Improving patient wait in the outpatient setting

Improving Patient Wait in the Outpatient Setting Utilizing Talk-to-Text Charting Item Type text; Electronic Dissertation Authors Nelson, Mykala Mikesell Citation Nelson, Mykala Mikesell (2021) Improving Patient Wait in the Outpatient Setting Utilizing Talk-to-Text Charting (Doctoral dissertation, University of Arizona, Tucson, USA) Publisher The University of Arizona Rights Copyright © is held by the author Digital access to this material is made possible by the University Libraries, University of Arizona Further transmission, reproduction, presentation (such as public display or performance) of protected items is prohibited except with permission of the author Download date 06/07/2023 03:48:39 Item License http://rightsstatements.org/vocab/InC/1.0/ Link to Item http://hdl.handle.net/10150/663129 IMPROVING PATIENT WAIT IN THE OUTPATIENT SETTING UTILIZING TALK-TO-TEXT CHARTING by Mykala Mikesell Nelson Copyright © Mykala Mikesell Nelson 2021 A DNP Project Submitted to the Faculty of the COLLEGE OF NURSING In Partial Fulfillment of the Requirements For the Degree of DOCTOR OF NURSING PRACTICE In the Graduate College THE UNIVERSITY OF ARIZONA 2021 ACKNOWLEDGMENTS I would like to acknowledge my project site for allowing me to my project at their clinic because without them this project would not have been successful Thank you to all the providers there who either participated in this project or took me on as a student to teach me and help me on my way to completing this degree I also want to acknowledge the professors in the college of nursing There have been so many great professors who assisted me with this project and helped me along the way Thank you all! DEDICATION I would like to dedicate this project to my amazing husband, family, and friends Without these amazing people in my life this project nor this degree would have been possible I truly have the best support system around me and I am so grateful for all the love, support, and help I have received throughout this process I love you all so much, thank you for everything! TABLE OF CONTENTS LIST OF FIGURES LIST OF TABLES ABSTRACT 10 INTRODUCTION 12 Background Knowledge and Significance 12 Local Problem 15 Intended Improvement 16 Project Purpose 16 Project Question 16 Project Objectives 16 Theoretical Framework 17 Lewin’s Theory of Change 17 Unfreezing 18 Changing 18 Refreezing 18 Literature Synthesis 21 Evidence Search 21 Comprehensive Appraisal of Evidence 23 Contributing Factors 23 Patient Factors 24 Provider Factors 24 Organization/Site-Specific Factors 25 Effects of Waiting on Health 26 Common Interventions 26 Scheduling 26 Clinical Processes 27 Number of Staff 28 Strengths of Evidence 29 TABLE OF CONTENTS – Continued Weaknesses of Evidence 30 Gaps and Limitations 31 METHODS 31 Project Design 31 Model for Implementation 32 Plan-Do-Study-Act (PDSA) Cycle 33 Plan 33 Do 35 Study 35 Act 36 Setting and Stakeholders 36 Planning the Intervention 38 Participants and Recruitment 38 Consent and Ethical Considerations 39 Timeline 39 Data Collection 40 Data Analysis 40 RESULTS 41 Outcomes 42 DISCUSSION 43 Summary 43 Interpretation 44 Implications 45 Practice 45 Education 45 Research 46 Policy 46 Limitations 47 TABLE OF CONTENTS – Continued DNP Essentials Addressed 47 Conclusions 48 Plan for Sustainability 49 Plan for Dissemination 49 Funding 49 APPENDIX A: FAMILY PRACTICE CLINIC SITE APPROVAL / THE UNIVERSITY OF ARIZONA INSTITUTIONAL REVIEW BOARD DECISION LETTER 50 APPENDIX B: CONSENT DOCUMENT (DISCLOSURE AND CONSENT FORM) 53 APPENDIX C: EVALUATION INSTRUMENTS (POST-IMPLEMENTATION SURVEY) 55 APPENDIX D: PARTICIPANT MATERIAL (PARTICIPANT EDUCATION) 57 APPENDIX E: PROJECT TIMELINE 69 APPENDIX F: LITERATURE REVIEW GRID 71 APPENDIX G: OTHER DOCUMENTS AS APPLICABLE TO THE PROJECT (PRISMA 2009 FLOW DIAGRAM) 78 REFERENCES 80 LIST OF FIGURES Figure Lewin’s Theory of Change 19 Figure IHI Model for Improvement with PDSA Cycle 34 LIST OF TABLES Table Post-Implementation Survey: Questions and Responses 42 68 69 APPENDIX E: PROJECT TIMELINE 70 Completion Date April 26, 2021 June 13, 2021 Planning June 28, 2021 July 13, 2021 August 19, 2021 September 16, 2021 SeptemberOctober 2021 November 18, 2021 Evaluation Obtain proposal approval from project chair Schedule proposal defense presentation with committee Proposal defense presentation June 15, 2021 July 6, 2021 Implementation Solidify site Submit project proposal to project chair June 14, 2021 June 28, 2021 Pre-Implementation Revise proposal from committee feedback Submit to UA IRB Obtain IRB approval Implement Begin data collection Data collection period concluded Data analysis Final defense presentation presenting findings Summary provided to project site 71 APPENDIX F: LITERATURE REVIEW GRID 72 Project Question: Will the implementation of emailing or mailing out new patient paperwork, prior to the visit, increase patient satisfaction and decrease the average waiting times during the check in process for the patients being seen in this clinic? Pub Year; Author’s Last Name Title of Publication Type of Study Main Outcomes of Findings Support for and or Link to Project 2021, Kagedan et al Behind the clock: elucidating factors contributing to longer clinic appointment Quantitative study using retrospective cohort design -Long wait times lead to patient dissatisfaction and poor perception of care -Low number experienced medical provider staff increased wait times -High number of patients seen during the day increased wait times -Lowest amount of waiting time seen with nurse practitioner providers -Project completed at site with nurse practitioners on staff -Long wait times lead to decreased satisfaction -Monitoring number of patients seen in a day and how many new patients are scheduling appointments to balance the number of patients seen in a day 2021, Kam et al Using lean six sigma techniques to improve efficiency in outpatient ophthalmology clinics Quality improvement -Higher number of patients seen in one day leads to increased wait times -Moved appointments earlier so screening could be done prior to seeing the provider so the patient was on time -Moved to patients being seen in chronological order based on appointment time -Poor communication leading to increased waiting time -Monitoring number of new patients scheduling appointments to balance the number of patients seen in a day -Increased communication with patient prior to their appointment -Having patients complete paperwork prior to their appointment so that they can be ready to see their provider 2020, Achuri et al Reducing patient wait times in Rwandan hospital outpatient services Quality improvement -Wait times affect quality of and access to healthcare -Patients avoid seeking care due to long waiting times which leads to health consequences -Areas of patient cycle contributing most to increased wait times were: Check-in and waiting to see the provider -Identified bottlenecks to decide at which point of patient cycle to implement intervention -Increased wait times due to check-in process -Waiting times lead to health consequences due to patients avoiding seeking care 73 Pub Year; Author’s Last Name Title of Publication Type of Study Main Outcomes of Findings Support for and or Link to Project 2020, Robinson Losing the wait: improving patient cycle time in primary care Quality improvement -Improve cycle time to less than 60 minutes for the whole visit -Improved wait times but maintained patient satisfaction with time spent with the provider -MA working to coordinate patient flow -Team engagement important -Discusses different PDSA cycles and interventions to decrease patient wait times -Found in their clinic that the check-in process was the place where the most holdup is -Satisfaction stayed the same or increased in many areas despite cutting down overall time spent in the clinic 2020, Tlapa et al Effects of lean healthcare on patient flow: a systematic review Systematic review with meta-analysis -Poor patient flow processes lead to delay of care, decrease patient and staff satisfaction, and decrease overall quality of care -Improving patient flow process efficiency shown to improve staff and patient satisfaction -Majority of improved areas were process type improvements -Patient-flow is an important factor regarding waiting times in the clinic -Inefficient processes leading to increased wait times -Improving process efficiency can improve wait times along with patient and staff satisfaction 2019, Aburayya et al An investigation of factors affection patients waiting time in primary health care centers: An assessment study in Dubai Quantitative study with audit of charting and employee surveying -Average of 35 minutes per patient -Registered within minutes of arrival -Had to wait between 25-38 days to get an appointment -Staff report wait times high due to low staffing, high workload, problems with management, and adequate facility availability -Examining where problems with wait times occur within the clinic -This clinic showed the hold-up is waiting for the providers instead of at check-in -Study design 2019, Chu et al The psychology of the wait time experience – what clinics can to manage the waiting Longitudinal qualitative study -Patients have a willingness to wait -Steps available to improve the experience of the patient’s wait time -Inform patient of delays -Wait times are inevitable -One of the main quality assessment scores from patient insurance surveys 74 Pub Year; Author’s Last Name Title of Publication Type of Study experience for patients: a longitudinal, qualitative study Main Outcomes of Findings Support for and or Link to Project -Apologize for delays -Have items available in the clinic to assist in diversion -Ways to improve the experience during the wait time -Talk with the patients and acknowledge the wait time and apologize for delays and have opportunities for diversion in the waiting room -Improve clinic experience -Let patients know that by filling out required paperwork before their appointment could reduce the amount of time spent waiting 2019, Godley & Jenkins Decreasing wait times and increasing patient satisfaction Quality improvement -Increased wait can increase anxiety and stress -Complaints focused on long registration/check-in process -Patient and staff dissatisfaction with inefficient processes -Paperwork filled out prior to patient check-in -Acknowledge patient and staff dissatisfaction -Focus on check-in process to improve efficiency 2019, Kovach & Ingle Using lean six sigma to reduce patient cycle time in a nonprofit community clinic Quality improvement -Patient wait time and patient noshow rates are one of the highest indicators of clinic quality -Wait time is directly correlated with satisfaction -Inefficient processes lead to increased waiting times -Long wait times are linked to decreased patient satisfaction -Inefficient processes lead to increased wait times -Patient no-show if they think there will be a long wait leading to health consequences 2017, Ansell et al Interventions to reduce wait times for primary care appointments: a systematic review Systematic review -Open access scheduling is the most utilized intervention to reduce wait times -Telephone follow-up calls reduced wait times -Discussed different interventions used to decrease wait times -Nurse practitioners showed link to reducing wait times -Compiled all articles relevant to this topic in one review -Having Nurse Practitioners on staff help reduce wait times 75 Pub Year; Author’s Last Name Title of Publication Type of Study Main Outcomes of Findings Support for and or Link to Project -Having a dedicated practitioner to triage patients assisted with lowering wait times -Email consultations also reduced wait times 2017, Ariffin et al An assessment of patient waiting and consultation time in a primary healthcare clinic Quantitative timed study with audit -Broke down waiting times by areas the patient encountered from entrance to exit -More than half of patients were registered within 15 minutes -Average wait time from registration to seeing a provider was 41 minutes -99% of patients waited less than 30 minutes to get their medication -Average consult time was 18 minutes -This clinic hired more staff for registration -Encouraging patients to come at their scheduled time instead of showing up early -Used staggered scheduling -Patients willing to wait for provider they had seen previously 2017, Oostrom et al Outpatient office wait times and quality of care for Medicaid patients Quantitative retrospective study -Increased wait times lead to frustration and dissatisfaction with the quality of care -Medicaid patients more likely to experience barriers to care -Medicaid patients tend to show up late to medical appointments -Access to timely and equitable care one of the areas on the Institute of Medicine’s crossing the quality chasm report -Waiting times affect patient satisfaction -Satisfaction with care on insurance surveys have implications for care reimbursement for the clinic -Patients with Medicaid tend to show up late to appointments so with scheduling can keep this in mind to schedule appropriately 2017, Pena & Lawrence Analysis of wait times and impact of real-time surveys on patient satisfaction Cross-sectional qualitative study -Patient satisfaction is linked to healthcare reimbursement -Survey completed as patient’s completed their visit -Patient satisfaction determines healthcare reimbursement -Wait times are consistently an area where the project site falls short 76 Pub Year; Author’s Last Name Title of Publication Type of Study Main Outcomes of Findings Support for and or Link to Project -Overall, patients are satisfied with wait times at this site -Increased patient satisfaction with wait times can lead to increased patient adherence to treatment plan and therefore improve healthcare outcomes -Improving wait times can also increase adherence to treatment and improve patient health outcomes 2016, BurlingPhillips Going lean, part 3: improve patient wait times Interview - grey source -Patient wait times are an indicator of healthcare performance -Use value-stream mapping to determine what is of value to the patient -Followed a mock patient through a patient cycle to determine where increased waiting times were occurring -Address areas of patient bottlenecking within the patient cycle -Focus on the change process of the intervention -Assign staff to complete tasks to improve flow -Assess performance and intervention efficacy 2016, Christiansen et al Patient empanelment: a strategy to improve continuity and quality of patient care Quality improvement -Patient with no assigned primary care provider within the clinic lead to increased wait times and costs -Assigning patient to a primary care provider reduced waiting time by twelve minutes and allowed the clinic to see an extra four patients per day -With the scheduling of new patient appointments, the reception staff will schedule the patient with the available provider or by patient preference and this will become their primary care provider -Establishing a primary care provider from the first patient visit will decrease wait times not only with the initial visit but throughout their time accessing healthcare at this facility 2016, Huang Appointment standardization evaluation in a primary care facility Simulation quantitative study -Standardizing appointment times between providers increase costs -Standardized appointments increase patient wait times -Increase provider idle time -Scheduling practices influence patient wait times -Appointment scheduling needs to be based on individual providers 77 Pub Year; Author’s Last Name 2016, Institute for Healthcare Improvement Title of Publication Shortening waiting times: six principles for improved access Type of Study Expert opinion grey source Main Outcomes of Findings Support for and or Link to Project -Increase provider overtime -Increase clock out times by 30 minutes -Decrease access for patients to health care -Individual scheduling approach saves money, increases access -When scheduling new patient appointments be mindful of individual providers schedules and inform patient -Understanding supply and demand is crucial to have adequate access and aim to eliminate waiting times -Recalibrate the system based on changes to eliminate backlog -Use queuing theory with appointment scheduling to reduce wait times or “lines” and reduce open appointments that aren’t being used -Create plan for when variation in practice occurs such as when many providers vacation during the holidays and there is an influx of patients in January and February -Influence the demand and ensure patients see their preferred provider and providers always see their actual patients -Manage constraints by delegating work and utilizing all members of the healthcare team to allow efficiency of provider and patient relationship -Many different ways to decrease wait times -Multifaceted issue that requires different approaches to decrease wait times in the clinic 78 APPENDIX G: OTHER DOCUMENTS AS APPLICABLE TO THE PROJECT (PRISMA 2009 FLOW DIAGRAM) 79 PRISMA 2009 FLOW DIAGRAM Screening Identification Records identified through database searching (n = 377) Records after duplicates removed (n = 377) Records screened (n = 377) Eligibility Full-text articles assessed for eligibility (n = 169) Included Additional records identified through other sources (n = 2) Studies included in qualitative synthesis (n = 2) Studies included in quantitative synthesis (meta-analysis) (n = 13) Records excluded (n = 208) Full-text articles excluded, with reasons (n = 150) 80 REFERENCES Aburayya, A., Alshurideh, M., Albqaeen, A., Alawadhi, D., & A'Yadeh, I A (2019) An investigation of factors affecting patients waiting time in primary health care centers: an assessment study in Dubai Management Science Letters, 10(6), 1265-1276 doi:10.5267/j.msl.2019.11.031 Achuri, D., Wilson, D R., Atwine, J., & Kamuhangire, E (2020) Reducing patient wait times in Rwandan hospital outpatient services Retrieved from https://www.msh.org/resources/reducing-patient-wait-times-in-rwandan-hospitaloutpatient-services American Association of Colleges of Nursing (2006) The essentials of doctoral education for advanced nursing practice https://www.aacnnursing.org/Portals/42/Publications/DNPEssentials.pdf Ansell, D., Crispo, J A G., Simard, B., & Bjerre, L M (2017) Interventions to reduce wait times for primary care appointments: a systematic review BMC Health Services Research, 17, 1-9 doi:10.1186/s12913-017-2219-y Ariffin, F., Azraii, A B., & Kamaruddin, K N (2017) An assessment of patient waiting and consultation time in a primary healthcare clinic Malaysian Family Physician, 12(1), 1421 Bakari, H., Hunjra, A I., & Niazi, G S K (2017) How does authentic leadership influence planned organizational change? The role of employee’ perceptions: integration of theory of planned behavior and Lewin’s three step model Journal of Change Management, 17(2), 155-187 doi:10.1080/14697017.2017.1299370 Burling-Phillips, L (2016) Going lean, part 3: improve patient wait times Eyenet Magazine, Burnes, B (2020) The origins of Lewin’s three-step model of change The Journal of Applied Behavioral Science, 56(1), 32-59 doi:10.1177/0021886319892685 Christiansen, E., Hampton, M D., & Sullivan, M (2016) Patient empanelment: a strategy to improve continuity and quality of patient care Journal of the American Association of Nurse Practitioners, 28(8), 423-428 doi:10.1002/2327-6924.12341 Chu, H., Westbrook, R A., Njue-Marendes, S., Giordano, T P., & Dang, B N (2019) The psychology of the wait time experience - what clinics can to manage the waiting experience for patients: a longitudinal, qualitative study BMC Health Services Research, 19(1), N.PAG-N.PAG doi:10.1186/s12913-019-4301-0 Data USA (2018) Lehi, UT: Data USA Datausa.io https://datausa.io/profile/geo/lehi-ut 81 Godley, M & Jenkins, J B (2019) Decreasing wait times and increasing patient satisfaction: a lean six sigma approach Journal of Nursing Care Quality, 34(1), 61-65 doi:10.1097/NCQ.0000000000000332 Gritters, J (2017) The cost of long wait times Retrieved from https://www.athenahealth.com/knowledge-hub/financial-performance/cost-long-waittimes Huang, Y.-L (2016) Appointment standardization evaluation in a primary care facility International Journal of Health Care Quality Assurance (09526862), 29(6), 675-686 doi:10.1108/IJHCQA-01-2016-0004 Hussain, S T., Lei, S., Akram, T., Haider, M J., Hussain, S H., & Ali, M (2018) Kurt Lewin's change model: a critical review of the role of leadership and employee involvement in organizational change Journal of Innovation & Knowledge, 3(3), 123-127 doi:10.1016/j.jik.2016.07.002 Institute for Healthcare Improvement [IHI] (2016) Shortening wait times: six principles for improved access Retrieved from http://www.ihi.org/resources/Pages/ImprovementStories/ShorteningWaitingTimesSixPri nciplesforImprovedAccess.aspx Institute for Healthcare Improvement [IHI] (2019) Science of improvement: how to improve Ihi.org http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprov e.aspx Kagedan, D J., Edge, S B., & Takabe, K (2021) Behind the clock: elucidating factors contributing to longer clinic appointment duration and patient wait time BMC Health Services Research, 21(1), 1-9 doi:10.1186/s12913-021-06079-y Kam, A W., Collins, S., Park, T., Mihail, M., Stanaway, F F., Lewis, N L., Smith, J E H (2021) Using lean six sigma techniques to improve efficiency in outpatient ophthalmology clinics BMC Health Services Research, 21(1), 1-9 doi:10.1186/s12913020-06034-3 Kovach, J V & Ingle, D (2019) Using lean six sigma to reduce patient cycle time in a nonprofit community clinic Quality Management in Healthcare, 28(3), 169-175 doi:10.1097/QMH.0000000000000215 Ogochi, D K (2018) Lewin’s theory of change: applicability of its principles in a contemporary Lewin’s theory of change: applicability of its principles in a contemporary organization Journal of Strategic Management, 2(5), 1-11 82 Oostrom, T., Einav, L., & Finkelstein, A (2017) Outpatient office wait times and quality of care for Medicaid patients Health Affairs (Project Hope), 36(5), 826–832 doi:10.1377/hlthaff.2016.1478 Pena, S M & Lawrence, N (2017) Analysis of wait times and impact of real-time surveys on patient satisfaction Dermatologic Surgery, 43(10), 1288-1291 doi:10.1097/DSS.0000000000001232 Robinson, J., Porter, M., Montalvo, Y., & Peden, C J (2020) Losing the wait: improving patient cycle time in primary care British Medical Journal Open Quality, 9(2), 1-6 doi:10.1136/bmjoq-2019-000910 Tlapa, D., Zepeda-Lugo, C A., Tortorella, G L., Baez-Lopez, Y A., Limon-Romero, J., Alvarado-Iniesta, A., & Rodriguez-Borbon, M I (2020) Effects of lean healthcare on patient flow: a systematic review Value in Health, 23(2), 260-273 doi:10.1016/j.jval.2019.11.002 Wojciechowski, E., Pearsall, T., Murphy, P., & French, E (2016) A case review: integrating Lewin’s theory with Lean’s system approach for change Online Journal of Issues in Nursing, 21(2), 1-1 doi:10.3912/OJIN.Vol21No02Man04