Team building is an ongoing process, and strong relationships, accountability, and trust among team members translates to outstanding patient care.
Daily: One way to foster trust and communication is to start the day with brief “gratitude” rounds, where each team members shares something they are grateful for. This centers the team in positivity and encourages relationship building. Following this, one team member should be designated to lead a “huddle” to review the patient panel and clinical considerations for each patient.
Weekly: Arrange 30-minute weekly clinical huddles with the practice and nursing manager to discuss any operational concerns that may have arisen, and to develop action plans for improvement. Foster an environment where any member of any role can ask clarifying questions, or contribute essential information.
Monthly: Consider planning standing get-togethers outside of work, so co-workers foster relationships as individuals rather than simply as co-workers.
As needed: Plan formal group de-brief sessions after challenging patient cases, for example, if a patient complication or complaint has occurred. Invite colleagues outside the clinic as needed, such as behavioral health colleagues to support mental health of team members, or clinical specialists that can provide continuing education in areas where clinic members may have knowledge gaps.
Initial consult appointments take 40-60 minutes; follow up appointments can often be fit into a 20 minute slot. However, appointment lengths can be much shorter or much longer than expected.
Case Study
Junie is a 41 year old, newly pregnant, who experienced vaginal bleeding, received an early ultrasound diagnosing a pregnancy loss, and called PEACE to schedule an appointment. She expressed to the patient services representative that she wanted to proceed with management of her miscarriage but was unsure if she wanted a procedure or medical management. She was scheduled at PEACE into a 40-minute appointment slot in two business days. Once she arrived at her appointment, she mentioned to her clinician that she had vaginal bleeding the night before, and an ultrasound in the office showed that the miscarriage was complete. She was appreciative of the guidance and follow up and was able to leave the office within 20 minutes of seeing her provider.
Mariah is a 22 year old who had medical management of a miscarriage two weeks ago through PEACE and was coming for a follow up appointment. She was scheduled into a 20-minute follow-up slot. She mentioned to her clinician that her bleeding was still quite heavy and she was feeling fatigued. An ultrasound confirmed that she had retained products of conception and she and her provider decided together that a uterine aspiration would be most appropriate today. She also desired a contraceptive implant placement. Her visit, including counseling, ultrasound, procedure, Nexplanon insertion, and recovery took a total of 90 minutes.
Tips for Managing Last-Minute Scheduling
Consider a “freeze/thaw” option for appointment slots: Certain appointment slots are frozen, or not allowed to be scheduled into, until 1-5 days prior to the appointment date.
Consider keeping a single appointment per day or per week frozen to be used only for urgent pregnancy concerns
Lesson Learned: Appointment Timing
Walk-ins and Direct, immediate referrals from the ED, radiology, or another practice are often not as helpful for patients as appointments 1-5 business days from initial diagnosis of early pregnancy loss.
Case Study
Tia is a 28 year old who came to the Emergency Department in the late evening for vaginal bleeding in early pregnancy. After waiting for 6 hours, she received an ultrasound diagnosing her with an early pregnancy loss. An ob/gyn resident saw her in the ED, deemed her to be stable, and recommended referral to PEACE. It was 8am in the morning and the resident requested to PEACE that the patient come straight to the office for management. Tia arrived to PEACE at 8:30, exhausted and distraught, and unable to bring her support person because they did not schedule time off of work. Tia scheduled a second appointment for the following day, after which she had time to rest, process, and consider her options.
Tips for Managing Long Appointment Times
Ensure that patients are given clear expectations for how long they will be at the office. Any patient services representative scheduling into early pregnancy visits should know to tell patients that they may be in the office for up to 2 hours.
Ensure a team-based approach in which counseling, paperwork, patient monitoring tasks are shared with ancillary and nursing staff. Each clinician should be matched with at least one designated medical assistant and nurse in order to appropriately task shift.
Case Study:
Rowena called for an appointment to receive care for an undesired pregnancy, 4 weeks and 2 days after a certain last menstrual period. Undesired pregnancy appointments are managed by our clinic’s family planning care coordinator, not the bigger appointment call center. This scheduler told Rowena to expect her visit to take up to 3 hours, and ensured she had an escort for a safe ride home. A member of our physician care team then called her 24 hours before the visit to obtain the mandatory state consent language required for an abortion in our state to ensure that she would be able to receive same-day abortion care.
At the visit, her pelvic ultrasound showed a 1.1 cm endometrial stripe, no gestational sac, normal ovaries with a corpus luteum in the right ovary, and no free fluid in the cul-de-sac—a pregnancy of unknown location (PUL). After a conversation with her physician assessing pregnancy desiredness for her PUL, Rowena was certain she did not want to continue with the pregnancy and wanted expedited resolution. She then received a uterine aspiration in the office. The following day Rowena’s hCG was 431 mIU/mL, and pathology showed chorionic villi, confirming that the pregnancy had been intrauterine and was now resolved.
Clinical Best Practices for Early Pregnancy Management
When establishing a PEACE practice, consider your resources (personnel, equipment, space) and aligning these with your practice goals and scope. An PEACE model may include any combination of the following practice scopes which range from narrow to broad:
In this model, your clinic may plan to complete ultrasounds in the office to evaluate any early pregnancy complaints including vaginal bleeding and cramping
Possible diagnoses may include pregnancy of unknown location, ectopic pregnancy, normal intrauterine pregnancy, pregnancy loss, incomplete spontaneous abortion
Clinics that practice in this expanded model will need clear protocols for emergency room referral for ectopic pregnancy, and outpatient protocols for pregnancy of unknown location management
Contact us to get expert guidance and quotes for individualized services. We offer one-time, time-limited, or ongoing support.
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