Project EARS (Efficiency, Accountability, Reduction, Streamlining)

NAME OF HEALTH DEPARTMENT: Person County Health Department

PROJECT TITLE: Project EARS (Efficiency, Accountability, Reduction, Streamlining)

LeighAnn Creson
336-597-2204 x2277
This email address is being protected from spambots. You need JavaScript enabled to view it.

Project Overview


Project Aim:
By January 1, 2013, we aim to provide high quality and efficient patient care in our Family Planning clinic by reducing the amount of time patients spend at their visit by 30% or 36 minutes.  It is important because it will allow us to serve more patients as well as increase the probability of patient and staff satisfaction.  We will achieve this by taking patients with appointments first over walk-in patients; by streamlining the documents and paperwork in patient charts and eliminating unnecessary or duplicated forms; and by training appropriate staff on clinic policies and procedure to better ensure that they are all being consistently followed. 


  • Reduce the time that a patient spends at a Family Planning visit (for a physical) by 30% or 36 minutes.
  • Increase the number of patients seen during a Family Planning clinic day by 25% or 4 patients. 


Project timeframe:
August 2012 – present

How was the need for the project determined?
Data through the department’s Medware system revealed that many Family Planning physical visits were taking 2 hours or more.  This was also verified by observational data. 


Does this quality improvement project link to accreditation?
This quality improvement project is linked to our accreditation process.  It was identified through our reaccreditation process in 2011/2012 that there was a need for formal QI training and a more structured QI program in our department.  Our accreditation consultant strongly encouraged participation in the NC Center for Public Health Quality’s Quality Improvement program. 

Areas for Improvement and Change Ideas Implemented


Improvement 1  (Correct Charts pulled)
Incorrect charts were being pulled for patients 2 times per week on average. This potentially added more time to visits as staff would have to go back and pull the correct charts.  Incorrect charts were being pulled because some patients not only have the same first or last name but also had the same whole name.

  • Front desk staff verified names and dates of birth (DOB) when patients made appointments and checked in for appointments.
  • Front desk staff verified names and DOB when pulling charts and preparing them for clinics.
  • Front desk staff organized charts by time of appointment on a cart to better ensure the correct charts were pulled and provided to eligibility staff.

Improvement 2  (Less movement in the clinic)
During Gemba Walks, it was observed that there was too much movement in the clinic by our staff, patients, the provider, a resident and often 2 medical students. 

  • There was communication with Duke on several occasions and requests made that they only send one student.

Improvement 3  (Student compliance with clinic practices; elimination of duplicated interviews)
During Gemba Walks, it was observed that medical students were spending on average about 15-20 minutes with patients in the exam rooms and they were basically repeating what was done in the pre-counsel nurse interview.

  • A list of “Student Guidelines” was developed.  These are reviewed with students each week.  Students are instructed not to duplicate an interview with patients. If they need the experience of interviewing patients they are permitted to do so during the pre-counsel interview. Students are instructed to follow other clinic practices also.  (“Student Guidelines” handout is attached.)

Improvement 4 (Reduction of time spend in pre-counsel interviews looking for information in charts)
Nurses were spending time during the pre-counsel interview searching through a patient’s chart to find the dates of their last Pap test and sickle cell test.  On some occasions, this took more time than others if the patient had a large chart.

  • A lab flow sheet was developed to collectively document information about lab tests. (The lab flow sheet is attached.)
  • Lab flow sheets are placed in all charts and are adhered to the top of the left hand side of the chart for easy access.
  • The day before clinics, eligibility and lab staff look up and cite dates of the last Pap test and sickle cell test on lab flow sheets in patients’ charts. This saves time during the pre-counsel interview.

Improvement 5 (Compliance with appointment protocols)
Compliance with appointment protocols was not being followed.  Patients who were showing up late for appointments were still being seen instead of being rescheduled, even if the clinic was busy.  Appointments were being scheduled during time slots that were designated for other type of appointments.  Patients were being allowed to check in more than 15 minutes early for their appointment and were taken back before they should have been. 

  • Management support and clinical staff were educated on appointment protocols.
  • Signage was posted on the front door informing patients that they would not be checked in any earlier than 15 minutes prior to their appointment and that if they were more than 15 minutes late they would be rescheduled.
  • New appointment cards were printed informing patients about the “15 minute stipulations”.
  • Front desk staff enforced appointment protocols by not checking in patients any early than 15 minutes prior to their appointment and by rescheduling patients if they were more than 15 minutes late.
  • With the exception of 2 OB nurses, management support staff is now the only staff permitted to make appointments. 

Improvement 6 (Increased assistance with pre-counsel interview; reduction in wait time)
There are usually only 2 nurses conducting pre-counsel interviews.  If there were more than 2 patients waiting to be seen then they would have to wait.

  • A third interview room was set up with the paperwork and equipment (computer, scales, etc.) needed to conduct interviews if needed.
  • It became practice that the clinic’s triage nurse would step in and help with the pre-counsel interviewing if the other nurses were occupied and patients were waiting.  

Improvement 7  (Elimination of unnecessary documentation)
Duplicate documentation was occurring. BMI (Body Mass Index) was being recorded in 4 different places.

  • Two sources of documentation were eliminated.

Improvement 8 (Reduction of unnecessary forms in charts)
Unnecessary lab requisition forms were being put in patients charts.  It has been standard practice for many years that lab requisition forms are put in charts by eligibility staff instead of during the pre-counsel interview by nursing staff. 

  • Lab requisition forms are now being put in charts during the pre-counsel interview by nursing staff.  This is more appropriate in 2 respects. (1) If a patient has a question about a certain test then the nurse is more qualified to provide an explanation. (2) If a patient opts out of a test then unnecessary forms are not be put in charts.

Improvement 9 (Reduction of unnecessary and unwanted lab tests being conducted.)
Some lab tests were being ordered for patients even though they opted out of them. Lab staff was being questioned about this.

  • Nurses were instructed not to order lab tests if patients opted out of them. They were also told not to put the paperwork in the chart.

Improvement 10 (Increased clinic flow and reduction of wait time)
Typically, there is one nurse designated to get exam rooms ready for patients as well as to make sure the necessary supplies are in the room for the provider.  This same nurse also accompanies the provider in the exam room.  Obviously, this nurse is stretched very thin as she could be needed in several places at one time.  This has the potential to back-up the clinic flow if she does not have any assistance.

  • Other clinic nurses were cross-trained to help make the necessary preparations to move patients into the exam rooms.
  • Nurses are assisting with these preparations and moving patients into exam rooms if the other nurse (who usually does all of this) is occupied. 


Overall Improvements

  • Incorrect charts are being pulled less frequent. 
  • Duke is only sending 1 student to clinics. 
  • Students are complying with the “Student Guidelines” and clinic practices.
  • Lab flow sheets are being placed in most charts.
  • Eligibility and lab staff are completing the lab flow sheets before clinics and are preventing the nurses from having to take time to look up information during the pre-counsel interviews.
  • Appointment protocols are being enforced with patients.
  • Patients are showing up on time for their appointment more so than in the past.
  • A third nurse is helping to conduct pre-counsel interviews if the other 2 are occupied and patients are waiting.
  • Some unnecessary documentation has been eliminated.
  • Some unnecessary forms are not being put in patients’ charts.
  • Patients are not undergoing unnecessary lab tests.
  • Average lead time for visits has been reduced periodically (still not enough consistently to be able to start adding appointments).
  • Insert any charts, graphs, pictures, and quotes that show your changes led to an improvement.

Management support and clinic staff came together for a luncheon/meeting in January.  When asked to name 1 positive outcome of the current project, they said:

  • Completing the lab flow sheets before clinics saved time during the pre-counsel interviews.
  • Decreased patient visit time.
  • Patients are on time more often.
  • Patient flow moves better.
  • Some patients call when they can’t come to their appointment so that others can have their appointment.

This process has prompted us to look into practices and protocols that we had not thought about when we started this project.  Our QI team has been very dedicated and continues to work hard to see our goals come to fruition, even though we have faced some challenges.

Lessons Learned

Staff, who we anticipated would be more resistant to change, should have been included on the QI team or at least been made an ad hoc member for this project.  The Family Planning Program Coordinator should have been included on the QI team.  We will include more “key players” and “front line staff” on future projects.  Our intent is that this will foster more buy-in and cooperation from staff.

What things do you wish you knew before tackling this specific project?  Change takes time and it may not always be within the timeframe mapped out for your project and that is ok!  Communication is imperative in making change and more specifically, consistent communication.  Expecting staff to implement change immediately and without error is unrealistic.  It may take months to make change part of the routine



Programs supported by:

BlueCross BlueShield of NC FoundatoinThe Duke Endowment

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