Yesterday our group at the VA took the next steps in moving forward our clinic quality improvement project.
We reviewed some initial data that we had gathered around how we document the patient agenda prior to the visit. Our current process involves an LVN calling the patient 2-3 days ahead of time to both remind them of their visit and to solicit any particular items they wanted to discuss with their provider. We found that out of a total of 24 patient-encounters that we reviewed, 3 were not called due to last minute appointment scheduling or time constraints, 8 calls went to voicemail so no agenda could be obtained, and 13 had “no urgent issues” or “will discuss with provider.” None of these 24 calls actually led to a documented agenda item in the pre-visit call note. Out of the 13 that had “no urgent issues” or “will discuss with provider,” there were 2 cases in which the patient was found to truly have no issues to discuss. Thus, only 8% of all of these patients had an accurate agenda documented prior to their visit. While this was a quick back of the envelope calculation, it certainly suggests a quality gap and an opportunity to improve how we care for patients in clinic.
Dr. Don Berwick, who founded the Institute for Healthcare Improvement (IHI) has said that “some is not a number, and soon is not a time” suggesting that to truly create change you have to have a specific goal with metrics and a goal date. To adhere to this principle we then created an aim statement focused around creating a SMART goal (specific, measureable, attainable, relevant, and time bound). Our aim is that for our subgroup of patients who present for follow up appointments in the Medical Practice clinic we will improve the percentage of patients with a documented agenda prior to the visit from ~10% to >25% by 11/17/15.
Next we reviewed a process map (see attached image) where we looked at all of the individual steps that a patient goes through to get to their appointment. By doing this (and in many cases actually going to the place where the work happens and observing the process in the wild) the group learned all of the small individual actions that have to work perfectly for a patient to actually have an agenda documented. We were then able to focus on specific steps that can easily lead to errors and brainstorm some potential counter measures to improve these steps and in turn improve the overall process.
At the end of our review, we identified two major areas where we thought we could improve the process of agenda setting:
- When the LVN calls the patient by improving the dialogue between the LVN and the patient by changing the script.
- By providing the patient with a sheet prompting them to list their agenda while they are sitting in the waiting room.
Our work for next week is to begin the final step of the IHI model for improvement in which the group will perform small tests of change as PDSA cycles and see if these ideas actually work.