Case Study Background You have been brought in to manage a portfolio of several specialty clinics in a large multi-physician group practice in an academic medical center. The clinics reside in a multi-clinic facility that houses primary care and specialty practice as well as a satellite laboratory and radiology and pharmacy services. The practice provides the following centralized services for each of its clinics: registration, payer interface, and billing. The CEO of the practice has asked you to initially devote your attention to Clinic X to improve its efficiency and patient satisfaction. Access Process A primary care physician, patient or family member calls the receptionist at Clinic X for appointment. If the receptionist is in the middle of helping a patient in person, the caller is asked to hold. The receptionist then asks the caller, “How may I help you?” If the caller is requesting an appointment within the next month, the appointment date and time is made and given verbally to the caller. If the caller asks additional questions, the receptionist provides answers. The caller is then given the toll free pre-registration phone number and asked to preregister before the date of the scheduled appointment. If the requested appointment is beyond a 30 day period, the caller’s name and address are put in a “future file” because physician availability is given only one month in advance. Every month, the receptionist reviews the future file and schedules an appointment for each person on the list, and a confirmation is automatically mailed to the caller. When a patient preregisters, the financial office is automatically notified and performs the necessary insurance checks and authorizations for the appropriate insurance plan. If the patient does not preregister, when the patient arrives in the clinic on the day of the appointment and checks in with the specialty clinic receptionist, she is asked to first go to the central registration area to register. Any obvious problems with authorization are corrected before patient returns to the specialty clinic waiting room. Receptionist’s Point of View The receptionist has determined the best way to not inconvenience the caller is to keep her on the phone as short an amount of time as possible. The receptionist also expresses frustration with the fact that there are too many things to do at once. Physician’s Point of View The physician thinks too much of his time is spent on paperwork and chasing down authorizations. The physician senses that appointments are always running behind and that patients are frustrated, no matter how nice he is to them. Patient’s Point of View Patients are frustrated when asked to wait in a long line to register, which makes them late for their appointments, and when future appointments are scheduled without their input. As a result of this later factor, and work of childcare conflicts, patient often do not show up for these scheduled appointments. Office Nurse’s Point of View The office nurse feels that he is playing catch up all day long and explaining delays. The office nurse also wishes there was more time for teaching. Billing Office’s Point of View The billing office thinks some care is given that is not reimbursed because of inaccurate or incomplete insurance or demographic information or that care id denied authorization after the fact. Data On the Picker Institute website (pickerinstitute.org), you will find the following patient expectations and dimensions of care for adults and children in their outpatient experiences with a hospital or clinic outpatient appointment: Respect for patient s’ values, preferences, and expressed needsCoordination and integration of careInformation and educationPhysical comfortEmotional support and alleviation of fear and anxietyInvolvement of family and friendsTransition and continuityAccess to care Your last quarter’s worth of performance data for clinic is Overall satisfaction with visit 82% Staff courteous and helpful 90% Waiting room time 64% Examination room wait time is less than 15 minutes 63% Patient no-show rate 20% Patient cancellation rate 11% Provider cancellation rate 10% Preregistration rate 16% Average number of patient visits per day 16 Range of patient visits per day 10-23 Instructions – Decide which problem your group wants to focus on as your first priority. Describe the problem and why you chose this problemState the goal for this improvement effortIdentify the fundamental knowledge that is required on the team to solve this problem. Define the people you will invite to participate on the team and the fundamental knowledge they bring to the team.Document the current process (as is described in the case) using a process flow chart.Identify your customers and their expectations.Explore and prioritize root causes of the problem by doing the following:Brainstorm root causes and document the causes on a fish bone diagramDescribe how you would collect data about how frequently root causes contribute to the problem.From the points mentioned below select and explain the ones that apply to improving your process. Be sure to take into account what you have learned from your work in question 1-6Eliminate waste (e.g., things that are not used, unnecessary duplication)Improve workflow (e.g. minimize handoffs, move steps in the process closer together, find and remove bottlenecks, do tasks in parallel, adjust to high and low volumes)Manage time (reduce steps and waiting times)Manage variation (create standard work)Design systems to avoid mistakes (use reminders)Incorporating what you learned in above steps, improve the process and document the improved process with a process flow chart or work flow diagram.Decide what you will measure to monitor the voice of the process and briefly how you would collect the dataBriefly explain your change effort using PDCA cycle. Source Kelly, D.L. (2011). Applying Quality Management in HealthCare. AUPHA.

Discussion: Cognitive Behavioral Therapy: Comparing Group, Family, and Individual SettingsPhoto Credit: Getty ImagesThere are significant differences in the applications of cognitive behavior therapy (CBT) for families and individuals. The same is true for CBT in group settings and CBT in family settings. In your role, it is essential to understand these differences to appropriately apply this therapeutic approach across multiple settings. For this Discussion, as you compare the use of CBT in individual, group, and family settings, consider challenges of using this approach with groups you may lead, as well as strategies for overcoming those challenges.To prepare:Review the videos in this week’s Learning Resources and consider the insights provided on CBT in various settings. By Day 3Post an explanation of how the use of CBT in groups compares to its use in family or individual settings. Explain at least two challenges PMHNPs might encounter when using CBT in one of these settings. Support your response with specific examples from this week’s media and at least three peer-reviewed, evidence-based sources. Explain why each of your supporting sources is considered scholarly and attach the PDFs of your sources. https://waldenu.kanopy.com/video/hans-eysenck-beha...https://waldenu.kanopy.com/video/counseling-and-psychotherapy-theories-contexhttps://waldenu.kanopy.com/video/rational-emotive-behavior-therapy-addictions

Conduct a comprehensive  analysis of the FDA’s framework for Benefit: Risk analysis (with  emphasis on RISK) for drugs/biologics and medical devices and discuss  this framework in the context of an approved drug, biologic, or medical  device that experienced a post-approval safety issue.   In sections 1 & 2 of this paper, based on what you have learned throughout the course, your task is to outline the key elements of the FDA’s Benefit: Risk framework for drugs, biologics, and medical  devices.  You should highlight the similarities and differences in the  relevant CDER/CBER vs. CDRH guidance documents, specifically those  aspects of the guidance’s that cover the risk aspect of the benefit-risk  paradigm.   In section 3 of this paper, you will select ONE approved  drug, biologic product that has experienced a  post-approval safety issue. You will analyze the publicly available safety  information about the product and provide a summary and analysis of the  safety issue that was identified and how the safety issue was addressed  (e.g., labelling change, risk management plan put into place, etc.).  THE DRUG SELECTED IS - VIOXX (ROFECOXIB)- IT IS A COX 2 SELECTIVE NON-STEROIDAL ANTI-INFLAMMATORY DRUG (NSAID) Your paper should include the following sections: Title page  Table of contents  Introduction Section 1: Benefit-Risk framework for NDAs/BLAs Suggested topics for discussion in this section include but are not limited to: What is Risk in the context of new drugs/biologics and how is it measured? Summary of pre-market and post-market risk-related activities. Description of pre- and post-market regulatory guidance and  reporting tools for gathering and analysis of risk-related information  about novel drugs/biologics.       Section 2: Benefit: Risk framework for new Medical Devices  Suggested topics for discussion in this      section include but are not limited to: What is Risk in the context of medical devices      and how is it measured? What role does Risk play in the initial      medical device classification and selection of appropriate approval      pathway? Summary of pre-market and post-market      risk-related activities. Description of pre- and post-market regulatory      guidance and reporting tools for gathering and analysis of risk-related      information about novel medical devices.     Section 3: Discussion of publicly available Risk (safety) information for approved drug - VIOXX(ROFECOXIB)    5. Conclusions: Summary of findings and analysis  Based on your independent research on the      product of your choosing as well as what you have learned in this course,      what do you think are some areas for improvement within the regulation of      safety-related aspects of drugs, biologics, and medical devices?