From the 2024 HVPA National Conference
Lauren Oshman, Postgraduate (University of Michigan), Firdesina Dervishi, Undergraduate, Jessica Burns, Undergraduate, Devon Kinney, Undergraduate, John Holkeboer, Undergraduate, Anthony Cuttitta, Graduate
Background:
Historically, ambulatory practices have relied on a uniform medical assistant (MA)-driven rooming protocol to obtain relevant information and vital signs from patients. The approach functioned well in the past, but in the resource-limited setting of MA workforce shortages, comprehensive standard protocols are not always feasible. This is further complicated by novel telehealth care models which do not include the MA rooming process at all. Despite the clear need to optimize rooming processes, little is known about which rooming tasks are high value, could be completed by the patient through electronic check-in, or could be de-implemented.
Objective:
The aim of this study is to A) better understand current patient rooming practices and perspectives (qualitative interviews & observation), and B) test the feasibility and acceptability of a patient-led rooming protocol in which high-value rooming tasks are performed by the patient and confirmed by the clinician (pilot intervention).
Methods:
A-Qualitative interviews & observation/MA shadowing: Key academic medical center stakeholders were recruited for interviews to learn their perspectives regarding current rooming practices, which tasks were high and low value, and barriers to improvement. Observational MA shadowing was then completed at one specific site to observe use of the standard rooming workflow.
B-Pilot intervention:
Interviews and observational learnings informed pilot design. Patients completed all elements of the system’s e-check-in process. The physician escorted each patient from the waiting room to the exam room, confirmed e-check-in data, and performed a total of ten candidate high-value rooming tasks including chief complaint, verification of medications, pharmacy and allergies, refill management, reconciliation of outside medications and immunizations, verification of tobacco use, alert management, and obtaining vital signs if relevant to the visit. An MA was available to perform immunizations and point-of-care tests if needed, during or after the visit.
Results:
A-Qualitative interviews & observation/MA shadowing: 12 key stakeholders were interviewed. Common themes included the following: There was an MA workforce shortage (understaffing, high turnover), rooming practices rarely follow the protocol because of time limitations, there are low-value inconsistencies across clinics, and high-value tasks include patient vitals and medication reconciliation. Observational MA shadowing of the rooming for 10 patients confirmed inconsistencies described in interviews, with only eight of 25 rooming workflow elements being completed the majority of the time.
B-Pilot intervention:
18 patients received the intervention between February and April 2024. The average rooming time was 5 minutes (range 51 seconds to 11 minutes). Reviewing medications (61 s) and obtaining vital signs (71 s) were the most time intensive and confirming pharmacy (6 s) and immunizations (11 s) were the least time intensive. Almost all patients were satisfied with the pilot (94%). Qualitatively, patients enjoyed the “stronger relationship” and “extra time” with their physician but preferred “waiting in the exam room” to the waiting room.
Conclusion:
Current rooming practices are onerous, include low-value tasks, and do not optimize the patient rooming process. A pilot intervention prioritized activities and showed very high patient satisfaction. To accommodate the time required without MA support in this PDSA cycle, patient throughput would decrease by 1-2 patients per day. Additional PDSA cycles are needed to refine this pilot.
Clinical Implications:
The pilot intervention improved the patient experience. Optimizing patient rooming also has potential to improve quality and safety by prioritizing high-value tasks in a very resource-limited practice environment.