Interview with Dr. Elaine Soriano, Regional Medical Director; Karina Farias, Center Manager; Annette Hodge, Director of Operations; Cheri Collett, Director of Quality Improvement; and Stacey Kuzak, Director of Nursing
Can you tell us how you selected your first Population Health Management Initiative (PHMI) project?
We started by interviewing our care team to identify barriers and challenges to improving both access and quality of patient care. Our PHMI Practice Implementation Coach, Eugenia Black, was especially helpful in identifying questions that would elicit ideas to optimize the care team at our Golden Valley Health Centers, Florida Suites site. Our original list had 10 projects, which we narrowed down to one by voting as a team. We included the clinic manager, supervisors, providers, and our medical assistants in the voting process. That was something new for us -- including everyone on our care team.
Ultimately you chose an immunization room for children as your first project. Can you tell us more about why that is important?
An immunization room has always been on our wish list, even before PHMI. Providers always want their patients to get their shots, but we had some barriers. For example, we had patients coming in for acute visits who were also due for shots, but they arrived late, so we ran out of time or there wasn’t a room available. We were missing a big opportunity to vaccinate these kids rather than schedule them for a later visit and potentially have them not return.
How did you bring your vision for the immunization room to life?
Once we were committed, we got creative about how to make it happen. The PHMI team brought focus, sharing a quality improvement perspective that helped us think sequentially through how to set goals for increasing our immunization rates. We continued working with the whole care team to identify process steps, holding a vision for all our team members to take part in creation of the room.
What was your first Plan-Do-Study-Act (PDSA) cycle?
Our first PDSA cycle involved one provider with their panel. We dedicated a room in the clinic to giving immunizations. Either two nurses, or one nurse and one medical assistant, would staff this immunization room. With the team’s insights, especially clinicians who were very engaged in the work and self-motivated to get involved in the trial project, we started looking at the immunization care gaps before and after the intervention to determine the effect of the intervention. We are now in the process of creating a tracker that looks at care gaps by provider, and we’re working on data validity. We’re also tracking how cycle time is affected by this intervention with our medical assistants, and we determined that this project improved the cycle time enough that it makes it worth adding more nurses to the team to staff the immunization room.
How did going through the process of identifying your PHMI project make you think differently about your care team?
One of the things that came up was that we had never really thought expansively about the variety of roles our medical assistants could play. For example, they can handle some internal referrals and coordination of care. They can also help our nurses, jumping in to support patient care that is within their scope. We’re now talking about new roles to expand even further, and we’re providing our medical assistants with education on quality care.
Tell us about the immunization room itself. What is it like and could other clinics replicate it?
We identified a room we could annex that was adjacent to the clinic, but we could have used an exam room or even a common space. There are lots of options for clinics that might want to replicate this model. We wanted to make the room kid-friendly, so we covered the walls with animal stickers. Now when a parent is with their child for an immunization, they can focus the child’s attention on a monkey or giraffe while our nurse or medical assistant is giving the vaccine. Currently, we’re working with a local artist who is going to create an original mural for the space. In the room, and throughout the clinic, we also have newly created patient education materials that are easily accessible to and used by our care team staff.
In addition to increasing patient immunization rates, what have some of the other benefits of the project been?
Before the immunization room, we struggled with scheduling, and making the immunizations happen often meant overworking our staff, which we try to avoid. It has really helped having the dedicated room. It’s also caused us to think differently about roles. For example, now we’re exploring creating more advanced medical assistant roles and providing training to our staff so they can step into those roles. We’ve noticed our team is more engaged in the morning huddle too, looking at what immunizations are needed for patients scheduled to come in, looking at our lists of care gap alerts, figuring out triggers we want to use for the care team. For the immunization room, we use a flag in Epic EHR to non-verbally let nurses know a patient in need of immunizations will be coming in.
What are you most excited about in terms of what’s coming next?
We really want to see improved immunization rates and reduction or even elimination of missed opportunities. If our current PDSA cycle is successful, then we’ll test to see if providers perceive having a less crammed schedule. We’ll also look at adding additional staff and automating our reports to close more care gaps. That’s going to take some additional data mining. There is a business case to it as well, with a workforce development opportunity. This is really a way to support our staff, who can get overwhelmed by the high demand at times. The initiative helps us take care of the people who take care of our patients, helping avoid staff burnout.
Ultimately, we’d like to expand to other sites, and increase support for the initiative especially in larger sites with pediatric providers who do a lot of immunizations. We’re also thinking about expanding the use of the immunization room to address other HEDIS measure care groups, broadening to make a quality care room where there is always a nurse who can meet with patients.