EP17
Culture of Safety EP17
- Provide one example, with supporting evidence, of a nurse-driven initiative based on patient feedback received as a result of a service recovery effort.
Greenwich Hospital Outpatient Clinic Service Recovery Effort
The Greenwich Hospital (GH) Outpatient Center is GH’s primary healthcare resource for the uninsured or underinsured in the community. Patients have access to a comprehensive range of healthcare services at the Outpatient Center, which sees over 1,500 patients (7,600 visits) each year for diagnosis, treatment and preventive care. The Outpatient Center serves a diverse patient population with a multitude of medical conditions and different social and economic backgrounds. Treatment for common medical needs are provided by a team of medical residents and interns, registered nurses, nurse practitioners and attending physicians. In addition to the medical team, specialists in the community donate their time to care for patients. The Outpatient Center offers many specialty services: Allergy, Cardiology, Dermatology, Endocrinology, Gastroenterology, Gynecology, Infectious Diseases, Neurology, Obstetrics, Ophthalmology, Orthopedics, Pulmonary, Renal, Rheumatology, Sleep, Surgical and Urology.
The Dermatology Clinic is a specialty clinic in the Outpatient Center that meets twice a month. It is one of the high-volume clinics, with 15-25 patients scheduled and seen at each session. This high-volume clinic, which runs from 1-3 p.m., is structured on a first come, first served basis, with all patients arriving at the same time, 1 p.m. The patients check in and wait to be called to see the physician. The clinic often ran longer than 3pm because sometimes there were three-hour wait times.
In May 2019, Greenwich Hospital began surveying outpatient clinic patients using the Press Ganey targeted outpatient Medical Practice survey. The survey is available in English and Spanish and is mailed to the patient’s home address. The survey responses identified the issue of long wait times and patients not being kept informed of delays in the Dermatology Clinic.
Patient Feedback
In July 2019, the Press Ganey surveys for the Outpatient Center revealed that patients in the Dermatology Clinic were dissatisfied with wait times and information about delays. Patients identified three-hour waits in the Dermatology Clinic (Evidence EP17-1, Press Ganey Survey Wait Time in Clinic, July 2019; Press Ganey Survey Information about Delays, July 2019) During the clinic, nurses received comments from patients including “I feel like cattle being round-up,” “I’m afraid to go to the bathroom or get something to eat because I may miss my name being called” and “It’s a free for all.” Patients respond to the survey questions using a scale of 1-5 (1=poor and 5=good) and write comments. As part of service recovery efforts, Kirsten Suarez, Manager of the Outpatient Center, and Ellika Mardh, MD, Director of the Outpatient Center, respond to each complaint with a follow-up phone call and then share this information with the nursing staff. (Evidence EP17-2, Follow-up Phone Call to Patients)
Nurse-driven Initiative
In August 2019, Suarez and Mardh met with Patty Willard, BSN, RN, Clinical Coordinator/Clinical Nurse; Olga Lipovetsky, RN, Clinical Nurse; Linda Foster, BSN, RN, Clinical Nurse; and Eileen Madsen, APRN, Clinical Nurse Practitioner, to review and discuss the Press Ganey survey results and comments nurses had received from patients during the clinic. (Evidence EP17-3, Outpatient Clinic Nursing Meeting Minutes, August 2019)
The nurses focused on two Press Ganey questions:
- Degree to which you were informed about any delays
- Wait time at the clinic (from arriving to leaving)
Outpatient Clinic Patient Satisfaction Committee
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Name |
Discipline |
Role |
Unit |
Patty Willard, BSN, RN |
Nursing |
Clinical Coordinator, Clinical Nurse |
Outpatient Clinic |
Olga Lipovetsky, RN |
Nursing |
Clinical Nurse |
Outpatient Clinic |
Linda Foster, BSN, RN |
Nursing |
Clinical Nurse |
Outpatient Clinic |
Eileen Madsen, APRN |
Nursing |
Advanced Practice Registered Nurse |
Outpatient Clinic |
Ellika Mardh, MD |
Medicine |
Physician |
Outpatient Clinic |
Kirsten Suarez |
Administration |
Manager |
Outpatient Clinic |
The team reviewed the issues and brainstormed strategies to operationalize the process for clinic appointments to keep the wait time to a minimum and patients informed during the wait time. The team quickly came to a consensus on the following strategies:
- Improve communication to patients by announcing what number is being called
- Numbers called in order of arrival
- Use a board with illuminated numbers in the waiting room
- Use cards with numbers in the waiting room
- Verbally call numbers and names in the waiting room
The nurses decided that calling patients by their first name and number would be helpful, as this would enable them to know where they are in the order to be seen and would not be afraid to step out to the bathroom or to get something to eat or drink while waiting to be seen. The nurses also decided that when the nurse goes to the waiting room to get the next patient, they would clearly state the number being called so everyone knows where they are in line and would stop to address any questions. Nurses believed that involving the patients in the process would increase their engagement and allow their questions to be answered, thereby improving patient satisfaction.
At the August 2019 staff meeting, Willard educated all staff members on the new procedure for calling patients from the waiting room for high-volume clinics. With the new procedure, which was piloted in the Dermatology Clinic, the patient registers as usual and obtains a number. The nurse prints out the patient list in order of arrival once all patients are registered and the clinic begins. When the nurse goes to get the patient in the waiting room, she clearly calls the patient by first name and number. If other patients have questions at that time, the nurse stops to answer them. The registrars at the front desk are also kept informed of where the clinic is in the process so they can answer questions if approached by patients from the waiting room. The pilot began in August 2019 in the Dermatology Clinic, with 20 patients scheduled. (Evidence EP17-4, New Process Dermatology Clinic Pilot August 2019)
The Press Ganey scores improved In September, October and November 2019, and there were no issues regarding wait times or information about delays in the Dermatology Clinic. (Evidence EP17-5, Press Ganey Survey, September 2019)
With the success of the trial of the new strategies in the Dermatology Clinic, this process has been instituted with all high-volume specialty clinics in the Outpatient Center: Gastroenterology, Gynecology, Obstetrics, Orthopedics, Pulmonary, Rheumatology and Surgical.
In July 2019 the Outpatient Center’s Press Ganey survey score for the question “Degree to which you were informed about any delays” was 77.8%. Post-intervention scores increased in September 2019 (84.6%), October 2019 (86.7%) and November 2019 (78.2%).
(Evidence EP-17, Greenwich Hospital Outpatient Clinic Service Recovery Effort)