The Florida Department of Health in Osceola County (OCHD), located in east central Florida, is one of the centralized Florida Department of Health’s 67 county health departments (CHDs). OCHD is unique in that it is one of only eight Florida CHDs also designated as a federally qualified health center. We have a network of five health centers providing public health and primary care medical and dental services. Population includes 40% White; 13% Black; and 46% Hispanic ethnicity. The combined Hispanic and Black populations represent a 59% majority, which is of significance as these groups are considered at greater risk of health disparities.
Many of Osceola’s population-based health status indicators are worse than state comparisons, national benchmarks, and Healthy People 2020 goals. Low first trimester prenatal care; high rates of low birth weight, prematurity, and infant mortality; diabetes; and cardiovascular illnesses are particularly evident in Osceola’s majority population (46% Hispanic and 13% Black). Statistically these groups are considered to suffer greater health disparities. The 2014 County Health Rankings shows Osceola ranks poorly in comparison to Florida’s 67 counties; 42nd for health factors and 57th for lack of access to healthcare. The primary care physician to population rate is 2,209:1 (Florida 1,426:1 and national 1,051:1). Osceola is a Health Professional Shortage Area (HPSA) for primary medical and dental. Access to health care was identified in Osceola’s three iterations of Mobilizing for Action through Planning and Partnerships (MAPP) as an issue of critical need, particularly for health disparate populations. Based on Osceola’s lack of access and in response to The Ten Essentials of Public Health to “assure the provision of health care when otherwise unavailable,” OCHD is the single largest primary care provider in the county.
OCHD’s quality improvement (QI) initiative focused on improving health outcomes by increasing early access to quality health care. Our “if-then” improvement theory prediction was “if...we reduce barriers to accessing care, then...we will have a positive effect on people obtaining earlier care, which could help improve health outcomes.” Our Aim Statement became: “By September 2014, we will improve access to primary care services by decreasing the appointment no-show rate from 40% December 2013 baseline to 20%.” (This goal was developed based on literature research of no-show rates for primary care clinical facilities across the nation).
Using a 9-Step Process Management Model with Plan-Do-Check-Act (PDCA), we determined that to improve the early access we would have to improve our appointment scheduling model. During the Plan phase of the PDCA cycle, we utilized QI tools to determine why we had long wait times, which included artificially imposed barriers such as multiple systems for rescheduling, walk-ins, and regular appointments. We drilled down to the root-cause as delayed access due to a large appointment no-show rate that clogged appointment schedules.
QI tools included Input/Output Diagram to define the scheduling process; Process flow charting to show the steps in the process; Fishbone Diagram to categorize potential causes of process problems and further refine the root-cause. In the next “DO” PDCA phase, we revised the Process Flow, eliminating the multiple appointment schedules and implementing an Open Access model. In the “Check” phase we monitored the no-show rate monthly, implemented improvement interventions, and monitored performance in the next monthly “Check” cycle.
Data showed improvement from a 40% no-show rate baseline in December 2013 to 11% in September 2014. We saw slight monthly data fluctuations in response to PDCA interventions and refinement of the Open Access model.
We meet all objectives, including: 1) Implemented Open Access model; 2) same-day/next-day appointment availability; and 3) reduced no-show rate. We achieved a 29% improvement in our no-show rate.
We attribute our success to using QI tools such as our 9-Step Process Management Model/PDCA as a detailed, systematic methodology to develop, implement, and manage processes. This approach was a roadmap enabling us to analyze performance; identify strengths and opportunities for improvement; and address performance gaps to better manage improvement efforts and positively impact early access to health care.
Managing our efforts to improve early health care access is a leading performance indicator in helping achieve lagging indicators such as better health outcomes. The majority of patients we serve are in health disparate groups; i.e. 98% are below 200% federal poverty; 83% are racial/ethnic minorities; 27% are better served in a language other than English; and 42% are uninsured. By improving our processes to provide patients earlier access to primary care, we have a better opportunity to have a positive impact on population-based health status outcomes.
Osceola County has several population-based health outcome indicators that are worse than national Healthy People (HP) 2020 targets and show a critical need for improvement (Florida CHARTS 2012). Included are:
· The HP 2020 target is to increase the proportion of pregnant women who receive prenatal care in the first trimester to 77.9%. While Osceola’s county rate is 81%, the rate for pregnant women who are patients at OCHD is 52%.
· Osceola’s fetal death rate per 1,000 deliveries is 6.5 (HP 2020 target is 5.6). The rate for Blacks is worse at 8.4.
· Osceola’s neonatal death rate is 4.5 per 1,000 live births (HP 2020 target is 4.1). The rate for Blacks is worse at 8.5.
· Osceola’s infant death rate is 6.3 per 1,000 live births (HP 2020 target is 6.0). The rate for Blacks is worse at 15.3.
· Osceola’s rate of 13.6% preterm births is worse than HP 2020 target (11.4%).
· Osceola’s low birth weight rate of 8.3% is worse than the HP 2020 target (7.8%).
The following health status indicators show Osceola’s rates are worse for the Hispanic and Black population groups that are at greater risk for health disparity. These health status indicators likely could be improved with early access to routine primary care prevention efforts.
· Diabetes: Hispanics (17.1); Blacks (17); Whites (11.3); compared to Florida’s rate of 9.6; 13.4; and 10.1 respectively.
· Obesity: Hispanics (45.5); Blacks (47.6); Whites (29.9); compared to Florida’s rate of 29.2; 42; and 25.9 respectively.
· Cardiovascular disease: Hispanics (11.6); Blacks (9.9); Whites (12.1); compared to Florida’s rate of 6; 7.6; and 10.6 respectively.
The 2014 County Health Rankings shows Osceola ranks poorly in comparison to Florida’s 67 counties; for example, 42nd for health factors and 57th for lack of access to healthcare. The primary care physician to population rate is 2,209:1 (Florida 1,426:1 and national 1,051:1). Osceola is a federally designated Health Professional Shortage Area (HPSA) for primary medical and dental. Access to health care was identified in Osceola’s three iterations of Mobilizing for Action through Planning and Partnerships (MAPP) as an issue of critical need, particularly for health disparate populations. Based on Osceola’s lack of access and in response to The Ten Essentials of Public Health to “assure the provision of health care when otherwise unavailable,” OCHD is the single largest primary care provider in the county.
Osceola’s estimated 2013 population was 298,504. The target population affected by the public health problem is the 46% disadvantaged that live at or below 200% federal poverty level; the 25% uninsured/underinsured; and those that do not have a regular source of primary care. Osceola’s population subsets (46% Hispanic and 13% Black) are those typically considered at greater risk for health disparities. When combined, these groups form a 59% majority population for the county overall.
OCHD served 23,030 primary care medical and dental patients during 2013. Of those, 84% were racial/ethnic minorities; 98% were below 200% FPL; and 43% were uninsured. The project target population was 100% of the patients served during the project timeframe of January 2014 through September 2014; which was 7,662 patients that had 16,202 clinical visits.
Our project reached 100% of the primary care medical and dental patients served during the 9-month project timeframe.
We had not adequately focused on addressing the problem in the past. We had internal processes in place for appointment scheduling that were based on what we had done for years and were not focused on reducing artificially created barriers to timely access. We continuously tried to tweak the appointment schedules in an attempt to accommodate patients that needed to be seen on the same-day/same-week and to account for a large no-show rate that clogged the appointment system. We ended up having multiple appointment schedules such as rescheduling clinic, walk-in clinic, and regular appointments. We were not managing the appointment system effectively or efficiently. An appointment for a new patient was at least three months out and two to three weeks for an established patient. We were not meeting the evidence-based Primary Care Medical Home operational characteristics standard for providing Superb Access to Care; which requires accessible services with shorter waiting times for urgent needs and flexible appointment hours and days of service.
Our project used a systematic process management approach to implement the current Open Access practice that improved timely access to primary care services on a same-day/next-day basis. We reduced those artificially imposed barriers in the appointment process that made the system work for us and not necessarily for our patients. We used process mapping to redesign the work flow. This PCDA process improvement intervention had a positive impact on timely access by efficiently managing the Call Center’s appointment notification process to the clinic medical records department so that patient records could be pulled and prepared prior to the time they arrived for the provider visit. Additional PDCA cycle improvement interventions included redesigning our electronic appointment system and installing phones in the lobby so that walk-in patients could schedule an appointment without waiting in line to see the front desk staff. This intervention helped to minimize waiting lines at the check-in window and enabled staff to more efficiently complete the check-in process. These improvement interventions had a positive effect on our in-process indicator of reducing the no-show rate from a baseline of 40% at the beginning of the project in December 2013 to 11% in September 2014. Our streamlined Open Access process also has helped to minimize insurance denials and scheduling errors. Most importantly, we are able to provide a vulnerable, disadvantaged population with earlier access to care in OCHD’s Joint Commission certified Primary Care Medical Home where their health needs can be addressed, resulting in an improved opportunity for better health outcomes. In this way, OCHD is meeting the Ten Essential Public Health Services by “assuring the provision of health care when otherwise unavailable.”
Our Open Access project creatively used and built upon existing quality improvement tools to combine into our internally developed 9-Step Process Management Model with PDCA. The Plan-Do-Check-Act is a widely accepted QI tool used for continuous improvement cycles. We included in our model the three questions from the Model for Improvement (“What are we trying to accomplish?” “How will we know a change is an improvement?” and “What change can we make that will result in an improvement?”) The Model for Improvement was developed by Associates in Process Improvement and used, among others, by the Institute for Healthcare Improvement and the HRSA Bureau of Primary Health Care’s national Chronic Disease Collaborative. One of the most effective elements we included in our process management model was a detailed description of what to do in each of the PDCA steps along with recommendations on which QI tools are appropriate for each step. Our 9-Step Process Management Model with PDCA became our roadmap to guide our QI team through our improvement cycles. Our model can be used for our ongoing QI efforts, as it is a concise roadmap/QI tool that will enable us to replicate our successful process management methodology with other QI projects.
The Primary Care Medical Home concept, which stipulates Superb Access to Care as one of the operational characteristics, is evidence-based through the following: 1) Agency for Healthcare Research and Quality’s Primary Care Medical Home (PCMH) Research Methods Series; 2) Commonwealth Fund’s Safety-Net Medical Home Initiative; 3) American Academy of Pediatrics’ National Center for Medical Home Implementation; and 4) McMaster University Evidence Based Medicine Resource Group.
Global Immunization|Nutrition, Physical Activity, and Obesity|Mother-to-Child Transmission of HIV and Syphilis|Teen Pregnancy|Tobacco
The QI team used an internally developed 9-Step Process Management Model with Plan-Do-Check-Act (PDCA) as a systematic approach to develop, implement, and manage the timeliness and efficiency of our Open Access appointment scheduling model. The QI team determined we could more effectively improve the waiting time for a primary care appointment, a lagging/outcome indicator, by addressing in-process/leading indicators that ultimately affect the outcome. We determined our in-process indicator would be reducing the no-show rate for scheduled appointments that clogged the appointment system. Our Aim Statement project goal was to improve (decrease) the no-show rate from a baseline of 40% to 20% during the 9-month project period.
We used various QI concepts and our 9-Step Process Management Model with PDCA to implement our program, including:
1. Input/Output Diagram – The QI Team defined the appointment process. This included: Inputs (patients needing primary care services); In-Process Activities (multiple appointment schedule templates); Outputs (patient received primary care service); and Outcome (earlier access to primary care and improved opportunity for better health outcomes).
2. Process flow charting – Once the QI Team had the appointment process defined, we used that information to develop a process flow chart. The process flow chart, which is a visual depiction, clearly showed the number of appointment scheduling templates staff had to utilize to make an appointment. The QI Team was able to clearly see a prolonged access to care for the patient and inefficient use of staff time and scheduling.
3. Brainstorming and Fishbone Diagram – The QI Team brainstormed the various issues involved in the appointment scheduling process. The issues have been captured in a Fishbone Diagram (cause and effect diagram), which serves as a visualization tool for categorizing the potential causes of process problems so that the root-cause can be identified.
4. Root Cause Analysis - The QI Team dug deeper among the various issues looking for the real root-cause. The QI Team also brainstormed ideas regarding which of the identified issues that we felt we could control or influence and then selected by consensus the most plausible root-cause. Using our 9-Step Process Management Model with PDCA, we continued through the steps that would test, by data analysis, whether our initial root-cause held up as the real root-cause. The QI Team concluded the root-cause to be “artificially imposed barriers to make system work for the agency and not necessarily for the patient, i.e. there was a high no-show rate for appointments due to scheduling appointment for new patients out 2-3 months, and returning patients out 2-3 weeks.” We needed to improve access by eliminating the multiple appointment scheduling templates and implementing an Open Access appointment system so that patients could be seen on a same-day/next-day basis.
5. Revised Process Flow – After completing the steps above, the QI Team developed a revised or improved process flow. Staff and patients were educated on the new Open Access model.
In the five steps above, the QI Team had followed the “Plan” and “Do” phases of our 9-Step Process Management Model with PDCA. We were now at the “Check” phase in which the QI team monitored the no-show in-process indicator on a monthly basis. We collected, analyzed, and graphically displayed the data. The data were presented each month to senior management, Call Center staff, and clinical staff; discussing with them what the data were indicating.
At this point the QI Team started the “Act” phase of the PDCA cycle by identifying opportunities for improvement through tweaking of the process flow, testing, and taking action to fix problems. Based on the data we then brainstormed with staff the potential problem areas. We used input from the staff to determine root-causes and what they thought, based on their experience, we could put into place as an intervention for improvement. The planned interventions for improvement were then set into place and the QI Team went into another “Check” cycle to monitor performance for the next month.
Monthly no-show rate in-process data showed an improvement from our baseline of 40% in December 2013 to 11% by September 2014. After the initial dramatic drop from 40% to 13% during the first month when the new Open Access appointment system was implemented, there were only slight monthly fluctuations in the data for the remainder of the project period. We were able to surpass our Aim Statement goal of a no-show rate of 20%, achieving 11% at the end of the project period.
All established and new patients requesting a primary care appointment were included. The timeframe was December 2013 to September 2014.
The Open Access project has been an OCHD internal process. There was a core group of four OCHD interdisciplinary staff members actively involved on the QI Team and they included other staff members at various steps in the implementation. OCHD’s Administrator has discussed the project findings during the Osceola Health Leadership Council (HLC), which includes members from key Osceola County community partners and stakeholders, as well as the OCHD Administrator. The HLC is the oversight body that has worked with OCHD in our public health role on the 2012 Osceola Community Health Assessment (CHA) process and the resulting 2013-2016 Osceola Community Health Improvement Plan (CHIP). The HLC routinely monitors the CHIP strategic objectives, measures, and action plans, several of which are directly linked to our Open Access project. The HLC performs an annual evaluation of the CHIP and assists in revisions of the strategic objectives/measures as indicated. CHIP objectives/measures that are linked to our Open Access project, which improves primary care accessibility, include the following:
· (Objective) Improve diabetes health outcomes: (Measure) Percentage of OCHD diabetic patients whose HbA1c levels are less than 9.
· Improve cardiovascular health outcomes: 1) Percentage of OCHD adult patients diagnosed with hypertension whose most recent blood pressure was less than 140/90, 2) Policy change to restrict tobacco usage in certain areas to create smoke-free environments, and 3) Policy change to restrict sale of candy flavored tobacco products.
· Improve fetal/infant mortality/morbidity rates: Percent of births to mothers that were obese at time pregnancy occurred.
· Expand primary care capacity for uninsured/underinsured residents: Number of patients accessing primary care services at OCHD health centers.
· Increase referrals to connect residents to Primary Care Medical Home: 1) Community awareness campaign to educate residents on importance of preventive health care and 2) Community Health Literacy campaign.
· Improve delivery and quality of health care using evidence-based best practices: Explore potential for setting up pilot programs to manage patients with multiple chronic diseases.
· Improve utilization of available resources: 1) Implement Phone-to-Home Patient Navigator referral system and 2) Increase number of residents connected to needed health / social services.
OCHD’s work internally on Open Access project and the work with community partners to develop CHIP objectives/measures have the potential to positively impact Osceola’s population-based health status indicators due to earlier access to primary care prevention and treatment efforts.
Since the Open Access QI project was part of OCHD’s continuous performance improvement processes, we did not incur any dedicated start-up. The following information provides an estimate of associated in-kind costs for staff salary and benefits:
Total number of staff on core QI team: 4
Total number of full-time equivalents (FTEs) on core QI team: 1.05 FTE
Estimated in-kind costs for salary/benefits: $72,040
Characteristics of QI Initiative team with their OCHD position and percentage FTE dedicated to project:
1. Project Champion - Administrator/Public Health Officer, FTE 0.05
2. Project Manager – Primary Care Services Operational Director, FTE 0.4
3. Open Access Process Owner – Call Center Manager, FTE 0.5
4. Clinical Lead – Assistant Nursing Director, FTE 0.1
Other multidisciplinary staff members participated in various aspects of the process improvement and management efforts.
The Open Access QI team determined we could more effectively improve the waiting time for a primary care appointment, a lagging/outcome indicator, by addressing in-process/leading indicators that ultimately affect the outcome. We determined our in-process indicator would be reducing the no-show rate for scheduled appointments that clogged the appointment system. Our project’s Aim Statement goal was to improve (decrease) the no-show rate from a baseline of 40% to 20% during the 9-monthproject period. We were able to surpass this goal during the 9-month project by decreasing the no-show rate to 11%.
The Open Access QI team used an internally developed 9-Step Process Management Model with PDCA as a systematic approach to develop, implement, and manage the timeliness and efficiency of our primary care access process. Step 7 in the “Check” phase of the PDCA cycle is to monitor performance. This phase established the basis for evaluating the impact of our QI Initiative.
The QI team determined we could more effectively improve the timeliness of a primary care appointment, our lagging/outcome indicator, by addressing in-process/leading indicators that ultimately affect the outcome. We determined our in-process indicator through a root-cause analysis to be “reducing the no-show rate for scheduled appointments that clogged the appointment system. Our project’s Aim Statement goal was to improve (decrease) the no-show rate from a baseline of 40% to 20% during the 9-month project period. We were able to surpass this goal by decreasing the no-show rate to 11% by the end of the project period.
The data source used to capture information about our in-process measure was our Health Management System (HMS) database that allowed us to track patient appointment no-show rates. This was done on a monthly basis so that we could measure the progress of our process improvement interventions during the 9-month project period. (Note: This monitoring tool is so effective that we have implemented it as an ongoing clinical performance tool that is reported to senior management and our FQHC Board of Directors).
The data the QI Team used to monitor our in-process indicator, i.e. the percent of no-show rate for appointed patients, showed slight monthly fluctuations after the initial dramatic drop during the first month of the project period. The monthly data along with PDCA-identified process modification interventions include:
December 2013: 40% - Baseline established. Process flow redesigned and the current appointment scheduling templates were closed to avoid long-term scheduling. Installed label makers in each clinic’s medical record department so that the Call Center could send a patient label with appointment time for staff to use in preparing patient record for the provider visit.
January 2014: 13% - Staff and patient education on new Open Access appointment scheduling. Lobby phone installed in each clinic for walk-in patients to schedule the appointment with the Call Center, which is in a centralized location.
February 2014: 13% - Exceptions to the Open Access scheduling template were developed for elderly patients due to transportation needs and patients needing professional interpreter services to be scheduled by OCHD at the time of their appointment.
March 2014: 14%
April 2014: 12%
May 2014: 12%
June 2014: 14%
July 2012: 12%
August 2014: 11%
September 2014: 11% - Standardization of a successful QI project!
The tremendous success we have achieved with the Open Access project has led to our standardization of the process into the routine clinical operations. Achieving standardization is the final step in our 9-Step Process Management Methodology. We will continue the monthly monitoring process to ensure continued timely access to primary care services.
Our Open Access QI project obtained tremendous improvement in our appointed patient no-show rate; decreased clogging of the appointment schedules which caused long waits for an appointment and then led to more no-shows; and enabled patient access to primary care services on a same-day/next-day basis as opposed to a 3-month wait for new patients and a 2- to 3-week wait for established patients. This achievement helped OCHD to realize the Primary Care Medical Home evidence-based operational characteristic of Superb Access to Care. We achieved a 29% improvement in our in-process indicator of the appointed patient no-show rate; from a baseline of 40% in December 2013 to 11% in September 2014. This accomplishment was a direct result of using a systematic process management methodology as we implemented improvement interventions based on our PDCA cycles and data analysis.
Lessons learned in relation to the practice include:
· It is important to restrict appointment scheduling capacity to a few key staff. In our case, the centralized Call Center staff is responsible for scheduling all primary care patients as opposed to our original model where all clinical staff could schedule an appointment.
· The scheduling criteria need to be consistent while still being flexible to accommodate exemptions such as elderly patients, those with transportation needs, and patients needing OCHD-provided professional interpreter services for their appointment.
· Monitoring is crucial. The core QI team reviewed appointment schedules and adherence to scheduling criteria on a weekly basis in order to avoid disruptions in the clinic flow.
· A major lesson learned is...”Why didn’t we do this before!”
Sustainability is achieved through several avenues, including linkage to OCHD’s formal 2013-2016 Strategic Plan; Osceola County’s 2013-2016 Community Health Improvement Plan (CHIP), which will be monitored by the Osceola Health Leadership Council made up of a variety of collaborative community partners; and inclusion in our OCHD internal Scorecard of Clinical Performance Indicators. Our Scorecard is a QI tool that reports baseline and actual performance against the established target for each of OCHD’s Clinical Performance Indicators. The data are presented quarterly in a dashboard format using red/yellow/green color coding to visually depict the progress of each measure against its target. The Scorecard is presented to senior management, the Board of Directors, and shared with staff. It is also included in our annual progress reports to HRSA’s Bureau of Primary Health Care as part of our federally qualified health center quality improvement efforts.
The last phase of our 9-Step Process Management Methodology with PDCA is the “Act” cycle where action is taken to maintain the improvements achieved.
OCHD’s mission is to “protect and improve the health of all residents in Osceola County.” Additionally, three strategic objectives in OCHD’s Strategic Plan link directly to our Open Access QI initiative: 1) monitoring/improving health status indicators; 2) improving access to health care services; and 3) integrating a culture of performance excellence/quality improvement throughout the organization. This linkage further enhances our ability to sustain this QI initiative and make it part of our Scorecard of Clinical Performance Indicators.
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