Jerry Shefren, MD, VP, Ambulatory Care
Joe Hopkins, MD, MBA, Associate Chief of Staff
Shridhar Seshadri, MBA, VP, Process Excellence
Paul Ford, MD, Clinic Chief
Nancy Morioka-Douglas, MD, Clinic Chief
Matt Wood, PhD, Biostatistician
Buffie Stark, BS, Project Manager
Sandra Rozmarin, RN, BS, Quality Manager
Jeanne McGrane, RN, MSN, MBA, Director, Ambulatory Care
Maureen Burke, RN, MSN, Director, Ambulatory Care
Paula Vannicola, RN, Director, Cancer Center

To decrease the wait for a new patient appointment to specialty clinics to no more than 14 days, to decrease the waits in clinic during the visit and to create change leaders in every clinic within eleven months.

• Third next new patient appointment
• Arrived visits
• Cycle time
• Patient’s experience

Our Collaborative most of the change package for waits and delays.  The changes below were tried by one or more clinics during the course of the Collaborative.

Reduce complexity of scheduling

• Reduce appointment types
• Change the master schedule of the electronic scheduling system
• Use scripts
• Create a database to track and manage referrals (Neurosciences)

Manage supply/demand

• Add sessions to work down backlog
• Add calls to patients in addition to automated call reminder system to prevent no-show
• Require lead time for physicians canceling sessions
• Developed referral criteria. This was tested for new patients and second opinions
• Reduce appointment lengths (in some clinics appointment durations were lengthened to prevent waits in clinic)
• Set and maintained standards for number and length of clinical sessions
• Added slots either short term or permanently
• Define population served (i.e. decline 2nd Opinions, accept only patients referred by a PCP)
• Group visits (Ophthalmology and Urology)
• Returned patients to their PCP
• Test attending alone vs attending and resident to see which model could see the most patients in a given time period
• Use email/telephone calls to reduce need for some visits and inbound calls
• Offer appointments with another provider in clinic if requested provider has less availability

Reduce waits and delays

• Introduce pause in schedule to enable catch-up work and prevent late afternoons
• Use pre-visit questionnaire to prepare patient and physician for visit
• Use scheduling system to flag patients needing more time than the visit type specifies
• Change appointment card to state arrival time
• Identify when residents do not have to report off to attending
• Plan to accommodate patients who arrive early
• Call patients when physician is running late, change appointment time
• Reschedule morning meetings to enable on-time start times
• Re-assign exam rooms
• Lengthen some appointment durations
• Provide more information to patients regarding expected arrival time
• Change appointment card to reflect when patient was supposed to arrive

Organize the Care team

• Co-locate care team
• Form care team i.e. assign an MA or RN to a specific physician(s)
• Use huddles
• Cross-trained staff

Reduce interruptions during exams

• Standardized supplies
• Added supplies
• Use walkie-talkies, cordless phone and intercoms
• Use huddles
• Improve chart prep

Changes in the delivery of care

• Re-design evaluation processes (i.e. Child Psychiatry reduced testing from 8 hrs to 4 hrs for about 25 percent of patients)
• Assign some return visits to a NP or PA
• Allowed trainees to present findings to attending with patient present

Our biggest improvement was in appointment access. Smaller gains were demonstrated in cycle time.  Patient feedback was consistent with the data for both appointment access and cycle time.  We enjoyed strong physician leadership in most of our team. The formation of improvement teams and the sharing of information between teams are two of the most valuable outcomes.

• Don’t begin without enthusiastic support form top leadership.
• The basic change package works.  Add to it has you learn from each team.
• Monitor team process closely in the beginning of a Collaborative.  Make sure everyone understands and uses the rapid cycle test model
• Teams learn the most from each other.  Create as many sharing opportunities as you can.
• Be flexible when working with heterogeneous teams.  Be willing to modify some metrics if needed.

Sandra Rozmarin, RN
Quality Manager
Stanford Hospital and Clinics

[Storyboard presentation at IHI's National Forum, December 2004]