Running head: QUALITY IMPROVEMENT PROJECT !

Quality Improvement Project

Caroline Kissam

Bon Secours Memorial College of Nursing

Quality and Safety in Nursing Practice

NUR 3241

Dr. Rani Sangha, DNP, MBA, RN

April 19, 2020

“I pledge…”
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Quality Improvement Project

Identify the Problem

The recent development of the COVID 19 pandemic has brought about the need for quick

implementation of telehealth, which our institution has not utilized in the clinic setting. This

emergency implementation has lead to a lot of frustration for the patients and the physicians.

Physicians find that patients have no understanding of how to do a telehealth visit so they spend

most of the allotted visit time helping the patient problem solve the technology instead of

assessing their health concerns. The patients feel frustrated because they cannot figure out how

to use the technology and feel like they haven’t received a thorough exam because they are used

to an in person office visit.

Contributing Factors

Most of our patients in the clinic are elderly and a large percentage of those patients do

not have the technology required to do a telehealth visit. Of those that do have the

technology many do not have a good understanding of the applications used for a telehealth

visits. This knowledge deficit leads to great frustration for patients and physicians. Another

issue that complicates telehealth visits in our clinic is that the schedulers do not anticipate the

problems patients may have and try to mitigate them before they occur. Therefore, many of the

telehealth visits result in frustration for the physician due to decreased ability to assess the

patient’s problems because they cannot see them and because visits take longer than the allotted

time to complete. As mentioned above, the patients also feel frustration over the visit because

they don’t understand how to use the technology and they don’t feel like they get the personal

interaction that they would with an in person visit.

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Plan and Do

The keys to a successful telehealth visit is twofold. 1) The schedulers need to assess the

patient’s ability to do a telehealth visit as well as their understanding of the technology and the

process. 2) The schedulers need to be able to educate the patient on how to use the applications

and how the visit process well go.

Initially when we began implementing telehealth we didn’t really consider the challenges

people would have doing these types of visits. The schedulers were given a physician schedule

and were told to call the patients and change them from an in office visit to a telemedicine visit.

The first day of telehealth visits did not go well. Physicians spent most of their time trying to

help themselves and their patients problem solve the technology. Most of the visits ended up

being a simple phone call because the patients could not figure out the technology.

Because telehealth was being implemented so quickly all over the state there was really

no example to pull from. The only specialty in our hospital system that utilized telehealth was

neurology for emergency assessment of stroke patients and this was initiated by the ER staff and

not by the patients themselves. In other words there was not example available for us to follow.

We were just blazing our own trail in an attempt to still provide safe patient care in the midst of

the COVID 19 pandemic.

At the end of day one of the telehealth implementation we acknowledged that the

outcome was not very desirable so we discussed what we could do to improve the process. The

discussion involved our lead physician, our management team and our lead scheduler. Our

observations were that the schedulers didn’t anticipate the potential problems. We agreed that

the schedulers needed to be given instructions regarding what to say and even educated on the
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problems encountered on day one of telehealth visits. Our discussion lead to the idea that we

needed a checklist for the schedulers to follow when making the telehealth visits. The check list

was a series of questions: 1) Are you willing to do a telehealth visit instead of an in person

visit? 2) Do you have a smart phone or tablet with video capability? 3) Have you activated your

MyChart account (MyChart being the application we use for telehealth visits)? 3) Have you

installed the MyChart app on your phone and/or tablet? If the patient was not able to

use MyChart for some reason the alternative was a Doxy.Me visit which required a smart phone

with a camera. The patients would receive a text from the physician with a link that allowed the

patients to connect with the physician simply by clicking on the link, typing in their name and

hitting the submit button. Doxy.Me was the least desirable method from the practice billing side

but it was an alternative that was better than a simple phone call which was utilized only as a last

resort. After going through the list of questions and determine that the patient indeed had the

ability to do a telehealth visit the scheduler was given instructions to give to the patient on how

to initiate the visit.

At the end of day two, which was day one of the patients that had been scheduled

utilizing the check list the physician reported much better success with the telehealth visits.

They reported that 50% of their visits went much better but, they still had visits that ended in a

phone call because the patient couldn’t figure out the technology. The team met again

and decided that we would make a second call to the patient to remind them of the visit date/time

and also confirm that they were able to use the MyChart app. Again we utilized a checklist with

the following questions: 1) Your appointment time is on this day at this time. Have you

downloaded the MyChart application and logged in to your account? 2) Did you see the
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telehealth visit on your visit schedule? 3) Did you click on the visit and run the test for

compatibility and was it successful? If the patient answered yes to all the questions we would

put a notation in the visit that MyChart app was confirmed so the physician could be assured that

we assessed their ability to do the visit and that to the best of our knowledge the patient knew

how to do the visit. If we could not confirm the use of MyChart we would instruct the patient on

Doxy.Me and indicate on the schedule that Doxy should be used to contact the patient. If it was

determined that neither video application could be used we would indicate that the patient

couldn’t use the video application and that the patient should be contacted by phone only.

At the end of day three when we used the confirmation phone call the physicians reported

that the success rate increased by approximately 25% and that the patients expressed their

appreciation of the staff going the extra mile to ensure that they knew how to do the telehealth

visit. Both the schedulers and physician reported this type of patient feedback and elaborated

that the patients expressed the understanding of the need to utilize telehealth during the pandemic

and that they appreciated the extra help preparing for the visit. Still at the end of day three there

were still patient visits that ended being done by a phone call only as the technology failed for

unanticipated reasons such as poor cell phone reception or a technical problem with the

application. All in all, we considered the process a success.

Timeline for the Proposal

Unfortunately due to the circumstances our timeline for implementation of the proposal

was very quick. We were given a days notice to begin changing visits to telehealth. This order

was issued on a Friday and we were instructed to do the best we could to have all visits changed

to telehealth within one week. We started that day with the appointments on the following
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Monday and worked our way through the week. Some routine follow up visits were moved out

to a later date but visits that needed to occur on the date they were originally scheduled were

changed to telehealth. We moved quickly and were able to get to some of Tuesdays visits by the

day’s end. On Monday we started working on the rest of Tuesday’s schedule and with mass

participation from staff the we pulled from other areas we were able to get through the rest of the

week by Wednesday. This was a huge effort. We are a large cardiology group and on any given

day we see 240-360 patients.

Test of Change and What Changes Will Result In Improvement

Change was tested mainly by physician feedback and patient feedback that is

communicated to the physician. Because we are on such short timeline of 1 week and we

had limited staff we did not survey patients. At the end of each day we had a round table

discussion with physicians, managers and schedulers to discuss the outcome and what changes

needed to be made. Physicians provided feedback on the number of visits they were able to

complete by telehealth successfully. Improvement was measured the positive feed back from the

physicians that visits went smoothly and by the increase in the number of telehealth visits

completed successfully in the amount of time allotted. Changes were made to create

improvement based on the roundtable assessment of physician feedback.

How Will We Know That Change Is An Improvement

We knew that change was an improvement based on the positive feedback from patients

and physicians that were able to use the telehealth method without difficulty, that the visit was

completed in the allotted visit time, and an increase in the number of successful telehealth visits

done in a day. 

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References

Davis, S. M., Jones, A., Jaynes, M. E., Woodrum, K. N., Canaday, M., Allen, L., & Mallow, J. A.

(2020). Designing a multifaceted telehealth intervention for a rural population using a

model for developing complex interventions in nursing. BMC Nursing, 19(9), 1-9. http://

dx.doi.org/10.1186/s12912-020-0400-9

Morrison, C. (2019). Technology isn't enough: Co-designing patient centered telehealth.

Retrieved from https://www.ihi.org/communities/blogs/technology-isnt-enough-co-

designing-patient-centered-telehealth

Sundstrom, B., DeMaria, A. L., Ferrara, M., Smith, E., & McInnis, S. (2020). "People are

struggling in this area:"a qualitative study of women's perspectives of telehealth in rural

South Carolina. Women & Health, 60, 352-365. http://dx.doi.org/

10.1080/03630242.2019.1643814

What is the plan-do-check-act (PDCA) cycle? (2020). Retrieved from https://asq.org/quality-

resources/pdca-cycle
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Appendix:

Fishbone diagram

People: Elderly patients without Process: Schedulers are calling to

access to technology o no
knowledge of technology and
schedulers that do not consider
patient’s potential challenges
Materials: Patients lack
technology, schedulers lack a
checklist of questions to ask
patient
Equipment: Lack of
ask patients to change
technology, no experience with
appointments from office visits to
technology, no knowledge of Problem: COVID 19
telehealth but are not assessing
technology pandemic created a
their ability to do a telehealth visit
need for patient visits
to be done via
telehealth. We have
not done this before
so patients and
physicians are
struggling to use the
technology
Management: No management successfully.
oversight, no specific
Environment: Virtual visit space
instructions for schedulers to
follow

Timeline:

Friday Monday Tuesday Wednesday Friday

3/20/20 3/23/20 3/24/20 3/25/20 3/27/20
Received order Telehealth visits Day 2 of Day 3 of Day 5 of
to change all begin. Telehealth Telehealth Telehealth
visits to First evaluation visits. Second visits. Third visits. All visits
telehealth visits of visits. Evaluation of evaluation of are not
Created visits. Decision visits. Marked telehealth.
checklist for to make second improvement of Physicians and
schedulers. phone call to visit success. patients report
confirm better success
MyChart app. with telehealth.