Friday, March 29

It is hard to believe that it is already the end of our second week here in Cape Town. Today (Friday) is actually a holiday and we are wrapping up some loose ends at home. Our last day at the clinic was yesterday.

The last two weeks have been extremely busy, but we also had a lot of fun working with the clinic staff and exploring this beautiful city and its surroundings after work and on the weekend. We wrapped up the week at the clinic with a big presentation at the monthly staff meeting. The audience included not only the clinic staff, but also two officials from the Western Cape Department of Health. We used this opportunity to summarize once again the patient flow problems of the Retreat clinic, to discuss the progress that we made during the two weeks on-site, and to propose ways for the clinic to continue to improve.

Ryan starts off our presentation at the monthly staff meeting.

Evaluating the four process changes

As discussed in our previous posts, we had the opportunity to implement four different process changes at the end of our first week here. Our hope was that these changes would reduce wait times for both booked and unbooked patients. The pre-triage wait times of unbooked patients were particularly troublesome because of the safety concerns associated with having people wait without knowing the seriousness of their conditions. For this reason we were very interested to see if the process changes actually caused patients to be triaged faster.

We had no easy way of calculating the exact wait times of the unbooked patients since their arrival times at the clinic are not recorded in a central location. However, by counting the number of patients triaged by 8am, 9am, 10am, and so on, we were able to compare the throughput of the triage room before and after the process changes. If the throughput increased significantly, this would indicate that patients move through the system faster and wait less before being triaged. (In order for this conclusion to be valid, there always has to be a backlog of unbooked patients waiting to be triaged. Otherwise the availability of the patients becomes the limiting bottleneck. However, there was a backlog of unbooked patients every morning during our time on site.)

We found that the throughput of triage room #4 was about 43% higher during the three days during which the new processes were in place. This meant that about 19 additional patients could be triaged between 8am and 1pm without any need for additional resources. This finding was extremely encouraging both for us and for the staff at the clinic.

Furthermore, we had gathered quotes from patients who had experienced both the old (at some point in the past) and the new prepping and triage processes. While this was obviously only anecdotal evidence, the feedback from patients was overwhelmingly positive.

Finally, we emphasized during our presentation that these improvements had been achieved despite the implementation challenges that we had encountered during the past week (discussed in one of our earlier posts). We praised individual staff members who had championed the changes in all three areas (reception, triage room, and prep room). In response, the audience enthusiastically applauded these individuals and we could see that the people we called out were very happy and proud of what they had achieved. All four of us were positively surprised by the amount of enthusiasm of the staff at the meeting.

Looking forward

In addition to discussing the past progress, we also discussed additional process improvements that we thought the staff should consider implementing. This part of our presentation was basically a preview of the final report which we will be writing for the clinic. The ideas fell into three broad areas:

Improving the waiting experience of patients:

1. Play content on the available TVs in the waiting area.
2. Have medical students give health education talks to waiting patients.
3. Announce staff shortages and staff meetings to patients in order to manage their expectations.
4. Post signs in the waiting area explaining the triage process and the clinic layout.
5. Create a play area for children in the courtyard behind the pharmacy. This would cause the waiting area to become less hectic.
6. Have a help desk window staffed by a volunteer in order ease the workload handled by reception.

Addressing corridor crowding:

1. Put up signs to direct patients.
2. Relocate reception window #5 away from the security gate.
3. Have booked patients line up for prep in the waiting area after check-in (i.e., designate a special bench for these patients).
4. Purchase additional weighing machines for the triage rooms.
5. Have a direct communication link between the prep room and reception.

Improving folder management:

1. Separate folders of yellow and green patients using separate bins.
2. Have separate bins for patient folders that are returned to reception at the end of the day.
3. Walk through all rooms to collect folders at the end of the day.
4. Sort appointment list by folder number or names.
5. Prioritize tasks for today over preparation for tomorrow in the reception area.
6. Implement scanning system to replace stickers.
7. Improve folders identification (e.g. use color codes, dividers, elevated labels, more durable materials).

Many of the ideas that we discussed in this section had once again been generated by the staff themselves and we made sure to give everyone credit during our presentation. This was also important in order to get people to take ownership of the changes and to get them to push forward with the improvements after our departure.

We concluded the presentation by thanking the staff and leaving them with some general thoughts about the continuous improvement cycle. During our debriefing session later that day, we all felt that the presentation had been a great success and an excellent way to conclude the on-site portion of our project.

Looking back

Reflecting on the past two weeks, it has been an intense and incredibly rewarding experience. We all enjoyed getting to know the clinic staff and working with them throughout this time. They welcomed us with open arms and provided a level of support for our project that far exceeded our expectations. Many of them went to great lengths to help us analyze the patient flow and to implement the new processes at the clinic. We felt that they all cared deeply about their patients, and they really wanted to improve the patient experience at the clinic. Most of them participated eagerly in our brainstorming sessions and they were very open to trying new approaches at the clinic. The staff also went out of their way to get to know us during the short time on-site and many of them ended up becoming good friends.

At the end of our last day on site, the staff invited us to a good-bye party with delicious snacks in the conference room of the clinic. Thank you to all the wonderful staff of the Retreat Clinic!