Improving patient wait in the outpatient setting

The purpose of this project is to improve patient wait times in the outpatient setting through the development and implementation of an individualized plan to decrease patient waiting t

Item Type text; Electronic Dissertation

Outpatient Setting Utilizing Talk-to-Text Charting (Doctoraldissertation, University of Arizona, Tucson, USA)

is made possible by the University Libraries, University of Arizona.Further transmission, reproduction, presentation (such as publicdisplay or performance) of protected items is prohibited exceptwith permission of the author

by Mykala Mikesell Nelson

Copyright © Mykala Mikesell Nelson 2021

A DNP Project Submitted to the Faculty of the

COLLEGE OF NURSING

In Partial Fulfillment of the Requirements

For the Degree of DOCTOR OF NURSING PRACTICE

In the Graduate College THE UNIVERSITY OF ARIZONA

2 0 2 1

ACKNOWLEDGMENTS

I would like to acknowledge my project site for allowing me to do my project at their clinic because without them this project would not have been successful Thank you to all the providers there who either participated in this project or took me on as a student to teach me and help me on my way to completing this degree I also want to acknowledge the professors in the college of nursing There have been so many great professors who assisted me with this project and helped me along the way Thank you all!

DEDICATION

I would like to dedicate this project to my amazing husband, family, and friends Without these amazing people in my life this project nor this degree would have been possible I truly have the best support system around me and I am so grateful for all the love, support, and help I have received throughout this process I love you all so much, thank you for everything!

TABLE OF CONTENTS

LIST OF FIGURES 8

LIST OF TABLES 9

ABSTRACT 10

INTRODUCTION 12

Background Knowledge and Significance 12

Local Problem 15

Intended Improvement 16

Project Purpose 16

Project Question 16

Project Objectives 16

Theoretical Framework 17

Lewin’s Theory of Change 17

Unfreezing 18

Changing 18

Refreezing 18

Literature Synthesis 21

Evidence Search 21

Comprehensive Appraisal of Evidence 23

Contributing Factors 23

Patient Factors 24

Provider Factors 24

Organization/Site-Specific Factors 25

Effects of Waiting on Health 26

Common Interventions 26

Scheduling 26

Clinical Processes 27

Number of Staff 28

Strengths of Evidence 29

TABLE OF CONTENTS – Continued

Weaknesses of Evidence 30

Gaps and Limitations 31

METHODS 31

Project Design 31

Model for Implementation 32

Plan-Do-Study-Act (PDSA) Cycle 33

Plan 33

Do 35

Study 35

Act 36

Setting and Stakeholders 36

Planning the Intervention 38

Participants and Recruitment 38

Consent and Ethical Considerations 39

Timeline 39

Data Collection 40

Data Analysis 40

RESULTS 41

Outcomes 42

DISCUSSION 43

Summary 43

Interpretation 44

Implications 45

Practice 45

Education 45

Research 46

Policy 46

Limitations 47

TABLE OF CONTENTS – Continued

DNP Essentials Addressed 47

Conclusions 48

Plan for Sustainability 49

Plan for Dissemination 49

Funding 49

APPENDIX A: FAMILY PRACTICE CLINIC SITE APPROVAL / THE UNIVERSITY OF ARIZONA INSTITUTIONAL REVIEW BOARD DECISION LETTER 50

APPENDIX B: CONSENT DOCUMENT (DISCLOSURE AND CONSENT FORM) 53

APPENDIX C: EVALUATION INSTRUMENTS (POST-IMPLEMENTATION SURVEY) 55

APPENDIX D: PARTICIPANT MATERIAL (PARTICIPANT EDUCATION) 57

APPENDIX E: PROJECT TIMELINE 69

APPENDIX F: LITERATURE REVIEW GRID 71

APPENDIX G: OTHER DOCUMENTS AS APPLICABLE TO THE PROJECT (PRISMA 2009 FLOW DIAGRAM) 78

REFERENCES 80

LIST OF FIGURES

Figure 1 Lewin’s Theory of Change 19 Figure 2 IHI Model for Improvement with PDSA Cycle 34

LIST OF TABLES

Table 1 Post-Implementation Survey: Questions and Responses 42

ABSTRACT

Purpose The purpose of this project is to improve patient wait times in the outpatient setting

through the development and implementation of an individualized plan to decrease patient

waiting times at a family practice clinic in north-central Utah

Background Waiting to be seen by a medical provider is common in healthcare today, which

can lead to patient and staff dissatisfaction Increased wait times also play a role in healthcare reimbursement by the patient’s perception of wait which impacts how a clinic is reimbursed by insurance Research shows inefficient processes are one factor contributing to increased patient wait, but studies focusing on the use of a talk-to-text feature when completing patient

documentation is lacking

Methods The Institute of Healthcare Improvement’s (IHI) Model for Improvement (MFI)

including the Plan-Do-Study-Act (PDSA) cycle was utilized to guide project development and implementation The site was approached regarding the potential project and with acceptance the site chose one of their willing healthcare providers to be the sole participant The participant was provided with education regarding the talk-to-text feature prior to implementation Four weeks after implementation the participant completed a survey determining satisfaction with the

intervention and desire to continue utilizing this documentation option

Results The result of the sole participant’s survey was analyzed along with provided comments

Conclusions were drawn from the participant’s perception of the talk-to-text intervention

Conclusions Though inefficient processes can be improved to decrease patient wait time, it is a

process to determine the correct intervention for a specific site From the collected survey after project completion the participant felt this intervention worsened patient wait time but wished to

continue to utilize this feature with a different program option From this project it shows that a talk-to-text feature is attractive to this participant, but the chosen software was not the right fit for this clinic This is a small project at one clinic with one provider, further PDSA cycles are needed to determine true efficacy of improvement of patient wait time with a talk-to-text

documentation option

INTRODUCTION

In the healthcare system, long waits to see health care providers are inherent in the

ambulatory care setting Beyond being a source of frustration for patients, increased wait times can also reduce patient and staff satisfaction, decrease patient access to providers in the

ambulatory care setting, and increase the frustration of clinic staff and management (Robinson et al., 2020) Therefore, clinics would benefit from efforts that improve waiting times During this Doctor of Nursing Practice (DNP) project, the author conducted a quality improvement (QI) project to improve the wait times experienced at a family practice clinic in north-central Utah The staff at this clinic determined what point(s) in the patient cycle led to increased wait times For the purpose of this project, the term “patient cycle” is defined as the total time a patient is in the clinic from time of entry to time of departure Patient wait times during check-in, before being shown to an exam room, while waiting for the provider, and waiting to check out are components of this cycle A needs assessment was conducted with the staff at the family practice clinic which informed a tailored intervention for making this process more efficient Improving patient flow from arrival through departure could reduce waiting times during various stages of the patient cycle and increase patient and staff satisfaction

Background Knowledge and Significance

Prolonged patient cycle times or patient waiting times are a common problem in

ambulatory healthcare settings As stated above, increased patient waiting times can lead to decreased patient satisfaction (Robinson et al., 2020) Patient satisfaction has become one of the primary metrics regarding healthcare quality and can be an area upon which healthcare

reimbursement is dependent (Pena & Lawrence, 2017) Indeed, as patient satisfaction has come

to the forefront of healthcare reimbursement, there has been a more significant push towards improving different healthcare processes to increase patient satisfaction scores on the surveys given to these patients

The issue of long patient wait times has significant implications for healthcare outcomes Patients who are dissatisfied with their healthcare are less likely to return to the entity delivering the care Some studies have found patients who experience long wait times have reported low scores for wanting to return to the clinic or recommend that practice to their family and friends (Godley & Jenkins, 2019) Achuri and colleagues (2020), also found if the patient thinks or believes there is going to be a long wait, they will avoid seeking care all together, even if it leads

to health-related consequences later (Achuri et al., 2020)

Clinic-to-clinic variations make studying this issue complicated, and every clinic has specific challenges that could be causing issues with their patient cycle The literature reflects these variances While some articles mention problems with the check-in and registration

site-process, other articles mention the extended time to be shown to a room before seeing the

healthcare provider (Aburayya et al., 2020; Ariffin et al., 2020) Another study focused on

wanting to improve the overall time the patient was physically in the clinic (Robinson et al., 2020) Because each clinic has its own individual problems regarding patient cycle time, the literature is often limited to the clinic in which the study took place Though the literature is limited to site-specific issues and their associated interventions, the literature provides

information regarding common challenges ambulatory healthcare facilities face regarding their patient waiting times Therefore, these studies can present possible solutions on how to combat similar struggles in a different clinic

For instance, one current resource that aids clinics in their patient cycle improvement initiatives is the Institute for Healthcare Improvement’s (IHI) guide to provide overall options and interventions for reducing wait times in the outpatient clinic setting (IHI, 2016) IHI

published six different ways to reduce wait times and improve access to healthcare services (IHI, 2016) In this article, the IHI (2016) recommends that clinics focus on: 1) scheduling

appointments based on supply and demand, 2) understanding that change is difficult and may seem like the workload is increasing to be able to catch up to the changes, 3) utilizing

appointment time to fit the needs of the patients 4) delegating tasks to ancillary staff, 5) creating contingency plans for patients who are late or do not show to their appointments, and 6) when possible, scheduling patients to see their chosen provider Similarly, Burling-Phillips (2016) conducted a study regarding various clinics’ approaches to decreasing wait times The common themes described in this study were, the majority of the clinics stated the importance knowing the patient cycle and the connection between each phase, assessing the patient cycle for any regular bottlenecks, understanding the patient’s perception of the wait, ensuring the patient’s comfort, reallocating tasks to streamline services, and evaluating the patient cycle regularly to determine if changes are required (Burling-Phillips, 2016)

There are many reasons this is a highly relevant and important topic First, long wait times have significant financial repercussions Clinics depend on having a particular patient volume to be financially salient If a clinic has a reputation for long wait times or bad patient experiences, there is a high possibility that patients will seek alternative places for treatment (Achuri et al., 2020) In turn, the clinics lose the needed patient volume threshold and may

eventually become unable to stay open as a functioning ambulatory care clinic

Recently in healthcare, there has been a shift to focus on health prevention, in which responsibility falls on the healthcare providers in the primary care setting With this

responsibility and the increasing number of patients wanting and needing to be seen in primary care, efficient health care processes also need to be in place to serve these patients to the full extent of the clinic Many of the processes in healthcare today are inefficient (Robinson et al., 2020), but striving for improvement of these healthcare processes can lead to supplying

healthcare for the increased demand, increasing patient satisfaction, increasing the efficiency of the team to see more patients, and improve the healthcare practice overall Advance practice nurses (APRNs) should also be aware of this clinical issue and involve themselves in

determining viable solutions With improved patient wait times, APRNs can see and care for more patients, which increases the community’s access to healthcare

Local Problem

Long patient wait times are an issue in most ambulatory care clinics around the world, and the clinics in Utah are no exception At a family practice clinic in north-central Utah, the staff is seeing inconsistencies with the patient cycle, specifically after the patient is shown to a room and they are waiting to see their provider Upon speaking with the staff and administration

of this clinic, this problem was identified when asked what is contributing to lower patient and staff satisfaction This issue is described by all primary care providers (PCPs) at the clinic, who include two medical doctors and one APRN The clinic support staff (i.e., reception desk staff & medical assistants), and the administration have also expressed concerns The identified issue in this clinic is leading to a decrease in patient satisfaction and increased staff frustration with the inefficient processes

After discussing these issues with the clinic staff, the consensus was the main source of increased wait times for patients was due the provider completing documentation on the previous patient prior to seeing the next patient leading to an increased wait for the patient after being shown to the exam room Each patient visit encounter must be documented, and currently the providers are typing out their notes by hand The stakeholders have voiced their frustrations and stated they are open to making some changes with this process to improve the patient’s

experience and hope to improve their frustration with this inefficient process The clinic staff and management expressed that a project focused in this area of the patient cycle would best address their current need

Intended Improvement Project Purpose

The purpose of this project is to improve patient wait times in the outpatient setting through the development and implementation of an individualized plan to decrease patient

waiting times at a family practice clinic in north-central Utah

• Problem areas were identified through a need’s assessment, completed by discussing areas of concerns with the healthcare providers and the clinic management

• Main problem area identified by the providers and management was the time patients spend waiting to see the providers after being shown to a room due to providers

attempting to complete documentation on previous patients

• The implemented intervention is the talk-to-text feature in the electronic health record and the education of one of the healthcare providers to utilize this technology

• Implementation started in August 2021

• Immediately following the provider education, a four-week implementation period began

• Upon completion of the measurement period, the healthcare provider was asked if the implemented intervention improved, did not change, or worsened the wait times

experienced at the family practice clinic in north-central Utah

• The assessment of the implemented intervention was completed in September 2021 This project aims to improve the patient experience for the patients receiving care at this family practice clinic and reduce patient waiting times to see their provider

Theoretical Framework Lewin’s Theory of Change

Implementing change in any setting is a difficult task to achieve because many people are resistant to change and enjoy the comfort of an established routine However, change is

necessary to create the opportunity to improve processes and in turn improve the patient’s

experience and ultimately health outcome Within organizational change there are nursing

theories guiding how change is brought about within the healthcare realm Lewin’s theory of

change is the chosen theory which provided the theoretical foundation for this quality

improvement (QI) project (Figure 1) Kurt Lewin developed his change theory in 1947 (Bakari et al., 2017; Burnes, 2020) Lewin’s theory of change is comprised of three components:

unfreezing, changing, and refreezing (Bakari et al., 2017; Burnes, 2020; Hussain et al., 2018;

Ogochi, 2018; Wojciechowski et al., 2016) Lewin first developed this theory within the topic of social change and originally created this theory to describe how human behavior, specifically in children, can be changed (Burnes, 2020)

Unfreezing

The three components of Lewin’s change theory start with unfreezing (Bakari et al.,

2017; Burnes, 2020; Hussain et al., 2016; Ogochi, 2018; Wojciechowski et al., 2016) During this step, the stage is being set for change by creating awareness of the problem, educating staff regarding the current issues, and creating an environment that fosters deviation from the current routine and processes (Wojciechowski et al., 2016)

Changing

The next stage of changing is where alternative solutions are being sought out to the

problem, staff are educated, and the push back or factors which negatively impact change are reduced (Wojciechowski et al., 2016) Overall, this step shows improvements to processes can be made, but change away from the current process and staff buy-in is a requirement for

improvement (Wojciechowski et al., 2016)

Refreezing

The final step of refreezing is where the process change implementation occurs

(Wojciechowski et al., 2016) This is the phase where the new process is integrated into the

workflow and stabilized to where this process now becomes the new standard of practice

(Wojciechowski et al., 2016) Another key aspect of this phase is the celebration of the change that occurred and the continuous monitoring of the process to ensure that the new process is working or to realize that this area needs to be evaluated and changed again (Wojciechowski et al., 2016) (Figure 1)

something chaotic and complex to something simple with a clear time frame based on what point

of the process the change is in

For this quality improvement (QI) project, the staff was educated on the current issue of the increasing wait times and the impact these wait times are having on their feedback surveys the clinic receives from the patient’s insurance companies These surveys have shown, as

reported by the clinic manager, high waiting times in the clinic is one area of these quality

control surveys this family practice clinic in north-central Utah is consistently falling short on The surveys returned to the practice demonstrate there is a need for change with the current patient cycle process and the staff and clinic manager agree By creating awareness of the

problem, the staff can start to see the issue for themselves and realize change is going to be required to improve their patient’s experience and satisfaction with their clinic visits Staff buy-

in is one of the most important aspects of creating lasting change, so by including the staff in the brainstorming process they feel involved, and their opinions and thoughts are taken into

consideration regarding a possible solution

Within the changing stage of this QI project, alternative ideas regarding the patient cycle

process were elicited from the staff Benefits of improving the patient cycle to in turn improve patient wait times, was discussed with each member of the staff to reduce the pushback that usually accompanies change The leaders facilitating the change to the workflow need to create

an environment to reduce the factors which negatively affect the proposed change moving

forward

It is at the refreezing stage where the proposed change is implemented into practice and becomes the new standard workflow (Wojciechowski et al., 2016) The implemented change was

the intervention of a talk-to-text software integrated into the electronic health record that has been agreed upon between the clinical site contact and the author of this project The

implemented change was tailored to suit the needs of this family practice clinic and was

implemented in the area found to be most contributing to the increase in wait times the clinic has been witnessing

Literature Synthesis Evidence Search

One crucial component of this program evaluation project is a complete and thorough search of the literature, which established the degree and manner increased wait times affect patient care outcomes and identified possible solutions and interventions The search was

conducted utilizing different scholarly databases and various search terms Google Scholar,

PubMed, and CINAHL were utilized to complete the literature search The search started within

CINAHL and the search terms of “patient waiting time,” “outpatient clinics OR ambulatory care

OR outpatient services OR outpatient care.” This resulted in 166 articles, which was further limited to full text articles, articles published in 2016 until present, and articles published in the English language The number of articles was narrowed down to 59 articles and then eight

articles were chosen to be utilized within this project due to duplicate sources and irrelevant topic focus of the articles found

PubMed was the next database utilized in the literature search The terms used to search PubMed were “patient waiting time,” “outpatient clinics OR ambulatory care OR outpatient services OR outpatient care.” These terms produced 93 results and then were further narrowed down using the filters of the articles having full text available and published within the last five

years A total of six articles were relevant to this project and chosen for incorporation after the use of these filters, excluding duplicate sources, and articles that focused on appointment

availability instead of waiting time once at the clinic for an appointment

Finally, Google Scholar was the final database searched to locate relevant sources of evidence for this project Within the search of Google Scholar, again, similar search terms were used The search terms for this search were “patient waiting time,” “outpatient clinics OR

ambulatory care OR outpatient services OR outpatient care,” which resulted in 19 studies These studies were filtered by being published within the last five years and four studies were chosen and synthesized for use in this DNP project

The total number of studies chosen for this project from the literature search is 15 articles and three other online grey sources published within the last five years from reputable sources excluding duplicate studies between the databases and articles which focused on referral,

obtaining an appointment, or waiting times for specialty appointments The types of studies chosen were 11 quantitative studies, two qualitative studies, two systematic reviews, and three online grey sources: an interview and two expert advice articles Overall, there was a substantial amount of evidence available to establish patient waiting times in the ambulatory care setting are

an increasing problem in healthcare, which leads to decreased satisfaction and may lead to

health-related problems for these patients The overarching themes made evident by this

literature search were: Contributing factors to longer wait times, effects of increased waiting times on the patients’ health, and common interventions used to decrease ambulatory care clinic waiting times A PRISMA flow diagram was created, and outlines article selection and number

of articles chosen (Appendix G)

Comprehensive Appraisal of Evidence

Contributing Factors

The search of the literature is a crucial step of this project to show which phase of the patient’s visit is leading to increased wait times in different ambulatory care settings throughout the world Increased patient wait times is truly a problem for all of healthcare, from Malaysia to Canada to Rwanda and even here in the United States (US) By examining these different factors that contribute to increased waiting time for patients, a plan can be formulated on which areas in the patient cycle are needing improvement Each source chosen discussed the factors which increased patient wait times The most common contributing factors were inefficient processes, large daily patient volumes, insufficient number of staff, and long or complicated registration processes (Aburayya et al., 2019; Achuri et al., 2020; Ansell et al., 2017; Ariffin et al., 2017; Christiansen et al., 2016; Kagedan et al., 2021) Other factors of note were providers starting their clinic day late, patients not showing up at their scheduled appointment time (Aburayya et al., 2019; Kagedan et al., 2021), patients showing up too early for their appointment, outdated equipment (Ariffin et al., 2017), and patients not assigned to a primary care provider

(Christiansen et al., 2016)

These identified contributing factors are interconnected, with many of these factors happening concurrently, causing increased waiting times for the patient Another way to examine these contributing factors is by dividing them up into groups such as: patient contributing factors, provider factors, and overall organization or site issues/factors

Patient Factors

One of the largest patient factors playing a role in patient wait time is the number of patients that are being assigned to each provider on a given day in the ambulatory care clinic Scheduling a large number of patients to be seen during one day leads to increased wait times from the beginning, simply due to sheer volume (Aburayya et al., 2019; Ariffin et al., 2017; Kagedan et al., 2021; Kam et al., 2021) With a high number of patients being seen and already anticipating a longer wait time, other patient factors increasing wait include patients arriving late

or early to their appointments or do not show up at all (Aburayya et al., 2019; Ariffin et al., 2017; Kagedan et al., 2021) These factors are areas that can be improved upon, but much of the research chosen for this project and their interventions for increased wait times are focused on provider and organization or site-specific factors

the organization’s processes (Robinson et al., 2020), which further increases waiting times

leading to lower patient satisfaction

Organization/Site-Specific Factors

Patient and provider factors are two areas of contributing factors that lead to increased waiting times in the ambulatory care clinic setting The final area of contributing factors are factors directly related to the organization or the clinic site experiencing increased waiting times This is the main area where interventions are implemented due to the ever-changing nature of healthcare and continuous cycle of process improvement The organization factors contributing

to increased wait times are not enough staff for the volume of patients being seen (Aburayya et al., 2019; Ariffin et al., 2017), long registration time with many forms to fill-out (Aburayya et al., 2019; Achuri et al., 2020; Ariffin et al., 2017; Godley & Jenkins, 2019), outdated equipment (Achuri et al., 2020; Ariffin et al., 2017), reduced number of nurse practitioners on staff or

presence of inexperienced nurse practitioners (Ansell et al., 2017; Kagedan et al., 2021, and patients not being assigned to a primary care provider or when seeking care not being scheduled with their assigned provider (Christiansen et al., 2016) These above-mentioned factors are specific to the site in which each study was conducted, but all these factors are examples of inefficient processes which was the largest reported contributing organization factor throughout the included sources (Aburayya et al., 2019; Kovach & Ingle, 2019; Robinson et al., 2020; Tlapa

et al., 2020) By examining these different organizational factors, though they are site-specific, it gives other clinics who may also be experiencing increased patient waiting times areas to focus

on and improve, to hopefully decrease the amount of time their patients are spending waiting in their own clinic

Effects of Waiting on Health

Though prolonged waiting times are very common throughout all of healthcare,

unfortunately increased waiting times have health consequences that could be detrimental to these patients (Ansell et al., 2017; Achuri et al., 2020; Aburayya et al., 2019) Ansell and

colleagues (2017) stated having increased access to primary care reduces patient mortality as they can seek care promptly for medical issues instead of waiting until they require a higher level

of care (Ansell et al., 2017) Indeed, increased waiting times discourage patients from seeking care and forces many people to rely on urgent care or even emergency care facilities (Ansell et al., 2017) Some patients delay care until their health deteriorates into an urgent or emergent health situation, which leads to a further decrease in the quality of care provided and the

accessibility of accessing healthcare services (Aburayya et al., 2019; Achuri et al., 2020; Ansell

et al., 2017) By focusing on waiting times in the ambulatory care setting, access to care can be increased and patients can have improved health outcomes (Pena & Lawrence, 2017)

Common Interventions

Most interventions described in the included literature are site-specific and tailored to those site’s areas identified as needed improvement However, other clinics who may be

experiencing increased wait times can use these examples of other clinic’s common interventions

to either implement them in their clinic or create their own intervention to combat this issue of increased patient waiting time

Scheduling

Scheduling initiates the patient visit starts and implementing some changes to the clinic’s scheduling processes can facilitate decreased clinic wait times Scheduling intervention examples

cited in the literature include: creating built-in dedicated appointment times for urgent or

emergent cases so other patients don’t have to be pushed back (Kam et al., 2021), implementing open-access scheduling, or scheduling with open slot flexibility so patients have more options for appointment times, to decrease the number of missing appointments (Ansell et al., 2017; Huang, 2016), shifting staff schedules to cover peak patient influx times (Achuri et al., 2020), schedule appointments based on average appointment types lengths (Godley & Jenkins, 2019) These scheduling interventions aid in reducing wait times because these are proactive steps each

organization can take to reduce the overall waiting time just by changing the way the staff’s time

is utilized and by the way the appointments are scheduled for each day This is one area of

interventions aimed at decreasing patient wait times requiring no extra funding and can be

accomplished by tracking average length of appointment, peak favorable appointment times, and keeping a few slots open for patients who need to be seen urgently These interventions are aimed at improving the clinical process of scheduling but through the literature there were a few sources outlining other no-expense interventions aimed at improving other common inefficient clinical processes

Clinical Processes

Clinical processes comprise how a clinic functions as a whole and includes the aspects of how patients progress through their healthcare visit Of the included research, several articles report inefficient clinical processes as a major contributor to increased patient wait times

(Burling-Phillips, 2016; Christiansen et al., 2016; Kovach & Ingle, 2019; Robinson et al., 2020) These common interventions in clinical processes mentioned in the literature are of no added expense to an organization and are interventions sites can utilize to decrease their patient wait

times and increase their patient satisfaction A few described interventions included: utilizing the medical assistant and clinic nurse as the patient flow coordinator to ensure patient has a smooth transition throughout the patient cycle (Burling-Phillips, 2016; Robinson et al., 2020),

implementing printed discharge teaching at the end of the ambulatory patient visit so patient can refer to the information discussed while with provider (Kovach & Ingle, 2019), and assign

patients to a primary care provider at initial visit and schedule them with that provider when making appointments (Christiansen et al., 2016) By implementing these interventions regarding clinical processes, the clinic runs more smoothly and efficiently so there are lower chances of bottlenecks occurring in the patient cycle, which in turn aims to reduce patient waiting time and improve patient satisfaction with their healthcare encounter While the last two areas of

interventions require no additional funding, that is not true of all interventions aimed at

improving patient wait times Some interventions require more staff to accommodate the number

of patients being seen to ensure smooth transition throughout the patient cycle

to see patients efficiently (Kagedan et al., 2021; Ansell et al., 2017) These interventions are of course going to be an added expense for an organization, but the literature shows by having more

employees available to help register and check patients in, this leads to a decreased chance of patient backlog at the check-in desk and an earlier chance the medical assistant can show the patient to their room (Ariffin et al., 2017) Ansell and colleagues (2017), in addition to Kagedan and colleagues (2021) stated by having nurse practitioners on staff and employing a higher number of experienced nurse practitioners, patients were seen more efficiently and timely than other providers in the clinic (Ansell et al., 2017; Kagedan et al., 2021) Though employing

advanced practice nurses as nurse practitioners is more costly to the clinic, they can see more patients and conduct a visit more efficiently, which in turn leads to an increased number of patients being able to be seen in the clinic, improved patient wait times, and increased patient satisfaction (Ansell et al., 2017; Kagedan et al., 2021) These interventions discussed may be of more cost to the organization or site, but by examining the possible benefits this is an

intervention that the organization can take into consideration and determine if this is the

appropriate intervention for their site and current situation

Strengths of Evidence

In the included literature of this DNP project many of the included articles did not

mention the strengths of their research but a few included studies did The overarching strength mentioned by these articles were large sample size (Kagedan et al., 2021; Kam et al., 2021; Oostrom et al., 2017), length of study (Chu et al., 2019), and the inclusion of the whole clinic team at their specific site (Robinson et al., 2020) These articles bring rigor to this literature search and aids in exemplifying the differences between the clinic sites where the research was conducted

Another strength of the chosen literature is the number of quantitative studies and

systematic reviews Quantitative studies give statistical information showing if and how an intervention works The systematic reviews synthesize all available data for easy interpretation and are therefore the strongest level of evidence The inclusion of these types of articles add to the strength of this DNP project and the interventions and recommendations discussed for future organizations to utilize these interventions knowing they are founded and based in the most current and up to date literature

Weaknesses of Evidence

One weakness of this evidence mentioned in two of the articles included in this literature search was the amount of time over which data collection took place (Aburayya et al., 2019; Ariffin et al., 2017) These articles stated the duration of the data collection period was too short

to be able to truly make a statement on the causative factors leading to increased waiting times for patients (Aburayya et al., 2019; Ariffin et al., 2017) Another weakness of the evidence is the three included grey sources (Burling-Phillips, 2016; Institute for Healthcare Improvement [IHI], 2016; Gritters, 2017) These sources are not peer-reviewed, they are easily available through any internet browser, and though they are from reputable sources, they lack the rigor and structure available within the other qualitative and quantitative articles that were included However, these sources do lend insightful information on different approaches to help decrease patient waiting times and include expert opinions from providers and clinic managers who have first-hand

experience implementing these different interventions to improve their practices

Another weakness of this literature mentioned in several of the articles chosen for

inclusion in this literature synthesis were conducted at one ambulatory clinic site (Chu et al.,

2019; Godley & Jenkins, 2019; Kagedan et al., 2021; Kovach & Ingle, 2019; Pena & Lawrence, 2017) Though this is a weakness of the literature, it is helpful to other ambulatory sites to have studies to examine and to use that information to develop a plan to improve the waiting times at their own clinics

Gaps and Limitations

The largest gap and limitation of the literature synthesized for this project is the overall problem of increased wait times is consistent across all ambulatory care settings, but the

interventions and the phase of the patient cycle where the intervention is implemented varies between each clinic site The variability between the articles highlights why this problem of increased waiting times is still such a large factor in the healthcare system and that is because the stated and described interventions of these studies are truly specific to each clinic This literature synthesis also exemplifies why so many different interventions are warranted because each clinic has a different area of the patient cycle they struggle with and need to strengthen in order to improve their patient and staff’s satisfaction

METHODS Project Design

The project’s purpose was to improve overall patient wait times at a primary care clinic

in north-central Utah by implementing an intervention within the electronic health record (EHR) enabling a talk-to-text feature allowing providers to quickly and accurately complete patient documentation This project’s design was a quality improvement design utilizing a post-

implementation survey that included open-ended questions (Appendix C) The PI (principal

investigator) collected data post-implementation using surveys from the healthcare provider participating regarding technology implementation and patient wait times

After IRB approval was obtained (Appendix A), the talk-to-text technology was added to the current electronic health record (EHR) eClinicalWorks, by the information technology (IT) representative from the EHR company The PI provided education (Appendix D) to the one medical doctor about the talk-to-text feature and how to utilize the intervention when completing documentation after completing the healthcare visit with the patient After the four-week

measurement period the provider completed the post-implementation survey (Appendix C), given on paper by the PI, regarding the satisfaction with the intervention, if they want to continue the intervention, and if they felt as if the implemented intervention improved patient wait time

Model for Implementation

The Institute for Healthcare Improvement’s (IHI) Model for Improvement (MFI) was designed to facilitate quality improvement (QI) in the healthcare setting (Institute for Healthcare Improvement [IHI], 2019) This model is not one to replace other models for improvement, but it helps the improvement move more quickly (IHI, 2019) Before any improvements can be made, there are three steps with associated questions that must be answered to establish the foundation

of the QI project: Setting Aims -What is trying to be accomplished? Establishing measures - How will it be determined that a change is an improvement? and Selecting changes - What change can be made that will result in improvement? (IHI, 2019) In this QI project, the principal investigator (PI) aims to improve patient wait times by increasing the speed and accuracy of patient documentation by utilizing a talk-to-text feature The outcomes were assessed following a

period of four weeks after intervention implementation analyzing the provider’s perception of the wait times in the clinic via the distributed survey (Figure 2)

Plan-Do-Study-Act (PDSA) Cycle

The IHI MFI utilizes the PDSA cycle (Figure 2), which is a way that changes can be tested to determine if there is improvement (IHI, 2019) If there has not been improvement, then the cycle can be started again with new interventions to improve a particular process The PDSA cycle is comprised of four different steps: Plan-Do-Study-Act (IHI, 2019) (Figure 2)

Plan

In the “Plan” stage, this is where the project’s objective is stated, and predictions are made about what will happen during this project and why (IHI, 2019) This is also the stage where the plan is developed on what change will be tested and how the testing of that change will be carried out (IHI, 2019) During this stage, it is important to ask the five ‘W’ questions: What is the change? Who is going to test the change? When will the change be tested? Where will the change be tested? and What data needs to be gathered during the testing of the change? (IHI, 2019) For this QI project, during the plan stage, the change of implementing a talk-to-text function within the EHR was determined and the objective is to improve patient wait times The one medical doctor at a family practice clinic in north-central Utah was the sole participant of this QI project, and this change was implemented and measured over the four-week period of August to September 2021 The data gathered during implementation includes how often the talk-to-text documentation feature was utilized (Appendix D)

How will it be determined that the change is an improvement?

Do: Implement intervention and educate medical doctor

at the family practice clinic

Do

The second step of the PDSA cycle is the “Do” stage During this stage, the change or intervention is implemented or tested on a small scale, meaning at one site or clinic (IHI, 2019) During the do phase it is imperative to document any problems with the change or test and

document any unexpected observations (IHI, 2019) Documenting these observations helps the team know what may need to be changed during the final phase of the PDSA cycle During the

do phase, this is also when the data is starting to be analyzed for trends and beginning to

determine if this change is starting to show improvement with the chosen process The do phase

in this QI project started with the intervention being implemented after receiving Institutional Review Board (IRB) approval from the University of Arizona The change of implementing a talk-to-text feature within the EHR was the change being tested This change was only tested at a family practice clinic in north-central, Utah Throughout the intervention, if implementation problems or unexpected issues arose, those were documented to be evaluated and analyzed during the next phase of the PDSA cycle, study

The PDSA cycle is a great tool that aids in quality improvement and helps accelerate change The IHI MFI is a model that is easy to follow, easy to apply to any type of improvement project, and keeps the team updated on where the project currently is

Setting and Stakeholders

The setting of this QI project was at a family practice clinic in north-central Utah This clinic in north-central Utah, is about an hour south of the capital of Salt Lake City, located in Utah County, and is defined as a medically underserved area The clinic site is not in a rural area, but recently has had a population boom with many new technologic companies moving their companies and their employees to this part of the Utah valley The chosen clinic is located on the outskirts of the downtown area of one of the cities in north-central Utah but is easily accessible off I-15, which is the one major freeway in Utah that is the main route of travel This area has a population of about 62,000 residents and is comprised of middle to upper-class people, with the median household income being around $90,000 per year (Data USA, 2018) Much of the

population is 87% Caucasian, 8% Hispanic, and the other 5% comprised of multiple different races and ethnicities (Data USA, 2018)

The stakeholders involved in this project were the one medical provider, the clinic

manager, the medical assistant, and the patients The one medical provider was a medical doctor (MD) The medical provider’s role in this project was to help with the data input and provide their feelings regarding the implemented intervention of integrating a talk-to-text feature into the EHR There are really no risks involved for the provider, but the benefits would be that the patients are less frustrated and have a higher level of satisfaction going from being shown a room until the provider sees the patient

The medical assistant’s role in this project was to ensure the patients were shown to a room as timely as possible after they check-in Medical assistants also have the imperative role

of marking where the patient is in the EHR, so the provider knows when the initial questions are finished, and the patient is ready to be seen The only risk involved with the medical assistant’s role is if they fail to mark the patient as ready in the EHR, the patient may end up waiting longer and the provider will not know the patient is ready and continue to complete other tasks

Another stakeholder for this project is the clinic manager The clinic manager’s role in this project was first allowing the project to be completed at this clinic and access to the staff surveys The risks involved on the clinic manager’s part were this is yet another change for the staff to make, leading to possible frustration The perceived benefit of this project was it would hopefully streamline the documentation process and increase patient satisfaction in that they can spend the time in the clinic seeing their medical provider instead of waiting for them to come into the room

Without the support of these stakeholders, this QI project would not have been able to be successful The buy-in was evident from each of the clinic stakeholders, all staff were willing to participate in their roles and carried out the intended intervention

Planning the Intervention

The plan for this intervention was to educate the medical provider at the clinic on the practice of how the talk-to-text function operates, how to access this technology within the EHR, and how to utilize this function when completing documentation of a patient encounter

(Appendix D) The expectation of this project was for each patient seen by the provider,

documentation of the patient encounter would be completed utilizing the talk-to-text function to verbalize the documentation in the EHR This process continued for a period of four weeks, August to September 2021 After that period, a paper survey was given to the medical doctor to rate the implemented intervention, associated patient wait-times, and how often he utilized the intervention (Appendix C) This survey (Appendix C) was turned into a folder in the office when completed by the participant, where it was stored in the file locked inside the participant’s desk until it was collected by the PI and converted to a Microsoft Word file on a password protected laptop

Participants and Recruitment

The participant for this QI project was a willing medical doctor recruited by the clinic manager The other providers and staff are excluded from this study to implement this project on

a small scale first This is a convenience method but provided the clinic manager and the clinic system with the information of how effective this intervention was, how patient wait times are

affected by provider documentation, and the participant’s perception of how useful the

implemented intervention was in enhancing their documentation experience

Consent and Ethical Considerations

Approval for this project was obtained through the Institutional Review Board (IRB) at the University of Arizona and from the chosen family practice clinic site (Appendix A) The employee participant received a disclosure statement prior to implementation about the project being conducted in which consent is implied when continuing to assist with the project

completion (Appendix B) There was no information collected regarding the employed staff, but ethical considerations will be in place to keep them safe throughout this project’s duration No protected health information was collected about the patients being seen during this measurement period The data was analyzed by the primary investigator (PI) and confidentiality was

maintained with no protected health information being recorded for this project Determination

of human subjects was obtained by the IRB prior to implementation of this QI project, and this project was deemed not human research Raw data collected during the implementation period will be sent to the University of Arizona College of Nursing for storage for a period of five years

Timeline

The timeline for this QI project started in August 2021 Education was provided to the medical provider after IRB approval was established Implementation and the data measurement period began in August 2021 The medical provider utilized this process for documentation for four weeks until September 2021 The PI checked-in with the provider to assess how the process was going and if there were any questions regarding the new process during the measurement