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A national initiative aims to improve outpatient care
The redesign projects at ThedaCare and PeaceHealth aren't isolated efforts.
These organizations are among two dozen group practices and IPAs participating
in a national re-engineering program. The three-year initiative at more
than 40 practice sites—both large and small—was organized by the Boston-based
Institute for Healthcare Improvement, which has been promoting clinical
quality improvement for a decade.
The overarching goal of the institute's Idealized Design of Clinical
Office Practices (IDCOP) program is to upgrade the quality of outpatient
care. The program proposes to remove barriers to patient access, reduce
waste and inefficiency, improve patient-doctor communications, expand links
with the community, and help physicians gain access to clinical knowledge
at the point of care.
IHI, which isn't blind to today's financial realities, also stresses
that re-engineering needs to improve a practice's bottom line. Pediatrician
Donald M. Berwick, president of the institute, notes this is especially
important for the health care systems that form the bulk of the program's
participants. A lot of them, he says, "are losing tens or hundreds
of millions of dollars on infrastructures they can't support."
Nevertheless, IDCOP organizations say that placing excessive emphasis
on profitability can be counterproductive. "When there's too much pressure
to improve the bottom line, it subverts the redesign effort," says
FP Gordon Moore, associate chief medical officer for Strong Health in Rochester,
NY. "It makes people grumpy and reduces morale. You really need to
have an all-encompassing focus. That's what gets the doctors and the offices
aboard."
Having seen many quality improvement programs come and go, physicians
are naturally skeptical of this one, too. When Moore talks about raising
the number of patients seen, he says, some doctors accuse him of trying
to turn their offices into health care mills. "What I say is, 'If you
think that's a problem, let's measure patient satisfaction every week. And
if it starts to dip, we'll back off.' " So far, he adds, patient satisfaction
is rising with improved access and efficiency.
The Latham Medical Group, a nine-doctor primary care practice in Latham,
NY, joined the IDCOP collaborative mainly because Latham's leaders recognized
that patients weren't being treated right. "Based on the number of
patient complaints we were getting, we felt that our overall quality of
service was poor," says Ed Enos, the group's administrator. "And
that tends to spill over to the staff and the docs, because a lot of time
is spent explaining to patients what our service limitations are. So poor
service diminishes staff satisfaction, as well."
Berwick says these kinds of problems are endemic to most medical offices.
If a practice is functioning properly, he says, its patients should be able
to say, "'They give me the help I want and need when I want and need
it.' There is no way this can be done in the current office environment."
To turn this situation around, says internist Charles M. Kilo, director
of IDCOP, the collaborative is trying to "redesign all components of
the office, assuring that we not only have the best components, but that
they interact together in a way that produces the best possible performance."
IDCOP organizations are trying to help each other reach that goal by
attending quarterly conferences, visiting other medical offices, and networking
by phone and over the Internet. Eventually, they'd like to spread their
innovations to all practice sites within their groups.
If you're in a small, independent practice, re-engineering may seem like
an impossible dream. You probably wonder how you can revamp your whole practice
without outside help, not to mention big bucks for a world-class computer
system. But many of the sites involved in IDCOP aren't highly computerized;
in fact, Kilo warns against waiting for an electronic medical record system
before you re-design your practice.
"Certainly, the office of tomorrow will be more computerized than
it is today, and that will make many things easier and increase the reliability
of medical diagnoses and treatments," he says. "But the transition
isn't easy, and we shouldn't wait for it, because there's too much we can
do today."
The IDCOP groups and parent organizations are spending $25,000 per site
per year to participate in the program. But you don't have to duplicate
their work to benefit from it, notes FP Bruce Bagley, leader of the Latham
Medical Group and president of the American Academy of Family Physicians.
"The purpose of IDCOP is to figure out what the right template is,
and that's extremely labor- and resource-intensive," he notes. "Once
the collaborative comes up with the theoretical right answer about how to
run an office—how the telephone system, the appointment scheduling system,
and the billing system should work—everybody else just has to implement
it."
Bagley says he wants the AAFP to spread the re-engineering gospel to
its members. He and other leaders of the society plan to meet with IHI officials
in February to map strategy. In addition, Kilo says, the American Academy
of Pediatrics has an internal office redesign program parallel to IHI's.
And a number of practices not involved in IDCOP are engaged in redesign
projects of their own.
To its proponents, re-engineering is an urgent mission for all doctors.
"The market's going to demand consistent quality in diagnosis and treatment,
and it's going to demand service," says Bagley. "Physicians who
don't meet those demands are going to be like the local hardware store when
The Home Depot comes in. They're just not going to make it."
One year into the redesign project, IDCOP is still grappling with fundamentals.
Even those organizations that are furthest along are still focused mainly
on improving access and efficiency. And, while some are spreading the gospel
to physicians outside their prototype sites, it's a struggle for these other
doctors to reach open access without adequate internal support systems.
That's a prime reason why only 30 percent of PeaceHealth's primary care
physicians offer open access now, vs 75 percent several months ago. "Some
of them backslid," says Littell.
Another obstacle: how physicians are paid. Production-based salaries,
for instance, don't motivate doctors to pack as much as they can into each
visit and to discourage non-essential visits—key redesign goals. While
many IDCOP participants are highly capitated, all of them are struggling
with the question of how to compensate physicians in ways that promote re-engineering.
There's also a question of physician leadership. Doctors with the kind
of vision required to champion re-engineering can't be found in every office.
That's why in larger, multisite groups, physicians like Littell have to
give up some of their practice time to help implement changes both within
their practices and beyond.
Then there are extra costs, including staff training and, in some cases,
the hiring of additional workers. At ThedaCare, for example, the busy physicians
wouldn't have been able to maintain same-day scheduling without adding an
extra midlevel practitioner, notes Long. The reason was contingency planning:
A doctor who takes time off needs another physician and a PA or an NP to
cover for him while he's gone.
Moreover, while re-engineering aims to give staffers more responsibility
and increase their job satisfaction, it can also be frustrating, confusing,
and time-consuming, especially at the outset. At Strong Health's prototype
sites, for instance, "there have been changes in job descriptions and
roles, and some staffers have been uncomfortable. Some have left,"
says FP Gordon Moore. Overall, though, Moore says re-engineering has led
to skyrocketing morale.
When busy physicians think about going to same-day scheduling, their
biggest fear is that they'll be inundated with patient visits. But that
shouldn't happen, unless a doctor's panel is too big. According to Charles
Kilo of IHI, 0.7 to 0.8 percent of a doctor's patients will call for an
appointment each day, on average, and 80 percent of those who call will
accept same-day appointments if they can get them.
Since Littell sees patients only three days a week, he keeps his panel
small. He gets about 15 visits daily, rising to a peak of 25 on some days.
On most days, however, he's able to leave work an hour earlier than he did
before. That's partly because he now does all his dictation, phone calls,
and refills between appointments. His full-time colleagues also tend to
leave earlier. While they could see more patients, he notes, they value
their lifestyles more than extra income.
In contrast, some physicians are using open access to expand their practices.
At Fairport (NY) Internal Medicine, which is owned by Strong Health, visits
are up 40 percent since last January, when the practice introduced same-day
scheduling. Each of the two doctors in the 2-year-old practice is bringing
in 15 to 20 new patients a week—which internist Wallace E. Johnson attributes
largely to open access.
FP Greg Long of ThedaCare, who has a relatively large panel, sees about
28 patients a day, compared with 32 before his office went to same-day scheduling.
When most of his appointments were prebooked, he'd leave four slots open
daily for urgent cases. Now he goes into each day with 15 open appointments.
"I'm able to see all my patients who call on any given day. But on
a light day, I might not fill all my open slots. And there are days when
I fill all 15 plus a couple more. So it's less predictable than it used
to be," he observes.
Nevertheless, open access has decreased the stress on Long. Like Littell,
he does most of his patient-related work during and after visits, so it
doesn't pile up at the end of the day. "It also seems that the nurses
are getting done a bit earlier, because we're able to get through phone
messages faster and more efficiently. Before, if I was running behind because
I had everybody double-booked, I'd want to keep doing patient care. So messages
would be the last thing I'd take care of."
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