Quality Improvement: Walk-In

Prevention
Savanna Hilles, Melissa Garvall, Sara Howser, & Alex Villanueva
BACKGROUND
● Patients are not making appointments and walking in to the
clinic
● Staff do not have time to handle all of the scheduled
appointments and walkins
● Patients are having to wait a long time or cannot be seen for
the day
FISHBONE
FISHBONE
ROOT CAUSE ANALYSIS
Patient has urgent need that needs to be addressed

Patient unable to schedule appointment over phone/online

PCP/nurse not answering patient’s messages in timely manner

Patient unaware about other resources and how to utilize them

Root cause: lack of response prompts patient to walk in

The Root Problem
Problem: Too many walk-ins

Plan: Respond to patients within 24 hours in Charlie clinic

Do: Unit time management training and establish incentives for goals met.

Study: Track walk-in frequency & track 24-hour response goal

Act: With 24-hour goal walk-in frequency has successfully decreased.

Implement plan to Delta & Juliet clinic. If successful, implement & standardize
in all clinics in LLVA
PDSA: PLAN
Current goal: Nurses will respond to secure emails from patients in 24 business hours.
Tasks: Nurses aim is to respond back to patients within 24 hours from receiving email
from patient.

Person responsible: Nurse manager and Quality Coordinator

When: Once training has been completed and plan approved of the new clinic response

goal.

Where: Charlie Clinic

PDSA: PLAN
● Obtain a baseline for current walk-in frequency in Charlie Clinic
■ Trend data for one month
● Train nurses on new response goal and time management
■ Provide employee and clinic incentives

● Once implemented, the frequency of walk-in will decrease.

● After 3 months, measure frequency of walk-in frequency
● Schedule weekly meetings with individual nurses and monthly clinic meetings.
■ Review effectiveness (cost & time)
■ Staff feedback
PDSA: DO
● New 24-hour response goal will be implemented.
● Nurse Manager will review secure messaging daily to
track goal progress and support as necessary.
○ Nurse manager will meet with each nurse to
reinforce 24-hour goal weekly
● Recognize nurses meetings the goal and give
incentives during weekly clinic meetings.
PDSA: STUDY
Prediction: The frequency of daily walk-ins will decrease.

Outcome: The frequency of walk-ins decreased and nurses were able to

meet their daily goals except on Mondays.
PDSA: STUDY
Problem: Secure messaging volume was higher on Mondays because nurses are off on
the weekends. No improvement of walk-in frequency on Mondays because patients not
getting a response over the weekend.

Solution: Educate patients about telephone nurse that they can call on the weekends if
they need a response before the next week.

Summary of findings: Nurses were not always able to meet 24 hour goal on Mondays
due to the higher volume of messages. More patients walking in on Mondays because
they did not receive a response over the weekend.
PDSA: ACT
Next steps: Continue to implement in Charlie clinic. Train and
implement plan in Delta and Juliet clinic. Continue to
evaluate and address clinic specific issues.
Stakeholder Analysis
Internal (unit) stakeholders:
— Employees,
managers, volunteers, government

External stakeholders: VA patients, tax payers

—
 Force Field
Analysis
Forces FOR Change Proposed Change: Forces AGAINST
● Meeting veteran needs, Change
increase experience and
satisfaction ● Resistant to change
● Decreasing unnecessary
24-hour response
walk-in appointments ● Increasing workload for
● Frustrated staff who have goal some staff
higher workload
● Reduce staff overtime (cost)
References
QI 102: How to Improve with the Model for Improvement. (2018). Institute for Healthcare Improvement. Retrieved from
http://app.ihi.org/lmsspa/#/1431fa43-38e4-4e40-ab3b-7887d3254f72/06f02446-7029-43bb-9802-
1ee6337d768e/lessonDetail/73959583-65a3-44eb-9d69-4299792016b9/page/3
Questions? Comments?