Knowledge Expansion Embedding a walk-in clinic into an internal medicine practice Insight Article Patient Flow Patient Access Practice Efficiency Sign in to save Michelle Corn MBA, CMPE Michael McNeal MD, MSc, FACP “No appointment needed” is something the Division of Internal Medicine at Baylor Scott & White Health in Temple, Texas, can now advertise. In early 2018, the division began exploring how to implement a walk-in clinic to improve patient access and convenience. After extensive discussion, the division launched a pilot to assess the demand for and delivery of care without a pre-booked appointment. The pilot began with limited walk-in access on Saturdays but quickly grew to six days a week. Key facts The walk-in clinic, at the Center for Diagnostic Medicine (CDM), is available for single-problem visits, such as cold, flu, allergies, gastrointestinal issues and medication refills. The clinic accepts adult patients, regardless of whether they have a primary care physician (PCP) within the division of internal medicine. The walk-in clinic is open 8 a.m. to 8 p.m. Monday through Thursday and 8 a.m. to 3 p.m. Friday and Saturday. Due to patients’ overwhelmingly positive response to the pilot, the division permanently adopted the walk-in clinic in April 2018. Since inception, the division has continually worked to enhance walk-in operations and quality, starting with effective team communication. Effective team communication was integral to ensuring sustained success of the walk-in clinic. Shortly after the clinic launched, leadership implemented weekly walk-in huddles. The huddles are short, 15- to 30-minute meetings that bring together a variety of stakeholders, including the medical director, operations director, advanced practice professional (APP) manager, nursing manager and other clinic leaders and staff. The huddles serve as a forum to discuss the prior week’s performance, review the upcoming week’s staffing and expectations, bring to light any issues or barriers, and solve problems. The weekly huddles spurred communication enhancements, including an agreement to transition the walk-in coverage schedule to a shared Outlook calendar. The calendar displays provider schedules for the walk-in clinic each day. This real-time tool replaced printed schedules, which would often become outdated due to providers calling in sick or switching shifts. The huddles also sparked the creation of a walk-in chat group using system software. The chat group includes all walk-in providers, nursing staff, check-in staff and clinic leadership. The team uses the chat group daily to discuss patient volumes, provider availability and staff schedules, as well as to bring up minor questions or concerns. Beyond fostering better internal communication, the weekly huddles also were the basis for externally facing process improvements. As word of the newly implemented walk-in clinic spread, patient volumes steadily grew. The increasing volumes prompted long lines and delays at check-in for both scheduled and unscheduled patients, since the clinics are co-located. In response, practice leadership investigated ways to improve walk-in patient flow without compromising scheduled clinic operations. Ultimately, the clinic converted one of its six check-in stations to serve as a dedicated walk-in window. A combination of signage and staff facilitation supported patient navigation and wayfinding to the appropriate area. This change allowed for the arrival of walk-in patients on a first-come, first-served basis without impeding the timely check-in of scheduled patients. When check-in personnel at any of the other five stations are not with a scheduled patient, they assist with walk-in patient arrival, as needed. In addition to optimizing patient flow, the division identified an opportunity around wait times. Clinic leadership routinely reviewed patient satisfaction survey results for insight on what was working well and what needed improvement. The surveys included recurring requests for better transparency about wait times. Check-in personnel amplified this theme, as they often reported that walk-in patients would frequently return to the front desk seeking updates about where they were in line and how much longer they had to wait. The clinic acted upon this feedback by installing a digital status board in July 2019. The status board is a monitor in the lobby that displays information from the EHR in real-time. Because the board does not include patient identifiers, there are no concerns with disclosing protected health information (PHI) or potentially violating HIPAA. The clinic developed an informational handout for each walk-in patient upon arrival. The handout includes a section for front desk staff to fill in the patient’s check-in time. Patients can then reference their check-in time against the status board to see where they are in line and how long they and others have been waiting. Once a patient is assigned a provider, his or her name is taken off the status board. The idea for the walk-in clinic status board was adapted from surgical and procedural areas, where they are common. Although the status board improved wait-time transparency, there was also a desire to improve the waiting experience itself. The clinic installed a wall-mounted charging station that includes a variety of cables compatible with most smart devices. Patients can plug in if they need to recharge their device while they wait. This allows patients to stay connected both in the clinic and throughout their day. The station is visible throughout the lobby, so users can keep an eye on their device from where they wait. The charging station did not mitigate efforts to reduce delays, but prolonged waits were sometimes inevitable, especially during peak times, making waiting room comfort a necessity. The walk-in clinic, by the numbers As the walk-in clinic evolved, so did data collection and monitoring. Initially, the division scheduled walk-in appointments as office visits. Because this was the same appointment type used for scheduled patient visits, the division did not have good visibility of walk-in metrics through December 2018. The division resolved this issue in January 2019 with the adoption of a distinct walk-in visit type. This change provided the ability to assess metrics that gave the division a deeper understanding of the walk-in patient demographic and behavior. For example, data analysis revealed: Mondays are the busiest day in absolute volume. Saturdays are busiest when adjusting for daily operating hours. Peak utilization occurs first thing in the morning, with 18% of patients arriving before or during the first hour of operation. The data also revealed that the majority of walk-in patients are females ages 66 to 75, and the chief visit complaint was cough. These and other measures have helped inform several strategic and operational decisions. Changes were also made to the CAHPS Clinician & Group Survey (CG-CAHPS) reporting logic. In June 2019, the clinic acquired the ability to separate walk-in visit performance from scheduled visit performance following a decision to administer a different survey type that removed certain questions that did not pertain to walk-in visits. Prior to this change, leadership lacked clarity on quantitative outcomes and relied heavily on free-text survey comments to prompt patient experience enhancements. Now, the clinic has quick and easy access to more meaningful survey intelligence. The data reveal that although walk-in scores have generally been below scheduled visit scores, performance is improving. This progress is arguably due to the aforementioned enhancements, among several other tactics. Patient survey responses will continue to be a key measure to evaluate the care experience, and the clarified outcomes will help focus clinic effort and resources. There are several types and sources of data in healthcare that help determine the quality and effect of services provided. Because the walk-in clinic is less than two miles from the nearest emergency medical center, the division naturally hoped the walk-in clinic would reduce unnecessary emergency department utilization. The Baylor Scott & White Quality Alliance (BSWQA) is the accountable care organization (ACO) affiliated with Baylor Scott & White Health. The BSWQA evaluated ED utilization data for BSWQA members from May 2017 to April 2018 (prior to and just as the walk-in clinic was fully implemented) and May 2018 to April 2019 (after walk-in clinic implementation). The data compares BSWQA members with a walk-in visit at the Center for Diagnostic Medicine (CDM) to those with a visit at all practices in the Temple, Texas, region. The data showed that ED utilization per 1,000 (ED/1,000) visits increased 13.3% for all practices, but the CDM only increased 6.2%. In addition, avoidable ED/1,000 visits increased 6% for all practices, but the CDM fell 4.2%, suggesting increased appropriateness in ED utilization. It is difficult to determine whether changes in ED utilization are causation or correlation to implementation of the walk-in clinic, but the numbers encourage continued advancement of clinic operations. Embedding a walk-in clinic into a busy internal medicine practice is a significant undertaking. Even with proper planning and communication, issues will arise but they will provide opportunities to learn, grow and improve. Success requires an engaged team, frequent and clear communication and continuous performance evaluation and development. The CDM walk-in clinic has undergone a substantial transformation and will continue to evolve so that it remains a staple of high-quality, convenient care within the practice and community.