One physician executive noted that there have been

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regarding the accuracy of documentation had improved. One physician executive noted that there have been challenges to implementing Lean in the ED because of a number of factors. For example, because of the nature of the department, the ED was constantly under stress and had difficulty retaining nursing staff. Further, Lean had to be halted at times in the ED because of staffing issues with nurses and an H1N1 outbreak. In like manner, it was also reported by staff that projects that focused on clinical operational process were more successful and were monitored more consistently through daily management of improvement when they included clinical staff only vs. when administrative staff were included on the teams. Pediatric Continuity of Care Project (Prospective) The Pediatric Continuity of Care project was the fifth project in the ambulatory care value stream. The project built upon a similar project conducted in the adult outpatient unit a few months earlier. Project Goals The Pediatrics Department sought to increase continuity of care for patients by increasing the number of patients who saw their assigned primary care physician in a subsequent visit, which would help to reduce insurance payment denials and lay a foundation for improved quality. In this way, the number of walk-in appointments necessary could also be reduced by redirecting patients to available appointments. Department Where Implemented: Pediatric Ambulatory Care This project was implemented in Ambulatory Care in the Pediatrics Outpatient Department. The department also holds specialty clinics (e.g., an HIV clinic) for pediatric specialists on certain days of the month. One executive stated that the outpatient units had an increasingly high volume of care. Everything is an emergency, and everything has been taken care of yesterday. [Which makes] concentrating on one problem [during an RIE] and not bringing in all the tangen ts [a challenge].” Physician executive
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188 Project Selection This project is part of the ambulatory care value stream, which was identified by the Executive Steering Committee during its Transformation Plan of Care review meetings. A couple of executives reported that ambulatory care was added as a value stream because it would provide a high rate of return, was in need of process improvement, and could break down existing silos among staff in different departments and across staff in different roles within the organization. Finally, one executive noted that changes to reimbursements based on the Ambulatory Patient Group, a patient classification system that was designed to be used as the basis for an outpatient prospective payment system, in 2010 made focusing on pediatric continuity of care a way to optimize the synergies between flow and financial aspects of care.
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