HomeProfessionalsCareer DevelopmentFellowsInnovations in Fellowship Education2013 ▶ University of Southern California
University of Southern California

Los Angeles, CA

Program Description
The USC Pulmonary and Critical Care Fellowship Program is one of the largest, most rigorous training programs in the nation. Our 21 fellows cover three hospitals--the Los Angeles County Hospital, Norris Comprehensive Cancer Center, and the Keck Medical Center of USC. Our fellows gain in-depth experience in not only basic MICU and pulmonary consultation services, but also significant training in surgical ICU, lung transplantation, cystic fibrosis, pulmonary hypertension, sleep, lung cancer, and advanced diagnostic bronchoscopy.

Type of Program
Pulmonary and Critical Care

Number of Fellows in Program

Submitter(s) of Abstract
Associate Program Director: Ching-Fei Chang

The Los Angeles County Medical Center, one of the largest public teaching hospitals in the nation, provides medical services to thousands of indigent and underserved patients a year. Being a government-run hospital, timely and efficient care is frequently problematic due to limited resources and bureaucratic processes. In our pulmonary outpatient clinic, we identified 3 major obstacles to patient access and continuity of care, which have negatively impacted the outpatient training experiences and education of our fellows for decades. These included an average wait time of 2 years to be scheduled, lack of continuity of providers from visit to visit, and a patient no-show rate of over 50%. A one year program improvement project involving both fellows and faculty, was initiated, using a FISH diagram in which these problems were dissected and solutions developed.

Waiting time was shortened by trimming the pre-existing list of 1000 patients to less than 400 by dropping all referrals over a year old, assuming that either the patient was deceased or the issue was resolved. A computerized system was created for new referrals and was reviewed and triaged daily by the clinic directors to ensure that urgent cases were given priority. As a result, median wait time for an appointment decreased from 2 years to less than 2 months.

To address continuity, fellow vacation, night, and ICU cross-coverage schedules were provided to the scheduling clerks. In addition, fellows are now paired, and if the initial primary physician fellow is not available to see the patient for a follow-up visit, his/her ‘partner’ fellow is the assigned default provider. As a result, continuity of care has improved from ~25% to over 70%.

Root causes underlying the high no-show rate were identified as 1) patients being unaware of their appointments and
2) dissatisfaction with the clinic experience. The previous approach of appointment by mail was replaced with phone scheduling and confirmation by a Spanish-speaking clinic staff member. If the patient could not be reached or was unavailable that day, they were rescheduled.

Problems related to patient satisfaction were identified and corrected. In addition to continuity issues, patients were unhappy with the time to discharge from clinic while waiting for orders and referrals to be entered by nursing and clerical staff, who processed paperwork in the order of receipt. Wait time was dramatically reduced by shifting the responsibility to the clinicians who complete this step electronically after seeing the patient.

In addition, number of hospital visits was reduced by providing same-day pulmonary function testing in the clinic, and processing oxygen and non-invasive ventilation equipment requests on-site. As a result of these interventions, patient questionnaires now reveal a 95% “very satisfied” rating, and the no-show rate has improved from greater than 50% to less than 20%.

Our successful project demonstrates a model for improving access and continuity of care issues commonly encountered within government teaching hospitals, while simultaneously enhancing fellow education and training in the context of several ACGME competencies. As a result of their daily involvement with improving clinic efficiency, continuity of care, and patient satisfaction, fellows were educated about professionalism and interpersonal communication, as well as systems-based practice in the context of a multidisciplinary team.


Last Reviewed: July 2016