SummaryHeartland Regional Medical Center operates a walk-in "Quick Clinic" that serves employees, physicians, spouses, and dependents covered by the medical center's health plan. The clinic, staffed by a part-time nurse practitioner, provides low-cost and accessible treatment for minor acute conditions, such as common respiratory, head/ear/eye, skin, digestive, and urinary problems. The clinic also serves as a place for the medical center to test innovations related to administration and care delivery. The clinic has been a significant contributor to recent reductions in employee absenteeism, has proved to be quite popular with employees and other users, has yielded modest cost savings for the system's health plan, and has made more primary care appointments available to other community members.Moderate: The evidence consists of recent trends in employee absenteeism due to minor illnesses and cost savings to the organization, along with post-implementation data on patient volume, satisfaction, and number of available primary care appointments.
Developing OrganizationsHeartland Health; Heartland Regional Medical Center
Date First Implemented2008
Problem AddressedAbsenteeism among health care workers can negatively affect employee morale and the continuity, quality, and costs of care.1 Although many factors contribute to such absenteeism, personal illness remains the most common cause.2 Those with minor illnesses are more likely to miss work if they have difficulty accessing primary care.
- Difficulty accessing primary care: Employees at Heartland Regional Medical Center who developed minor conditions complained about difficulty in accessing their primary care physician (PCP) on an unscheduled (walk-in) basis. A department within the medical center offered preemployment screenings, tests, and vaccines, along with ongoing surveillance and screening for occupational risks and exposures, but did not provide treatment for illnesses and injuries not related to the job.
- Leading to absenteeism: Employees who could not quickly access primary care reported missing work for a day or two while awaiting an appointment. Even those who could get an appointment—or who chose to access a high-cost setting such as an urgent care clinic or the emergency department (ED)—often missed several hours or even a full day of work. As a result, the medical center experienced a meaningful number of employee absences due to conditions related to respiratory, gastrointestinal, dermatological, and other minor acute conditions.
- Disruption to workflow: Medical center leaders found that partial day absences for minor acute conditions affected the productivity of employees and disrupted the workflow within affected departments and units, sometimes creating additional work for other staff and leading to more overtime hours. Additionally, employees did not want to use their paid time off for minor illnesses that necessitated a visit to a health care provider but did not prohibit them from continuing to work.
Description of the Innovative ActivityHeartland Regional Medical Center operates a walk-in "Quick Clinic" that serves employees, physicians, spouses, and dependents aged 18 years and older who are covered by the medical center's health plan. The clinic, staffed by a part-time nurse practitioner, provides low-cost and accessible treatment for minor acute conditions, such as common respiratory, head/ear/eye, skin, digestive, and urinary problems. The clinic also serves as a place for the medical center to test administrative and care delivery innovations. Key elements of the program include the following:
- Focused on treating minor, acute conditions: The clinic focuses on treating minor, acute, self-limiting conditions, such as common respiratory, head/ear/eye, skin, digestive, and urinary problems. The nurse practitioner uses rapid screening tools for the diagnosis of conditions such as influenza, mononucleosis, strep throat, blood sugar, and pregnancy. From 2009 to 2010, the clinic also offered H1N1 influenza vaccination. The clinic does not provide routine physicals or well-care, manage chronic conditions, or provide emergent care (e.g., to treat chest pain, sprains, lacerations that might require suturing) or care that might require diagnostic or ancillary tests (other than the rapid screening tests noted earlier). For any patient who needs medications, the nurse practitioner can electronically fax a prescription to the pharmacy of the patient's choice, including several that offer delivery service to the medical center.
- Convenient location and hours to maximize accessibility: The clinic operates out of a building adjacent to the medical center to allow for easy, walkable access for employees. The building also has convenient off-street parking for off-campus employees. The clinic facility has a small waiting room, office, and one examination room, located next to the medical center's Employee Health Services Department. Staffed by a nurse practitioner, the clinic operates Monday through Thursday mornings from 8:30 a.m. to 11:30 a.m. The average visit takes approximately 18 minutes, with patient served on a walk-in basis only.
- Promotion of clinic to employees: Employees learn about the clinic through the hospital's weekly newspaper, on the internal closed-circuit video channel, and on the hospital intranet's employee opinion page, which regularly receives anonymous comments from satisfied employees/customers, further boosting awareness among employees. In fact, word-of-mouth advertising among employees has been the best and most widespread form of marketing, with many customers commenting that a coworker suggested the visit.
- No copayment: Initially, covered employees, spouses, and dependents paid a $10 copayment per visit, deducted from the employee's paycheck. However, information provided in December 2011 indicates that the copayment was eliminated, since collecting and processing the copayments was non-value-added work; this step has further increased the clinic's popularity.
- Physician oversight of nurse practitioner: A primary care physician from Heartland Clinic (a 107-physician group practice affiliated with the medical center) regularly reviews Quick Clinic patient charts and provides general oversight of the nurse practitioner. (This same physician provides oversight at the local university student health center where the nurse practitioner works in the afternoon.) The nurse practitioner can contact the physician for a consult and/or advice at any time by telephone. As a credentialed provider of Heartland Clinic, the nurse practitioner is periodically reviewed according to established procedures of Heartland Regional Medical Center.
- Documentation in electronic medical record (EMR): Heartland maintains a comprehensive EMR for all consults, laboratory work, radiology services, and visits to the medical center, outpatient clinics, and ancillary service providers. To facilitate documentation of a visit to the Quick Clinic, a registration and clinical documentation module within the EMR allows the nurse practitioner to quickly create and document a patient encounter using scripts and pulldown lists; additional modules that outline the clinical pathways for common reasons for visits also aid in documentation. These modules were added to the EMR specifically for the Quick Clinic, thus allowing clinic visits to be documented in the same manner as any other encounter, which, in turn, permits physicians and other providers to view details and outcomes related to the visit in the EMR.
- A venue to test innovations: The clinic also serves as a "quasi" operational testing center, allowing the medical center to test administrative and care delivery innovations in a setting that minimizes disruption to caregivers and patients. For example, to provide services to community members looking for a cost-effective, convenient, and accessible source of care for minor acute conditions, Heartland Regional Medical Center opened a Heartland Clinic in a local Walmart using the "template" for the Quick Clinic. Going forward, the clinic may pilot test a Web-based portal with administrative features (e.g., preregistration templates, systems to capture demographic updates, payment management functions) that could be adopted by Heartland-affiliated primary care practices.
References/Related ArticlesNational Institute of Standards and Technology. Baldrige National Quality Program. 2009 Press Release. Health Care: Heartland Health. Available at: http://www.nist.gov/baldrige/award_recipients/heartland_profile.cfm
Contact the InnovatorDavid McDonald, RN, BSN, COHN-S, FABC
Director, Employee Health Services
Heartland Regional Medical Center
St. Joseph, MO 64506
Innovator DisclosuresMr. McDonald has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.
ResultsThe clinic has been a significant contributor to recent reductions in employee absenteeism, has proved to be quite popular with employees and other users, has yielded modest cost savings for the system's health plan, and has made more PCP appointments available to other community members.
Moderate: The evidence consists of recent trends in employee absenteeism due to minor illnesses and cost savings to the organization, along with post-implementation data on patient volume, satisfaction, and number of available primary care appointments.
- Major contributing factor in reducing minor illness-related absenteeism: The number of employees who took paid time off for illness decreased by 40 percent between fiscal year 2008 (before the clinic's opening) and fiscal year 2010, even with growth in the number of medical center employees and dependents. Although the specific reasons for this recent decline cannot precisely be determined, medical center leaders believe the clinic has been a significant contributing factor. Anecdotal reports from patients confirm this view, as many have noted on feedback forms that the clinic's easily accessible location and quick service has allowed them to avoid or shorten intraday and short-term absences.
- Quite popular with employees, other users: Clinic visits have increased by 70 percent since the clinic's opening, from an average of 50 per month initially to over 100 patients per month by mid-2012. Patient satisfaction scores have averaged 4.9 out of 5 on a survey that evaluates quality, timeliness, access, and cost of care.
- Modest cost savings: The per-visit cost of providing care in the Quick Clinic is 63 percent less than the per-visit fee that Heartland's self-insured plan would pay for care in a PCP's office, thus generating cost savings for Heartland Health as a whole.
- More PCP appointments available for community members: Since the Quick Clinic began providing simple treatment for minor employee and family illnesses, more than 1,000 appointments with PCPs have opened up for community members, allowing Heartland to work closer to its core competency of improving individual health in its community.
Context of the InnovationHeartland Regional Medical Center is a 352-bed hospital serving a 21-county area in Northwest Missouri, northeast Kansas, southwestern Iowa, and southeastern Nebraska. Each year, the medical center handles 20,000 inpatient admissions, 200,000 outpatient visits, and 50,000 ED visits. The medical center is part of Heartland Health, an integrated delivery system that also includes Heartland Clinic—a multidisciplinary independent practice association, Community Health Improvement Solutions, and Heartland Foundation. Heartland Health has 3,300 employees and a medical staff of 301 physicians and dentists, the vast majority of whom are covered by the system's self-insured health plan. Heartland Health received a 2009 Malcolm Baldrige National Quality Award.
In 2008, Heartland Health leaders decided to move a large, well-established Heartland Clinic primary care practice from its location within the medical center to an outlying, growing area so as to better serve that community. Leaders became concerned, however, that the move would inconvenience medical center employees, many of whom sought care at this practice. The idea of creating a Quick Clinic within the medical center was stimulated by this relocation, along with anecdotal employee reports of difficulties in accessing primary care quickly and the adoption of a new, more flexible employee benefit structure that created incentives to avoid unnecessary time off.
Planning and Development ProcessKey steps in the planning and development process included the following:
- Creating evaluation team: Hospital leaders created a multidisciplinary team, led by the head of Employee Health Services, to evaluate the implications of the primary care practice relocation for employee access to health care. The team included individuals from across the organization, including representation from Employee Health Services, Heartland Clinic, operations (including decision support, technology, EMR, and maintenance/support services), and human resources. The team followed the Heartland-developed, five-step, problem-solving methodology called PASTE (problem-analysis-solution-transition-evaluation), which led to the idea of creating the clinic.
- Analyzing reasons for visits: The team analyzed the most common reasons that employees and dependents visit primary care providers, which led to the creation of a list of minor acute conditions to be treated in the Quick Clinic.
- Selecting and renovating space: The team selected a small vacant space adjacent to the Employee Health Services department to house the clinic. The space required a small amount of renovation and furnishing; carpeting, painting, computer setup facilities, and furniture were already available due to the aforementioned primary care practice move.
- Selecting nurse practitioner: The team posted the half-time nurse practitioner position and hired someone already working half-time in the student health services department at the nearby university.
- Deciding on funding mechanism: Initially, to keep overhead costs down and pass the savings to employees, Heartland's Technology Services department created a simple and innovative billing system that allowed Quick Clinic copayments to be handled as a payroll deduction. This paperless, electronic system was designed to prevent cash billing errors, simplify the billing process, reduce waste, and lower the costs of supplies. It also eliminated the need for an access representative, made documentation of visits easy, and allowed the nurse practitioner to spend more time with patients. Information provided in December 2011 indicates that, now that copayments have been eliminated, this mechanism is no longer used.
- Modifying and using patient satisfaction forms: The director of Employee Health Services worked with the medical center's market research staff to modify the Press Ganey customer satisfaction surveys used at Heartland's urgent care and primary care practices for use in the Quick Clinic. The clinic began surveying customers soon after opening to gauge patient satisfaction and to elicit suggestions and requests.
- Expanding client base: The clinic initially offered services only to physicians and hospital employees who have health insurance coverage under Heartland's health plan. Based on client requests, the clinic began serving covered spouses (a few months later) and dependents aged 18 years and older (8 months after opening). In June 2010, program developers submitted a request to the medical center's Board of Trustees to open the clinic to dependents aged 12 years and older, and to any employee or family member (i.e., even those not covered by Heartland's health plan).
Resources Used and Skills Needed
- Staffing: The program requires a half-time nurse practitioner.
- Costs: Upfront costs ran approximately $600 for renovations. Data on ongoing operating costs are not available, but they consist primarily of compensation for the half-time nurse practitioner and the physician providing clinic oversight. The clinic generates enough funding from reduced insurance payments to cover operating expenses and even operates at a profit.
Funding SourcesHeartland Health; Heartland Regional Medical Center
Getting Started with This Innovation
- Include frontline staff on development team: As with all its quality improvement programs, Heartland Regional Medical Center engaged frontline staff in providing ideas and suggestions related to the clinic's development and ongoing evaluation. For example, operations staff serve as part of the evaluation team.
- Highlight clinic services whenever possible: In addition to the traditional ways of sharing information about the Quick Clinic (e.g., through the employee intranet), the director of Employee Health Services presented a storyboard at the medical center's "Quality Week celebration" that highlighted the clinic and how it fits into medical center strategies. With the entire organization participating in this event, representatives from multiple entities, service lines, and support areas learned about the clinic and other process improvements and innovations.
- Focus on potential benefits, not pitfalls: Creation of this type of clinic involves several risks, including the potential for disruptions to usual care, employee reluctance to embrace the concept, and inefficiencies. Program leaders did not let these potential problems prevent them from testing the clinic model. Instead, they focused on the potential benefits of the approach, including reducing the burden on busy community-based PCPs, enhancing access to care, and improving satisfaction by responding to employee requests for better access to primary care.
Sustaining This Innovation
- Engage customers regularly to obtain feedback and comments: Use customer satisfaction surveys and other mechanisms to ensure that the "voice of the customer" can be incorporated into clinic enhancements. At Heartland, client feedback directly led to decisions to expand services to other populations (e.g., spouses, dependents).
- Collect and analyze data: Ongoing data analysis helps detect emerging trends or issues related to clinic use, thereby informing potential opportunities for improvement.
- Leverage "word-of-mouth" advertising: Although formal advertising strategies can be important, providing excellent service will encourage customers to tout the clinic's benefits to others, which can be a very powerful way to generate new clients.
1 Harter TW. Minimizing Absenteeism in the Workplace: Strategies for Nurse Managers. Nursing Economics. March 2001. Available at: http://findarticles.com/p/articles/mi_m0FSW/is_2_19/ai_n18611768
Aldana SG, Pronk NP. Health promotion programs, modifiable health risks and employee absenteeism. J Occup Environ Med 2001;43(1):36-46. [PubMed]
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Service Delivery Innovation Profile
Original publication: December 08, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: January 09, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: December 10, 2012.
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.