Patients with thyroid cancer were often arriving for their follow up visits without necessary labs or imaging leading to an unproductive visit. This information would need to be reviewed at a later time asynchronously with the patient, leading to delays in treatment and inefficient workflow.
As we sought to understand the different causes of this problem, we prioritized having a patient advocate as part of the team. This was because patients were major stakeholders in this issue. Specifically, we sought to better understand patient-centered factors such as insufficient patient education that could have been contributing.
Other causes identified included expired orders and delays in calling to schedule radiology imaging (leading to radiology appointments being scheduled after the visit with the physician).
We believed that having a patient advocate on the team would help our team develop optimal interventions. The key drivers the team identified included patient education about their disease, motivation to have productive visits, a reminder system for patients to have labs and imaging completed prior to the visit, and ensuring that orders were not expired.
After identifying the key drivers, we generated several interventions. The interventions included creating a new standard workflow for the PCC to check that active orders were present at the time patients made their follow up appointment, 3 weeks prior to the visit check that patients had labs and ultrasound imaging scheduled or completed and send patient reminders to have them completed. For patients with expired or missing orders, the PCC was to pend orders for the nurse. For patient education, patients were verbally told the follow up plan, and the plan was written in the after-visit summary and provided to the patient on my health.
While implementing the PCC workflow, we heavily involved the PCC in order to have more effective PDSA cycles. Unfortunately, and despite this, during these early PDSA cycles, we did not document the standard workflows well, nor did we specifically analyze when the steps were happening or why. Because of this, we had some challenges in sustaining the intervention. After this was recognized, we did begin to document what you see above. Moving forward we will be including this documentation in future training of PCCs.
Overall, these interventions proved to be very successful. They helped to improve the rate of productive clinic visits and led to a superior patient experience. From a provider standpoint the increase in clinical efficiency of practice would be expected to improve professional fulfillment and reduce symptoms of burnout.
The outcome of this project actually surpassed our SMART goal. We remain limited however by our interventions being manual and dependent upon adequate staffing. Future work will be directed at creating more automated solutions.
In reflecting on this project, we have emphasized several learning points:
- We were successful at improving the percentage of productive visits. The majority of our interventions however relied on Level 1 or Level 2 sustainability. We subsequently had difficulty with sustaining our new workflow and were unable to fully expand it out to other clinics. Sometimes level 1 reliability interventions will fall through and it’s really critical to consider that in your sustain plan. Recognize that level 1 reliability interventions are staff dependent. If you don’t have the staff or the staff doesn’t have the time, it won’t happen. When designing the intervention, try to make it as simple as possible. That way it’s actually easier for people to follow the process then to work around it.
- The sustain plan did not account for major disruptions such as encountered during the COVID-19 pandemic. The pandemic caused resources to be stretched. We have now decided that we need to embed reviewing this process into our standard operations and will do this twice per year.
- It is very important to document PDSA cycles. This includes what worked, what didn’t work and what you may have learned. The A3 is great for overall status of the project and initial problem solving, but isn’t great for this level of detail, so you’ll need something else for documentation. Make a point of documenting it somewhere!
Katherine Wurdinger (RN), Susana Herrera (PCC), Robert Duffy (Patient Advocate), Sana Siddiqui (Medical Scribe)
Eva-Marie Alexander, Tim Morrison