Defining Ambulatory Care Intake Requirements

In a recent visit from The Joint Commission, it was evident that there was not a clearly defined minimum expectation for documentation of clinic intake in ambulatory care spaces across our institution, which conducts over 3 million outpatient visits yearly (including pediatrics and regional facilities). Before our change, different specialty areas prioritized different clinic intake elements for their patient populations, and there was even variation between staff members in the same department. This resulted in an inconsistent experience for our patients and confusion for our staff and providers. To address this issue, nursing informatics services worked closely with quality and safety, as well as nursing and provider executive leaders to define minimum standards and develop a tool for all ambulatory care spaces to help guide staff through those questions that formed the minimum standards. In doing so, we helped ensure a consistent experience across all ambulatory care areas for our patients, families, staff, and clinicians. Our change also helped ensure regulatory compliance and enhanced the safety and efficacy of clinic intake.

Using a PDSA (plan-do-study-act) cycle, nursing informatics services worked with the eStar ambulatory care analyst team to develop a “checklist” that displays in the intake activity within eStar. It displays the organizational minimum requirements, and once a staff member addresses that item at the correct interval – for example, an annual item addressed within the last 365 days – it is checked off the list. This also helped reduce the number of questions asked to patients by crossing encounter departments. For example, if you had been asked in primary care about your advanced directive last month, you would not be asked again in ENT today.

We launched this project in all ambulatory care areas at once! It was such an intuitive design that staff required little at-the-elbow support. The checklist helped guide them through the minimum requirements as designed.

In a second phase of our project, we allowed patients to answer most of the required intake elements via our patient portal system. In doing so, we helped reduce staff documentation burden. This was integrated with our previous checklist work, and many times the patient’s checklist would be completed before they ever sat down in the clinic room for intake.

Overall, we achieved the outcome of defining the core minimum intake requirements and developing a tool to encourage adherence to the new standards. Also, staff reports an increased ability to determine the required documentation for ambulatory care encounters since the change was implemented. Prior to the change, 33% of polled staff reported that it was “very easy” to determine required documentation for clinic intake. After implementation, that number rose to 51%. Perceived documentation time was also reduced. Before our change, 20% of staff felt that they could complete clinic intake in less than 5 minutes. Afterward, 27% reported being able to complete the process in less than 5 minutes.

Through a multi-team approach, we improved nursing workflow and patient satisfaction by helping define minimum documentation standards that meet regulatory requirements and satisfy quality standards.