Wait no more

By Victoria Houghton, managing editor, September 3, 2018

Dermatology World talks with Benjamin Chong, MD, MSCS service chief of dermatology at Parkland Health and Hospital System in Dallas about how he addressed long wait times.  

Dermatology World: Describe the access issues with the dermatology clinic at Parkland Health.

Dr. Chong: Parkland Health and Hospital System is a safety net hospital for patients in Dallas County. Parkland serves patients with little to no insurance coverage in Dallas County who can apply for county-supported insurance to get their health care. During my first years at Parkland from 2008 to 2012, we were facing prolonged wait times that were as high as more than a year for new patients and three months for follow-up patients.

Dermatology World: What were some of the roadblocks you were facing that exacerbated the wait-time issue?

Dr. Chong: We were unable to add new clinics due to us sharing clinic space and support staff with other medical specialties. We could not substantially increase the number of patients seen per clinic because of the aforementioned personnel and clinic space constraints.

Dermatology World: What changes did you make to clinic scheduling?

Dr. Chong: We did not have a standardized template for scheduling patients. Thus, we designated a specific number of slots for new patients and established patients. We also saved a number of slots for overbooks, which were for patients with urgent medical issues.

We adjusted the work shifts of the nurses and medical assistants. Toward the end of clinic, there were staff members who had already left for the day because they had reached their maximum work hours for the day. Therefore, we staggered work shifts that began and ended at different times of the workdays to make sure that there was adequate coverage at the end of clinic.

Dermatology World: What changes did you make to improve work flow?

Dr. Chong: We found a few clinic flow issues that slowed us down. First, whenever a patient required a skin biopsy, the patient had to wait for a nurse — who was often working with another patient — to be available to perform consent, and prepare the biopsy procedure. To avoid this delay, we initiated a separate procedure room that was dedicated to doing biopsies. This room would have a dermatology resident and a nurse that would concentrate on performing the biopsies for all patients in that clinic. Thus, patients requiring skin biopsies can be immediately moved to the procedure room to get the biopsy done, and patients waiting to be seen could be then roomed. It was one of my prior chief residents, Dr. Pamela Aubert, who came up with the idea of the dedicated procedure room for biopsies to improve clinic flow.

Dermatology World: What hiring decisions did you make and why?

Dr. Chong: We hired an outstanding physician assistant, Rosemary Son. During her first year with us, we trained her in dermatology using a rigorous curriculum similar to that of our residency program. After that supervised year, she could confidently see patients with moderately complex skin problems. Thus, this allowed us to focus on seeing more patients with urgent needs and complex issues. We also found that the nurse-to-provider ratio was suboptimal so we hired extra nursing support to help with the patient flow.

Dermatology World: What did you do to improve patient triage?

Dr. Chong: We had patients with low acuity and stable skin problems that could be managed by their primary care doctors. We discharged many of these patients back to their primary care providers with instructions on what to do in the long term. This cleared the way to accommodate more patients into our clinic. We didn’t sense significant pushback from the primary care physicians because they eventually realized that this would help their referred patients be seen in our dermatology clinic faster.

Dermatology World: How did you get your administrators on board with these changes?

Dr. Chong: Working with the administration was not an obstacle for us. I have an outstanding nurse manager, Mike Estabrooks, who oversaw the clinic, and clinic team leaders, namely Samantha Martinez and Lurlene Walls. They all worked with me to develop this plan. We were all on the same page in our goals. The Parkland administration has been very supportive because one of their large goals was to improve access to specialty care for their patients.

Dermatology World: What were the results of the changes you implemented?

Dr. Chong: From May 2012 to September 2015, these interventions led to a significant decrease in new patient wait times from 377 days to 48 days, and established patient wait times from 95 days to 34 days. The administration has been very supportive with this as a model and has encouraged other specialties to do something similar. There’s been a lot of positive energy that has come from this.

Dermatology World: If a smaller, private practice were interested in increasing access and reducing wait times, what suggestions would you have for them?

Dr. Chong: The limitation of our initiatives is that they are not generalizable to every clinic setting because not everyone has residents and every clinic size is different. However, I recommend providers sit down with their nursing, support, and scheduling staff to get their opinions and ideas to improve access to care. I think it’s important to be on the same page.

I also encourage providers to be creative with their resources at hand and be open to different ideas. Hiring a physician assistant was not something I anticipated, but the idea grew on me after seeing how they have been valuable in other clinics.

Lastly, look at the patient population and determine the types of patients that are being seen, what the patients’ needs are, and which patients need the most help. From there, one can better understand how one can triage patients more effectively. One can triage patients more effectively by educating support staff about common problems. Providers can also educate referring providers about urgent and non-urgent cases. That can be helpful in getting patients who need to be seen sooner.

Dermatology World: What was the one prerequisite before implementing these changes?

Dr. Chong: It’s important that the clinic team is on board and is supportive of the changes. For us, ensuring this unified approach required dismissing members who were reluctant to embrace our changes. My clinic leaders were vital in establishing a new culture to improve clinic access and optimize clinic workflow. We also had strong buy-in from the administration, faculty, and residents, who ultimately were committed to providing the best patient care. 

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