A team-based initiative in the Orthopedics Clinic at University of Colorado Hospital has helped slash patient wait times and improve productivity even as clinic volumes have increased significantly.
The positive changes are the result of a process-improvement project initiated with the Institute for Healthcare Quality, Safety and Efficiency (IHQSE). The IHQSE, launched three years ago by UCH, the CU School of Medicine and College of Nursing, and Children’s Hospital Colorado, equips staff and providers with training and skills to address operational issues in clinical settings.
The project used time and motion studies conducted in May and October 2015, respectively, to evaluate the effectiveness of changes instituted to improve clinic workflow. Staff time-stamped each step of a patient’s clinic visit, from check-in to check-out, in May, then repeated the process in October. An evaluation of roughly 250 patients in each study showed the changes helped to cut patient wait times in half – from 31 minutes to 16 minutes. The time providers spent with patients increased by a third, from 24 minutes to 32 minutes. The time patients waited to leave the clinic after their appointments fell by about 80 percent, from 11 minutes to 2 minutes.
The improvements came during a time of substantial clinic growth in patient volume – roughly 1,000 more clinic visits in 2015 than in 2014 – and the number of providers, said Laura Nelson, practice manager for the Orthopedics Clinic. The key to success, Nelson said, was “a complete redefinition of the staffing model.”
Certified athletic trainers (ATs) played an important role early on in the process redesign by acting as physician extenders. They took on tasks that include coordinating patient care, answering patient questions, providing instructions, discussing plans of care, and completing after-visit summaries. This work helps to free physicians to move on to their next patient and prevent bottlenecks in the clinic.
More broadly, ATs are now one part of subspecialty-based teams (see box) that include nurses, medical assistants (MAs), physician assistants (PAs), and physicians. Each has defined roles aimed at maximizing their skills, said Dan Ruedeman, an AT with the trauma team. The assigned tasks may overlap – performing a history and physical might be handled by either an AT or an MA, for example – and the specifics vary from team to team. But there are no questions about who can do what for a given patient on a given day, Ruedeman said.
“Staff is more accepting of their roles because they have defined duties,” he said.
The collaboration doesn’t end with the clinic-based team, he added. They also work closely with front-desk staff and with schedulers to stay on top of changes in the patient flow, such as walk-ins – a regular occurrence for Ruedeman’s trauma group.
Outside the walls of the clinic, communication with X-ray is also important, to ensure patients get imaging studies in a timely fashion, Ruedeman said. In addition, Nelson huddles with managers of other clinics on the fourth floor of the Anschutz Outpatient Pavilion (AOP) to plan placing patients in available exam rooms. The overriding aim: avoid wasting patients’ and providers’ time.
“No matter how many patients we have, the clinic runs smoother because we can adapt on the fly,” Ruedeman said. “We know where we can put add-on patients, and that improves same-day access. Everything is addressed in a timely fashion.”
The new model has helped the trauma team absorb the addition of two new PAs, each of whom run half-day clinics that see 10 to 18 patients, without sacrificing the quality of care, Ruedeman added.
“We’re accommodating 20 to 30 more patients in a week than we did before,” he said.
The increased volume is a plus for providers, said Craig Hogan, MD, who sees hip- and knee-replacement patients. Hogan was the first physician in the Orthopedics Clinic to move to the subspecialty-based team model and has helped to promote the idea to his colleagues. There was some initial reluctance to accept a change in the established process, but the efficiency gains – improved patient access and satisfaction; increased clinic and procedural volume – quickly overcame that, he said.
“I’ve heard nothing but positive things from providers, and the response from patients has been overwhelmingly positive,” Hogan said.
Hogan, who typically sees 30 patients during his three-quarter-day clinic Wednesdays in the AOP, said he finds the biggest benefit of the new system at the end of the visit. He answers the patient’s questions, then leaves for the next one while his ATC, Katie Forsyth, prepares the after-visit summary, goes over the plan of care, sets up coordinated care, enters Hogan’s orders in Epic, and completes other time-saving tasks.
A two- to three-minute savings per patient quickly adds up, cutting the amount of time Hogan spends after the last patient leaves catching up on his charting and other tasks. “It’s a significant amount of time saved. At the end of the day there is less work to do,” he said.
Hogan’s support for the change was indispensable to its success, Nelson said. “He understands the clinic’s needs from a physician’s perspective, but has also worked to problem-solve with staff,” she said. “He truly understands both sides. The success has taken a team culture, with everyone truly on board. That has taken us through the bumps and the hiccups.”
Orthopedics Team Members
Sub-specialty teams at UCH:
- Adult Reconstruction
- Foot and Ankle
- Hip Preservation