Clinically Speaking

(August 2019) Kenneth Hunt, MD, Associate Professor in the Department of Orthopedics and Director of the UCHealth Foot and Ankle Center, and Tatiana Abigail, Manager of Clinic Operations, knew that a foot and ankle clinic was needed and had a vision for what it would offer: services with multiple specialists to address foot and ankle problems, from orthopedic surgeons to physical therapists and athletic trainers, all in one place.

Nothing like it existed, which was both the opportunity and the problem.

“We had nothing to go by. It was a brand new clinic with 15 staff and 17 multispecialty providers around foot and ankle, and every provider had their own workflow,” explains Abigail. “We knew we needed to do something to standardize the workflow and make it smoother so our staff wouldn’t get burned out.”

Abigail knew that she and Dr. Hunt wouldn’t be able to tackle everything all at once despite their passion and commitment to creating a state-of-the-art clinic. The question was, what factors needed to be addressed first? What changes would have the biggest impact?

Enter the Institute for Healthcare Quality, Safety and Efficiency (IHQSE), a collaborative effort on the Anschutz campus to ensure every patient receives the highest quality of care while avoiding harm, minimizing inefficiencies and improving the care experience. They had the tools to help Abigail and Dr. Hunt assess the clinic’s trouble spots.

“The strength of IHQSE is its experience in catalyzing productive change in different parts of the healthcare system,” says Read Pierce, MD, co-leader of the institute. “Sometimes it’s process improvement that’s needed, or a shift in team culture, or a switch to more user-centered design thinking. We help identify the most promising interventions and guide organizations through implementation.”  

First, they did a patient survey and learned that patient wait time was too long, so they did a time study to find out what was causing the delays. They found that the average patient visit was 60 minutes long and that over a quarter of that time the patient was just waiting, first in the waiting room and then for each service.

“There was all of this waiting time, and yet the staff and providers felt rushed and inundated, with no time for the necessary administrative work,” Abigail says. “So when we got the results of the time study, we surveyed staff and providers to find out what they thought was the cause. The facility? The procedures? Personalities? What was it?”

They learned that both the facility and the clinic’s procedures made communication difficult. Many of the initial fixes were simple, like making room number signage visible to someone standing at the end of a long hallway. The clinic also implemented a walkie-talkie system that allowed them to easily communicate from anywhere in the clinic without having to walk across the whole space.

They also standardized how they “room” patients – what happens once the patient is brought from the waiting room to an exam room. The providers agreed on how this process would be done, what questions would be asked, and how the clinic would track the patient’s progress through the visit.

One important lesson for Abigail was how valuable – and interesting – it was to have data about the workflow. “I don’t think of myself as a numbers person in general. I thought I’d find it boring to go through the IHQSE process and review the data. When I saw how helpful it was to calculate results, I actually got excited about the analytics. The numbers don’t lie, and I started looking at numbers more seriously to understand what was happening.”

She was also pleased to learn that the staff and providers were “110 percent invested” in the process and the success of the clinic. The key to a successful study, she found, was to keep staff and leadership updated and involved, so that they saw the process as theirs, and not an outside mandate. “The culture of the Foot and Ankle Center and full commitment of the staff were critical to achieving our goals” said Dr. Hunt.

The results? “We cut visit length by 15 minutes yet increased provider time with patients by one minute. We decreased wait time in the waiting room from 15 to 6 minutes, and in radiology from 7 to 3 minutes,” Abigail reports. With the additional time gained in the day, they were able to open up appointments to more patients and triple their patient volume without sacrificing quality.

“The vision we have for the clinic has become a reality in large part due to the knowledge and support we gained from IHQSE,” says Dr. Hunt. “The clinic’s success depends on small decisions about workflow that have a big impact on the patient and staff experience.”

There is still work to do. Abigail and Dr. Hunt want to make this clinic the top foot and ankle center in the country. They are working on streamlining patient education with after-visit summaries and other tools. As they move forward, Abigail is “definitely watching numbers. We will always look for how we can improve.”

With the help of IHQSE, they now have the tools and data to make that improvement possible.