Improve access and efficiency, and your patients and staff
will have something to smile about. Here's how some medical offices are
doing it.
Something amazing happened to FP Greg Long last February. That was when
his four-doctor practice in Appleton, WI, began offering patients appointments
the same day they called. Previously, they'd had to wait 10 to 14 days for
a nonurgent appointment, and up to six months for a physical. Now, Long
and his colleagues can see their patients when they want to be seen—and
without working longer hours.
"My job satisfaction has increased, because I know I'm giving my
patients better service," says Long. "And I know they're happier,
because they're telling me they are."
The nurses are happier, too. "They don't have to sit on the phone
trying to keep people out of the office," notes Long. "Nurses
can put patients in appointment slots when they need to be seen. That gives
the nurses time to do more patient care."
Long's practice is one of two offices in the ThedaCare health care system
trying out re-engineering techniques that will eventually affect all 100
of the system's primary care physicians. Same-day access is only part of
the comprehensive redesign going on in those two sites. Another strategy
affects triage nurses: Instead of having one for each physician, Long's
clinic plans to let any available nurse take calls from any doctor's patients.
The calls will also be routed directly to the nurses, rather than being
screened by receptionists, as they are now. The twin goals are to streamline
scheduling and to free the receptionists for other duties.
PeaceHealth, an integrated delivery system based in Bellevue, WA, has
traveled further down the re-engineering road. One-third of the 50 primary
care physicians employed by the system are offering same-day scheduling,
and one 10-doctor office has fundamentally reorganized its clinical work
processes.
Internist Frank H. Littell, one of several physicians who's orchestrating
the changes at PeaceHealth, works in the prototype site in Eugene, OR. He's
part of a "care team" that includes two other internists and the
five staffers who interact with their patients, including medical assistants
and an LPN. (The FPs and pediatricians in the office also belong to care
teams.) What makes these teams so efficient and boosts their productivity
is their physical proximity and the cross-training of staff members.
This strong, flexible staff support has been a key to making same-day
access feasible in Littell's practice. Another factor was the internists'
decision to expand appointment slots from 15 to 20 minutes each.
"That's allowed us to dictate the chart right after each visit,
grab the piles of things in the inbox, and deal with any phone calls as
they arise," explains Littell. "So it's a function of being realistic
about the other work that we do beyond seeing patients. That's been the
key. I have added some time to my bookable hours. On the other hand,
my total in-office time has shrunk, because I'm not batching stuff at the
end of the day or at lunch."
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."
The IDCOP participants are still trying to work out the right size and
composition of a care team. But the consensus seems to be that it should
include two or three physicians and four or five staff members who should
be cross-trained to back each other up. That flexibility saves time and
prevents work from slowing down or halting when a key person is missing.
In the past, notes Frank Littell, the staffers in his practice did their
own jobs and ignored everyone else's. Scheduling, for example, was the province
of phone receptionists, not nurses. But it's the nurses who know more about
patient needs. Under the new system, they can schedule, and the receptionists
(all LPNs or medical assistants), who now sit in the back office, can order
refills with the help of protocols. (The few greeters left in the front
office just collect copayments and alert the care team when patients arrive.)
Having the receptionists do 75 percent of refills, he adds, has greatly
reduced the number of charts he has to look at.
While nonphysician members of the care team rotate through jobs other
than their own, they primarily focus on one thing at a time. This, he says,
produces greater efficiency and fewer errors than the previous system, in
which his nurse often got backed up and would be rushing between different
tasks.
Although ThedaCare hasn't yet formed care teams like those at PeaceHealth,
it's changing staffers' job descriptions. Instead of Greg Long's nurse handling
referrals to specialists and labs between her other duties, as she does
now, receptionists will be in charge of referrals. They'll have time to
do them once incoming phone calls are routed directly to the triage nurses.
Other staffers now do paperwork that used to drain hours from Long's
schedule each week. The radiology technician fills out patient reports for
normal mammograms, and Long's nurse does the same for normal Pap smears.
A medical-records clerk has been trained to complete disability forms, each
of which used to take Long 15 to 20 minutes.
FP Gordon Moore of Strong Health notes that even small time wasters can
add up to gross inefficiency. At Fairport Internal Medicine, for instance,
the day's appointment schedule was posted on a piece of paper between the
front office and back offices. "Whenever a patient called to change
an appointment, the receptionist would have to get up from her desk, walk
back to look at the schedule, get back to the patient on the phone, then
go back to see if another appointment was available," Moore says. "The
nurses also had to walk back and forth to look at this piece of paper."
The solution was to use the practice's computerized scheduling system not
only for booking patients ahead, but also for adding and dropping appointments
on the day's schedule.
Some simple changes can not only improve efficiency but raise staff morale,
as well. At the Latham Medical Group, for instance, charts used to be filed
in a small, cramped area upstairs, and the doctors would be furious because,
half the time, they couldn't find charts in time for appointments. The situation
was so frustrating that about two-thirds of the medical-records staff quit
last year. After the practice created a better record room downstairs and
relabeled the charts by number instead of name, doctors were able to get
their hands on most charts, and the staff turnover stopped.
Greater efficiency also pays off in terms of patient satisfaction. Prior
to the redesign of Frank Littell's office, for example, patients complained
they couldn't get through to the office by phone. Afterward, the percentage
of callers who hung up or were cut off dropped from 35 to 8 percent, he
says.
The idea of caring for some patients without seeing them may appeal more
to physicians in highly capitated practices than to those who depend mainly
on office visits for income. But to IHI president Don Berwick, "The
more you can move demand away from office visits, the more time you'll have
to deal with patients who really need personal interaction."
Ed Enos of the Latham Medical Group points out, "Patients don't
always want to come to the office. Sometimes they just want advice from
one of our triage nurses." A woman with a urinary tract infection,
he adds, can drop off a urine specimen and, depending on the test result,
might receive a prescription for an antibiotic without seeing a physician.
This option, he notes, "is very convenient for working women."
Now that the triage nurses in Greg Long's practice spend less time on
routine visit scheduling, "they're able to do more active management
of diabetics over the phone," he says. "They're instructing patients
on diet and exercise, getting them scheduled for their eye exams, and so
on."
Long believes this kind of activity limits return visits. "We've
always assumed that people have to get their care in face-to-face visits.
But a big part of IDCOP is getting people to do more care management over
the phone or the Internet. That's going to decrease the need for visits."
A growing number of physicians, both inside and outside IDCOP, are communicating
with patients by e-mail. A few doctors are even using e-mail to handle
their patients' simpler health problems.
For AAFP President Bruce Bagley, this approach is "a bit of a stretch."
On the other hand, he points out, "We're doing a lot more telephone
medicine now than we did five or six years ago. That doesn't necessarily
mean we're diagnosing and treating over the phone, but we're giving out
health advice that people used to come to the office for."
The toughest obstacle: Cultural change
Ultimately, the biggest challenge to re-engineering is not technological,
but behavioral. Physicians aren't used to thinking of themselves as part
of a team; and, even if they see the need for change, Bagley points out,
"they're fearful it's going to interfere with their patient focus."
"The question is, should we gear up to provide customer service
at all hours of the day, or should we inform patients that we're here after
hours for acute care only? Some of our docs believe we should be providing
all services at all times, and others tend to resist that." Latham's
solution: Put on extra nurses to take routine calls in the evening, and
ask physicians to respond to insistent callers only. The doctors have complied,
and Enos believes this has raised patient satisfaction.
Physicians are also reluctant to take responsibility for problems they
create with their staff, contends Gordon Moore of Strong Health. "In
the typical doctor's office, the staff views the customer as the doctor,
not the patient," he says. "If an employee angers the doctor,
she's in trouble. And that's wrong. So you get into a re-engineering workshop
and you try to figure out why so many patients are complaining that they're
not getting test results on time. It's because Dr. So-and-So sits on his
hands, not getting the forms back in time to patients. The secretaries know
this. They're the ones getting the heat. But the patients won't say boo
to the doctor; he walks on water. That puts the secretaries in the middle,
and it's a miserable position.
"So when we're getting ready to switch to same-day scheduling, we
tell the doctors, 'You've got to take responsibility and be available to
sign the forms.' When you do that, you take away a lot of pressure and make
it easier for the secretaries to do their jobs."
Knee-deep in the redesign process at PeaceHealth, Frank Littell finds
that "stress is up, but satisfaction is up. We hope the stress level
will come down." Before that happens, though, the group will have to
do a better job of planning for contingencies. Some of the pressure would
be relieved if PeaceHealth hired more midlevels, he says. But just as important,
he emphasizes, the physicians need to start planning their vacations cooperatively.
"Traditionally, doctors just sign out. That doesn't work in a group
doing open access. They have to be more cooperative. We're still dealing
with some of the realities of culture and history."
Written by
Ken Terry. Re-engineer your practice--starting today. Medical Economics, www.memag.com
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My goal as a physician is to deliver superb care in a vital and sustainable practice. 