Decreased Maternal Health Visit time

NAME OF HEALTH DEPARTMENT: Columbus County Health Department

PROJECT TITLE: Decreased Maternal Health Visit time

Martha Faulk
304 Jefferson St.
P.O. Box 810
Whiteville, N.C. 28472
Phone: 910-640-6615 Ext. 374
Fax: 910-640-1088

Project Overview

Project Aim:
The overall aim of the Columbus County QI team is to improve the efficiency of the Maternal Health clinic by greatly reducing clinic visit times. This project is important because it will improve client satisfaction and will increase staff involvement. We will accomplish this aim by using data and QI methods (Lean and the Model for Improvement) and tools to remove waste from the entire clinic visit process.

Project timeframe:
June 1, 2012-January 1, 2013

How was the need for the project determined?
Decrease in number of prenatal patients and patient satisfaction had decreased.

Does this quality improvement project link to accreditation?
Yes. Quality Improvement for whatever reason or area is a part of our accreditation process. Accreditation wants to see we have a plan in place and the plans are implemented for improvement.


Areas for Improvement and Change Ideas Implemented


Improvement 1
Scheduling process. Patients were being scheduled by Nurse Practitioner and appointments stacked on top of each other ultimately resulting in increased waiting time. Scheduling too many patients at one time. Scheduling up to 7 patients for the same 15 minute time frame.

  • Nurse practitioner no longer schedules appointments from her desk. At the end of each visit the patient is escorted to the scheduler and the appointment is made and put in the computer.
  • Patients are now being scheduled in 30 minute increments or time slots and no more than 3 patients are scheduled at a time in each of these slots.
  • See the old schedule verses the new schedule attached links below.
  • Old Schedule    New Schedule 

Improvement 2
Clinic flow was disorganized and confusing

  • Patients were being moved from room to room to see the provider(s).
  • RN checking Fetal Heart rates, LPN assessing and not feeling comfortable with history questions.
  • Staff members were opening the doors while patient in exam room looking for other staff member, HIV forms, providers and charts.
  • MH registration staff was placing all registered MH patient charts inside the door of the closet on the WH Hall.
  • Charts and patients were being pulled to WIC and other areas without MH staff being aware of the location due to the MH scheduling procedures and all patients coming in at one time. This caused confusion and wasted time looking for charts and sometimes patients.
  • Nurses were leaving the patient in the exam room and going into another clinic room to retrieve a HIV form for testing (while  patient was in this room)  and then returning to exam room to complete the form and then going down the hall to make a copy for the chart and then place the original in the lab.
  • Patients in for labs such as GTT were lost in the shuffle and waited much longer than necessary due to lab results not being reviewed in an orderly manner.
  • All paperwork needed not in rooms.
  • Some best practice standards were not being consistently followed.
  • Clinic staff did not know clients could receive state flu vaccine.  Vaccine was not offered during the history interview
  • MH staff unable to access NCIR or document immunizations.
  • Punch key pad on door from waiting room to clinic hallway which over takes more time than a swipe type of device.
  • All exam rooms will be stocked alike with the same supplies (i.e. paper work, Doppler, BP cuffs, calendars clocks, etc.) Room # 1 wall clock replaced and calendars placed in all rooms.
  • Initiated the flag system to identify who is working with patient or needs to see patient next.
  • Work standards and Best Practice standards reviewed and documented as well as being presented at the Report Out. See links below
    1. LPN Practice Standard of work
    2. RN Practice Standard of work
    3. OB/GYN Practice Standard of work
    4. Review of Best Practices Standards
  • Registration will now print our NCIR reports for MH patients and place on patient record. They are to also update NCIR when new immunizations are given to MH patients and place updated record in chart.
  • An electronic card swipe device was placed at the door between the waiting room and the clinical area access, replacing the more time consuming key punch pad.
  • Coat and purse hook place on wall beside the scales to assist the patient and staff when weighing and measuring patients.
  • Set up chart holds in lab e for incoming and outgoing lab charts to ensure incoming into a clean area and outgoing in a more visual area for staff.
  • Rearranged stations at front area (scheduling) to reduce patient walking down hallway. See attached link below.
  • HIV forms relocated in a central location in the laboratory along with the HIV log book as well as a copying machine being placed beside the forms to decrease interruptions and walk time down the hallway to make copies of forms.
  • Patients will remain in one room during their visit and not be moved from room to room.  
  • Clinic flow policy and procedure written and reviewed by staff see  attached link: Maternal Health Clinic Flow Policy and Procedure
  • Chart holders for exam rooms are on hold at this time due to staff preference for keeping the closet door for charts.
  • Met with one of the supervising physicians for suggestion on improvements.

Improvement 3
Data collection meets with some resistance. The first month of data collection went fairly well but began to taper off and become inconsistent and incomplete. Each person’s time was not being documented and especially documenting the time out which would at least give you an idea of the longevity of the visit.

The Nurse practitioner resigned to take a job closer to her home effective 8/24/12 leaving only one nurse practitioner on staff.

Improvement 4
Patient no show for visits

  • 13% no show rate  in June 2012 which steadily increased over the next few months.
  • Encouraged staff to provide patient education on no shows on a continuing basis.
  • Created a Patient Appointment agreement to be initially reviewed and signed by all new MH patients and existing MH patients.  See attached: Appointment Agreement
  • 25 patient surveys done regarding their perception and feelings about the Appointment Agreement.  See attachment for results: Appointment Survey Results


Overall Improvements

Lessons Learned

  • Documentation of clinic flow data.
  • There were many variables that had to be taken into consideration such as the extra time for Glucose Tolerance Testing and new patients vs. established patients.
  • We only see new patients on Mondays, Wednesdays we see those high risk and new patients that have to be seen by the physician, and on Fridays the regular established patients. Each one of these days and times varied from each other due to the types of patients seen.
  • Visit time went up in the clinic after we lost one Nurse Practitioner from our staff.  It is to be noted that the clinic times have started to increase somewhat, even though we still have only one nurse practitioner at this time.
  • The no show rates went up through the summer months as well. We implemented an appointment agreement with the patients. Initially the no show visits were at 13% and went up to 22% and they were back down to 13% for the month of November. Whether this is seasonal effect or an effect of our implemented agreement is uncertain at this time. We will continue providing the Appointment Agreements and continue to monitor throughout this year.
  • We would encourage any Health Department taking part in this process for the first time to schedule the Kiazen event as early as possible after the first workshop.
  • Research and choose your measures and goals wisely and carefully. Follow the existing process from start to finish before implementing any change. Start with small steps and not large leaps.
  • Studies PDSA’s and understand you can make short term changes and see if it has a positive effect and if not go back and take another look at what might be done.
  • Be prepare there will be unexpected obstacles and unmet goals, but understand the overall process does yield positive results even if the specific goals were not met.
  • Be persistent in the quest for change and improvement.
  • Team Huddles can be as or more productive that “meetings”.
  • Assess data weekly if possible and not monthly.



Programs supported by:

BlueCross BlueShield of NC FoundatoinThe Duke Endowment

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