Triage Call Reduction

in the OB GYN Clinic A Lean Six Sigma Green Belt Project

Robyn Thurston, MBA, CMPE

Practice Director, Obstetrics & Gynecology

Loyola University Health System

October 9, 2013

Charter

D M A I C

Project Overview

Problem Statement: Due to program growth, telephone

encounters by nursing staff have significantly increased over the

past year. This increase must be more efficiently managed in

order for nurses to spend time with patients in the clinic or

manage acute callers.

Goal: Reduce phone volume by 20%.

Resources

Champion: Cathy Lenz, Dr. Sondra Summers

Process Owner: Robyn Thurston

OpEx Mentor: Marque Macon

Margaret O’Connor, Nancy McDermott, Sharon Bird, Jennifer

Dudek, C. Bailey, M. Steinbrenner, Urogynecology RN team.

SIPOC

D M A I C

Inputs

• Health Care

Providers

• Nursing

• Service Reps

• Lab Techs

• Counselors

• Historical

Medical

Records

Suppliers

• EPIC

• Medical

Equipment

• Clinical

Supplies

• Pharmeceutical

s

• Facility/space

Customers

• THE PATIENT

•

Outputs

• Resolved

complaint

• Patient

receives

medical care

• Results of

testing

• Interpretation of

results

• Patient

receives guide

to better health

Patient arrives

for clinic visit

Patient receives

assessment, dx,

lab/radiology

orders – in req.

Patient receives

a treatment plan

Patient received

appropriate

intervention to

eliminate need

to call between

visit A and

visit B

Process Map

The Goal: Patient receives all appropriate intervention

necessary to eliminate the need to call between Visit A

and Visit B.

D M A I C

Patient arrives in

CLINIC

Order tests and or labs

Verify Patient Registration

Physician/Provider complete an

evaluation and assessment

Diagnosis during

course of visit?

Schedule follow up

testing or appointments

RN/PCTII takevitals, reconcil

meds and document reason

for visit

Document DiagnosisDevelop treatment

plan

Go to Lab or Fetal Monitoring

Tests are resulted,further diagnosis

Plan of care developed

Complete labs or testing today?

Schedule a follow-up

vis it??

Labs required? GO HOME

Yes

Yes Yes

NoNo

No Yes

Data Collection

Epic telephone encounters are tracked through

Ambulatory Services portal application. The following is

captured in a clarity report:

Date of telephone encounter

RN generating telephone encounter

Physician

Reason for call

Nursing documented 130+ reasons for patient calls.

These were grouped into 14 major groups. Beginning

August 15, nursing has narrowed reason for call into the

following groups:

D M A I C

14 Reasons for Call

Advice/Sick

Question

Results Follow Up

Orders

Appointments

Surgery Scheduling

Disability form

Needs Medication

Pain/Vaginal or Vaginal Problem

Heavy Bleeding

Prior Authorization/Disability Letter

Pareto

Questions, advice, and test results account for

50% of total volume

D M A I C

593581

363

331

281

218

188

138

90 9074

5239 31

19

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

0

100

200

300

400

500

600

Num

ber o

f Call

s

Reason for Call

Women's Health - Telephone Encounter VolumeApril 2012-June 2012

Call Volume by Reason

Pareto

Patients from two

providers account for

65% of total volume

Providers not shown are

grouped in “other” and

each account for less

than 20% of total call

volume

D M A I C

678

416

201

175

115 11291 86 86 83 81 81 78 76 74

63 62 6047 43

360

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

0

100

200

300

400

500

600

700

Nu

mb

er

of

Cal

ls

Provider Name

Women's Health Center Telephone Encounter Volume by Provider

April 2012-July 2012

Fishbone Diagram

Reasons for a high volume of triage calls

People

Materials

Method

Environment

Growing clinical practicePatient expectations

for resultsPatients not aware

of MyLoyolaAcute appts

Train delay

Unclear signage

Patient arrivesAt wrong location

Printers not in every exam room (AVS summary)

Poor patient education

Patients wanting sooner appts

Doc cancels clinic

AVS disregarded

Surgical scheduling

CommunicationOf results

AVS not charted

MFM scheduleNot released

High volume = less time w/patient

D M A I C

Pilot Plan – Affinity Grouping

Patient Education: AVS (discharge planning)

must be clear, charted and discussed with

patient

Results Expectations: Patient given clear

expectation as to when test results will be

available and how they will be communicated

(MyLoyola)

Appointments: Patient makes future appts to

discuss status of new treatment plans

D M A I C

Future State Map

D M A I C

Loyola Outpatient Center - Women's Health Center - Obstetrics and Gynecology Practice

Telephone Encounter Phone Triage Reduction Project

Future State Map - October 2012

Verify

Registration, print meds,

labels,

MyLoyola

Pat

ien

tS

ervi

ce R

epR

N/P

CT

IIP

rovi

der

Arrives in

Clinic

Vitals, medication

reconcil, reason for visit

Completes an

examination, evaluation/assessment

Diagnosis?

Order Diagnosic

testing, print AVS

Document Diagnosis

develop treatment plan, print AVS

Follow-up visit?

Communicate

results during f/u visit or MyLoyola

Communicate order

for next visit(ex: one year, further symptoms, referral

Obtain AVS, review patient

education, and discuss f/u with patient, expect results via

MyLoyola

Obtain AVS from hall

printer and discuss f/u with patient,

expect results via

MyLoyola

Direct

Patient to use PC for MyLoyola

Verify MyLoyola

access; Offer first time MyLoyola

parking

Schedule

F/U Visit

PCTII/SR

Schedule F/U Visit

Sign up for

MyLoyola

Leaves with clear patient educational materials,

MyLoyola access, and follow-up appointment

Pilot Plan

Selected highest call volume practice to pilot interventions – MIGS/CPP

Incorporate – Welcome to Our Practice Letters

Patients actively approached to sign up for MyLoyola (Tablet and Parking)

Patient educational materials placed in the exam rooms

Physicians to include specific information re: condition and plan in pt. instructions

Primary RN to MIGS/CPP at Check Out Area

AVS is charted, discussed and handed to patient

Use APN to f/u appointment with providers – develop scripting to direct patient to

APN schedule

Printers in exam rooms (pending)

D M A I C

Data After Pilot

D M A I C

Control Plan

SR Checklist:

Print MyLoyola access code for all inactive

arrivals – encourage enrollment in wait room

PCT/RN Checklist:

Offer patient tablet to sign up for MyLoyola

Make f/u appointment from exam room – using the

AVS

Ask patients on intake if they need letters, refills,

or have specific questions of providers prior to

assessment – be prepared with patient

educational materials

D M A I C

Lessons Learned

Robyn: “Find the data – map the process, what

we thought was a solution, was only part of the

solution. Pilot one practice, follow results one

practice, be open to changing route prior to

general roll out.”

S. Bird – “Patients in pain call often – but if we

can impact this group, we can have a major

impact on the entire practice.”

D M A I C