Larchmont Health opened its first urgent-care clinic in Raleigh in 2014. Twelve years later it runs eleven of them, from Wilmington to Asheville, with 214 people on two shifts: days from 7:00 AM to 7:00 PM, nights from 7:00 PM to 7:00 AM. The two shifts overlap for about twenty minutes, and for a long time those twenty minutes carried everything.
“Every morning at six the phone tree started,” says Rowan Castellano, who directs clinical operations. “Night leads calling day leads to ask where the new flu-swab protocol was, whether the X-ray vendor had changed, who had approved a schedule swap. The answers existed. They were in a binder in Cary, a shared drive nobody could search, and two people’s heads.”
Four binders and a shared drive
Larchmont had tried a wiki twice. Both times it filled up fast and went stale faster. Nobody knew which version of the sepsis screening checklist was current, so staff kept printing their own. In one audit the team found seven copies of the same intake script, three of them wrong.
The problem was not writing things down. It was knowing whether what was written down was still true, and knowing who to ask when it was not.
One owner per page
Rowan’s team moved the clinical protocols first, in the spring of 2025. Every page got an owner: usually a clinic lead, sometimes the medical director. Quill asks each owner to verify their page every ninety days, and a page that lapses says so at the top in plain words.
- Protocols: 186 pages, each owned by a named clinician.
- Front desk and billing: 94 pages, owned by the four regional leads.
- Facilities and vendors: 61 pages, owned by one very organized person in Durham.
“The verified badge did more than any policy we ever wrote,” Rowan says. “If a page says it was checked on August 4 by Dr. Patel, nobody prints their own copy.”
Decisions that survive the shift change
The bigger change came with Discussions. Before, a decision made at 2:00 AM (move a patient flow, swap a vendor for the night) lived in a text message. Now the night lead opens a discussion on the page it affects, the day lead weighs in when they arrive, and whoever opened it writes the decision before they go home. It pins itself to the page and lands in the decision log.
In the first quarter the clinics closed 312 discussions. The median one stayed open for nineteen hours, which is to say it crossed exactly one shift change.
The decision log is the first place a new lead goes now. It answers the question every new person has: why do we do it this way?
A year on
Larchmont tracks handoff calls because they are expensive: every one pulls a lead off the floor. They have fallen by 83% since the move. A new front-desk lead used to need 26 days of shadowing; the last three hires needed eleven, mostly spent with patients rather than looking for paperwork.
The binders are still in Cary. Rowan keeps them on a shelf in the operations office, closed, as a reminder.
