SummaryUrban Health Plan, a federally qualified health center providing care to underserved communities in the South Bronx, reformed operational processes and aspects of physical design in two clinics to ensure that they were truly prepared to begin work upon opening in the morning. These changes, referred to as the First Hour project, were designed to improve the efficiency of patient care throughout the day. The program has reduced wait times, increased patient satisfaction, and improved patient–provider interactions.Moderate: Evidence consists of comparisons of pre- and post-implementation data on average patient wait times, along with post-implementation patient satisfaction surveys and anecdotal reports from providers and patients.
Developing OrganizationsUrban Health Plan, Inc., Bronx NY
Date First Implemented2007
Problem AddressedLack of preparedness during the first hour of the day often results in extended wait times for clinic patients and reduced productivity, patient satisfaction, and quality of work.
- Lack of preparedness, leading to reduced productivity, delays: Clinics and other medical institutions are often not well prepared to begin work each day, as they fail to complete certain "readiness" tasks, such as preparing and supplying examination rooms and turning on office machines. As a result, these tasks often must be completed at the beginning of the work day, leading to reduced efficiency and delays in seeing early-morning patients. These delays often cascade, affecting patients throughout the day.
- Leading to lower quality, more dissatisfaction: Because of the slow start, patient visits often become bunched toward lunch time and the end of the day, putting pressure on staff to complete visits quickly, thus reducing the amount of time available with patients. At Urban Health Plan, providers working under these constraints had less time to investigate patient complaints and to teach patients about self-management. The combination of long waits and little time with physicians often becomes a key source of dissatisfaction for patients.1,2
- At-risk patients particularly affected: A majority of Urban Health Plan's patients are Hispanic or African American, with 67 percent of residents in the agency's South Bronx catchment area living below 200 percent of the Federal poverty level.3 Although these patient populations often face disproportionate rates of chronic diseases, reduced clinic efficiency and bunched patient visits often prevent providers from spending adequate time with them.
Description of the Innovative ActivityUrban Health Plan reformed operational processes and aspects of physical design at two clinic sites to ensure that they were truly prepared to begin work on opening in the morning. These changes, referred to as the First Hour project, were designed to improve the efficiency of patient care throughout the day. Key elements of the project include the following:
- Selecting target sites: Urban Health Plan selected two sites that serve at-risk, primarily Spanish-speaking populations for the program—El Nuevo San Juan Health Center's busy walk-in clinic and Plaza Del Castillo Health Center, a smaller satellite clinic.
- Establishing governing principle: Urban Health Plan established the following core governing principle: Each participating clinic must be fully ready to receive, care for, and treat patients on opening for business each morning (at 7 a.m. for El Nuevo San Juan and 8 a.m. at Plaza Del Castillo).
- Reforming operational processes and physical design: Based on this governing principle, the program implemented a package of changes designed to better prepare the clinics to open each morning:
- End-of-day checklist: Clinic staff found that it made the most sense to prepare for the next day's opening the night before. To facilitate this process, they created and implemented an end-of-day checklist to be reviewed each afternoon/evening by medical support personnel. The checklist guides support personnel in ensuring that key tasks are completed before they leave the office at the end of each day, including checking all office and examination room equipment to ensure proper functioning, making sure that all examination rooms are tidy and fully stocked, and ensuring that all office and administrative supplies needed for the next day are stocked and in place.
- Beginning-of-day checklist: In followup to the previous night's preparations, a medical assistant uses a beginning-of-day checklist before the clinic opens each day. The assistant ensures that all computers, phones, printers, and fax machines are turned on and functioning properly; looks at all examination rooms to make sure nothing unexpected took place overnight; and performs quality control and calibration checks on all examination room machinery.
- Redesign of examination rooms: Clinic staff reorganized the examination rooms to establish a universal standard across all Urban Health Plan sites. All examination rooms are arranged in an identical fashion, with labels placed on cupboards and shelves, thus making it easy for staff to see whether the rooms are ready for the day (and if not, to locate needed supplies). The uniform organization also facilitates greater levels of productivity for Urban Health Plan providers who work out of more than one site. As of September 2010, this standard is being integrated into the organization's nursing manual.
- Reevaluating staffing levels: Both clinics examined staffing assignments to ensure that levels were appropriately assigned based on patient volume at various times of day. For instance, weather in some seasons has led more patients to show up first thing in the morning; during such weather, staff has been redistributed to accommodate more early-morning patients.
- Encouraging patient self-advocacy: To encourage patients to advocate for themselves regarding wait times, both clinics posted signs (in English and Spanish) in all waiting areas and near the registration desk inviting patients to ask to speak to a supervisor if they have issues or concerns regarding their visit. A supervisor or administrator immediately comes to speak with any patient who expresses a concern.
Context of the InnovationUrban Health Plan is a federally qualified health center providing affordable and comprehensive primary and specialty care to underserved residents of the South Bronx. The center serves more than 31,000 patients at a number of clinical and school-based sites. The First Hour project grew out of the center's Cycle Time team work that focuses specifically on addressing what had become the number one complaint of Urban Health Plan patients: long waits. Having heard about a package of first-hour changes being tested by Dr. Frank Estrada at Elmhurst Hospital (a large urban hospital in Queens), Urban Health Plan's Institute for the Advancement of Community Health Director Debbie Lester proposed that the team adapt a similar approach for use in the center's clinics. The Institute for the Advancement of Community Health oversees, trains, and guides performance improvement teams made up of interdisciplinary staff and providers developing performance improvement and safety initiatives.
ResultsComparisons of pre- and post-implementation data, along with patient surveys and anecdotal reports, suggest that the program has reduced wait times, increased patient satisfaction, and improved patient–provider interactions.
Moderate: Evidence consists of comparisons of pre- and post-implementation data on average patient wait times, along with post-implementation patient satisfaction surveys and anecdotal reports from providers and patients.
- Shorter waits: Average wait times fell nearly 50 percent at the El Nuevo San Juan clinic, from roughly 3 hours at baseline to between 90 and 100 minutes by April 2009. At Plaza Del Castillo, average wait times have fallen from 80 minutes to between 50 and 65 minutes over the same time period. According to information provided in September 2010, Urban Health Plan spread these improvements to the Bella Vista and Plaza del Sol Health Centers in 2009, with an improvement in wait times from 88 minutes to 68 minutes.
- More satisfied patients: Patients responding to a March 2009 satisfaction survey provided overwhelmingly positive feedback on their clinic experience, reporting appreciation for the shorter wait times and for the kindness and respect shown by physicians.
- Improved patient–provider interactions: Staff anecdotally report that greater efficiency during the first hour results in a more evenly paced workload throughout the rest of the day, allowing them to work more comfortably with patients and other staff. As a result, patients feel better served and more at ease.
Planning and Development ProcessKey steps in the planning and development process included the following:
- Gathering data to support and inform project: With the help of a data analyst, the Cycle Time team mined Urban Health Plan's electronic patient and clinic data to evaluate wait times and determine the scope of the problem. They also systematically tracked patient volume, demographics, and chief medical concerns at each hour of the day to determine the characteristics and needs of their patients, particularly those coming in first thing in the morning.
- Mapping patient visits: Team members met to brainstorm the "ideal" clinic visit. Afterward, they partnered with frontline clinic staff to shadow actual patients at a number of clinic sites, clocking each patient's visit from moment of entry to exit. This process helped to determine gaps in the delivery system that lead to clinic inefficiency that did not surface from the data review.
- Obtaining staff buy-in: Representatives from each participating Urban Health Plan clinic (who were also members of the Cycle Time team) used site-specific weekly staff meetings and daily huddles to build staff support and enthusiasm for the project. Most staff members were receptive to the changes after seeing the data demonstrating the magnitude of the problem.
Resources Used and Skills Needed
- Staffing: All existing staff at the two clinics, along with members of the Cycle Time team, participated in the development and implementation of this program, with participation being a part of their regular duties. All staff continue to participate on a daily basis by following the revised operating procedures as a part of their regular jobs, with no new staff having been hired.
- Costs: No additional funding is required for this project.
Getting Started with This Innovation
- Gather data: Collect as much patient, clinic, and staffing data as possible before implementing the project, and monitor the data over a period of time. This process helps to inform and direct the project, as well as garner support.
- Tailor project to clinic, staff, and patient population: Each clinic should study its own situation (e.g., operations, staffing, patient characteristics) and then evaluate best-practice approaches to identify those that can be customized to the unique characteristics of the clinic.
- Engage staff: Because clinic staff are responsible for carrying out the project, they must support it. Support will come if staff believe they have contributed to the project's development and that they and their patients will benefit from it.
- Cultivate a culture of improvement: Generate energy and enthusiasm for improvement work by maintaining a positive teamwork approach to all changes. Keep meetings upbeat and under an hour in length, and ensure that they include all staff.
Sustaining This Innovation
- Identify and cultivate staff skills: Some staff may be better suited to checking all the examination rooms to ensure their readiness for the day. Others may be better at managing patients before providers arrive or ensuring that the clinic has sufficient supplies.
- Share credit: As successes occur, project supervisors should share the credit liberally, which gives others ownership of the process and makes long-term staff commitment to the project more likely.
- Create ways to maintain momentum: Recognize that the staff’s initial enthusiasm may fade with time. Anticipate this development by creating ways to sustain staff commitment to the project.
Contact the InnovatorDebbie Lester, LSMW
Director, Institute for the Advancement of Community Health
Urban Health Plan, Inc.
1065 Southern Boulevard
Bronx, NY 10459
Phone: (718) 589-2440 x3163
Fax: (718) 589-4793
Community Research Associate
Urban Health Plan, Inc.
1065 Southern Boulevard
Bronx, NY 10459
Phone: (718) 589-2440 x3918
Performance Improvement Coordinator
Urban Health Plan, Inc.
1065 Southern Boulevard
Bronx, NY 10459
Innovator DisclosuresMs. Lester, Ms. Salcedo, and Ms. Maldonado have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesThe Urban Health Plan Web site is available at http://www.urbanhealthplan.org/.
Anderson RT, Camacho FT, Balkrishnan R. Willing to wait?: the influence of patient wait time on satisfaction with primary care. BMC Health Serv Res. 2007;7:31. [PubMed]
Leddy KM, Kaldenberg DO, Becker BW. Timeliness in ambulatory care treatment. An examination of patient satisfaction and wait times in medical practices and outpatient test and treatment facilities. J Ambul Care Manage. 2003;26:138-49. [PubMed]
3 Urban Health Plan, Inc. Letter from CEO Web page. 2006.
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Original publication: August 19, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: November 06, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: September 20, 2011.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.