“Improvement Movement” Increasing the Percentage of WIC Patients that Keep Appointments

NAME OF HEALTH DEPARTMENT: Davidson County Health Department

PROJECT TITLE: “Improvement Movement” Increasing the Percentage of WIC Patients that Keep Appointments

Barbara Jones
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Project Overview

Project Aim:
We aim to increase the percentage of WIC participants who keep their appointment to 90% by improving our appointment and visit processes.  This is important because: improved client satisfaction will drive WIC participation to maintain at least 97% of our caseload as required by the Public Health Agreement Addendum; elimination/reduction of non-value added time will improve client and staff satisfaction through increased productivity and efficiency; the change to Open Access appointment scheduling is part of the agency strategic plan. We will achieve this by: utilization of the QI processes learned in this course; implementation of evidence based best practices of other WIC programs, including but not limited to, those related to open access scheduling; implementation of those open access appointment scheduling methods and enhancement and utilization of automated call distribution within the phone system to meet our agency and client needs; utilization of the Lean Kaizen event to identify and eliminate/reduce wasteful activity.


  • Increase the WIC client show rate from 70% to 90%.
  • Offer WIC clients an appointment in accordance with NC WIC Program processing standards within 10 minutes of the contact.
  • Each nutritionist will average 15 client encounters /day maximizing efficiency and improving staff/client satisfaction.
  • Decrease the average WIC appointment visit time from 63 minutes to 50 minutes.

Project timeframe:
Completed by September 2011

How was the need for the project determined?
Visit times documented on client satisfaction surveys indicated there were times when client visits were lengthier than we desired and client comments on satisfaction surveys included dissatisfaction with these times. Appointments were made up to three months in advance with an average show rate of 70%. Based on this, appointments were overbooked to assure WIC met its 97% of caseload reimbursement requirement.  On the occasions when there were unexpected staff absences simultaneously with a higher than normal show rate, it was more difficult to provide services in a timely manner which was also very frustrating to staff.

Does this quality improvement project link to accreditation?
This project does link to accreditation. Accreditation standards include the necessity for health departments to assess consumer and community satisfaction with its services and to use this data to make changes to improve its services (Benchmark 27.1 and 27.2). There is also the expectation that health departments are fiscally responsible and this includes the efficient and productive utilization of its resources including staff. Additionally implementing Open Access appointment scheduling for the WIC program was a component the agency’s strategic plan.

Areas of Improvement and Change Ideas Implemented

Improvement 1
Developed Standards of Work

  • Client arrival – clients were provided appointments for services but were actually seen in order of arrival and walks ins were often entered into this mix – this often resulted in clients with appointments not being seen timely. There were no definite guidelines for staff to follow in dealing with late and early arrivals and walk-ins and management staff would have to be found to deal with situations as they arose. The decision was made that walk-ins would not be accepted unless an open appointment was available at the time or an unusual situation was present and management approved. A client arrival tree was developed and provided to staff to test. Staff response was that this made their job easier and was readily adopted.
  • Vouchers – The placement of Summary Sheets when ready for voucher issuance was such that the clerks could not readily view them in order to provide timely services or to determine if backup assistance was needed. Several locations were tested and staff responses were used to determine the final location. Pocket wall files were mounted on the door where the voucher issuance process occurred. This allows the clerks to easily see the number of clients ready for their assistance enabling them to call for backup assistance promptly when needed. This also allows for transfer of the record by the by the nutritionist – preventing them having to enter the room and navigate around the multiple staff in this work area with an additional benefit of deceasing the congestion and noise in this area.
  • Nutritionist – there was no written standard of work for nutritionist to follow from the receipt of the client record to completion of the encounter documentation and refilling of the record. This process is now documented to allow for a consistent provision of services, assuring that all required activities occur.
  • Interpreters – There was no designated place for interpreters to be stationed to wait for a call for assistance and no means to know where and when the interpreter was currently involved with a client. Several stations have been tested. Currently a station is always designated but the decision for a permanent station has not yet been reached by staff consensus. There is a sign out board at the designated station which allows the interpreter to document their location when away from the station and allows staff to leave messages directing where interpreter assistance is needed upon the interpreter’s return to the station.
  • Rest rooms – clients seeking services include children and pregnant women resulting in frequent unplanned needs for rest rooms breaks – often interrupting a staff encounter with the client or delaying the start of an encounter. Staff determined the breaks in the visit process that clients would typically need to wait for staff to prepare for the next encounter in the process. Staff routinely asks clients if a restroom break is needed at this time to potentially alleviate the need for these breaks during an encounter or causing staff to have to wait for the client to return from such a break.
  • Client confirmation script – a common occurrence was for a client to present for services and not include the names of other family members who were eligible for services or share they were pregnant and now eligible for services at registration or even until the check-out process. This resulted in much extra work for staff and extended the visit. A script was developed to verify with the client all the persons needing services at each staff encounter during the visit. This was presented for staff to try and was adopted as a standard practice.
  • Guardian Change – at times clients present stating they are now the legal representative for the child although our records do not include this information. When this occurred, staff had to locate the WIC Director or consult the program manual to determine what needed to be done. This could take a good deal of time if the director was not readily available and delayed the delivery of services for this client as well as for later appointments. A guide was developed to allow staff to handle these situations without having to seek guidance. This was presented to staff and adopted as standard practice. 

Improvement 2
Developed Eligibility Notebooks

  • Clerks were responsible for collecting their own materials to take with them when they entered the client centered room to determine eligibility. Forms were not maintained in each room.  A point-of-use tool was developed for staff to use. The idea initially was for each eligibility clerk to carry this tool with her. During the testing process, it was determined the tool was useful but the eligibility clerks did not want to carry the tool at all times. A spot was designated in the service hall that was easily accessible to these clerks to pick up for use at any time needed. Each clerk is responsible for restocking her own notebook.

Improvement 3
Developed visual aids/signage

  • There are entrances to 10 client centered rooms, the WIC lobby, the check-in/check-out office, the lab and a staff office entrance along one long hall in the client service area. There is no rest room in the area – clients must leave the WIC bay and return to the main lobby to access a rest room. When clients needed to go to the restroom during their visit or ask a question of a staff member, they could not determine how to exit the area or where to ask for assistance. Signage was place above the lobby and check-in/check-out entrances to help direct clients.
  • Client centered rooms are numbered 1 – 10 and staff would write the room number on the client’s “summary sheets” which are printed off at registration and are used by staff at each encounter to route the client to the next step in the visit process. At times the wrong number would be written down by a staff member and subsequent staff would have to go from room to room to locate the client. A magnetic clip was attached to the door frame of each room and numbered stickers were inserted, allowing staff to pull a sticker off and apply it to the summary sheet to ensure the correct number was used. Staff tested this and it was adopted as standard practice. A problem encountered was finding numbered stickers. The solution was to use numerical end tab file folder labels.   

Improvement 4
Used 5S to organize client materials in WIC office

  • All educational materials were stored in file cabinet drawers and a disorganized bookcase on the opposite side of the room where the nutritionist cubicles are located. There were no dividers, etc. in the file drawers to keep the materials separated so they could easily be retrieved. Using 5S, a review of the materials revealed many were outdated or no longer used. The ones frequently used by the nutritionists were organized and moved to a bookcase placed in the “walk-way” space on the side of the room where the nutritionist cubicles are located. There were additional materials which the nutritionist use occasionally with client encounters and the nutritionist were presented with the idea of moving these materials as well. The nutritionist were agreeable to moving the frequently used materials but preferred the less frequently used materials remain in the original location as made their “walk-way” space cluttered. The less frequently used materials were left in the file drawers but were organized and labeled.
  • Client teaching models (food and breast feeding models, etc.) were stored in an unorganized file drawer, requiring staff to rummage through the drawer to find the desired models. There were numerous sets of some of the models with one set being sufficient to meet staff’s needs. Using 5S, these models were separated and organized, making them easily accessible.
  • A large lateral file with telescoping doors was located in the check-in/check-out office for client record storage. Records for clients with pending appointments were retrieved from the health department’s central files and placed here prior to the pending appointments. Clerks retrieved the clients file when the client arrived for services and nutritionist returned the records at the end of the day. This much activity in a small work area housing 4 clerks coupled with the noise of file doors opening and closing created congestion and made it difficult for staff to remain focused on their job duties.  A tub file was moved to the check-in/check-out office to store records retrieved for pending appointments.  The lateral file was moved to the nutritionist office area for the nutritionists to re-file the records at the end of each day.

Improvement 5
Planned and implemented Open Access appointments scheduling

  • Developed and tested client education materials prior to implementing Open Access appointment scheduling. Numerous PDSAs were completed during the development of educational materials to be provided to clients receiving services beginning May 16, 2011. These educational materials instructed clients in the process for obtaining their next appointment through Open Access appointment scheduling rather than being provided a subsequent appointment at the time of service delivery. Drafts of these materials were tested by the “fresh eyes” on the QI Team, by WIC staff, by random health department staff and by current WIC clients with much tweaking prior to the final instructions being adopted.
  • Updated and tested ACD phone technology prior to implementing Open Access appointment scheduling. Additional capabilities were added to the current WIC phone system allowing for monitoring of calls waiting in cue, number of dropped calls, routing of calls, etc. Staff was trained in use of the phone system by the phone vender prior to the Open Access appointment scheduling implementation date. After completion of staff training, a PDSA was completed with the phone vender and County IT director providing on-site support. During this PDSA, numerous health department staff called in for WIC appointments during a one hour time span to assess staff’s knowledge as well as the capability of the phone system to handle the volume of calls anticipated. A technical glitch occurred at the beginning of the PDSA but was immediately corrected by on-site support and there after staff and the system functioned flawlessly during the PDSA.
  • Implemented Open Access appointment scheduling. Clients began making their appointments through Open Access appointment scheduling effective August 16, 2011. The time frame for appointment scheduling was decided to be same day appointments. Clients needing pre-scheduled appointments fill the first one hour appointment slots each day, allowing time for clients to call to make and arrive for their same day scheduled appointment. Appointments are made all day until the schedule is full at which time clients are told to call back on another day that is convenient for them. Five clerks are assigned to be available to take calls for appointments. The number of clients receiving services each day was monitored daily initially to assure we were providing enough services not to adversely affect our participation rate. Concerns were 1) the spread of appointment requests – would there be days with no requests and days with too many requests 2) Would our participation rate decrease because clients forgot to call 3) would assigned staff be able to handle the volume of calls for appointments 4) would the phone system be able to function with the volume of calls for services.


Overall Improvements
Standards of work addressing:

  • Client arrival – makes service provision more timely for clients who have scheduled appointments by eliminating the walk-in effect of early and late shows.
  • Vouchers – better visibility allows more timely response by clerks when client is ready for voucher issuance process and allows these clerks to signal for help more easily when a backlog occurs.
  • Nutritionist – establishes a consistent and efficient process for nutritionist to follow from receipt of client’s chart until completion of encounter documentation and chart is ready to be refilled. A uniform process assures completion of all required encounter activities and eliminates delays and additional time required for regrouping when distractions occur.
  • Interpreters – Allows staff to readily locate interpreters when needed and allows interpreters to know when and where they are needed after the completion of a current encounter, thus decreasing visit times.
  • Rest rooms – prevents interruption or delay of staff encounter with client due to client needing unexpected rest room break resulting in prolonged visit time for the involved client as well as delaying services for subsequent clients.
  • Client Confirmation Script – allows staff to determine all services needed during the visit at the beginning of the encounter. This prevents an extended visit when the need for additional services is discovered later during the course of the encounter and the resultant delay in the delivery of services to subsequent clients.
  • Guardian Change – enhances staff ability to handle the increasing number of guardian change situations independently without having to take additional time to locate a manager for guidance.

Developed Eligibility Notebook

  • Allows clerks to have all tools and forms needed when entering client centered room for client eligibility interview rather than having to repeatedly leave the room to obtain needed tools and forms thus decreasing encounter time.

Instituted client completion of questionnaires

  • Client completes questionnaire during wait while nutritionist reviews client record and prepares for the encounter – shortens the time required for the nutritionist encounter with client. The nutritionist needs only to provide follow-up on client responses as applicable.

Developed visual aids/signage

  • Signage directing clients to the lobby from service provision hallway with multiple doors allows clients to find exit to rest room when needed during their visit, decreasing staff time in leading clients to lobby door way.
  • Room number stickers on the door frame for each client centered  room allows staff to pull off  and apply a sticker to the encounter form, preventing incorrect numbers being manually written on the form and causing subsequent staff having to go room to room to locate the client
  • Signage designating door to office allows clients to come to this door when needing assistance while waiting in their client center rooms rather than wandering down the service provision hallway looking for a staff member to assist them. Notices were also posted on the inside of each client centered room above the doorknob directing clients to notify office staff if they need to go to the restroom while waiting for the next staff encounter.

Reorganized client education materials and moved file cabinet

  • Frequently used educational materials were organized and moved near the nutritionist work space saving 78 feet in walking distance for each client encounter and allows for decreasing nutritionist associated visit time.
  • Less frequently used materials were sorted and those in continued use were organized and labeled for quicker retrieval when needed for client encounters.
  • Client education models were sorted and organized for quicker retrieval when needed.
  • Moving the lateral file from the check-in/check-out office to the nutritionist office area reduced the walking distance for the nutritionists to re-file records at the end of each day by 70 feet. This allows for decreasing nutritionist associated visit time as well as increasing clerk efficiency in the check-in/check-out office due to more space and less distraction and congestion in this work area.

Planned and implemented Open Access appointment scheduling

  • The provision of client education materials describing the new process for making an appointment, the update to and staff training regarding the ACD phone capabilities in the WIC office as well as the PDSA testing the ACD system facilitated a flawless transition to Open Access appointment scheduling effective August 16, 2011. Show rates improved from 70% to 88% during the 2 weeks in August when Open Access appointment scheduling was initially implemented and to 92% during the month of September. The provisional case rate for September 2011 was 100.5% - an improvement from 93.3% during the first quarter of 2011. The phone system has functioned without problems and assigned staff has been able to handle the volume of phone calls for appointments without any problems.

The project promoted team work within the WIC department and encouraged staff to make suggestions for improving their processes. Additionally, another QI project was started in our Clinical area before our WIC project was completed. This has resulted in increased communication and understanding between these two divisions.

Lessons Learned:

  • Moving some less frequently used client materials closer to staff who utilized these materials was not acceptable to that staff – they felt it made their work area cluttered and preferred to walk the extra steps when these materials were needed
  • Unable to remove obstacle of chart storage – WIC records are combined with Personal Health records in the  central file storage on  the second floor of the building while the WIC office is located on the first floor. This requires WIC staff to make numerous trips upstairs to the central files daily to retrieve records prior to pending visits and re-file records after the completion of visits. This involves the time for numerous staff to travel 344 feet, including 44 stair steps, round trip outside the WIC suite numerous times daily.  Although walking has its health benefits for staff, this definitely does not lend itself to improving staff efficiency and productivity.
  • More focus initially on obtaining buy-in from staff in the work area involved that improvement is needed – focusing on outcomes desired and creating sense of urgency when appropriate.
  • Assure that the correct measures are selected and that accurate data is obtained at the beginning of the project. We found that the number of daily nutritionist encounters was not needed as a measure of improvement for our project.
  • More focus on reassuring staff that the collection of initial data is not intended for punitive reasons. This was stressed but is a major obstacle to overcome and can prevent staff buy-in to the process.
  • Promoting greater use of the “Parking Lot Board” by staff that is not on the QI Team to identify processes needing improvement or suggestions for improvement.
  • Determine as many ways as possible to keep staff in the involved work area updated on the project and encouraging their interest and participation in the project. Encourage their sense of inclusion by soliciting their input, ideas, suggestions and feedback. The QI Team needs to be perceived as the facilitator of improvement rather than a dictator of improvement!
  • Prepare staff regarding what to expect during this process, allowing them to be more open and less threatened by the fast pace and the numerous ideas considered and tests involved.

Programs supported by:

BlueCross BlueShield of NC FoundatoinThe Duke Endowment

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