Decrease Cycle Time for Initial Maternal Health Visit

NAME OF HEALTH DEPARTMENT: Wilson County Health Department

PROJECT TITLE: Decrease Cycle Time for Initial Maternal Health Visit

Valerie Bulluck, RN 
Wilson County Health Dept.
(252) 237-3141 ext. 6749

Project Overview

Project Aim:
We aim to decrease the lead time (entrance to exit) for a patient’s initial maternity visit with ancillary services (e.g. WIC, Pregnancy Care Management) by 30minutes from baseline of 2 hours 49 minutes by December 2012. This is important because we want to improve patient satisfaction, improve staff satisfaction, increase the capacity for patient care, provide multiple same-day services, and promote quality and timely services by patient word of mouth. We will achieve this by utilizing QI methods provided in the Public Health QI 101 course.


  • Increase patient satisfaction with improved efficiency and time management
  • Decrease the total lead time for initial maternity visit by 30 minutes from baseline of 249 minutes.
  • Increase staff satisfaction.

Project timeframe:
June 2012 - February 2013

How was the need for the project determined?
The Health Director identified a potential backlog of patients seeking WIC services and wanted to evaluate and improve the wait time associated with the WIC process, especially as it related to maternal health patients. In evaluating the processes, the QI team quickly identified a problem with navigating the maternal health process that prevented patients from even making to WIC. We decided to narrow our scope to evaluate the process for the initial new maternal health patient in MH and to elect to follow the WIC process for maternal health patients after completion of the original project.

Does this quality improvement project link to accreditation?
This project directly relates to:

  • Benchmark 27:  The local health department shall evaluate all services it provides for effectiveness in achieving desired outcomes.
  • Activity 27.3:  The local health department shall employ a quality assurance and improvement process to assess the effectiveness of services and improve health outcomes

Areas for Improvement and Change Ideas Implemented


Improvement 1
We noticed patients “bottle-necked” at 8am and 1pm at the start of clinic cycle because of space and available staff support.

  • We implemented use of 2 rooms to assess weights and vital signs and required all available staff to assist in the process to prevent the backlog of patients signing in and waiting at start of clinic.
  • We assigned interpreters and RNs to assist rather than waiting for 1 CNA to complete the work and forward the patients to them. (These staff members had been traditionally socializing and waiting for the CNA to finish “her job” before they would do any active.

Improvement 2
In our initial Gemba walks we noticed excessive back & forth motion for patients and staff from one area to the next.

  • Rerouted patient flow and provided maps of floor plan detailing flow for the patients
  • Providing maps and detailed instructions at the front desk the patients were able to proceed to the lab and clinic unescorted. Prior to change, a staff member was required to escort the patient and sometimes to try to locate a patient that lost their way to clinic. This eliminated a lot of motion and freed up staff to manage patients in the clinic area while others completed their lab work.


Improvement 3
Staff requested clarity of roles in a staff satisfaction survey.

  • Assigned staff members to patients on whiteboards for job clarity
  • Clinic staffing patterns have changed through attrition, budgeting, etc. and has left WCHD with 60% of staff that it had 2 years ago. As a results, staff members are doing “more with less” and starting to feel the stress of some of us not “carrying our load.”  We PDSA’d a plan to assign new OB patients to a designated RN to assure prompt processing for interview. We assigned small tasks that we being overlooked, such as checking vaccine refrigerator temps, restocking rooms to designated employees to assure1) they were being done, 2) provided a level of accountability when they were not done. Immediate feedback after a huddle at weeks end for greater than 95% of staff appreciated the change and wanted to implement it fully. It decreased the undercurrent of “I’m not doing all the work” we had been hearing from the staff members at large.

Improvement 4
A significant amount of RN time was spent “prepping the chart” for new OB patients presenting for their 1st visit.

  • Maternal Health staff prepared records for the initial visit 1-2 days before scheduled visit (after reminder calls to ensure their appearance).
  • Maternal Health secretary and interpreters call OB patients scheduled for initial prenatal appointment to remind them of their appointments. During these calls we could ascertain if they were planning to keep their appts. Or if they had decided to go to a private provider (we found that a few patients would schedule with private providers once their Medicaid was approved).
  • Maternal Health RN would “prep” the record filling out lab slips, demographic information on the history forms, review past medical history 1-2 days before the scheduled appointment. This decreased the patients cycle time on visit day and provided a smoother flow for the RNs interviewing the patients.

Improvement 5
Redundancy in maternal health history and repeat RN signage in multiple places on forms

  • Revised maternal health history form decreasing pages from 14 to 11. Consolidated consent forms resulting in decrease from 4 required RN signatures to 1.
  • This action decreased the time required in the actual interview allowing the patient to be ready for exam sooner.     

Improvement 6
Excessive clutter, unnecessary motion for staff procuring equipment/documents..

  • 5S to front desk. Maternal Health clinic areas.
  • Cleared registration desk of papers taped to the window preventing full visualization of clients coming through the door.
  • Obtain expendable file folders with required forms for each of the Women’s Health clinic
  • Straightened and sorted papers at the front desk.


Overall Improvements

  • Revised MH history forms (consent form and preprinted formatted labels)
  • Implemented routing to lab before MH clinic with maps
  • Utilized 2 rooms for vital signs/weights
  • Prep charts for initial OB visits prior to appointment
  • Prep eligibility record prior to initial visit
  • Wrote staff assignments in clinic on the nursing station whiteboard
  • 5S front desk, MH clinic
  • 5S front waiting room
  • Created 5s check sheet for all clinics
  • Requested door flag signals for clinics (pending approval)
  • Wrote standard work guidelines for patient registration
  • Posted Do not enter sign on exam rooms with “jack& Jill” doorways
  • Re-started reminder calls to verify patient appointments
  • Summarized kaizen week into data charts
  • Implemented new maternity patients’ lab sheets in envelopes at eligibility to facilitate patient going to lab unescorted.
  • Implemented staff improvement ides sheet on clinic work areas.
  • Utilized door hanger or “next patient” sign in clinic to alert FNP/CNM where to go next, until we get confirmation on door flags.
  • Mounted hand sanitizers dispensers on wall to move out of reach of small children
  • Utilize a kanban systems for replenishing supplies/stock
  • Insert any charts, graphs, pictures, and quotes that show your changes led to an improvement.
  • What additional unintended benefits did your team observe?  (e.g. improved team work, etc.) 
  • Completed an updated VSM
  • Provided a maternal health schedule to WIC dept. to alert them to new patients that may need to be seen

Lessons Learned

  • We implemented a box to place OB records in in the WIC dept. for the nutritionist while they renovated but it was not utilized as intended and may have cause some “overlooks” with patient’s whose records were placed in it.
  • The scope of the work. While it is truly a valued learning experience there is a lot of leg work (but it’s made smarter).

Programs supported by:

BlueCross BlueShield of NC FoundatoinThe Duke Endowment

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