What Do Rheumatology Patients Want in an After-Visit Summary? A Kano Analysis of Patient Preferences.

BACKGROUND: After-visit summaries (AVS) are patient-specific documents curated by providers to summarize the content of medical encounters. Despite widespread use, little is known about rheumatology patient preferences for AVS content and style. The aims of this quality improvement project are to identify patient preferences and to design a rheumatology-specific AVS, using the Kano method. METHODS: This quality improvement project consists of 4 parts. First, investigators interviewed veterans and clinic staff to derive a list of potential features. Second, a Kano questionnaire assessing satisfaction with the presence or absence of each feature was distributed to veterans. Third, qualitative and quantitative Kano analyses were performed to categorize features as mandatory, performance, attractive, or indifferent. Fourthly, based on these findings, an AVS was drafted and distributed to Veterans with an associated survey to assess satisfaction with content, visual appeal, and readability. RESULTS: Nine physicians, 5 veterans, 5 schedulers, 3 nurses, and 3 medical assistants identified 15 features for inclusion in a Kano-style questionnaire. The questionnaire was distributed to 50 Veterans using consecutive sampling. Quantitative Kano analysis demonstrated 4 mandatory, 2 performance, and 3 attractive features that were ultimately included in the AVS; 6 indifferent features were excluded. A postintervention survey of 50 Veterans showed high satisfaction scores in AVS content (4.3/5), visual appeal (4.6/5), and readability (4.4/5). CONCLUSIONS: We developed an AVS that included 9 mandatory, attractive, and performance features, as identified by the Kano method. Veterans were highly satisfied by the content, visual appeal, and readability of the AVS.

Development of a COVID-19 Vaccine Readiness Kit for Veterans With Rheumatologic Diseases on Immunomodulators: A Quality Improvement Project.

BACKGROUND: The advent of multiple safe and effective vaccines to prevent SARS-CoV-2 infection represents a major step in resolving the COVID-19 global pandemic. Vaccination of individuals with rheumatologic diseases on immunomodulators represents an additional challenge because data suggest that certain immunomodulators may impact vaccine efficacy. METHODS: At a large, predominantly rural Midwestern Veterans Affairs rheumatology clinic, an interprofessional group of investigators conducted a quality improvement project to develop a COVID-19 vaccine readiness kit, consisting of patient education materials and a readiness questionnaire to help guide veteran decision-making. Using a Lean Six Sigma approach and the DMAIC (Define-Measure-Analyze-Improve-Control) framework, the investigators identified customer values, needs, and barriers to participation. Return rates and responses from the questionnaire were tracked over 28 days. RESULTS: One hundred seventy-nine veterans were identified and mailed kits; 129 (73%) returned the questionnaire within 28 days. Ninety-seven percent of those opted to hold immunomodulators after at least 1 administration of the vaccine; 3.1% were not interested in vaccination. Veterans voiced satisfaction at the simplicity of the process, comprehensibility of materials, and the clarity of communication. CONCLUSIONS: The Lean Six Sigma approach, systematically focusing on identifying the values, needs, and barriers of veterans on immunomodulators, was critical to high participation rates from veterans. This approach is cost-effective for resource-poor settings, audiences without access or familiarity to digital content, and rural settings separated by large geographic distances.

Using Lean Six Sigma to Improve Pneumococcal Vaccination Rates in a Veterans Affairs Rheumatology Clinic.

Pneumonia is a major cause of morbidity and mortality in the United States. Therefore, prevention of pneumococcal pneumonia by administering effective and well-tolerated vaccines is an important goal, especially in the immunocompromised patients who are at an increased risk of infections. At a large Midwestern Veterans Affairs Rheumatology Clinic, an internal audit revealed a baseline immunization rate of 3%. Through the Lean Six Sigma approach, the investigators sought to increase the rate to 70%. An interprofessional approach incorporating provider education, reinforcement at the point of care, and workflow simplification was sequentially implemented. Lean Six Sigma tools, including process mapping, voice of the customer, and statistical process control charts were utilized. These interventions increased the percentage of eligible patients receiving vaccinations from 3% (n = 19/687) to 23% (n = 11/48) and decreased the vaccine administration time from 15 to 7 minutes. No adverse reactions were reported. This was balanced by an increase in appointment time by 4 minutes in those who received vaccines. The Lean Six Sigma approach was critical to reducing waste and improving value for patients and providers by increasing pneumococcal vaccination rates among the immunocompromised veteran population in a Midwestern Veterans Affairs Rheumatology Clinic.