When is it safe to go to the doctor again? Ask four questions

Posted on 06/29/2020 by John Toussaint

Patient Volumes have not returned to normal in most health care organizations in the U.S. One of the main reasons is people are scared to go to the doctor’s office. We might get infected from workers, other patients, even doctors. To assure it’s safe look for the following four things.

Is a drive through visit available? Everyone has heard about drive through testing; what about a drive through doctor’s visit? At the Christie clinic, a multispecialty physician clinic in Champaign Illinois, urgent care visits have been completely redesigned. As the number of COVID cases diminished at the beginning of May, non-COVID patients weren’t coming in for urgent care visits. Patients thought COVID patients might be seen in the clinic increasing their risk of contagion. Christie clinic created a process based on a “care at the curbside” idea from staff. They dedicated an urgent care clinic to COVID curbside care and started seeing patients in their cars. When symptomatic patients called their primary provider at other sites, they were directed to the COVID designated urgent care center. Providers, mostly advanced practitioners, in protective gear stood in a makeshift car port on the side of the building and not only tested suspected COVID patients but also examined them. If lab or x-rays were ordered, patients entered the clinic through a side door and donned PPE given to them by staff. No other patients were exposed because they didn’t check in at the desk and they didn’t sit in the waiting room. Patients went directly back to their car after testing to wait for results and prescriptions. By mid-May the waiting room at the urgent care clinic was empty most days despite seeing close to the same number of patients each day.
Do you have to wait more than 5 minutes for anything? If the waiting room is even half full there is a problem. In addition to urgent care, Christie runs many outpatient clinics. What they learned from the urgent care center were applied to the clinics. Doctors realized that the traditional way of checking in patients was an infection waiting to happen. At peak hours, as many as 10 people were standing in line. A team of medical assistants (MAs) and nurses had the idea to prescreen patients on the phone thereby reducing the face time in the clinic. They could easily gather information before the patient arrived at the clinic and speed the visit process. The goal was to have no one waiting anywhere. Pre-COVID, the MAs would room the patients. It took 11 minutes. With virtual rooming the day before, they reduced that time to 3 minutes. They gathered the usual information including medication reconciliation, allergies, med/surg history and chief complaint without seeing the patient. The result: 70% of the patients were prescreened. As of June 15^th, prescreening has been more difficult due to people returning to work and not being available, but still the rate has been maintained at 60%.
How many times do you have to register? Utilizing the principle of one-piece flow, patients were instructed to come only 5 minutes before their scheduled appointment unless they had ambulation issues. Pre-COVID all patients had to register first at central scheduling at Christie’s large multispecialty clinic. There are 115 physicians and 85 advanced practitioners covering 40 departments at all of the campuses. That could take several minutes waiting in line. Then they had to register again at the specific specialty office. Then they sat in the waiting room. But the Christie team that included staff from clinical serves, facilities, and business services created a new process in which there was fast check-in at the clinic, meaning no stop at central scheduling. For return patients this takes 3 minutes, for new patients about 5 minutes. The patient goes directly from registration to the exam room therefore no public waiting.
Is a video visit available? Outpatient visits moved to phone visits at Christie Clinic early in the pandemic but have now transitioned to video visits. About 20% of all visits are virtual. Video visits have had unintended positive consequences. Providers who were chronically behind in their daily schedule began to intersperse video visits with face-to-face visits. This allowed them to catch-up as the video visits were usually check-ins for follow-up, which were less intensive and could be accomplished faster than face-to-face visits. With patients arriving only 5 minutes before their appointment and doctors generally on time, patients didn’t see each other in the waiting room or anywhere else along the way. Some patients did not want to be seen in the clinic despite the above processes designed to protect them. Physicians have realized how effective video visits can be. A physician recently commented, “I can see where the patient lives, meet their cat, and have a more personal connection, I could never do that at the clinic”. Pre-COVD Christie clinic saw 2200 patients a day as of the week of June 15^th they were at 2000 +per day and increasing.

There are some important lessons from the Christie experience that are applicable to all providers anywhere. Flow management is one. Flow was at the center of the work in curbside care, registration, virtual pre-visit, and even video visits. Whether patients were driving up in cars or arriving immediately before their scheduled appointment, flow was the key to not being exposed to patients who might be sick. Improved flow required doctors to change. Standing in car ports waiting for patients and in car examinations is not usual physician practice and seeing patients on a video screen isn’t either. They kept constant focus on reducing wait times. Every improvement reduced or eliminated waiting and therefore, reduced contagion opportunities. At the same time overproduction was reduced. Single registration is a great example of eliminating nonvalue added steps in a process. Leaders and clinicians applied the fundamental principle of customer value and embraced radical redesign ideas over incremental change. The change in thinking led to the remarkable work at Christie Clinic. The work is fluid, however. Changes in the financing of care allowed Christie to innovate. Medicare early in the pandemic began reimbursing video outpatient clinic visits at the same rate as face to face. Most commercial insurers followed suit. This has allowed for the continuation and potential growth of video visits. Some clinics in Northern California are reporting as many as 40% of visits are now virtual. But will this financing be continued? The innovations at Christie are facing other barriers. As the temperatures have risen this summer, providers are complaining about standing outside in the overheated car port. Winter will be a different challenge. But front-line design teams are well versed in applying PDSA cycles to improve the standard while capturing new staff ideas. In this time of crisis every new idea may have a chance to be tested and our old thinking about care delivery forgotten so we can create better and safer ways and follow the lead of Christie clinic.

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