Health System Spotlight with University of Nevada Las Vegas: Clinic Workflow Assessment-Health System Spotlight with UNLV: Clinic Workflow Assessment

Health System Spotlight with UNLV: Clinic Workflow Assessment

Video Transcription

So thank you for the opportunity to share our work, and of course, although I'm the one presenting this, this is the work of a lot of people, including CMSS, CDC, ACE, and  then UNLV health team. So this is where we are. The backdrop is our, you know, clinic where we have our diabetes center.  We'll go over the background for the workflow assessment, what we did, what we found, and then the implications of our findings.  So our clinic is located, you know, right in the middle of the city of Las Vegas, very close to the downtown area, and as you can see, typically, we get patients that are  in the medically underserved population, being so close to the downtown area. Our typical demographics are about 25% Hispanic or Latino, 20% Black, and 61% are White, including  Hispanic, and then 18% are, you know, other population, mostly Asian, we have a big Filipino population here, and then as far as our pay-on-mix, mostly 46% Medicaid.  This includes, you know, straight Medicaid and managed care Medicaid, and then 17% are Medicare and a big 11% self-pay and 20% commercial.  So as you can see, these are the, you know, the demographics kind of reflect our population that we serve.  And then looking at our vaccination status, we found that, you know, on the first look, we had a low rate of vaccination. Example is the influenza was about 12%.  However, this is not truly that low, we're not doing that poorly. The reason for the 12% is because a lot of the information wasn't crossing over from  the immunization information system. So that was one of the QI projects that we embarked on.  However, this low vaccination rate, you know, triggered us to start to think about how we can improve our, you know, vaccination status amongst our population.  We did have informal discussions and we, you know, talked about so many issues that we could improve upon, but we did a formal assessment using a root cause analysis to try to kind  of formally identify what are some key things that we can work on and to help us to keep track of some of those potential problems that we could fix. So that led to this finding.  This is developed from, you know, the team sitting down and kind of going over these questions and trying to understand what are possible drivers for our low vaccination rates.  And of course, we did identify that workflow was an issue. And fortunately, as we are doing this, we got an invitation to, you know, do a workflow  assessment, you know, thanks to the support from the CDC and the CMSS. So it was a, you know, kind of a golden opportunity for us.  And we went ahead and, you know, worked with the team to kind of do the workflow assessment. But as you can see, there were other issues.  And some of these are part of, you know, things that will be factored into the workflow because, for example, you know, vaccination storage and supplies, you know, or having  access to vaccines in the clinic, these are things that need to be accounted for if we're trying to improve the workflow overall.  So everything sort of ties back to the, most of these problems tie back to the workflow  during the encounter.  So the purpose of our workflow assessment was to define our current clinic workflow,  and this is important when trying to do a workflow assessment because, you know, you need to have a good reflection of what we do.  We'd recognize that and having a good reflection of what we do will help us to find where there were, you know, things that could potentially be fixed.  And then the second objective was to identify how to improve the vaccination rate through the workflow, through modification of our workflow, using the CDC standards for adult  immunization practices, which, you know, where I think this was the primary reason, the charge from the CMSS and CDC.  And then, of course, in the process to identify the most efficient and effective interventions. And this, my interpretation was this was, you know, through, you know,  embarking on different QI projects.  So in preparation, we identified facilitators, you know, included myself at UNLV. And of course, a big shout out to ACE, Elizabeth Lepkowski and Audrey Shively came  down to help facilitate the workflow assessment.  And what we did to prepare, we reviewed information on workflow analysis, which was  shared with us by CMSS, created a draft clinic workflow, then prepared information on vaccination and project. So we kind of as an introductory information to share with the team.  Then we, of course, you know, important, you know, prepared a space, got material that we needed and, of course, arranged lunch because we want people to be relaxed during the,  you know, the assessment. And then for the clinic staff, about a week before we did the actual workflow assessment,  we reviewed, we sent out information to them on, you know, vaccinations, the standard for adult immunization practice, gave them the root cause analysis that we did with the  fishbone diagram, and then sent the current workflow that we drafted and asked them to, you know, look at the workflow to make sure that this reflected what we were doing.  And everybody was in agreement. So and then the date we selected was July 20, 2023. It was about an hour and a half long over lunch. It was in the clinic education room.  And we tried to get participants from across the different, you know, levels of care, you know, in the continuum of care for our patients, because we recognize that and this is  really important if you're trying to do a workflow assessment, because, you know, having representation will help you to have a wider impact in the sense that everybody knows  what is happening and nobody's left out in the dark. And there's other reasons which I'll talk about in some subsequent slides.  But we tried to get providers, medical assistants, front office staff, clinic administrator and practice plan administrator, and as well as some information  technology representation. And this is this is the initial workflow before we did any modification. And this was what we shared along with the fishbone diagram with the staff.  And as you can see, this is typical for most clinics. And I think most of us will identify this as, you know, our typical workflow. There's some chat prep ahead of the visit.  When the patient present, the front office does the registration and they fill some paperwork. Patient is in the waiting room.  Then the medical assistant takes them to the back and does the vitals and history and other downloads and all that before the patient goes to wait in the exam room for the  provider. And then there's an encounter with the provider. Then if there are things to be done after the visit, they have another visit with a  medical assistant. If there's nothing to be done after the visit, they proceed to the front office for checkout.  So this is simple. Our current, you know, prior to the intervention to the modification, this is where we often sometimes we did vaccinations.  But you can see that this happens after the provider encounter. So oftentimes this is triggered by the provider or the patient bringing up the discussion about vaccinations.  So, of course, there we identified that definitely there were lots of areas we could improve on, you know, improving the vaccination, not just waiting till maybe it  becomes kind of a side conversation, but to make it something that we intentionally  make a change. So we we did on the day of the workflow assessment, we did a brief presentation. This was like less than 10 minutes, talked about the vaccine project so  that the staff will have some sort of background about what we're doing. We reviewed the CDC standards for adult immunization practice components with them  again. And then we talked about the process for the workflow. We had a poster size, again, another important point, which is to have, you know,  during the workflow assessment, we made a big poster size workflow, just like the one that the previous one that I shared.  And I think this is helpful because this helped facilitate our discussion. It was right there, you know, we looked at each step, starting from the beginning, and  we encouraged each of the staff members to kind of try to think about their particular role in the during the encounter to make sure that the to think about what we could  modify from from their perspective. And then they we had a discussion.  We went from each step to the next and using different colors of Post-it notes, we wrote down the possible interventions we could change.  And these Post-it notes, you know, we tried to level them according to the standards for adult immunization practice, the four standards, and each standard had a color.  And we used that to make the post to make the comments and then put it on the poster size workflow. At the end, we summarized the responses and discussed potential challenges to the  implementation. And then much later, after the workflow assessment was done, we compiled the responses and created a modified workflow, which I'll share with all of  us shortly. So this is how it looks on the day that we did the, you know, the assessment.  We had this and, you know, had all the posters. And I think the staff had fun and it was really very engaging for for everybody  involved. So we in preparation to modify the workflow, we kind of redid the original workflow. This is still the same components, just that is stretched out into one linear  format. And then this is the final product that incorporated some of the comments, you know, into the workflow and then as components of the workflow and also  side, you know, other notes and comments that we also raised, you know, things that we should consider during the implementation.  I think these slides were shared or this was shared with all of us prior to the meeting. So you can take a closer look.  But the point is, you know, this created, made us aware that there were lots of things that we could modify in our process.  The original workflow components are in white.  And then the additional things that we added are the ones in green.  And then the yellow boxes are just other comments, things to consider. And and we highlighted areas of educational opportunities.  So summary of our key findings, staff was enthusiastic about participation. So I think that was really important.  Representation is important because you have different perspective from different aspects of your workflow. It's easier to implement change.  So right now, as we are trying to implement some of the interventions, the people that are doing those changes were part of creating those ideas.  So they have a sense of ownership and buying, which helps us to facilitate, you know, some of the interventions that we were trying to do.  Of course, major majority of modifications involved assessment and recommendation of vaccinations. And then front office and medical staff were crucial to implementation of  this workflow. So this is our own experience.  And some of the potential delays that we identified, you know, of course, I think you can imagine that with this busy workflow, it potentially could create a whole lot more  time constraint during the visit. But, you know, we did recognize that the most effective way was to find the highest impact and the least time consuming interventions.  And we did recognize that you can't implement everything at the same time. You have to select what which interventions to to implement and then modify as we go  along. So our next step, you know, was implementation.  This was through quality improvement intervention cycles and then an indication of educational materials that we could use for those interventions.  And this is an example of one of the interventions we've made.  We've started doing routinely that the medical assistants will assess vaccination status during the check in.  And then if it's up to date, patient just continues in the usual pathway. But if it's not, that's a whole process that they do an assessment and then  reconciliation of the EHR with the Web IZ, which is something that we found that, you know, even though a lot of them had vaccination, received their vaccination, it was  not reconciling with our EHR, which is epic. So there's a button that you have to refresh. So that work that got into incorporated into the workflow.  And then in addition to recommending vaccinations to the patients. And another illustration of, so this model was created by the EHR analyst that was part of the workflow.  Because she was there, she understood what we're doing and it was very easy to get the buy-in to do this modification that we use for our vaccine assessment  for this MA workflow intervention.  So in summary, involving staff in the workflow assessment is really important for successful implementation. Having the poster size workflow  was facilitated discussion and participation. Identifying and implementing high impact and least time consuming modifications were really critical for us.  And the modification of the workflow were all potential QI projects along the whole, all the ideas that were raised. And I'd like to, of course, end by acknowledging support  from my home organization, ACE, CMSS and CDC definitely,  this project wouldn't be possible without that. And of course the UNLV health team, this is just a representation of those that, some of the people that helped.  There's a lot more people involved that are working in the background. So I'll stop there for some questions.  Stop sharing.  Okay.  Wonderful. Thank you so much. So first of all, feel free to drop a question in the chat, raise your hand.  Interested to see if, I'm assuming some of this sounds familiar, probably things that all of you have encountered as well, but any other thoughts or questions for UNLV?  Great stuff. I took a couple of screenshots and we'll use your RCA to hopefully expedite hours and make sure that it is as full and robust as yours.  Yeah, we'll be happy to share. I think this slides, you can, you know, you can share the slides with everyone. That's fine.  Great. We'll send them around after the call. Okay. Thank you.  And we do have one question for you in the chat. I don't know if you see it. Yeah. So did the new process add time? I think again, that was the number one thing  that we're really worried about. And you'd be surprised how much less time you think it will take, because we thought that this was gonna take a lot of time,  but because the people that were doing the intervention know exactly what they're doing. And we had this module that was created it doesn't really take more time.  I mean, it takes a little bit more time, obviously, you know, but I haven't had any complaint from anybody from the physicians. They don't complain about patients waiting too long  before they are roomed. The MAs, they're not complaining because they know what they're doing. They are the ones that brought up the ideas.  You know, the IT team are very, you know, involved. They're very responsive. If you have any issues, like currently we are trying to have the assessment.  Because for some reason it doesn't go into the health maintenance, you know, permanent record. So we're trying to walk through that.  So we've received very, you know, good participation. Let me put it that way. So I agree that it may take a little bit more time,  but you'd be surprised that if everybody's on board, you know, and some of the things like doing the reconciliation of the vaccinations,  we do that even before the patients get there. So that when they get there, when they get there, you don't have to interview everybody  because those that have their vaccines up to date, don't need to be, you don't need to go through the questions with them anyway. So that will make your work a lot less.  Okay, so I don't know the questions.  I think most of them are appreciation for the detail,  which is great. We do have, oh, Joe Allen has his hand up.  There's a question about, oh, okay, go ahead.  Oh, sure. I was just going to ask, I see in your workflow, you're having the medical assistants kind of be the first touch point. And I think that's great.  If folks kind of push back because we've found physicians are the most credible kind of recommendation source, what was the discussion of the group  of having the medical assistants approach the patients first? Is that kind of like, oh, we'll break them in, but if they have questions then we can let the provider know,  or how are you dealing with kind of that first touch point being somebody that maybe doesn't have the same trust or maybe they have more trust. I don't know. I'm just trying to,  everybody says we should have the physicians doing this, but it looks like you're having the medical assistant take the first. Yes. So thank you. That's a very good question.  And definitely we thought about that, but the patients, because what we did was we created like a standing order where if the medical assistant does the assessment  and the patients want to take the vaccination, they'll give it to them right away without even having to talk with the physicians.  So, and we haven't had any pushback.  And in the workflow that we have in the module that was created by the IT, there's a button where if the patient declines, they'll check the button  and then they'll flag it for the physician to follow up with the patient during the visit. So there's still the opportunity for the physician, but yeah, so you can think of it  as maybe some sort of a first touch by the MAs. And if it doesn't go, if there's any questions or if there's any declination, then it goes to the physician.  Thank you. Thank you.  And there's another question from Constantine.  Yes, it's me. Yeah, I was just looking at this revised workflow. It's actually very cool, but one thing I don't understand is the first part  when the patient documentation and the chart preparation leads to update vaccination in EHR and reconcile with WebIZ. It's done at the level of front desk.  So, I mean, how is it done? I mean, basically for the front desk person to-  For the front desk person, so- So that is, if you notice, that particular workflow component happens before the patient arrives. So it's done by any of the staff, really.  So those that do the chart prep before the patient actually comes to the visit. Okay, so the idea is you do it before the patient gets there.  So the reconciliation is, you know, like I said, the, we noticed that a big proportion of our patients that have their vaccinations outside of our practice,  the WebIZ is our Nevada Immunization Information System. So it resides there, but it doesn't cross over to the Epic automatically. You have to refresh it. So that's what we do.  So we're not really talking to the patient. This is just making sure that the information is up to date by the time they present for their visit.  Okay, so you get the name of the patient, you check with the state WebIZ, and then you update your Epic, right? No, it's automatic. You know, remember that it's bi-directional,  the communication between the Epic and the WebIZ. Oh, you already have bi-directional? Yes, we do. Man, oh yeah, that, I mean, yeah, you're in heaven. Okay, well, okay, okay.  Well, I mean, that's the law. It should, most, all the EHRs should have bi-directional communication. I agree with you 100%, but you know, in real life,  in Arkansas, I mean, not in Las Vegas, there is not even a unidirectional yet. I'm telling you, I mean, yeah. I mean, like, you are completely different level.  We're trying to, you know, we're doing everything manually. I mean, just, you know, looking at the patient, you know, but I mean, yeah, this is completely different.  Okay, now all the questions, now I understand. Thank you so much. Okay.  And it looks like you have one other question from George Sue, I think, too. Okay.  Any selection proposals that were considered off the table, parked until more resources available? Um, so, I mean, that, so like you see,  there are lots of potential interventions. I mean, if you look at that, it's a very busy workflow. And the question of, we thought, we, I mean,  there are things we could do, like we thought, we talked about doing like vaccination fairs, you know, where you do a mass vaccination. Those are things that we could do,  but of course that takes some planning. So that's an example of something that we kind of put, okay, maybe we'll do that at some point.  But yeah, but like I said, I think we've had good buy-in. We had somebody from, you know, upper administration present during the workflow.  So they advocate for us when we ask for things to do. They understand what we're doing. They see that we're being successful. And, you know, as a matter of fact,  another little thing is, you know, there's this thing about push for, you know, quality improvement in health, you know, pay for performance and all that.  And influenza vaccination is one of them. So the practices, you know, a lot of practices are looking to ways to improve. And this is a way to kind of, you know,  you can buy into your, get your system to buy into what you're doing by letting them know that this can actually help in that push for improving quality measures for patients.  Great, thank you. And you have one more, maybe two,  one from Elise and then from Shane. Okay, we have a similar model for project. I'd love to know how you get buy-in from physicians. Well, that's a very good.  No, so as you see right now, first, I mean, what we tried was want to include physicians during the workflow assessment, but a lot of the interventions are led by the front office  and the MAs and the physicians are kind of agreeable. They don't oppose what we're doing. And we try to, you know, as present this to the group as frequently as we can.  So definitely, you know, and I think that if you can avoid steps that would delay too much, like during the clinic visit, you know, if the patients are waiting  like an extra five minutes to be roomed, that's when you're going to get a lot of pushback. But if it's to flag a patient and say, hey, you know,  this patient needs vaccine assessment by the physician after the MA has done it. We haven't gotten a lot of pushback, but to be honest, we haven't, we're thinking of that  as a different QI intervention because you can't, you know, do all of the interventions at the same time. So we're looking at the MA level to see how successful we are.  And eventually we're going to probably expand it to,  you know, have the physician intervention, you know, that's kind of further down in the workflow.  And I think some systems have different models of, you know, trying to incentivize their physicians, which again, I don't do that, but, you know,  I know there's some systems like, you know, having them, you know, I don't know, do different things to, about the vaccinations.  Maybe, I think, is there another question regarding the bi-directional functionality? When you run your report, do you have the external vaccinations included?  Yeah, so when we run, so we actually did a QI project on this and what we noticed is that about more than half of our patients that have vaccinations don't have it in our EMR.  And the problem is that there's a sort of, I won't call it a glitch, it's just like to get the information to crossover from our state's IIS,  you have to actually manually click on a button to refresh. It doesn't just cross over. And I think that's something that, you know, needs to be fixed.  You know, we've talked about it in our ACE meetings,  but I think that, you know, the bi-directional,  when we run the reports, oftentimes it's just, most of the time it crosses over if it's been done. Now, sometimes we're into problems  with when the names don't match exactly as it is on the two different systems. That's when you have to, and our MAs actually have access to the state IIS.  So they actually have access to login and actually manually look up patients. And if those patients are vaccinated, because we ask them, if they say yes,  and it doesn't cross over, we manually log in and retrieve it and then do a manual update on our system.  Great, and then we have a question from Shane. I don't know if it sounds like it may be to anyone, but would love your thoughts on this.  So leveraging technology with patient communications, has anyone explored direct text messaging to support vaccine education empowerment?  I'll start briefly. We did raise this as one of the potential, remember that what we laid out is not what we're doing. Like, you know, the whole modified workflow  are things we aspire to do. So one of those was, you know, like using text message reminders for patients.  So I'll stop for that.

Video Summary

The speaker discussed a project focused on improving vaccination rates in a clinic setting through workflow modifications. The team engaged in a workflow assessment which involved staff members at various levels. Key findings highlighted the enthusiasm of staff participants and the importance of including different perspectives in the process. Modifications included having medical assistants assess vaccination status during patient check-ins and incorporating bi-directional communication between EHR and the state immunization information system. The revised workflow aimed to streamline vaccine assessment and administration. Physician buy-in was facilitated through involving them in discussions and showing the potential impact on quality measures. Future steps include implementing quality improvement interventions and educational materials to support the workflow changes. Additionally, exploring technological solutions such as text message reminders for patient engagement was considered.

Asset Caption

On the March 2024 SSAAI Quality Improvement and Data Leads call, Dr. Kenneth Izuora from University of Nevada Las Vegas shared how his clinic used a team-based approach to reviewing and modifying clinic workflows to integrate CDC’s Standards for Immunization Practice (SAIP) with the goal of improving vaccination rates for patients with diabetes. In this presentation, Dr. Izuora shares the original and modified clinic workflows and describes the process his team used to develop the modified workflow.

Keywords

vaccination rates

workflow modifications

staff engagement

bi-directional communication

quality measures

patient engagement