PDSA 2 Change Implemented: Work up room staff will write No on the Face sheet if family doesn t request SWE instead of leaving it blank.

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1 Improving Efficiency and Patient/Provider Satisfaction Through Standardization of School/Work Excuses in a Pediatric Resident Clinic, a Retrospective Chart Review Michael Tjahjadi, MD, PGY-2 Sara Sterne, RN, Jennifer Amrol, MD, Kathryn Stephenson, MD University of South Carolina/Palmetto Health Department of Pediatrics Abstract Given the rise of administrative duties required by physicians in the outpatient care facility setting, a system that allows for optimum efficiency in these duties is key in order to allow for maximal direct patient contact. In the Children s Hospital Outpatient Center (CHOC) of the Palmetto Health Children s Hospital, the residents (MDs) are in charge of creating school/work excuses (SWE), which was the process targeted for improvement and standardization. Prior to the project, SWEs were usually requested by the patient/family at their discretion. The implemented change trained the work up room staff to ask all patients/families if they require an SWE or not and to document accordingly on the face sheet to be given to the MD. Implementation of the change did not cause a significant increase in total number of SWEs requested. Over the course of two PDSA cycles, both the rate of SWEs that were failed to be given when requested (17% in PDSA 1, 0% in PDSA 2) and the rate of failing to document a requested SWE on the face sheet (23% in PDSA 1, 10% in PDSA 2) decreased. This project can pave the way for other quality improvement projects, demonstrating how even small changes in efficiency and increases in patient/provider satisfaction can be significant when extrapolated over multiple providers over time. Introduction In the outpatient care facility setting, providers can be faced with the constant challenge of budgeting their time effectively between meeting the demands of direct patient care and the requirements of office work. A survey of 4720 physicians from 2014 revealed that physicians on average spend 8.7 hours per week on administrative duties (16.6% of working hours) [1]. A different study revealed how interns in particular at one particular center spend up to 40% of their time in clinical computer work [2]. Ideally, in whatever setting, the system in place would allow the administrative tasks to be completed in the most efficient manner, granting the provider maximum time to be spent in direct patient care. In order to achieve this goal, a streamlined process that allows for effective use of time, resources, and personnel, is crucial for a well functioning practice. Serial analysis of possible ways to improve the systems in place, even small changes, may lead to a profound effect on the overall time saved when extrapolated over each patient encounter. School/work excuses are one of the common requests made by patients and their families, and are one of the many small but frequent tasks performed by physicians and/or other staff. At CHOC, the MD is currently in charge of writing these excuses. In the current model, SWEs are given when either the patient or family asks for one, or if the MD takes the initiative to ask if they require one. Although this normally may not pose a problem, there are some scenarios in which this model may impede work flow. Should this request be made at the very end of the visit after all the patient s materials have been printed out and given, the MD is required to revisit the patient s chart in order to create the excuse, costing a small amount of time that may add up cumulatively.

2 CHOC requires documentation for every SWE given, which precluded the option of giving out generic SWEs at the front office. Therefore, given that the MDs are still responsible for the creation of the SWEs, the aim of this project was to find a standardized method that would allow for maximum efficiency in the clinic. Methods Prior to implementation, SWEs were requested by the patient or family at their discretion, and no prompt on the face sheet filled out by the work up room was yet created. After implementation, a check box for SWEs was included on the face sheet, and the work up room staff was trained to ask each family whether they required a SWE for that day. All data was collected via retrospective chart review. Data points taken include: 1) Whether or not the SWE was written by the MD when requested on the face sheet. 2) Whether or not an SWE was written by the MD in the absence of a request from the face sheet. PDSA 1 Change Implemented: Face sheet was modified to have a box indicating if an SWE is requested. Work up room staff asks each patient/family if SWE is needed and checks the box if so. In order to determine whether or not implementation would significantly increase the number of total SWEs requested, a total of 39 charts on a date prior to implementation ( ) and a total of 49 charts on a date after implementation ( ) were reviewed, and the total number of documented SWEs were counted. Between and (blocks 6-8, whereby resident rotations are based on blocks each spanning 4 weeks), 30 charts with the SWE request box checked were chosen at random. Charts which did not have a documented SWE the same day were counted as a miss. Also, during the same time period, 30 charts with the SWE request box unchecked were chosen at random. Charts which did have a documented SWE the same day were counted as a miss. PDSA 2 Change Implemented: Work up room staff will write No on the Face sheet if family doesn t request SWE instead of leaving it blank. For retrospective chart review, the same method in PDSA 1 was applied to PDSA 2. Between to (block 9), 20 charts with the SWE request box checked were chosen at random. Charts which did not have a documented SWE the same day were counted as a miss. Also, during the same time period, 20 charts with the SWE request box unchecked or listed as no were chosen at random. Charts which did have a documented SWE the same day were counted as a miss.

3 Results The primary goals in data assessment were as follows: 1) Ensure implementation of plan did not significantly add extra work (that is, ensure that implementation did not result in a significant increase of SWE requests). 2) Once the above process has proven effective, two further goals were addressed: A) Consistently write SWEs for patients/families who request an SWE. B) Avoid excess work by not writing SWEs when not requested. PDSA 1 All charts on a random date prior to implementation and all charts on a random date after implementation were reviewed for total number of SWEs written. A total of 39 charts on (pre-implementation) were reviewed, and a sum of 15 SWEs were given that day (38% of visits). A total of 49 charts on (post-implementation) were reviewed and a sum of 14 SWEs were given that day (29% of visits). Implementation of the change did not cause a significant increase in total number of SWEs requested. 30 charts with the SWE box checked were reviewed from to (block 6 8). 5 out of 30 were not given the SWE (17% missed). 30 charts with the SWE box left blank were reviewed from to (block 6 8). 7 out of 30 were written a SWE (23% missed). See Figure. PDSA 2 20 charts with the SWE box checked were reviewed from to (block 9). 0 out of 20 were not given the SWE (0% missed). 20 charts with the SWE box left blank or checked no were reviewed from to (block 9). 2 out of 20 were written a SWE (10% missed). See Figure.

4 Discussion The aim of this quality improvement study was to find ways to increase efficiency within CHOC. Several simultaneous QI projects in CHOC were being developed to achieve this goal, though my role more specifically was to standardize the way SWEs were given as the primary focus of this project. Prior to implementation of this project, SWEs had to be requested by the patient/family, and many times this would be asked at the end of the visit after all the paperwork had been delivered, forcing the MD to return to the work room, reopen the chart, and create the SWE document that could have been created concurrently with the other required depart paperwork. Since our work flow at this time does not allow us to delegate the SWE to the front desk staff, any requests by the patients/families prior to exiting would necessitate the staff members tracking down the appropriate nurse or MD to write the SWE, causing further inefficiencies in time and work flow. The pre-implementation and post-implementation data show that the number of SWEs did not significantly increase after implementation. During PDSA 1, per CHOC s nurse manager, it took some time for the staff to get used to the new face sheet, and not every patient/family may have been asked if they needed an SWE consistently. The exact incidence of misses is unknown, although anecdotally, with practice the rate approached close to 100% with the right personnel. This may have been complicated by the hiring of and training of new staff members during the project duration. After PDSA 1, there remained some confusion as to whether or not an unchecked SWE box indicated no SWE was needed, or if the question was failed to be asked, which prompted PDSA 2, whereby the work up room staff was asked to write yes or no on the face sheet. There are some limitations with regards to interpreting the data. First of all, if the SWE was checked as a yes on the face sheet, efficiency is assumed only if this successfully prompts the MD to write the SWE in tandem with the other required depart paperwork, and not prompted by reminder from the patient/family. This was not able to be measured, although anecdotally the workflow and efficiency increased as the MDs became accustomed to the new form. Likewise, if the SWE was left blank or checked as a no, but an SWE was written by the MD anyway, this may imply a miss from the work up room staff in failing to ask the question, a change in mind from the patient/family, or a miss from the MD in failing to recognize an SWE was not needed. One of the major limitations includes not having measurements in regards to time taken for creation of SWEs pre-implementation and post-implementation. This would have been difficult to assess on a number of fronts. If the SWE were requested at the end of a visit or upon exiting at the front desk, total time spent in the SWE creation process would be variable depending on the situation. This would have not been easy to measure, as the MDs would be required to time themselves during the SWE creation process, thereby causing a potential transient decrease in workflow, as well as an experimental bias, where the MD may be prompted to ask the patients/families if they require an SWE when they may have not done so otherwise, which could produce a possible skewing of results. Despite the limitations, there have been multiple positive reports from staff as well as patients/families regarding the new change throughout the development of the project, and this should not be underestimated. Although one may argue the data is insufficient to quantify an accurate estimate of how much time is actually saved by the implementation, this

5 project does demonstrate how a quality improvement endeavor can at the very least determine whether or not a proposed change causes significant barriers to workflow or decreases in efficiency. If anything, one could infer the process has likely allowed an increase in efficiency, even if it can t be quantified, and in addition has addressed the endpoint of patient satisfaction, which is now becoming a prominent marker of quality. The project does reveal the important role clear communication between staff members has in order to increase the chances of success of any project, and it can pave the way for other future quality improvement endeavors. Though such projects by themselves may appear small in the grand scheme of things, when added together and extrapolated over multiple providers and time, they can add up to significant increases in efficiency and patient/provider satisfaction [3]. References 1. S. Woolhandler, D. Himmelstein. Administrative Work Consumes One-Sixth of U.S. Physicians' Working Hours and Lowers their Career Satisfaction. International Journal of Health Services. October 2014, Volume 44, Issue 4, pp K. Fletcher, A. Visotcky, J. Slagle, S. Tarima, M. Weinger, M. Schapira. The Composition of Intern Work While on Call. Journal of General Internal Medicine. November 2012, Volume 27, Issue 11, pp S. Shipman, C. Sinsky. Expanding Primary Care Capacity By Reducing Waste And Improving The Efficiency Of Care. Health Affairs. November 2013, Volume 32, Issue 11, pp