The document describes a PDSA cycle to improve communication of clinic delays at an orthopedic faculty clinic. The clinic was experiencing unpredictable wait times due to variations in patient arrival times and service times. A standalone whiteboard was purchased to display information about clinic name, provider availability status, and delays. Front staff agreed to update the board daily. The goal was to improve communication of delays, provider availability, and the Press Ganey score on information about delays by 15%. Measurements like the Press Ganey score and staff/patient feedback would be used to monitor the change over 6 and 12 months.

1. 1
PDSA – Goal: Improve Communicating OFC Clinic Delays
PDSAName: OFC Stand Alone Communication Boarda Performance Improvement Initiative
Start Date: 2/15/2012 PDSA Cycle Number: 1 Resource owners:Al Lopez
________________________________________________________________________________________
Background Information
Visiting hospital outpatient clinics is a very common way for patients to access health care.
These clinics typically schedule appointments for patients in advance, and patients arrive to
the clinic expecting service to begin at their scheduled time. The Orthopedic Faculty clinic is
one such clinic. However, due to the patient arrival time and service time variation some
patients end up waiting notwithstanding they have reserved time slots. Furthermore, it is
common practice at many outpatient clinics for providers to book multiple patients at the same
time. This is an OFC practice as well. Part of the reason for this is to ensure that patients are
always available to see doctors or other expensive scarce health care resources. However, if
all scheduled patients show up on time or early, significant patient waiting is a certainty if the
provider has no LIP help. Likewise, it is not uncommon for a patient to see the same resource
more than once during a visit to the clinic. Thus, patient flow is also highly disarrayed and
unpredictable process. While some patients’ paths vary significantly through all the clinic
resources, by a significant margin, the x-ray machines/technicians and the surgeons are the
busiest resources (OFC time studies). Essentially all patients see the surgeons and 30-95% of
patients have x-rays, depending on the surgeon. Most (but not all) x-rays are pre-ordered and
completed before a patient is invited in to an examination room. This is one improvement
process that radiology has implemented successfully and it has demonstrated to improve
patient flow (staff interviews and OFC time studies). However, not all stakeholders participate
in the per-ordering x-ray process.
Likewise, we have found it necessary for both x-ray technicians to make themselves readily
available to avoid significant patient backlog. However, in actual practice the clinic’s x-ray
technicians needed to take occasional breaks, or they are asked to perform other tasks that
caused the x-ray machine to become unavailable. Thus, another improvement option identified
and implemented was to stager the technologist starting time, lunch time and ending time so
they can cover each other for breaks and to coordinate staff schedules to ensure that the x-ray
machine is always available during the busy days in the clinic.
The negative effects of waiting on patients are well documented. However, clinic staff also
experience negative effects due to patient congestion. The concern with waiting is the patient
dissatisfaction it may cause. In addition, growing lines of patients put the staff under significant
work pressure and often requires them to deal with annoyed patients. In the long run, such
pressure can create morale problems and likely contributes to absenteeism and diminished
interest in work.
Presently, the front staff intermittently communicates clinic delays and/or provider availability
directly to patients. Clinic delays negatively affect clinic efficiency resulting in greater economic
cost to the patient and clinic. This existing condition is contradictory to any value-based
solutions that focus on better health outcomes at the lowest cost. Patients’ want information
supplied to them voluntarily and consistently; they don’t believe they should have to ask
(personal interviews with patients 2012 - 2013). The front staff occasionally scripts patients in
the front waiting area due to their proximity however no formalized scrip has been designed.
Therefore, scripting variability also exist. Moreover, particular conditions such as when the
clinic’s demand is high, staff shortage/s or any other service time variation it becomes

2. 2
exceedingly difficult for the front staff to script delay of services bearing in mind the register’s
myriad of jobs task. Additionally, with the increasing demand for orthopedics services
(Becker’s Spine Review, Prepare for More Orthopedics: Demand to Increase by 2014),
registering clerks find themselves registering more patient per/IDX session to keep the patient
flow moving rather than communication delays. Some patients wait apprehensively for
orthopedics services and may think they are forgotten. As a result of the ambiguity they
become uneasy and anxious. And sometimes they approach the front staff requesting details
why they are waiting so long. The front staff member who is approached has to stop their
registration process with the patient they are currently registering, investigate the details for the
patient who is asking about the wait time and when appropriate defused the patient(s)
disapproving annoying attitude. Periodically, when contentious strategies cause conflicts to
escalate a supervisor must interact with the patient to avoid Patient-on-Professional hostility.
Empirical evidence pronounces that prolonged waiting times in A&E departments and general
practice led to aggression due to frustration; it generally being directed towards receptionists–
with approximately 73% of doctors becoming involved (Hobbs and Keane 1996). This
dysfunctional situation interrupts all staff work flow, interrupts patient flow, negatively effects
overall patient satisfaction and the overall clinics quality score. This is supported by the OFC
Press Ganey Medical Practice report benchmarked data period 01/01/2012 to 01/31/2012.
This is also supported by personal interviews with Carla and Reyna the OFC clinic supervisors.
To improve the broadcasting of “Delay of Services” it was agreed to develop an economical
testable methodology. We elected to start with a single standalone white board. The white
board was approved to be placed in the front waiting area.
The standalone communication board is used to inexpensively disseminate information such
as the clinic’s names (Orthopedics Specialty, Bone Density), clinic hours, basic registration
instructions, providers availability status (e.g. doctor xyz here, doctor XYZ out ) , and “Delay of
Service” (doctor xyz late 20 minutes, x-ray machine down ETA 30 mins ect…).
Communicating the aforementioned has been demonstrated to positively impact the Press &
Ganey quality indicator “Delay of Service” score, improve the clinic’s overall quality score and
improve the continuity and delivery of care (Press & Ganey website). When a provider is late
or out, and if this is written on the communication board as such, this information helps
patients’ to determine if they would like to reschedule or wait for the provider. The information
is anticipated to help reduce the probability of the patient developing a negative outlook toward
OFC and improve clinic flow. The major function of this board is to communicate – Clinic
name, provider status, and Information about Delays. By reducing the variation in wait times
between patients and clearly communicating any delays, we anticipate reducing the chances
of patients experiencing unacceptable delays in treatment.

3. 3
Plan: Analyze process to be improved and determine what changes to make
Goal: What are we trying to accomplish?
 Develop a reliably method to disseminate delay of service information.
 Improve information delivering to patients about changes in provider’s availability.
 Improve information delivery to the patient what clinic they are at.
 Improve staff confidence that patient are aware of provider availability and delays.
 Be consistent with any national goals relevant to the length of the project. (Keep 'em moving:
joint commission ramps up expectations on patient flow, Health Facil Manage. 2013
Apr;26(4):37-9.).
 Introduce measures and targets where there had previously been none.
 Provide evidence to those involved that change is required.
 Apply best practices standards to organizational process.
 Improve the Press and Ganey percentage information about delays score by 15%.
What change(s) will we make to improve the process?
 Purchase and develop a communication board to improve communicating delays and provider’s
availability.
 Front registration staff, MA’s and Ortho Tech’s agreed to write their assigned providers
availability and wait time daily on the front whiteboard.
What improvement(s) do we expect to happen?
 Improve the Press & Ganey Information about delays score.
 Improve communicating provider availability.
 Improve the relationships skills inherent to understanding the patient perceptions concerning wait
time and build trust.
 Improve service quality and delivery.
 Reduce preventable communicational errors regarding information about delays.
 Reduce the probability of developing a confrontational relationship with any patient.
What measurement(s) will we use to monitor the change? How will we collect and share the data?
 We intend to document and monitor data using an Excel assessment spreadsheet concerning
efficiency and effectiveness from the Press Ganey Medical Practice report benchmarked data period
01/01/2012 to 01/31/2012 (information about delays Press Ganey score x̅ = 62.1 n = 29)
 Front staff’s comments
 All staff’s observations
 Patient comments
Do: Implement and test the changes
What were the experiences, problems, surprises that occurred?
Study: Monitor and analyze the results of the doing stage
What were the improvements that occurred from the change? How did the measurements change?
Upon the conclusion of 6 months and 12 months the owners of this PDSA will enter and analyze the current
trend results and provide the findings to the OFC clinical supervisor and the front staff supervisor. At that point

4. 4
it will be determined the communication board effectiveness. It will also be determined whether if additional
training is required for some or all staff.
Act: Fully implement, revise or abandon the improvement changes
Is the change ready to be implemented? If no, what modifications need to be made to continue the
improvement process and start the PDSA again?
Upon completion of studying the information the educators will act upon that information.
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 65" high display

5. 5
PDSA – Goal: Improve Communicating OFC Clinic Delays
PDSA Name: OFC Stand Alone Communication Board a Performance Improvement Initiative
Start Date: 7/11/2012 PDSA cycle number: 2 Resource owners:Al Lopez
________________________________________________________________________________________
Plan: Analyze process to be improved and determine what changes to make
Goal: What are we trying to accomplish?
 Develop a reliably method to disseminate delay of service information.
 Improve information delivering to patients about changes in provider’s availability.
 Improve information delivery to the patient what clinic they are at.
 Improve staff confidence that patient are aware of provider availability and delays.
 Be consistent with any national goals relevant to the length of the project. (Keep 'em moving:
joint commission ramps up expectations on patient flow, Health Facil Manage. 2013
Apr;26(4):37-9.).
 Apply best practices standards to organizational process.
 Improve the Press and Ganey percentage information about delays score by 15%.
What change(s) will we make to improve the process?
 Develop or purchase additional communication board for the examination rooms to further
improve information delivery regarding provider’s availability and the Press and Ganey
percentage score – Information about delays.
 MA’s and Ortho Tech’s agreed to write their assigned providers availability and wait time daily
on the front whiteboard and whiteboards in the examination rooms.
 Use volunteers to communicate providers’ availability and information about delays.
 Begin designing a scripts for staff.
 Accelerate the pace of change and make changes sustainable.
What improvement(s) do we expect to happen?
 Improve the Press & Ganey Information about delays score.
 Improve communicating provider availability.
 Improve the relationships skills inherent to understanding the patient perceptions concerning wait
time and build trust.
 Improve service quality and delivery.
 Reduce preventable communicational errors regarding information about delays.
 Reduce Variation in Clinical Pathways to Reduce Delays
 Reduce the probability of developing a confrontational relationship with any patient.
What measurement(s) will we use to monitor the change? How will we collect and share the data?
 We are using an Excel assessment spreadsheet to monitor information about delays using the Press
Ganey Medical Practice report benchmarked data periods 01/01/2012 to 01/31/2012 x̅ = 62.1, n = 29
and information about delays Press Ganey score 06/01/2012 to 06/30/2012 x̅ = 65.6 , n = 35 for the six
months analysis (graph provided below).
 Front staff’s comments
 Staff’s observations
 Patient comments
Do: Implement and test the changes
What were the experiences, problems, surprises that occurred?
 When we have “float” staff filling in at the front registration area they are not informed about writing the
information on the board.

6. 6
 Back staff is not consistently communicating their provider status using the examinations whiteboards.
The staff stated they are finding it difficult to communicate provider’s status due to increasing
administrative requirements and increasing patient load.
 The volunteers have not been introduced to the PDSA’s objective nor have they been encouraged to
participate.
 The need for dedicated time to do the mapping and the right facilitation. It takes time to plan
and take the improvement work forward.
Study: Monitor and analyze the results of the doing stage
What were the improvements that occurred from the change? How did the measurements change?
The Press Ganey score correlated to information about delays improved by 3.5x + 58.6 with R2
= 1.
Upon the conclusion of 12 months, the owners of this PDSA will analyze the tracking tool results and provide
the results to the OFC clinical supervisor. At that point it will be determined the communiqué board
effectiveness. It will also be determined whether if additional training is required for some or all staff.
Act: Fully implement, revise or abandon the improvement changes
Is the change ready to be implemented? If no, what modifications need to be made to continue the
improvement process and start the PDSA again?
 The change is fully implemented. Nevertheless, to further improve we elected to post additional
whiteboards in the examination rooms with the information who is the patient’s provider, who is the
charge nurse, who is the MA, and information about delay.
Upon completion of studying the information the educators will act upon that information
Analysis Date Range x̅ in percent n
01/01/2012 to 01/31/2012 62.1 29
06/01/2012 to 06/30/2012 65.6 32
The PressGaney Medical Practice reportbenchmarkeddataperiods01/01/2012 to 01/31/2012 x̅ = 62.1, n = 29 and
informationaboutdelaysPressGaneyscore 06/01/2012 to 06/30/2012 x̅ = 65.6 , n = 35 - SIXMONTHS ANALYSIS

7. 7
PDSA – Goal: Improve Communicating OFC Clinic Delays
PDSA Name: OFC Stand Alone Communication Board a Performance Improvement Initiative
Start Date: 2/6/2013 PDSA cycle number: 3 Resource owners:Al Lopez
________________________________________________________________________________________
Plan: Analyze process to be improved and determine what changes to make
Goal: What are we trying to accomplish?
 Improve the staff/patient communication effectiveness.
 Improve response to changes in provider’s availability and delays of services
 Improve staff confidence that patient are aware of provider availability.
 Apply best practices standards to organizational process.
 Improve the Press and Ganey percentage score – Information about delays.
What change(s) will we make to improve the process?
 MA’s and Ortho Tech’s continue to agree to write their assigned providers availability and wait
time daily on the whiteboards in the examination rooms.
 Use volunteers to communicate provider’s availability and information about delays at the
greeting station.
 Radiology Technologist agreed to rove every 15 mins and script patients concerning delay of
services.
 Acquire recovery cards to give to patients and make them readily available for all staff
 Follow-up on the TV so we can use it to communicate – Information about delays
 Add another white board at back area to communicate information about delays
62.1
65.6
y = 3.5x + 58.6
R² = 1
60
61
62
63
64
65
66
01/01/2012 to 01/31/2012 06/01/2012 to 06/30/2012

8. 8
 Involve and communicate with people who will be directly involved in the pathway
 Gather and use all available evidence to underpin arguments for change.
 Select key players and ensure that whenever possible, they become engaged in the process.
If not actively engaged, then at least keep them updated with developments.
 Link in with other directorate personnel who are experiencing similar problems and support
each other.
What improvement(s) do we expect to happen?
 Improve the Press & Ganey Information about delays score.
 Improve communicating provider availability.
 Improve the relationships skills inherent to understanding the patient perceptions concerning wait
time and build trust.
 Improve service quality and healthcare services delivery.
 Reduce preventable communicational errors.
 Reduce the probability of developing an adversarial relationship with any patient.
What measurement(s) will we use to monitor the change? How will we collect and share the data?
 We are using an Excel assessment spreadsheet to monitor information about delays using the Press
Ganey Medical Practice report benchmarked data periods 01/01/2012 to 01/31/2012 x̅ = 62.1, n = 29
and information about delays Press Ganey score 06/01/2012 to 06/30/2012 x̅ = 65.6, n = 35 for the six
months analysis and data period 02/06/2013 n=31 (graph provided below).
 Front staff’s comments
 Staff’s observations
 Patient comments
Do: Implement and test the changes
What were the experiences, problems, surprises that occurred?
 Continued issues - When we have PRN staff at the front registration they are not writing the information
on the board.
Study: Monitor and analyze the results of the doing stage
What were the improvements that occurred from the change? How did the measurements change?
The Press Ganey score correlated to information about delays improved by 13.7% with R2
= 0.7806
Upon the conclusion of 12 months, the owners of this PDSA will analyze the tracking tool results and provide
the results to the OFC clinical supervisor. At that point it will be determined the communiqué board
effectiveness. It will also be determined whether if additional training is required for some or all staff.
Act: Fully implement, revise or abandon the improvement changes
Is the change ready to be implemented? If no, what modifications need to be made to continue the
improvement process and start the PDSA again?
 The change is fully implemented. Nevertheless, to further improve we elected to post additional
whiteboards in the examination rooms with the information who is the patient’s provider, who is the
charge nurse, who is the MA, and information about delay.
Upon completion of studying the information the educators will act upon that information

9. 9
Analysis Date Range x̅ in percent n
01/01/2012 to 01/31/2012 62.1 29
06/01/2012 to 06/30/2012 65.6 32
2/6/2013 75.8 31
The PressGaney Medical Practice reportbenchmarkeddataperiods01/01/2012 to 01/31/2012 x̅ = 62.1, n = 29 and
informationaboutdelaysPressGaneyscore 06/01/2012 to 06/30/2012 x̅ = 65.6 , n = 35 and 2/6/2013- 1 yearANALYSIS
Anothertacticto be implementedinclinicsisapatientroomingprocesscalledroomandround.In summary,the
conceptallowsthe staff tomaximize patientflow inthe clinicwhile providingtimelystatusupdatestopatients.Whena
MA takesthe patienttoan examroom,he or she acknowledgesthe patient,providesacourteousintroductionand
informationaboutthe durationof the appointmentandexplainsthe servicestobe provided.Finally,the MA will take
patientvitalsanduponexitingthe examroomassuresthe patientthathe or she will be keptwell informedof any
delays.Toimprove customerservice,employees shouldwarmlygreetapatientandthe family,explainwhatwould
happen,whowouldtreatthemandhowlongtheirvisitwouldtake.Lastbut notleast,patientswouldbe thankedfor
choosingUNMH. This isnot happening.
We developedthe ideaof takinga dryerase board andwritingthe actual,updatedwaittimesforeachof the providers
scheduledinOFCclinicforthe day.The board includedthe surgeon'sname and anotationsignifyingwhetherthe
providerwasontime or delayed.If aproviderwasrunningbehind,nurseswouldregularlyinformfrontdeskstaff of the
projecteddelaytimesandthatinformationwouldbe passedalongtowaitingpatientsviathe dryerase board.Thisisnot
beingdone.
Staff sensitivitytopatientneeds,response toconcerns/complaints,andcommunication of reasonsfordelayedcare and
overall cheerfulnessof the practice are topprioritiesforpatientsatisfaction.Byengagingateamof "mysteryshoppers",
62.1
65.6
75.8
y = 4.3357x + 60
R² = 0.7806
0
10
20
30
40
50
60
70
80
01/01/2012 to 01/31/2012 06/01/2012 to 06/30/2012 2/6/2013
Percentmeans
OFC - Informationabout delays
13.7% IMPROVEMENT

10. 10
we provide promptfeedbacktoourstaff to improve theirresponsivenessandabilitytoprovide efficientandpatient-
focusedassistance ateveryinteraction.
What are we measuring?
Bundledinthe VisitExperiencescore are the responsestothe particularquestionsof:
•Lengthof waitbefore goingtoan examroom
•Informationaboutdelays
Newchart - Source of comparisondata: PressGaneyNational Database Participants(n=702sites) andPressGaney
CustomComparative Database Participants(n=51sites)
assignsa liaisontocheckinwiththose waitingevery20minutes.
We measure the qualityof yourcare by howwell we meetyourexpectationsandthe highestnational standardsof
safetyandeffectiveness.We strive toprovide youwith care thatis:
•Safe—avoidinginjuriesfromthe care that isintendedtohelpyou
•Timely—reducingwaitsandsometimesharmfuldelaysforyouwhoreceive care andalsofor the personwhogivescare
to you
•Effective—providingcare toyouand all otherpatientswhocan benefitandrefrainingfromcare if youand other
patientsare notlikelytobenefit
•Efficient—avoidingwaste,inparticularwaste of equipment,supplies,ideas,andenergy
•Equitable—providingcare thatdoesnot vary inqualitybecause of gender,ethnicity,geographiclocation,and
socioeconomicstatus
•Patient-centered—providingcare thatrespectsyourpreferences,needs,andvaluesandensuringthatyourvalues
guide all clinical decisions
Engage and empowerthe frontstaff
identifyanappropriate assessmenttool toconducta gap analysisof the currentstate of knowledgeaboutqualityand
patientsafety
Taxonomy of Quality Improvement Strategies With Examples of Substrategies
QI Strategy Examples
Provider reminder systems
 Remindersin chartsfor providers
 Computer-based remindersfor providers
 Computer-based decision support
Facilitated relay of clinical datato
providers  Transmission of clinical data from outpatient specialty clinic to primary care provider by meansother than medical
record (e.g., phone call or fax)

11. 11
QI Strategy Examples
Audit and feedback
 Feedbackof performance to individual providers
 Quality indicatorsand reports
 National/State quality report cards
 Publicly released performance data
 Benchmarking – provisionof outcomesdata from top performersfor comparison with provider’sown data
Provider education
 Workshops and conferences
 Educational outreach visits(e.g., academic detailing)
 Distributed educational materials
Patient education
 Classes
 Parent and family education
 Patient pamphlets
 Intensive educationstrategiespromoting self-management of chronic conditions
Patient reminder systems
 Materialsand devicespromoting self-management
Promotion of self-management
 Postcards or callsto patients
Organizational change
 Case management,disease management
 TQM, CQI techniques
 Multidisciplinary teams
 Change from paper to computer-based records
 Increased staffing
 Skill-mix changes
Financial incentives, regulation,
and policy
Provider directed:
 Financial incentivesbased on achievement of performance goals
 Alternativereimbursement systems(e.g., fee-for-service, capitated payments)
 Licensure requirements
Patient directed:
 Copaymentsfor certain visit types
 Health insurance premiums, user fees
Health system directed:
 Initiativesby accreditation bodies(e.g., residency workhour limits)

12. 12
QI Strategy Examples
 Changesin reimbursement schemes(e.g., capitation, prospective payment, salaried providers)
Dashboard
Despite the benefitsaffordedbythe initiatives,there weremanychallengesthatwere identifiedinimplementingthe
variousinitiatives:
•Lack of time and resourcesmade itdifficulttoimplementthe initiativewell.82
•Some physicianswouldnotacceptthe newprotocol andthwartedimplementationuntil theyhadconfidenceinthe
tool.103
•Clearexpectationswerelacking.86
•Hospital leadershipwasnotadequatelyengaged.86
•There was insufficientemphasisonimportance anduse of measures.86
•The numberandtype of collaborativestaffingwasinsufficient.86
•The time requiredfornursesandotherstaff toimplementthe changeswasunderestimated.120
•The extenttowhichdifferencesinpatientseverityaccountedfor resultscouldnotbe evaluatedbecause severityof
illnesswasnotmeasured.89
•Improvementsassociatedwitheachindividual PDSA cycle couldnotbe evaluated.89
•The full impactonthe costs of care, includingfixedcostsforoverhead,couldnotbe evaluated.89
•Failure toconsiderthe influence of factorssuchas fatigue,distraction,time pressures.82
•The Hawthorne effectmayhave causedimprovementsmore sothanthe initiative.118
•Many factorswere interrelatedandcorrelated.96
•There was a lack of generalizabilitybecauseof small samplesize.93,119
•Addressingsome of the problemscreatedothers(e.g.,implementingcomputerizedphysicianorderentry(CPOE)).110
•Targets set(e.g.,100 percentof admissions)mayhave beentooambitiousandwere thus alwaysdemandingand
difficult-to-achieve service improvements.119
2.Developthe teamaroundthe patientjourney 3.Make the patientandcare experience central toeverystage of the
journey 4.Make sure there iscapacity to meetpatients'needsateverystage of the journey
Highand lowimpact Stakeholderanalysis –customeranalysis Creatingabenefitsrealisationplan
Staff involvementandtrainingtosustainthe process
real-time observationshave shownthatinheavybutfree flowingtraffic,jamscanarise spontaneously,triggeredby
minorevents

13. 13
As a non-productiveactivityformostpeople,congestionreducesregional economichealth.
Muti-channelingprocess
Addingmore capacityat bottlenecks(suchasbyaddingmore lanesat the expense of hard shouldersorsafetyzones,or
by removinglocal obstacleslike bridge supportsandwideningtunnels) Creatingnew routes
‘5 whys’and ‘5 hows’methodology
The team thenidentifiedthe top10 requirementstomake the future state areality:
• effective leadership
• clearcommunication
• standardworkingpractices
• sevendayweekforall services
• quick,effective discharges
• patients:rightplace,firsttime,staythere
• bestmulti-disciplinaryteamwork
• quick,effective diagnosis
• easilyaccessible diagnosticequipment
• accessible userfriendlypatientrecords.
reducedlengthof stayand associatedcosts.
Keypoints
• The importance of all membersof the currentprocessunderstandingthe processandwhatadds
value forpatients.
• The needfordedicatedtime todothe mappingandthe rightfacilitation.Ittakestime toplan
and take the improvementworkforward.