1. Lubbock IMPACT/TTUHSC Student-Run Free Clinic FreeClinic@ttuhsc.edu THE 5 MINUTE RULE: MAKING TIME FOR EVERY PATIENT

2. STUDENT-RUN Free Clinic Mu Chen, MS II AnaMaria Hoyos, RN, BSN FNP Student Jennifer Roh, MSII Megan Shupp, MSII Harjot Singh, MSII Students CAN make a difference!

3. Presentation Outline The 5 Minute Rule Clinic Flow and Operation Implementing Efficiency Providing Good Patient Care Providing a Quality Student Education

4. The 5 Minute Rule What is it? Triage teams have 5 minutes to complete triage. Assessment teams have 5 minutes to perform a FOCUSED exam. Constant attention to time efficiency

5. The 5 Minute Rule Why did we do this? We frequently had more patients than we could see. We made changes that allowed us to see more patients without compromising patient care. By seeing more patients, we were better able to improve the health of the COMMUNITY How do we maintain quality patient care? To understand this, we need to go over our clinic:

6. Lubbock County, Texas Population in 2009: 270,550 Uninsured in 2007: 60,032 % Uninsured under age 65: 26.4% Lubbock is the “Hub City” of West Texas: Some patients come from 100+ miles away Source: http://www.census.gov/did/www/sahie/index.htmlhttp://www.census.gov/did/www/sahie/index.html http://quickfacts.census.gov/qfd/states/48/48303.html

7. Lubbock, TX

8. Lubbock Impact/ TTUHSC Free Clinic

9. When: Wednesday 6PM-9PM Opened: August 9, 2009 # Patients Seen per night: 20-30 # Patient Encounters in 1 Year: 1000+ Max # patients in 3 hours: 35

10. Clinic Flow and Operation All Volunteer Staff 4 Physicians 5 Student Leadership Team members 10-14 Medical students in 5-7 teams 2-3 Nurses/Nurse Practitioner Students 2 Receptionists 1 Medical Insurance Resource Counselor 1 Diabetic Educator

11. Clinic Flow and Operation Layout 3 Exam Rooms 2 Triage/Exam Rooms Point of Care/Nursing Area Social Work Office 1 Markerboard Lost Exam Room Time = Lost Patient Time

12. Clinic Flow and Operation Patient Flow Registration Triage: 5 minutes! Focused Exam: 5 minutes! Untimed presentation Untimed attending assessment Nursing, Social work, Interdisciplinary care

13. Clinic Flow and Operation Patient Flow The average patient spends at least 45 minutes interacting with members of the Free Clinic. The key is: maximize patient care by minimizing “down-time”

14. Implementing Efficiency The Board

15. Implementing Efficiency The Board A tool to instantaneously view the status of all the exam rooms

16. Implementing Efficiency The Board Information included: List of attendings Each room has its own space with: – Student who is in the room – Time student entered – The attending, after the student has presented – Special status: Procedures, etc.

17. Implementing Efficiency The Board “The Knock” If a student exceeds 5 minutes, the board person knocks on the door and politely asks, “Is there anything I can do to help you finish up?” The key is: maximize patient care by minimizing “down-time”

18. Implementing Efficiency The Board We DO NOT track every patient – that is the responsibility of the patient’s medical student team One person is assigned to the board: Their only responsibility is to update the board and manage patient flow through the exam rooms

19. Implementing Efficiency: Other Strategies : Other Strategies

20. Implementing Efficiency Other Strategies “Immediately Fill All the Rooms” At the start of clinic, the first 3 patients are immediately placed into exam rooms and those students will have 10 minutes to perform triage as well as a focused exam. This means that all 5 rooms are utilized as quickly as possible.

21. Implementing Efficiency Other Strategies “Med Refill Room” On especially busy days, a room without equipment can be used to assess patients who do not require much examination, such as patients with a rash or seeking a blood pressure medication refill. In the past, we have used the sanctuary and pastor’s office.

22. Providing Good Patient Care

23. Patient-Centered Approach to Efficiency Although the students only have 5 minutes, we allow an unlimited amount of time for attendings and nursing care, and interdisciplinary discussions. Always keep the patient in mind when implementing efficiency measures!

24. Providing Good Patient Care Patient Flow The average patient spends at least 45 minutes interacting with members of the Free Clinic. 5 minutes with the triage team 5 minutes with the assessment team 20+ minutes with the attending and medical students 15+ minutes with Nursing, Social Work, and diabetes education The key is: maximize patient care by minimizing “down-time”

25. Providing Good Patient Care Patient Flow The average patient spends at least 45 minutes interacting with members of the Free Clinic. Since exam rooms are limited, patients are moved out of the room as quickly as possible without compromising care. Many nursing procedures occur in a separate area. Resource counselors and diabetic educators have their own rooms. The key is: maximize patient care by minimizing “down-time”

26. Providing Good Patient Care Patient-Centered Approach to Efficiency “Immediately Fill all the Rooms” The patient experiences a benefit. Instead of 2 student teams spending 5 minutes each, 1 student team spends 10 minutes with the patient “Med Refill Room” The patient may feel awkward being seen in a non-clinical setting. If so, offer the option of an exam room once one is available.

27. Providing Good Patient Care FLEXIBILITY with the Rules If it is a slow day (< 20 patients), the “5 Minute Rule” becomes the “10+ Minute Rule”. The leadership team must always be aware of the clinic’s flow and adjust to the situation. Patient care is our main objective and thus we do not always adhere to the 5 minute rule. We will give student teams additional time based on patient needs.

28. Providing Good Patient Care Patient-Centered Approach to Efficiency: That was a bad idea… “Procedure Corner” A corner of the big room was sectioned off with a room divider to do simple procedures such as EKGs and ear irrigations. The area was poorly lit, the area was too small, and the patient could hear everything being said in the room. We abandoned the idea.

29. Providing a Quality Student Education

30. MS1 Triage Teams Modeling year III and IV for Student Teams The limited exam time teaches students how to efficiently yet compassionately work with patients Students are allowed to perform nursing procedures and interact with the other disciplines SOAP Note

31. Thanks!