Plan during spring and summer During March 2007 through August 2007 the Implementation Committee: defined flow and location of clinic, equipped and stocked the clinic, hired Advanced Practice Clinician providers (to split time between primary care and GQC) trained staff on new processes. On September 4, 2007 the new clinic service was opened. 16

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18 Gopher Quick Clinic Services Gopher Quick Clinic is limited to addressing one of the following concerns per patient visit. 18 Common Illnesses: Bladder Infection Bronchitis Cold/Cough Ear Infection Laryngitis Mononucleosis Respiratory Flu (without vomiting or diarrhea) Seasonal Allergies Sinus Infection Strep Throat Swimmer¹s Ear Skin Conditions: Athlete's Foot Cold Sores Impetigo Minor Sunburn Poison Ivy Ringworm Warts (three or fewer, does not include genital warts) Vaccines: Tetanus Vaccines (Td and Tdap) Flu Vaccine (when flu shot clinics not running) Additional Services Pregnancy Test

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20 Boynton Gopher Quick Clinic 20

21 HOW DOES IT WORK? FRONT DESK STAFF: Checks in patient, schedules them for next available slot (every 15 minutes), tells patient approximate wait time, gives them Short Health History form to fill out. Handles any co-pay/insurance issues 21

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25 HOW DOES IT WORK? GQC PROVIDER (Team of 6 PAs, 2 NPs): Calls patient from schedule on computer, brings back to room Interviews patient (uses paper form) Obtains vitals (Spot Vital Signs) Examines patient Performs any point-of-care labs [Strep, Mono, Flu, Urine dip, urine pregnancy test; Throat cultures, Urine cultures sent to lab] Writes any Rx, educates patient, uses pt. education materials Patient leaves room, provider finishes any documentation 25

26 Boynton Gopher Quick Clinic Exam Room 26

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28 HOW DOES IT WORK? MEDICAL RECORDS: Collects paper encounter forms daily Sorts for billing, clinical record Scans the paper visit for our EMR (usually within 1 day) Abstracts pertinent data directly into our EMR: Reason for Visit, Vitals, Labs done, Assessment, Medications prescribed (usually within 1-2 days) 28

29 Control Phase (Fall 2007) The week of October 22-26, 2007 BHS sent a survey to all current Gopher Quick Clinic patients to assess satisfaction with the service. Katie Lust, PhD, Director of Research and Surveillance, evaluated all surveys 29

30 October 2007 Survey Results Compare Satisfied vs. Not so Satisfied Satisfied = Excellent, Very Good and Good Not so Satisfied = Fair and Poor 81.2% of the patients surveyed rated the entire visit as satisfactory. Target is 90% satisfaction rate. Patient concerns identified were: 1) wait time in the lobby 2) time spent with the provider in the exam room 3) privacy 30

31 OCTOBER SURVEY PROCESS IMPROVEMENT PLAN WAIT TIME : Added appointments over the 1-2 p.m. lunch time Changed marketing material to indicate that GQC was: 1) first-come-first serve and 2) capacity for the clinic may be reached prior to the 5 p.m. closing TIME SPENT WITH PROVIDER: Changed marketing material to say Visits last approximately 10 minutes. PRIVACY: Performed a second survey asking more specific privacy questions Changed location of urine sample drop-off from Lobby to Front Desk 31

32 Control Phase (Winter 2008) On January 22, 2008 BHS sent a 2 nd survey to all current Gopher Quick Clinic patients to assess the following: Wait Time expectations Satisfaction with amount of time spent with the provider in the exam room Level of comfort with: 1) check-in procedure 2) location of waiting room 3) location of exam room Level of comfort with the process for giving a urine sample as it related to: 1) location of restroom 2) privacy of restroom 3) walking from restroom to drop-off box 4) location of drop-of box and overall urine collection procedure 32

33 JANUARY 2008 SURVEY RESULTS Compared Satisfied vs. Not so Satisfied Satisfied = Excellent, Very Good and Good Not so Satisfied = Fair and Poor 89.0% of the patients surveyed rated the entire visit as satisfactory. Target is 90%. Patient concerns identified were: 1) location of lobby in relation to exam room, 2) location of restroom in relation to drop-off box and 3) wait time 33

34 JANUARY SURVEY PROCESS IMPROVEMENT PLAN Exam Room Location: Moved exam room from off of Lobby to interior exam room within Primary Care South (PCS) Restroom and Drop-off Box Location: Changed restroom and drop-off box location to be within PCS clinic space Wait Time: Added second GQC provider in the PM. 34

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36 Fall of 2008 – Opened Coffman Satellite Opportunity arose to utilize the Minute Clinic site across the street in the Union Hired 3 new staff to accommodate new full- time GQC clinic and have back-up, as well as rotate into primary care to make the position more appealing. Front desk to be staffed from Patient Assistance Dept Challenging new workflow to get supplies, equipment (LN2), labs, etc. back and forth Set up remote access via computer as well Marketing! 36

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40 COFFMAN GOPHER QUICK CLINIC Specific Challenges to the satellite site: Tried to make it as much like the original GQC as possible for provider staff and patients Had to set up courier drop off in AM, pick up in PM for supplies/labs Slightly more complicated transfer of patients to Urgent Care if needed – more hassle for patients Much less privacy, both in the lobby and the public restrooms Had to determine which site to close if providers are absent? 40

41 Visit Statistics for vs

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43 Cycle Time Statistics for vs

44 SUMMARY OF GQC STATISTICS (from previous slides) From to , GQC visits from a comparable period increased from 3787 to Average total cycle time decreased from 37 to 29 minutes. Average wait time in the Lobby decreased from 25 to 18 minutes. Time with provider remained essentially constant. 44

45 NOVEMBER 2008 SURVEY RESULTS Compared Satisfied vs. Not so Satisfied Satisfied = Excellent, Very Good and Good Not so Satisfied = Fair and Poor Again, 89.0% of the patients surveyed rated the entire visit as satisfactory. Target is 90%. Issues identified were: 1) wait time satisfaction improved from Spring 08 2) Significant concerns regarding Privacy/Comfort at Coffman GQC, especially with regard to waiting area and urine sample collection 3) Patients who rated overall visit as fair or poor were expecting or would have liked to have more time with the provider 45

46 NOVEMBER 08 SURVEY PROCESS IMPROVEMENT PLAN Wait Time: Front Desk staff continue to offer Coffman as an option if the wait time is > 30 minutes at BHS Coffman Privacy/Comfort Concerns: In talks now with Coffman Building services about possible remodeling of the space to allow private waiting area. Unable to change restroom location. Expectations regarding time with provider: Make sure marketing materials and those encouraging the service are clear as to its limitations 46

47 IMPACT ON PROVIDERS Gopher Quick Clinic Providers Simple, easy visits? Or mind-numbingly boring after 25/day? Mix of GQC time with Family Practice is seen as a job satisfaction issue from a provider perspective, but results in possible Excess Access in clinic schedules Primary Care Providers Initial skepticism regarding continuity of care Concern over loss of quick visits that allow for make-up time for more involved visits. Perception that the complexity of visits has increased in Primary Care, though RVUs via coding has not yet borne that out. All agree Quick must not sacrifice Quality – evidence- based guidelines and judicious use of Antibiotics important 47

48 CodeDescrCountOfCode 462ACUTE PHARYNGITIS2, ACUTE URI NOS1, URIN TRACT INFECTION NOS ACUTE SINUSITIS NOS VIRAL WARTS NOS ACUTE BRONCHITIS DYSURIA ACUTE TONSILLITIS ALLERGIC RHINITIS CAUSE UNSPECIFIED STREP SORE THROAT COUGH AC SUPP OTITIS MEDIA NOS NONSUPP OTITIS MEDIA NOS131 V72.40PREGNANCY EXAM/TEST UNCONFIRMED82 V06.1VACCIN FOR DTP HERPES SIMPLEX NOS78 075INFECTIOUS MONONUCLEOSIS INFEC OTITIS EXTERNA NOS INSECT BITE NEC DYSFUNCT EUSTACHIAN TUBE58 Top 20 Diagnoses for Gopher Quick Clinic 48

49 IMPACT ON PRIMARY CARE VISITS Percent of minor acute illness was reduced from 18% to 15% 49 Top 10 DX for 0607Top 10 DX for 0708 Screen for Venereal Disease1838Screen for Venereal Disease2236 Routine Medical Exam1805Routine Medical Exam1725 Routine GYN Exam1548Routine GYN Exam1427 Acute Pharyngitis1517Acute Pharyngitis1024 Nonspecific Skin Eruption833Pap and Pelvic1005 Viral Warts715Nonspecific Skin Eruption745 Pap and Pelvic710Acne604 Acne594Dysuria585 Joint Pain – Ankle and Foot538Backache513 Fatigue538Viral Warts513

50 IMPACT ON URGENT CARE Percentage of visits for minor acute illness was reduced from 51% to 20%. Target was to reduce the percentage by 50%. 50

51 GOPHER QUICK CLINIC AND URGENT CARE VISITS ACADEMIC YEAR 0708 VS. ACADEMIC YEAR

52 SUMMARY OF CHANGE IN VISITS (from previous slides) GQC visits have continually increased in the same ratio as Urgent Care visits have fallen. Total GQC visits have increased. Total UC visits have decreased. Overall total visits to combined departments have increased. 52

53 Financial Impact: Visits and RVUs 53

54 FINANCIAL MODELING 54

55 FINANCIAL ASPECTS The breakeven point for visits is three visits per hour. 55

56 CONCLUSIONS AND FUTURE CONSIDERATIONS 1. We have met our goal of an average cycle time of 30 minutes or less. 2. We have met our goal of reducing the percentage of minor acute visits in Urgent Care by 50%. 3. We have not met our goal of reaching an over-all satisfaction rate of 90% (but so close at 89%!). 4. We need to balance access and/or services to remain financially sound. New Services? How to increase utilization of Coffman site? 5. Anecdotally, there has been a slight shift in acuity in visits in Primary Care, requiring more people staying late. 56

57 Looking Forward – Whats next? Remodel of Coffman Gopher Quick Clinic to allow for private waiting area Move another Gopher Quick Clinic into our St. Paul clinic for ½ day Monday-Friday. (Dropping 2 nd PM provider at BHS) Looking at financial feasibility and/or profitability of adding some preventive services (Cholesterol screen, BP screen) 57

58 CHALLENGES to the CONVENIENCE CARE MODEL Balancing schedule – having back-up to remain open as advertised, but avoiding excess access Appropriateness (or not) of self-triage Repeat visits for same issue Higher acuity or complexity than GQC can handle, and subsequent re-triage of patients If desires of patient dont fit GQC model (wanting more time, more than one concern, etc.) Getting all information into EMR in a timely way EMR wasnt quick enough for pilot, but templates are in development that are more user-friendly, quick-templates – will still likely have to abstract some historical medical information H1N1 Swine Flu… 58

59 QUESTIONS?? Special Thanks to Mary Alderman, Director of Clinic Operations, and Carl Anderson, Chief Operations Officer! 59


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