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Question: Reflection on the “key differences” in the original assessment “as-is” as compared with the final assessment of “to-be”. Includes discussion of how improvement methodologies and literature review surfaced key differences and led to original Aim Statement / PDSA and new Aim Statement/PDSA Case Sudy – APRN Managed Clinic A clinic serving clients with significant health-disparities, is run by three nurse practitioners, who are assisted by two registered nurses (RNs), one LVN, one medical assistant, and one receptionist. The office has two persons who work in billing, and a pharmacy with a pharmacist and pharmacy tech. While the nurse practitioners see established patients throughout the day they also see numerous walk-in patients with a majority of minor illnesses but on occasion, acute illnesses which require additional time. The clinic is the primary medical access for a large population in the city of 100,000 people. The three nurse practitioners regularly see patients every 15 to 25 minutes, depending on the severity of the patient. They each normally see approximately 20 patients each day, 15 scheduled patients and 5 walk-in patients. They each have an hour at the end of the day designated to complete charting, review labs, and make follow-up calls. The RNs are responsible for bringing patients back, taking histories, and vital signs. The LVN is responsible for administering medications, discharging the patients and helping RNs with VS and lab draws as needed. One staff in charge of billing works only on billing, busy with paperwork and taking phone calls. The second biller helps at the front desk with taking money and follow-up appointments. The pharmacists and pharmacy tech fill mediations and during this time, they have multiple patients in line. The director of the clinic is MBA prepared who is in charge of grants and scheduling. During a particularly busy time with flu, an upper respiratory illness, the nurse practitioners become overwhelmed with the influx of walk-in patients. Each nurse practitioner has 25, along with their regularly scheduled patients. The waiting room is full with 45 additional patients, ages 1 year to 90, with most being complaints of upper respiratory illnesses. Current Work Flow: • Reception area • Waiting room • 6 exams rooms • 1 lab • 1 pharmacy • 3 NP offices • 1 nurse station • 1 Pharmacy • Patients enter the clinic and sign in at the check-in desk with the receptionist. They give their primary complaint along with their method of payment (insurance, self-pay…). Information is entered into an EHR which flags the RN with an updated schedule. ≈ 10 minutes to check in. Waiting room time = 45-90 minutes in busy times. • RNs call patients back to empty rooms in order of their arrival. Weight taken before going into room ≈ 5 minutes. • RNs obtain CC, history, ROS, update medications and take VS = 15 minutes • LVN assists RNs as needed with VS. • Each NP moves between 2 designated rooms after RN has placed chart outside room. The NP reviews information with the patient, examines the patient and then orders lab, tests, medications (during this time, the RN pulls another patient back). Add 15-30 minutes depending on complexity of the patient Module 4 – Case Studies Nurs 5353 Case # 2 Informatics, Quality and Safety ______________________________________________________________________ • If lab/tests are ordered, one of the RN’s will draw lab, perform flu swabs, strep swabs, EKG, or send patient to a local facility for x-rays. The RN will insert the results in the chart and flag the chart. (During this time, the NP sees another patient) = Add 10-15 minutes depending on the lab • The NP returns to the room, reviews lab/tests, completes the assessment and plan for the patient. If a prescription in required, the NP writes the prescription and answers questions from the patient/family, and provides education. Add 10-15 minutes depending on education. • LVN’s administer medications (IM, SQ…) and discharge the patient. Add 10-15 min for med administration. • The patient goes to the pharmacy (if needed) = 10 minutes • The patient then checks out at the receptionist desk = 5 minutes Average time for patient upon entering the clinic and checking out – 1 hour. Complex patients = 1 to 3 hours Patients: Arrival to clinic: 10am. One of the walk-in patients is Mr. Jones, an 84-year-old who is an established patient with a history of cardiovascular disease, 2 MI’s, DMII and hyperlipidemia. He is complaint with medications. Mr. Jones has a complaint of increased temperature, cough and shortness of breath. He also complains of chest pain but states he believes it is soreness from coughing for the last three days. He is number 12 in line with 45 other walk-in patients and scheduled patients. Arrival to clinic: 12:00pm. John is a 5-year-old brought in by his mother. John is a new patient, never seen in this clinic before. His only significant history is asthma. He takes no regular medications except occasional albuterol nebulizer treatments. Mother states that he has been running between 102-104 temp since last night. She has not been able to get his temperature below 101 with Tylenol, Ibuprofen, or tepid bathing. He has had a productive cough for three days. The child is quiet, asleep in mom’s arms and is number 18 in line of 45 other walk-in patients. Arrival to clinic: 1:30pm. Veronica is a 17-year-old female with complaints of right lower quadrant pain for two days which has increased over the last 4 hours. She is not able to walk upright. Her only significant history is Chlamydia which was diagnosed three months ago. She was seen in the clinic by one of the nurse practitioners in the clinic at that time. She completed treatment and re-tested negative. She also is concerned about possibly being pregnant. She admits to being sexually active without protection in the last month. Veronica is number 31 on the list of 45 walk-ins

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