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Sharp Rees Stealy Urgent Care Centers

  • Location: San Diego, CA
  • Award: Evidence-Based Leadership Healthcare Organization of the Month
  • Awarded: June 2006

Sharp Rees-Stealy, the first medical group of its kind in San Diego, was established in 1923 on a foundation of leadership, collaboration and compassion. As the city’s original multi-specialty practice, we broke new ground and quickly set the standard for the entire region.

Sharp Rees-Stealy has 13 main clinic locations throughout San Diego County. Most offer a variety of services under one roof including laboratory, rehabilitation and radiology services, a pharmacy, an optical shop, urgent care, primary care and specialty care. The medical group employs more than 330 primary and specialty care physicians representing many areas of specialty. The group is affiliated with Sharp HealthCare, the region’s most comprehensive health-care system.

Nationally known for superior clinical practices and research, Sharp Rees-Stealy has been certified – an industry benchmark for quality of care and services – by the Accreditation Association for Ambulatory Health Care.

Sharp Rees-Stealy has five Urgent Care Centers in San Diego County. Collectively, we care for more than 10,000 patients per month and register over 120,000 visits annually. Our patients represent a diverse age group, with varied illnesses, acute and non-acute.

The success that the Sharp Rees-Stealy Urgent Care Centers have achieved in patient satisfaction and quality is a result of a solid partnership with the various operational units: care providers, administration, nursing, clerical and support services. An essential element of this partnership, and the most difficult in the initial phases, was accountability. A common failing in complex systems is for each part of the operation to point to inadequate support from another part, or the intrinsic “impossibility” of the undertaking, to explain the failure to achieve stated goals.

Our efforts were based on the concept that we were not interested in lamenting the problems; we were only interested in finding solutions. Our progress and our failures alike were measured, tracked, posted and discussed. With the help of our Studer coach, our clinics began to demonstrate that it could be done with simple, achievable techniques.

As the results began to show, the focus changed. Instead of, “how could we possibly do better with our limited resources?” the staff began to ask, “how can we do even better?” As our patients became happier, and began to freely express their appreciation for our efforts, our staff began to enjoy their work more. This unexpected and much appreciated outcome has provided significant motivation for further improvement.

In January 2005, the urgent care provider, nursing, and front desk leadership decided to partner with one another to improve the patient experience in our clinics. We recognized the need to work together as a team in order to improve patient satisfaction and our working environment. We agreed to be a united front for the rest of the providers and staff—no managing down, no we/they. We agreed to discuss our issues and concerns with candor. We agreed to absolute accountability and set up communication channels to report physician and nursing concerns in a constructive manner. We agreed to a “no excuses” culture.

During our first meeting, we identified four quality initiatives that would serve as the foundation for our efforts. They were: registration check-in times, pain assessment, pain control, and door to doctor time. We built a 90-day plan around our quality initiatives. Within the 90-day plan, we identified our quality and service goals as well as personnel or process barriers that needed to be addressed prior to implementation. Our goals were and are as follows:

  • Door to doctor time of 30 minutes Patients will be seen within 30 minutes of registration. In order to track our times, door to doctor time is tracked electronically, both collectively as an average and by individual physician.
  • Registration check-in time Since a patient’s clock starts ticking the minute they walk into the lobby, we redesigned our check-in process at several sites to allow 75 percent or more of our patients to be registered within five to 10 minutes.
  • Pain Assessment Patients will be assessed for pain upon arrival and any reports of pain will be addressed during the course of their visit.
  • Pain Control Patients with complaints of pain will have comfort measures offered and provided to them within 45 minutes of arrival.

Tools and Tactics:

The following tools and tactics were used to help achieve our service and quality goals:

  • Rounding for outcomes—rounding logs were created for leaders and charge nurses with specific questions relating to priority index items. Providers and front desk staff were also given training on rounding on patients to inform about delays and inform about treatment plans.
  • Discharge phone calls—made by nursing and provider staff and tracked for accountability.
  • Thank you cards—sent by front desk staff and nursing to our patients.
  • Key word training and implementation—all providers and staff trained on use of key words such as “informed”, “concerned”, “pain control”, and “very good care”.
  • Pain control protocol was created to allow nursing staff to provide comfort
    measures to patients prior to physician involvement.
  • We identified and tracked the following key areas on the Press Ganey survey: overall score, overall nursing, overall provider, overall patient service representative (front desk), informed about delays, staff cared about you as a person, and how well was pain controlled.
  • Data out in front—results were published system wide for staff to follow
    progress.
  • Reward and recognition—desired improvements, behaviors, and results were rewarded and recognized consistently and publicly. For example, the urgent care centers won two awards for service excellence. An award ceremony was held for staff and providers. Each urgent care received an engraved trophy and every staff member received a certificate honoring the accomplishment.
  • Accountability—based on the Studer Group principles of high, middle, and low (HML) performers, the HML process was formally rolled out at all sites. Additionally, the patient satisfaction goals were tied to a percentage of physician compensation and staff merit increases.
  • Floats, per diems, travelers, and registry staff were given the same guidelines and expectations as the permanent staff. Accountability procedures were set up with the various groups to ensure compliance with departmental goals.
  • Leadership role modeling—the urgent care leadership had to look in the mirror and ensure that they were representing the behaviors expected from providers and staff.

Results:

  • Our door to doctor time was successfully reduced at all clinics from 90 + minutes to 25 to 35 minutes. Some minor modifications were made to provider, nursing, and front desk staffing in order to facilitate success.

     

  • Registration changes which included refresher training and improved work flow processes has resulted in at least 75 percent of our patients being registered within five to 10 minutes. Outliers include patients from outside medical groups and other contracts that require prior authorization and therefore may increase registration time.

     

  • Upon arrival, 98 to 100 percent of our patients are assessed for pain.
  • Collectively we provided comfort measures to our patients with complaints of pain within 45 minutes of arrival 75 percent of the time.
  • The urgent care centers finished in the 81st percentile for Q1/06. The providers finished in the 93rd percentile for Q1/06. The nurses finished in the 87th percentile for Q1/06.
  • The urgent care centers went from the 19th percentile to the 81st percentile for overall satisfaction with visit.
  • The urgent care centers went from the 18th percentile to the 86th percentile for “How well pain was controlled.”
  • Urgent care has maintained overall satisfaction above the 75th percentile for the last three quarters.
  • 78 percent of our urgent care providers achieved patient satisfaction scores of 70th percentile or higher.
  • 66 percent of our urgent care providers achieved patient satisfaction scores of 90th percentile or higher.
  • 50 percent of our urgent care providers achieved patient satisfaction scores of 98th percentile or higher.
  • On average, the Downtown, Mira Mesa and Rancho Bernardo Urgent Care Centers are consistently ranked between the 80th and 90th percentile or greater in the following areas: provider overall, nursing overall, informed about delays, staff cared about you as a person, and how well was pain controlled.

The Sharp Rees-Stealy Urgent Care Centers have truly changed their working environment. Through the process improvements, quality initiatives, and service goals, we have created a better place to work, practice medicine, and receive care. We are continuing to focus on all of our quality and service goals and consistently track and measure outcomes in these areas.

We know we are making a difference because a statistically significant number of patients tell us that we are doing the right things. We consistently receive cards, calls, or other comments, from patients who have been long time users of the urgent care centers. They go out of their way to tell us what a difference they have noticed in the care they receive from us. The staff is more attentive, the staff cares about their pain and other needs, the providers saw them in a timely manner, and from the moment they checked in until the moment they left, they felt taken care of.

The efforts that went into creating this change and the continued efforts to sustain the gains we’ve made takes relentless pursuit of excellence, starting with the leadership team. The fact that the urgent care centers have managed to create and sustain success in five different clinics, in five different areas of San Diego is truly extraordinary and representative of the wonderful leaders, providers, and staff that are working to make it happen every day—every patient, every time.

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