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Abstract
Background The University of Florida (UF) Equal Access Clinic Network (EACN) is the largest student-run free healthcare clinic network in Florida. The UF EACN serves those who are underinsured or uninsured in Alachua County and its surrounding area. Nationally, average total clinic time per medical visit has been established to be 84 min.
Problem Before this project, average patient cycle time at the UF EACN was 125.3 min, and there was no established quality improvement (QI) team to implement changes to address inefficiencies.
Methods This was a prospective QI study that recorded patient cycle times for patients who received healthcare at any of the four primary care free clinics across the UF EACN from 5 July 2022 to 6 April 2023.
Interventions Eighteen Plan–Do–Study–Act cycles were tailored to each of the four primary care clinic’s needs with a focus on reducing patient cycle time by addressing the following identified problems: prolonged intake process, translation services, limited numbers of volunteers, and other inefficiencies and bottlenecks in workflow.
Results The median patient cycle time at the EACN shifted from 125.3 min to 112.7 min over a nine month period. This drop of 12.6 min meant patients saw a 10.1% reduction in patient cycle time across the EACN.
Conclusion Underserved patients at EACN are experiencing increased value by having shorter patient cycle times.
- Quality improvement
- Medical education
- PDSA
- GENERAL PRACTICE
- Health Equity
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
The average total time per ambulatory care visit is 121 min broken down into 37 min of travel time and 84 min of clinic time.
The average opportunity cost per healthcare visit in the United States for patients is about $43.20.
Longer wait times are negatively correlated to patient satisfaction scores, confidence in care providers, and perceived quality of care.
WHAT THIS STUDY ADDS
This project demonstrates how a student-led quality improvement (QI) team can be incorporated into a student-run free health care clinic to implement positive change and add value to the patient experience.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Patients who receive health care through a free clinic are entitled to quality care.
Medical student QI teams can create high value in the health care system.
Introduction
Problem description
In the USA, average total time per medical visit has been established to be 84 min (95% CI 81 to 86) of clinic time.1 The University of Florida (UF) Equal Access Clinic Network (EACN) is the largest student-run free healthcare clinic in Florida.2 Before implementing a quality improvement (QI) project in the EACN, average patient cycle time within these clinics was 125.3 min, impacting student volunteers, volunteer licensed providers and most importantly, impacting the patients of the EACN. From further analysis, this lengthy delay was found to be attributable to a prolonged intake process, translation services, limited numbers of volunteers and other inefficiencies and bottlenecks in workflow.
Available knowledge
Ray et al found that the average total time per ambulatory care visit in the USA was 121 min broken down into 37 min of travel time and 84 min of clinic time. Using these times, the average opportunity cost per visit was calculated to be $43.20.1 Many of EACN’s patients require public transportation or ride share services to arrive at the clinic. In addition, the average patient cycle time in the clinic was 125.3 min. Thus, the opportunity costs were even higher for EACN patients.
It has also been established that longer wait times are negatively correlated to patient satisfaction scores, confidence in care providers, and perceived quality of care. This results in diminished perceptions of information, instructions, and the overall treatment received by patients.3 Long patient cycle times could therefore impact a patient’s compliance with an established care plan and overall willingness to seek medical care when needed.
Each year, the EACN serves over 2200 patients. The U.S. Center for Disease Control ’s most recent National Health Statistics Report found 9.7% of those living in America are uninsured,4 making the EACN an invaluable resource to the people of Alachua County and the surrounding community. In its more than three decades of treating patients, there has never been a dedicated QI initiative to help improve on systems processes to enhance the experience of being a patient or volunteer at the EACN.
To our knowledge, there has not been a QI project across multiple student-led free clinic sites. Therefore, we present a novel, student-run QI project aimed at reducing patient cycle time across four primary care sites in the UF EACN to serve our uninsured or underinsured patient population in Alachua County.
Rationale
We hypothesised the incorporation of student-led QI teams would lead to increased value for patients who receive their healthcare from the EACN. Through the continuous, iterative improvement process and usage of QI methodology, we anticipated the implementation of QI teams to produce systematic, positive change leading to reduced patient cycle time.
Specific aims
The original aim for this project was to reduce patient cycle time at UF’s EACN’s four primary care clinic sites from an average of 125.3 min to 90 min over a period of six months (later extended to nine months), with a global aim to reduce the time burden on patients who receive healthcare through a free clinic.
Methods
This was a prospective QI study recording patient cycle times for patients who received healthcare at any of the four primary care clinics across the UF’s EACN from 5 July 2022 to 6 April 2023. This study followed the Standards for Quality Improvement Reporting Excellence (SQUIRE V.2.0) reporting guideline.5
Context
The EACN’s vision statement is, ‘to improve the physical, mental and social well-being of all, by enhancing access to high-quality, comprehensive, patient-centred care and by facilitating community-level action’.6 Founded in 1988 by UF College of Medicine students, student volunteers from the UF’s undergraduate campus, pharmacy, physician associate (PA), medical, dentist, public health, social work, clinical psychology, and physical therapy schools have operated four primary clinic sites, in addition to several specialty clinic sites, with the support of UF faculty members.6 The EACN clinics are located in a suburban, North Central Florida setting.
Every clinic accepts patient appointments and walk-ins and offers basic laboratory testing onsite, such as urinalysis, human chorionic gonadotropin testing, and HbA1c measurements. EAC’s located in a clinic-setting also offer pap smear testing. All other lab work is provided for patients at any Quest location and is paid through the EACN. Pharmacy students are available onsite to assist with prescriptions and medication reconciliations.
Spanish Seventh Day Adventist Church Equal Access Clinic
The Seventh Day Adventist Church Equal Access Clinic (EAC) location provides primary care services on Monday nights. It serves a primarily Spanish-speaking population, and to accomplish this effectively, many of its volunteers and clinic officers are Spanish speaking. The clinic is held in a church with classrooms converted into exam rooms, and the church sanctuary is converted into a waiting area. During this project, the Seventh Day EAC saw an average of 12 patients per night, typically with two physician volunteers present: one attending and one resident. There were multiple barriers to patient cycle time; noteworthy examples included its unique location, makeshift facilities, largely Spanish-speaking patient population often requiring interpreter assistance, and its low number of providers.
Eastside Equal Access Clinic
The Eastside EAC location serves patients on Tuesday evenings. It is in a family medicine clinic on the eastern side of Gainesville, FL in a low-income census tract. During this project, Eastside served approximately 12 patients per clinic night through their weekly primary care services, biweekly LGBTQ-specific (Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, intersex, asexual, and more) services (eg, gender affirming therapy, pre-exposure prophylaxis initiation) and monthly psychiatry and dermatology services. The main barrier to patient cycle time was the low relative priority of the QI project for clinic volunteers and officers. While there was widespread buy-in across the clinic with the idea of reducing patient cycle time, volunteers and officers had many competing priorities, including quality of patient care and student and resident education, both of which were often perceived to be improved with a longer visit.
Bartley Temple Equal Access Clinic
The Bartley Temple EAC location serves approximately eight patients per night on Wednesday evenings. Bartley Temple serves a large population of paediatric patients on any given clinic night and is the only EAC site with a specific focus on paediatric care. Additionally, approximately 64% of paediatric patients and 34% of adult patients seen required translation services. Rather than being in a traditional clinic setting, the clinic occurs in the fellowship hall of a local church. Medical supplies and equipment are often limited, and the clinic’s setting must be set up and taken down in the same night. These challenges in combination posed the most significant barrier to decreasing the time that patients spend in the clinic.
Main Street Equal Access Clinic
The Main Street EAC location serves patients on Thursday evenings, with appointments and walk-ins. It also offers monthly gynaecology (with birth control initiation, such as intrauterine device insertions) and cardiology (with cardiogram) services. Patients are seen in a family medicine clinic in central Gainesville, FL. On average, the Main Street EAC serves approximately 17 patients per night, including patients who are attending specialty clinics. This establishes the Main Street EAC as the highest patient-volume clinic of the EACN. Due to its high patient volume, efficiency and workflow bottlenecks were most associated with increased patient cycle time.
Interventions
In early July 2022, each student leader associated with the EACN was asked to complete an anonymous Google Form needs assessment survey to gauge their perspectives on (1) what their clinics needed help with and (2) if they would be interested in having a student-led QI team at their clinic to aid. Each clinic communicated a desire to reduce patient cycle time, which was a noticeable problem many volunteers and patients recognised, too.
Twenty-nine student leaders across the EACN responded to this survey, with responses from each clinic site and each specialty night associated with the EACN. When asked, What causes long in-clinic time for patients? responses consistently mentioned: bottlenecks when medical students are waiting to present a patient to a resident/attending; long intake process run by the undergraduate volunteers; limited resources; lack of room availability; complexity of patient care; and language barriers.
Many common themes emerged from responses to the question, What do you think would decrease the amount of time patients spend in the clinic? These included streamlining the undergraduate volunteer intake process; adapting the undergraduate volunteer role; recruiting more licensed healthcare volunteers; recruiting more medical student volunteers; time limits for each volunteer; increasing the number of rooms available for use and improving lack of resources. Approval was granted by the EACN student director to move forward with a student-led QI project
Based on this survey’s responses, an overall key driver diagram was created to address overarching goals to reduce patient cycle time across the entire EACN (figure 1).
The overall EACN key driver diagram. This project’s timeline was later extended to nine months. EACN, Equal Access Clinic Network; UF, University of Florida; HOQI’s, undergraduate student volunteers known as Health Outreach and Quality Improvement Program.
After brainstorming sessions between newly developed QI teams and the existing clinic leadership, each of the four primary care clinics also created site-specific key driver diagrams.
Recognising the unique challenges, the different clinic sites experienced, each team was given autonomy to conduct Plan–Do–Study–Act (PDSA) cycles based on discussions and partnership with each clinic site’s student directors. This was found to be the most effective way for each team to create stakeholder buy-in and meet their individual clinic’s needs.
Based on run chart analysis, the following interventions showed the most impact as indicated by a downward median shift, which occurred after six data points of average patient cycle times were lower than the original median. The first downward shift was seen in the Bartley Temple EAC in week 14, three weeks after the first PDSA cycle. This PDSA cycle was a change in workflow, which transferred the responsibility of assessing vital signs during intake from undergraduate student volunteers to medical/PA student volunteers. This responsibility freed undergraduate volunteers to focus on patient check-in to streamline clinic flow. Variations of undergraduates no longer recording vitals were implemented in all four clinics. The variation found to be most efficient was having EAC student officers complete vitals following check-in to streamline the intake process, and it was later adopted by the Bartley Temple EAC during week 26. This helped create a standardised workflow across the entire EAC Network.
The Main Street EAC saw a downward shift in week 20 following implementation of a shortened intake form that was implemented across the entire EACN. This was then quickly followed by a second PDSA cycle, which created a fast-track system that identified patients who had less complex clinical presentations (eg, prescription refills, lab results). These patients were then triaged and ‘fast-tracked’ to improve clinic turnover. Prior to enacting this PDSA cycle, patients were seen on a first-come, first-serve basis. Patients who were being seen for what should have been a quick appointment would be caught in the backflow created by more medically complex patients. The ‘fast-tracked’ patients were identified and instead seen by physician volunteers earlier, so student volunteers could spend more time working up medically complex patients, thus reducing the workflow bottleneck.
The final downward shift we saw was at the Eastside EAC after PDSA cycle 4, between weeks 28 and 33. This downward shift highlights the importance of awareness and accountability to improve outcomes. In this intervention, one EAC student officer was assigned the responsibility of monitoring the clinic tracker each night, which documented where patients were in the process of their appointment. Prior to this intervention, multiple student officers shared this role, resulting in gaps where no one was monitoring patient movement through the workflow, delaying volunteers’ ability to progress to the next step of evaluation.
For a complete list and description of each intervention listed by clinic site, please refer to online supplemental table 1 located in the appendix.
Supplemental material
Study of the interventions and measures
Patient cycle time data was collected at each of the four primary clinic sites on a weekly basis. Clinic trackers were used at each of the clinics prior to this QI project’s initiation, so data collection did not add a cost or interfere with clinic efficiency.
Patient cycle time was defined as Patient Arrival Time to Patient Departure Time and was manually converted into minutes in a separate spreadsheet. This measure defined eligible patients as those who completed an appointment at any of the four primary clinic sites with recorded arrival and departure times. Patients who left without being seen or who had incomplete timed data were excluded from data collection. This process relied on the accuracy of data from each clinic’s tracker. Other data recorded included the time spent at each stage of workflow, presenting concerns, need for language interpretation and level of experience for the student volunteers. No personally identifiable patient data were collected.
Once each patient’s cycle time had been converted into minutes, average times for each clinic were calculated for the following categories on a weekly basis: all patients seen, appointments that did not use a translator, appointments that used an in-person translator, appointments that used a phone translator service, primary care patients, specialty night patients, returning patients, and new patients. Averages for the previously listed categories were also separated by PDSA cycle.
Mean times from each clinic date were plotted on site-specific run charts to track trends in patient cycle times preinterventions and postinterventions. Mean patient cycle time for all four clinics was plotted on an overall EACN run chart for weeks in which all four clinics had data. For the EACN run chart, data were excluded from weeks in which one or more clinics had no data (eg, holiday or hurricane cancellation, clinic tracker malfunction).
Baseline data of average patient cycle time for each clinic were based on weeks prior to the launch of their first PDSA cycle. Baseline data of average patient cycle times for the EACN were collected from 5 July to 25 August 2022, or during weeks 1–8, as the first PDSA cycles were launched during week 9. The median of the baseline data averages was plotted on run charts. A shift in the run chart’s median occurred when six mean patient cycle time data points were either all above or all below the baseline data’s median. Similarly, shifts were recorded when six mean data points were either all above or all below the previous recorded median for each clinic’s run chart.
Analysis
This project used Microsoft Excel spreadsheets to track patient arrival and departure times as well as to calculate average patient cycle times per day and note any extenuating circumstances (eg, clinic closure). Average patient cycle time for each clinic was then tracked on run charts for each clinic site, in addition to an overall run chart to assess network-wide change. Qualitative feedback was not analysed formally but was incorporated into developing and revising PDSA cycles.
Results
Our run chart data from 5 July 2022 to 6 April 2023 show the median time patients spent at an EACN clinic shifted from 125.3 min to 112.7 min (figure 2). This drop in 12.6 min meant our patients saw a 10.1% reduction in patient cycle time across the EACN. There was a downward shift to a new median of 112.7 min when there were six data points between weeks 9 and 22 that all had average patient cycle times lower than the original 125.3 median. This downward shift in data was maintained through the remainder of the project. Data were pooled from all four primary care clinic sites across the EACN (figure 3). Weeks that did not have data from all four clinic sites (1, 4, 5, 6, 10, 13, 14, 15, 16, 17, 19 21) were excluded.
EACN Run Chart for weeks in which all four primary clinic sites had data. EACN, Equal Access Clinic Network; PDSA, Plan–Do–Study–Act; HOQI’s, undergraduate student volunteers known as Health Outreach and Quality Improvement Program.
Individual clinics’ run charts for (A) Seventh Day Adventist Church EAC, (B) Eastside EAC, (C) Bartley Temple EAC and (D) Main Street EAC. EAC, Equal Access Clinic; PDSA, Plan–Do–Study–Act; HOQI’s, undergraduate student volunteers known as Health Outreach and Quality Improvement Program.
Spanish Seventh Day Adventist Church Equal Access Clinic
The Seventh Day Adventist Church EAC run chart (figure 3A) shows patient cycle time data from 11 July 2022 to 3 April 2023. The median time patients spent at this clinic had an upward shift from 109.3 min to 133.7 min. This increase in 24.2 min meant patients saw a 22.1% increase in patient cycle time. Baseline data were collected between weeks 2 and 8, and PDSA cycles were implemented during weeks 9, 11, 16, 24 and 30. There was an upward shift to a new median of 133.7 min when there were six data points between weeks 26 and 33 that all had average patient cycle times higher than the original 109.5 median. This shift in data was maintained through the remainder of the project. The Seventh Day Adventist Church EAC was the only clinic to show an upward shift in patient cycle times. While student officers at Seventh Day Adventist Church EAC subjectively expressed improved organisation with clinic flow, this clinic also saw an increased number of patients over the course of this project. This clinic was closed during weeks 1, 10, 27 and 32 of the project due to the Fourth of July, Labor Day, Martin Luther King Jr. Day, and President’s Day holidays, respectively. On week 16, the Seventh Day Adventist Church’s clinic tracker malfunctioned and no time data were recorded.
Eastside Equal Access Clinic
The Eastside EAC run chart (figure 3B) shows patient cycle time data from 5 July 2022 to 4 April 2023. The median time patients spent at this clinic had a downward shift from 123.4 min to 107.6 min. This decrease in 15.8 min meant patients saw a 12.8% decrease in patient cycle time. Baseline data were collected between weeks 1 and 8, and PDSA cycles were implemented during Weeks 9, 16, 20, 26 and 31. There was a downward shift to a new median of 107.6 min when there were six data points between weeks 28–33 that all had average patient cycle times lower than the original 123.4 median. This shift in data was maintained through the remainder of the project. During weeks 21, 25 and 35 of the project, the Eastside clinic tracker malfunctioned and no time data were recorded.
Bartley Temple Equal Access Clinic
The Bartley Temple EAC run chart (figure 3C) shows patient cycle time data from 6 July 2022 to 5 April 2023. The median time patients spent at this clinic had a downward shift from 126.5 min to 105.0 min. This decrease in 21.5 min meant patients saw a 17.0% decrease in patient cycle time–the strongest decline in patient cycle time of any EACN clinic. Baseline data were collected between weeks 1–9, and PDSA cycles were implemented during weeks 10, 22, 26 and 30. There was a downward shift to a new median of 105.0 min when there were six data points between weeks 15 and 23 that all had average patient cycle times lower than the original 126.5 median. This shift in data was maintained through the remainder of the project. This clinic was closed during week 21 due to the Thanksgiving holiday. Hurricane Ian, Hurricane Nicole, and poor weather conditions caused clinic closures during weeks 13, 19 and 25, respectively. During weeks 17 and 35 of the project, the Bartley Temple clinic tracker malfunctioned and no time data were recorded.
Main Street Equal Access Clinic
The Main Street EAC run chart (figure 3D) shows patient cycle time data from 14 July 2022 to 6 April 2023. The median time patients spent at this clinic had a downward shift from 136.8 min to 119.8 min. This decrease in 17.0 min meant patients saw a 12.4% decrease in patient cycle time. Baseline data were collected between weeks 2 and 10, and PDSA cycles were implemented during weeks 11, 20 and 27. There was a downward shift to a new median of 119.8 min when there were six data points between weeks 20 and 26 that all had average patient cycle times lower than the original 136.8 median. This shift in data was maintained through the remainder of the project. This clinic was closed during week 21 due to the Thanksgiving holiday. Hurricanes Ian and Nicole caused clinic closures during weeks 13 and 19, respectively. During weeks 1, 4, 5, 6, 14, 15 and 16 of the project, the Main Street clinic tracker malfunctioned and no time data were recorded.
Discussion
Summary
While we did not reach our goal of reducing patient cycle time across the EACN from 125.3 min to 90 min, this project demonstrates a QI team can be incorporated into a student-run free healthcare clinic to implement positive change and add value to the patient experience. Through the iterative QI process, multiple PDSA cycles to reduce patient cycle time were implemented based on each clinic’s individual needs. Of these interventions, two were implemented across the entire EACN: a revised intake questionnaire that reduced redundant questions, along with EAC student officers recording patient vital signs during the intake process to streamline clinic workflow.
Interpretation
On initiation of a QI project in the EACN, the median patient cycle time shifted down and was maintained throughout the duration of this project.
It was anticipated that each clinic would see a decrease in patient cycle time through the implementation of a QI project into the EACN. It was an unexpected finding when one of the four clinics saw an increase in patient cycle time. The Seventh Day Adventist Church EAC QI team and clinic leadership state this could be due to the EAC officers’ efforts to increase clinic tracker accuracy. Additionally, there was an increase in the number of patients the clinic saw over the course of this project.
Another unexpected outcome of this project was that at each clinic, the undergraduate volunteer role evolved from being a medical assistant to a patient advocate. While this decreased patient check-in time across all clinics, the undergraduate volunteers preferred their previous clinical role with patients.
Most QI teams were able to have good buy-in from the key stakeholders by asking clinic officers what they needed help with most. This was essential to establish a positive relationship and build trust with the clinic leadership. Common barriers across each clinic site included maintaining trust with clinic leadership when PDSA cycles were not successful or if a change was large. Other barriers included the variability each clinic experienced from week to week and faulty clinic trackers.
Overall, having a student-led QI team in the EACN resulted in a decrease in patient cycle time across the EACN. This impacts patients, who are now having shorter appointment times, in addition to student and faculty volunteers. As time is our most valuable resource, reducing patient cycle time by improving clinic workflow is an initiative any outpatient clinic could pursue. Being a student-run free clinic network, this project had to create PDSA cycles that did not cost money and catered to the low-resource setting, making implementation of QI teams a project other student-run free clinics could replicate.
Limitations
This project was conducted at four primary care sites across a student-led free healthcare network. Due to having different student and faculty volunteers each week, in addition to yearly changes in student leadership, this creates inconsistencies that an established primary care clinic may not have. As a student-run clinic network, additional time is required for each student volunteer to present to a licensed healthcare provider, who then also evaluates patients. The time required for such is dependent on the number of faculty volunteers, which also varies weekly. The EACN operates with limited resources that may be different from resources seen at other free primary healthcare clinics.
Internal validity could have been affected during this project, as the process of collecting patient cycle time data relied on the accuracy of each clinic’s student officers’ documentation of patients’ Arrival and Departure times. There were several patients who were excluded from the study due to not having a recorded Arrival and/or Departure time. Additionally, there were 12 weeks when all four clinics did not have patient cycle time data, either from closures or clinic tracker malfunctions. The EACN QI directors were in regular contact with EAC officers at each clinic to confirm validity of patient timing when outliers were noted. When a clinic tracker malfunctioned, the EACN QI directors would contact EAC Technology Support to troubleshoot and fix the clinic trackers. In addition, the EACN QI directors held monthly meetings with the EACN director for additional support on enforcing accurate data collection.
Finally, an additional limitation of this project was that not all EAC QI team leads held significant leadership positions at the clinic in which they were leading a QI team. This created a larger barrier to build trust between the stakeholders (EAC directors and officers) and the QI team. It was also more difficult for the QI team to understand the nuances of how their clinic operated, making it harder to identify where to target changes that were most needed. The two clinics who had EAC QI team leads who were also EAC officers of the primary care clinics (Eastside and Bartley Temple) had the greatest success in gaining buy-in of key stakeholders and reducing patient cycle time in their clinics.
Conclusion
In conclusion, our EACN patients are experiencing increased value and lower opportunity costs by having shorter patient cycle times. These patients will continue to experience reduction of patient cycle time as further QI initiatives are implemented.
The next steps for this QI project are to continue implementing PDSA cycles aimed at reducing the time patients spend at EAC while continuing to track average length of stay at each clinic.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
Per the Common Rule (45 CFR §46), this QI project did not require review by the institutional review board. This study was also registered with the University of Florida Quality Improvement Project Registry under project identification number 2295. As the study compared patient cycle time through patients’ arrival and departure, no personally identifiable information was obtained. There were no potential conflicts of interest in the conduction of this project.
Acknowledgments
The authors would like to acknowledge and thank the 2022–2023 University of Florida (UF) Equal Access Clinic Network (EACN) Quality Improvement team members and all 2022–2023 UF EACN leadership for their contributions and dedication to this project, without whom support this project would not have been possible. The Seventh Day Adventist Church EAC team members were Daniel Chong, Melissa Vaz-Ayes, Caroline Lamoutte and Daniel Reich. The Seventh Day EAC clinic director was Michael Mathelier, and officers who made significant contributions in carrying out PDSA cycles included Haley Fox, Julia Thielhelm and Raven Wright. The Eastside EAC QI team members were Alexandra Iakovidis, Jamie Harris, Miranda Solly, Abigail Huelsman and Ethan Kramer. The Eastside EAC clinic directors were Alyssa Nielsen and Monica Rodriguez-Fernandez. The Bartley Temple EAC QI team members were Megan Rizer, Kerry Farlie, Jacob Surges, and Hannah Rains. The Bartley Temple EAC clinic director was Sarah Masten. The Main Street QI team members were Aleeza Kessler and Ryan Grabau. The Main Street EAC clinic director was Helen Ernyey and the Senior Operations Coordinator was Joseph Calpin, and officers who made significant contributions with systems clarification processes included Emily Astrita. The EAC Technology Support for the EACN were Jeffrey Dela Cruz and Shay Bidani. Finally, we would also like to acknowledge the University of Florida College of Medicine Quality Improvement and Patient Safety Discovery Track for facilitating training, mentorship and opportunities related to quality improvement.
Supplementary materials
Supplementary Data
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Footnotes
Contributors RMK: 2022–2023 QI Director; conceptualisation, methodology, formal analysis, investigation, resources, data curation, writing—original draft (lead), writing—review and editing, visualisation, supervision, project administration, guarantor. ASS: 2022–2023 QI Director; methodology, formal analysis, investigation, resources, data curation, writing—original draft, writing—review and editing, supervision, project administration, guarantor. MJR: 2022–2023 Eastside QI Lead; investigation, writing—original draft, writing—review and editing. WHS: 2022–2023 Seventh Day Adventist Church QI Lead; investigation, writing—original draft, writing—review and editing. CEH: 2022–2023 BT QI Lead; investigation, writing—original draft, writing—review and editing. MNL: QIPS Faculty Advisor; resources, writing—review and editing. AK: 2022-2023 Main Street QI Co-lead; investigation, writing—original draft, writing—review and editing. KC: 2022–2023 Main Street QI Co-lead; investigation, writing—original draft, writing—review and editing. PMM: 2021–2023 EACN Director; resources. CKH: Project Faculty Advisor and QIPS Faculty Advisor; resources, writing—review and editing, supervision.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer-reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.