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Improving Genetics Clinic Efficiency and Capacity Using Design/Human Factors Methods
Event Type
Poster Presentation
TimeThursday, April 152:00pm - 3:00pm EDT
LocationHospital Environments
DescriptionINTRODUCTION
Patients being served by the Genetics Clinic at the Children’s Hospital of Eastern Ontario in Ottawa, Ontario, Canada, are currently experiencing long wait times for non-urgent visits (> 1 year). The Genetics Clinic team believes these challenges are related, in part, to workflow inefficiencies. Virtual care was implemented due to the COVID-19 through CHEO’s Epic Systems’ integrated zoom platform as part of their electronic medical record software application. The introduction of virtual care has brought about additional challenges but also opportunities related to workflow . For example, clinicians foresee potential to see more patients because of the flexibility offered by virtual patient care and that prior constraints suspected to be a result of limitations with their physical space are could be better addressed with a hybrid (in-person and virtual) model of care.
This quality improvement study focused on developing a better understanding of factors influencing the efficiency of prenatal genetics counsellors (GCs)to see patients during pandemic conditions in order to develop strategies to improve their workflow using techniques from human factors and design. We studied how GCs performed work virtually and on-site and time on tasks to assess the possible influence of ‘artefacts’ (digital technologies, existing space design/layout) being used/not used in work on the team’s workflow and patient interactions. With this understanding, our aim is to develop concepts to improve workflow so that GCs can see patients within a 4 month of referral. Although many factors will likely emerge in this study, the main focus will be on the potential impact of the physical space on workflow as virtual workflows could not be directly observed due to patient privacy considerations. However, our team tracked the types of tasks being performed virtually and amount of time performed on tasks to provide what we feel will be early studies revealing on the nature of virtual care tasks performed by genetic counsellors. There are certain constraints in proposing concepts for improvement. For example, with any intervention we propose, the number of providers and support staff cannot change, and the space configuration cannot change due to lack of infrastructure resources.

PARTICIPANTS AND METHODS
The study received clearance from CHEO’s and Carleton University’s Research Ethics Board takes place in the Prenatal Genetics Clinic at CHEO where the on-site and virtual workflows of GCs were documented.. Within the context of the COVID-19 pandemic, we were limited to certain methods to understand the differences in workflow before and after the pandemic.
Planning the study involved a literature review of workflow studies in other genetics clinics, stakeholder meetings and archival analysis of previous studies from the clinic which tracked workload minutes prior to the pandemic for routine and complex prenatal patients, the expected number of new patients per full-time GC, the target number of new patients per fiscal year, etc. Stakeholder meetings and mapping were used to identify the prenatal genetics team and their roles. Then, a brainstorming session was held with the prenatal GCs to learn about their thoughts, concerns and ideas regarding digital platforms to conduct virtual care. At the time and due to the novelty of the pandemic situation, there was little known about the indirect time that clinicians were spending on virtual care (preparing for the visit, sending requisitions, writing reports, etc.).
All prenatal GCs (4 in total) were asked to report time-on-task in a diary study to understand the potential for time-intensive challenges to provide virtual care. The 4 participants have different workloads; 2 full-time, 1 part-time, and 1 with an 80% workload. GCs were asked to document the duration of the tasks they perform (in minutes) for 5 days. In total, 22 workflows were documented and analyzed, 19 full-time workflows and 3 part-time workflows.
This was followed by 6 naturalistic observation sessions totalling 18 hours which included following a genetic counsellor through a patient care workflow, observing and questioning counsellors as they perform tasks, and documenting these steps to identify their activities, general tasks performed in the clinic, as well as paths and spaces used to perform these tasks at the clinic. A task analysis was developed to map the on-site workflow at the Prenatal Genetics Clinic to identify efficiency issues related to the design of the space, process and the use of artefacts (paper-based work, equipment, digital platforms, etc.). The basic elements of our task analysis included defining the task or activities performed at the clinic, dividing these activities into subtasks/steps, and specifying the aretfacts/tools/techniques involved in the performance of these activities. Weekly meetings were held to discuss the preliminary findings with stakeholders.
One of the strategic design tools used in this study to improve clinical flow was The Lean Improvement Approach. Lean was pioneered by Toyota in the 1970s, emphasizing stable, standard processes to provide the best quality and efficiency by eliminating waste/ unnecessary steps (Flanary, Rocco, Dougherty, & Christman, 2020; Lin, Gavney, Ishman, & CadyReh, 2013). This methodology suggests small incremental changes in process that, over time, can have an enormous effect on an enterprise as a whole and can have an immediate effect on smaller groups within the institution (Waldhausen, Avansino, Libby, & Sawin, 2010). Lean Improvement projects propose a Define-Measure-Analyze-Improve-Control (DMAIC) methodology (Gijo & Antony, 2014), a method we are using but also assessing for appropriateness to this context of study.

RESULTS
The analysis of the data collected thus far has greatly increased our understanding of workflows at the Prenatal Genetics Clinic at CHEO, allowed us to define challenges for GCs, and evaluate the existing process to help identify systemic design problems and opportunities for improvement. We will present these results at the symposium. Our preliminary results of virtual and on-site workflows show that genetics providers spend at least half of their time on tasks before and/or after the patient’s appointment. The results highlight the potential challenges prenatal genetics counsellors face to reduce patient wait times in light of ‘work as done in reality’ versus ‘work as imagined’ (Katz & Gurses, 2018). Therefore, looking at potential inefficiencies or bottlenecks in workflow may help improve patient access to genetics services.
The analysis of the results is now informing the development of a strategic plan for improving the work efficiency at the Prenatal Genetics Clinic. We anticipate these strategies will be completed during the time of the conference.

DISCUSSION
The demand for Prenatal Genetics Clinics is rising which has increased pressure on GCs to become more efficient (Attard, Carmany, & Trepanier, 2019). Genetic counselors can improve access to their services by reducing the time spent on the tasks performed before and after a genetic counseling encounter, thereby increasing the number of patients they see (Attard, Carmany, & Trepanier, 2019).
With the current pandemic, we faced a challenge observing typical clinical flows due to physical distancing restrictions and the limited amount of work that is currently taking place at the clinic. In addition, improvements suggested through this analysis will be constrained to the number of providers and support staff and current space configuration. However, this also brings unprecedented opportunity given the rapid uptake of virtual care that has occurred and could be further leveraged as part of a comprehensive strategy to meet the goals of this improvement project.