May 29, 2009 – Jill Wooldridge P.A.-C.
Boynton Health Service, University of Minnesota, Minneapolis, MN
Topics to be Covered:
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Define Convenience Care
How we came to develop/improve Gopher
Quick Clinic
How Gopher Quick Clinic Functions
Display data about utilization of GQC
Impact on Providers, Primary Care, Urgent
Care
Financial Impact
Future Considerations and Plans
Challenges to the Model
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“CONVENIENCE CARE”
WHAT IS IT?
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Provides care for Minor Acute Illness (strep throat screens,
bladder infections, sinus infections, warts, impetigo etc.),
some basic vaccinations and basic testing.
A Walk-in patient centered model usually staffed by
Advance Practice Clinicians.
Patients evaluate their own needs and pick care time that is
convenient to their schedule.
One Stop Care. Total patient interaction is in one location
and usually a single face-to-face interaction with a single
Clinician.
Since the first Convenient Care clinics opened in 2000, the
industry has grown quickly – today approximately 1,200
such clinics are in operation (many in retail locations)
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HOW WAS THE BOYNTON PROJECT IDENTIFIED?
An effort to support the University’s
strategic mission to improve services to the
student population.
 Community trends and patient expectations
for more choice and control over how they
access care – and Boynton’s and
University Human Resources’ desire to
meet these.
 An identified internal challenge in our
current Urgent Care model to optimally
serve acute care patients.
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PURPOSE OF COMMITTEE
October 10, 2006 - Committee charged
by COO to evaluate:
The
benefits of providing a “Convenience
Care” model of service.
The appeal of “Convenience Care” to our
patients and third-party payers.
The impact of this service on Urgent and
Primary Care.
Over-all financial impact.
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COMMITTEE MEMBERS
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Chair: Mary Alderman - Director Clinic Operations
Co-chair: Dave Dorman – Health Promotion
Beverly Carpenter – Administrative Assistant
Joyce Fortier – Executive Secretary
Jill Wooldridge, PA – Provider
BJ Anderson, MD - Provider
Britt Bakke - Marketing and New Program Development
Paula Miller, RN – Student Health Advisory Committee
member
Barb Rangel, LPN – Supervisor Patient Assistance and
Information
Virginia Tranter, RN – Lead Nurse Immunization Clinic
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QUALITY IMPROVEMENT PROCESS
DMAIC:
DMAIC is a basic component of the SixSigma methodology (Business Management
Strategy) - a way to improve work processes
by improving efficiency and eliminating
defects.
In its methodology, it asserts that in order to
achieve high quality business processes,
continued efforts must be made to reduce
variations.
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DMAIC MODEL
DEFINE PHASE:
What are the issues and desires for improvement
MEASURE PHASE:
Data collection to direct improvement efforts
ANALYZE PHASE:
Clarify and identify root cause of issue
IMPROVE PHASE:
List of all potential solutions and their impact with implementation
plan and milestones
CONTROL PHASE:
Pilot plan, process control, implementation of solutions and
transition control plan
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Define Phase
COLLECTING THE VOICE OF THE
CUSTOMER
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Conducted informal focus groups with the
Student Health Advisory Committee (SHAC).
Conducted informal focus groups with Boynton
Health Service (BHS) staff: Providers, RNs,
Pharmacy, Lab, Front Desk and Support staff.
Created open message board for comments
from BHS staff on shared network drive.
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Measurement Phase
Measured interest in a “Convenience Care”
model
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An online survey sent to 4,000 students,
with a return rate of 32%, showed 68%
were interested.
•
An online survey sent to 2,000 faculty and
staff, with a return rate of 38%, showed
53% were interested.
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Measurement Phase (continued)
PROBLEM: Urgent Care process of dealing with
Minor acute illness is inefficient and lengthy for
the patient.
Measured current process efficiency for treatment
of minor acute illnesses in Urgent Care.
Urgent Care Cycle-time study:
Urgent Care Provider Average Cycle Time =
80.5 minutes
RN Average Cycle Time = 54.5 minutes
RUC Average Cycle Time = 66.0 minutes
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Measurement Phase (continued)
Reviewed 12-Month (9/05 - 8/06) Total
MinuteClinic® Utilization
U of M Student Benefit Plan (SBP) – 61
visits
 U of M Graduate Plan – 75 visits
 U of M Staff/Faculty Benefit Plans – 1,885
visits
Of the total Staff/Faculty MinuteClinic®
visits, 389 were seen at the Coffman site
(just under 50/month).
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Analyze Phase
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Analyzed results of student, staff and faculty online
surveys.
Reviewed list of factors identified in the formal focus
groups.
Performed a Root Cause analysis on current model of
care.
Consulted with Boynton Health Service Chief
Operating Officer (COO) to examine fiscal
implications of implementing a “Convenience Care”
model.
Toured the University of Minnesota Duluth QuickCare
Clinic.
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Improve Phase
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In March 2007 the Committee recommended that
BHS provide a “Convenience Care” model service as
a pilot, effective fall 2007.
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The service was named “Gopher Quick Clinic”.
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The hours of service were to be Monday through
Friday , 9 a.m. to 5 p.m. with no coverage over the
lunch hour (1-2pm).
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The service was not offered during holidays/breaks.
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Unless year-round fees were approved and a need
for summer services was established, the service
would not be offered during the summer.
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GQC IMPLEMENTATION TEAM
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Chair: Mary Alderman - Director Clinic Operations
Co-chair: Jill Wooldridge, PA – Provider
Britt Bakke - Marketing and New Program Development
Margaret Dahl, RN - Nurse Supervisor Primary Care
Davin Hedin - Principal Accounts Specialist
Sue Jackson - Director Student Health Benefit Plan
Amy Murphy – Executive Accounts Specialist
Barb Rangel, LPN – Supervisor Patient Assistance and
Information
Deb Sandberg, MD – Medical Director
Karen Strauman-Raymond, RN – Nursing Director
Gina Tran – Supervisor Patient Accounting
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Improve Phase (continued)
BHS Marketing Department implemented
the “Marketing Plan” during spring and
summer 2007.
 During March 2007 through August 2007
the Implementation Committee:
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• defined flow and location of clinic,
• equipped and stocked the clinic,
• hired Advanced Practice Clinician providers (to
split time between primary care and GQC)
• trained staff on new processes.
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On September 4, 2007 the new clinic
service was opened.
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Gopher Quick Clinic Services
Gopher Quick Clinic is limited to addressing one of the following concerns per patient visit.
Common Illnesses:
Bladder Infection
Bronchitis
Cold/Cough
Ear Infection
Laryngitis
Mononucleosis
Respiratory Flu
(without vomiting or diarrhea)
Seasonal Allergies
Sinus Infection
Strep Throat
Swimmer¹s Ear
Skin Conditions:
Athlete's Foot
Cold Sores
Impetigo
Minor Sunburn
Poison Ivy
Ringworm
Warts (three or fewer, does not include
genital warts)
Vaccines:
Tetanus Vaccines (Td and Tdap)
Flu Vaccine (when flu shot clinics not running)
Additional Services
Pregnancy Test
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Boynton Gopher Quick Clinic
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HOW DOES IT WORK?
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FRONT DESK STAFF:
 Checks in patient, “schedules” them for next
available slot (every 15 minutes), tells
patient approximate wait time, gives them
Short Health History form to fill out.
 Handles any co-pay/insurance issues
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HOW DOES IT WORK?
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GQC PROVIDER (Team of 6 PAs, 2 NPs):
 Calls patient from schedule on computer, brings
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back to room
Interviews patient (uses paper form)
Obtains vitals (Spot Vital Signs)
Examines patient
Performs any point-of-care labs [Strep, Mono,
Flu, Urine dip, urine pregnancy test; Throat
cultures, Urine cultures sent to lab]
Writes any Rx, educates patient, uses pt.
education materials
Patient leaves room, provider finishes any
documentation
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Boynton Gopher Quick Clinic
Exam Room
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HOW DOES IT WORK?
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MEDICAL RECORDS:
 Collects paper encounter forms daily
 Sorts for billing, clinical record
 Scans the paper visit for our EMR (usually
within 1 day)
 Abstracts pertinent data directly into our
EMR: Reason for Visit, Vitals, Labs done,
Assessment, Medications prescribed
(usually within 1-2 days)
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Control Phase (Fall 2007)
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The week of October 22-26, 2007 BHS
sent a survey to all current Gopher
Quick Clinic patients to assess
satisfaction with the service.
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Katie Lust, PhD, Director of Research
and Surveillance, evaluated all surveys
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October 2007 Survey Results
Compare Satisfied vs. Not so Satisfied
Satisfied = Excellent, Very Good and Good
Not so Satisfied = Fair and Poor
81.2% of the patients surveyed rated the entire visit as
satisfactory. Target is 90% satisfaction rate.
Patient concerns identified were:
1)
wait time in the lobby
2)
time spent with the provider in the exam room
3)
privacy
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OCTOBER SURVEY PROCESS
IMPROVEMENT PLAN
WAIT TIME :
 Added appointments over the 1-2 p.m. lunch time
 Changed marketing material to indicate that GQC was:
1) first-come-first serve and
2) capacity for the clinic may be reached prior to the 5 p.m. closing
TIME SPENT WITH PROVIDER:
Changed marketing material to say “Visits last approximately 10
minutes.”
PRIVACY:
• Performed a second survey asking more specific privacy questions
• Changed location of urine sample drop-off from Lobby to Front Desk
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Control Phase (Winter 2008)
On January 22, 2008 BHS sent a 2nd survey to all current Gopher Quick Clinic
patients to assess the following:
 Wait Time expectations
 Satisfaction with amount of time spent with the provider in the exam room
 Level of comfort with:
1) check-in procedure
2) location of waiting room
3) location of exam room
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Level of comfort with the process for giving a urine sample as it related to:
1) location of restroom
2) privacy of restroom
3) walking from restroom to drop-off box
4) location of drop-of box and overall urine collection procedure
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JANUARY 2008 SURVEY RESULTS
Compared Satisfied vs. Not so Satisfied
Satisfied = Excellent, Very Good and Good
Not so Satisfied = Fair and Poor
89.0% of the patients surveyed rated the entire visit as
satisfactory. Target is 90%.
Patient concerns identified were:
1) location of lobby in relation to exam room,
2) location of restroom in relation to drop-off box and
3) wait time
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JANUARY SURVEY PROCESS
IMPROVEMENT PLAN
Exam Room Location:
 Moved exam room from off of Lobby to
interior exam room within Primary Care
South (PCS)
Restroom and Drop-off Box Location:
 Changed restroom and drop-off box
location to be within PCS clinic space
Wait Time:
 Added second GQC provider in the PM.
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Fall of 2008 – Opened Coffman
Satellite
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Opportunity arose to utilize the Minute Clinic
site across the street in the Union
Hired 3 new staff to accommodate new fulltime GQC clinic and have back-up, as well as
rotate into primary care to make the position
more appealing.
Front desk to be staffed from Patient
Assistance Dept
Challenging new workflow to get supplies,
equipment (LN2), labs, etc. back and forth
Set up remote access via computer as well
Marketing!
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COFFMAN GOPHER QUICK CLINIC
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Specific Challenges to the satellite site:
 Tried to make it as much like the original GQC
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as possible for provider staff and patients
Had to set up courier drop off in AM, pick up in
PM for supplies/labs
Slightly more complicated transfer of patients to
Urgent Care if needed – more hassle for
patients
Much less privacy, both in the “lobby” and the
public restrooms
Had to determine which site to close if providers
are absent?
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Visit Statistics for 2007-08 vs. 2008-09
Number of GQC Visits
2007-08 vs. 2008-09
7000
6000
Number of visits
5000
4000
3000
2000
1000
0
2007-08 GQC
2008-09 GQC
Sept
477
852
Oct
584
977
Nov
493
871
Dec
294
589
Jan
326
503
Feb
565
875
March
479
854
Apr
569
938
YTD
3787
6459
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Cycle Time Statistics for 2007-08 vs. 2008-09
250
198
200
162
150
138
126
100
50
36
25
18
11
37
37
29
11
0
Lobby Wait Time - Lobby Wait Time - Time with Provider - Time with Provider - Total Cycle Time - Total Cycle Time Avg.
MAX
Avg.
MAX
Avg.
MAX
2007-08
2008-09
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SUMMARY OF GQC STATISTICS
(from previous slides)
From 2007-08 to 2008-09, GQC visits
from a comparable period increased from
3787 to 6459.
 Average total cycle time decreased from
37 to 29 minutes.
 Average wait time in the Lobby decreased
from 25 to 18 minutes.
 Time with provider remained essentially
constant.
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NOVEMBER 2008 SURVEY
RESULTS
Compared Satisfied vs. Not so Satisfied
Satisfied = Excellent, Very Good and Good
Not so Satisfied = Fair and Poor
Again, 89.0% of the patients surveyed rated the entire visit as
satisfactory. Target is 90%.
Issues identified were:
1)
wait time satisfaction improved from Spring 08
2)
Significant concerns regarding Privacy/Comfort at Coffman
GQC, especially with regard to waiting area and urine sample
collection
3)
Patients who rated overall visit as fair or poor were expecting or
would have liked to have more time with the provider
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NOVEMBER ‘08 SURVEY PROCESS
IMPROVEMENT PLAN
Wait Time:
 Front Desk staff continue to offer Coffman as an
option if the wait time is > 30 minutes at BHS
Coffman Privacy/Comfort Concerns:
 In talks now with Coffman Building services about
possible remodeling of the space to allow private
waiting area. Unable to change restroom location.
Expectations regarding time with provider:
 Make sure marketing materials and those
encouraging the service are clear as to its
limitations
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IMPACT ON PROVIDERS
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Gopher Quick Clinic Providers
 Simple, easy visits? Or mind-numbingly boring after
25/day?
 Mix of GQC time with Family Practice is seen as a job
satisfaction issue from a provider perspective, but results
in possible “Excess Access” in clinic schedules
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Primary Care Providers
 Initial skepticism regarding continuity of care
 Concern over loss of quick visits that allow for “make-up”
time for more involved visits. Perception that the
complexity of visits has increased in Primary Care, though
RVUs via coding has not yet borne that out.
 All agree “Quick” must not sacrifice “Quality” – evidencebased guidelines and judicious use of Antibiotics
important
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Top 20 Diagnoses for 2008-09
Gopher Quick Clinic
Code
Descr
CountOfCode
462
ACUTE PHARYNGITIS
2,149
465.9
ACUTE URI NOS
1,815
599.0
URIN TRACT INFECTION NOS
811
461.9
ACUTE SINUSITIS NOS
617
078.10
VIRAL WARTS NOS
404
466.0
ACUTE BRONCHITIS
365
788.1
DYSURIA
249
463
ACUTE TONSILLITIS
244
477.9
ALLERGIC RHINITIS CAUSE UNSPECIFIED
207
034.0
STREP SORE THROAT
179
786.2
COUGH
152
382.00
AC SUPP OTITIS MEDIA NOS
150
381.4
NONSUPP OTITIS MEDIA NOS
131
V72.40
PREGNANCY EXAM/TEST UNCONFIRMED
82
V06.1
VACCIN FOR DTP
80
054.9
HERPES SIMPLEX NOS
78
075
INFECTIOUS MONONUCLEOSIS
69
380.10
INFEC OTITIS EXTERNA NOS
68
919.4
INSECT BITE NEC
62
381.81
DYSFUNCT EUSTACHIAN TUBE
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IMPACT ON PRIMARY CARE VISITS
Percent of minor acute illness was reduced from 18% to 15%
Top 10 DX for 0607
Top 10 DX for 0708
Screen for Venereal Disease
1838
Screen for Venereal Disease
2236
Routine Medical Exam
1805
Routine Medical Exam
1725
Routine GYN Exam
1548
Routine GYN Exam
1427
Acute Pharyngitis
1517
Acute Pharyngitis
1024
Nonspecific Skin Eruption
833
Pap and Pelvic
1005
Viral Warts
715
Nonspecific Skin Eruption
745
Pap and Pelvic
710
Acne
604
Acne
594
Dysuria
585
Joint Pain – Ankle and Foot
538
Backache
513
Fatigue
538
Viral Warts
513
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IMPACT ON URGENT CARE
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Percentage of visits for minor acute illness was
reduced from 51% to 20%. Target was to reduce
the percentage by 50%.
Reduction of Minor Acute Illnesses in Urgent Care
Total UC Provider Visits
6805
Total GQC Like Visit
6685
3822
3489
2683
760
51%
2006-07 Sept-May
40%
2007-08 Sept-May
20%
2008-09 Sept-Apr.
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GOPHER QUICK CLINIC AND URGENT CARE VISITS
ACADEMIC YEAR 0708 VS. ACADEMIC YEAR 0809
7000
6000
5000
4000
2007-08 GQC
2008-09 GQC
2007-08 UCC
3000
2008-09 UCC
2000
1000
0
Sept
Oct
Nov
Dec
Jan
Feb
March
Apr
YTD
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SUMMARY OF CHANGE IN VISITS
(from previous slides)
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GQC visits have continually increased in the
same ratio as Urgent Care visits have fallen.
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Total GQC visits have increased.
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Total UC visits have decreased.
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Overall total visits to combined departments
have increased.
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Financial Impact:
Visits and RVUs
Department
PRIMARY CARE
URGENT CARE
Visits
(2006-07)
23,778
3,991
RVUs
(2006-07)
51,240
9,665
RVUs per
Visit
2.15
2.42
Department
GOPHER QUICK CLINIC
PRIMARY CARE
URGENT CARE
Visits
(2007-08)
3,822
28,150
5,446
RVUs
(2007-08)
5,971
60,659
11,608
RVUs per
Visit
1.56
2.15
2.13
Department
GOPHER QUICK CLINIC
PRIMARY CARE
URGENT CARE
Visits
(2008-09)
7,770
31,390
4,893
RVUs
(2008-09)
13,273
64,752
10,534
RVUs per
Visit
1.71
2.06
2.15
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FINANCIAL MODELING
GOPHER QUICK
CLINIC
Patients per Hour
Average Office Revenue per Visit
Average Ancillary Revenue per Visit *
Revenue per Hour
Average Provider Cost per Hour
Nursing Support Cost per Hour
Other Cost per Hour **
Total Cost per Hour
Margin per Hour (full booking)
PRIMARY
CARE
URGENT
CARE
4
$63
$8
$284
3
$95
$15
$329
2
$119
$25
$287
$51
$0
$45
$96
$67
$23
$55
$145
$95
$63
$55
$214
$188
$184
$74
* Lab, Radiology, Pharmacy
** Facility, Med Rec, Billing, Admin, Misc
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FINANCIAL ASPECTS
The breakeven point for visits is three visits
per hour.
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CONCLUSIONS AND FUTURE
CONSIDERATIONS
1.
2.
3.
4.
5.
We have met our goal of an average cycle time of 30
minutes or less.
We have met our goal of reducing the percentage of
minor acute visits in Urgent Care by 50%.
We have not met our goal of reaching an over-all
satisfaction rate of 90% (but so close at 89%!).
We need to balance access and/or services to
remain financially sound. New Services? How to
increase utilization of Coffman site?
Anecdotally, there has been a slight shift in acuity in
visits in Primary Care, requiring more people staying
late.
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Looking Forward – What‘s next?
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Remodel of Coffman Gopher Quick Clinic
to allow for private waiting area
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Move another Gopher Quick Clinic into our
St. Paul clinic for ½ day Monday-Friday.
(Dropping 2nd PM provider at BHS)
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Looking at financial feasibility and/or
profitability of adding some preventive
services (Cholesterol screen, BP screen)
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CHALLENGES to the CONVENIENCE CARE MODEL
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Balancing schedule – having back-up to remain open
as advertised, but avoiding excess access
Appropriateness (or not) of self-triage
 Repeat visits for same issue
 Higher acuity or complexity than GQC can handle, and
subsequent “re-triage” of patients
 If desires of patient don’t fit GQC model (wanting more
time, more than one concern, etc.)
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Getting all information into EMR in a timely way
 EMR wasn’t quick enough for pilot, but templates are in
development that are more user-friendly, quick-templates
– will still likely have to abstract some historical medical
information
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H1N1 “Swine Flu”…
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QUESTIONS??
jwooldridge@bhs.umn.edu
Special Thanks to Mary Alderman, Director of Clinic Operations, and
Carl Anderson, Chief Operations Officer!
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