Improving Patient Visit Times and Satisfaction by

Pre-vaccinating in the Outpatient Setting

Rangel QI 2009-2010Caryn 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 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 Visit time for 2, 4, 6 month well child

care visits  Residents: 129.5 minutes Attendings: 112.8 minutes Residents + Attendings: 120.5 minutes

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.”

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 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

Project Design Questionnaire developed to assess

parental feelings regarding pre-vaccination, wait time and overall visit satisfaction

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

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

Mid-project Improvements Prior to patient arrival

Clinicians - Review patient schedules Pre-order vaccines for appropriate patients

With patient arrival PFA, MA, Nurses

*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 open for patient*MD with another patient

*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

*Chart to nurse’s box*Vaccines

*Nurse asks parent if they’ve seen the MD yet.

MA, Nurse

*Chart to PFA to make follow up appointment

*Patient satisfaction survey to PFA

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

Mid-project Improvements EPIC access Resident and Attending attendance at

Rangel staff weekly meeting Reviewed positive feedback with MAs,

Nurses

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

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

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

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

Cycle Times

Pre-vaccinated

Not Pre-vaccinated

All Change

Residents 121.2 110.8 114.7 -14.8

Attendings 128.2 94.6 103.0 -9.8

Residents+Attendings

124 102.3 109.0 -11.5

Provider Satisfaction/Future Directions

19 responded 42% resident 21% attending 16% nurses 16% PFAs 5% MAs

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

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.

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.

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

Previous QI Projects 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