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Envision the ideal medical office, a place where patients can call for an appointment and come in the same day. It’s an office where staff morale is high and patients feel like partners in their care. There is a steady flow of information allowing physicians to discover inefficient or faulty processes and fix them.
Medical groups around the country are trying to turn that vision into reality through a project sponsored by the Institute of Healthcare Improvement (IHI) in Boston. Rather than seeking to address a narrow quality improvement goal, 42 quality improvement (QI) teams at 23 health care organizations are working to become prototypes of a patient-centered and quality-based practice through the "Idealized Design of Clinical Office Practices" project. (For a list of the principles for clinical office practices, see box, p. 146.)
"It really is daunting," says Frank Littell, MD, an internist with Peacehealth Medical Group in Eugene, OR, and a faculty member with the IHI project. Yet the dangers of not acting were even greater. "The challenge we faced is that like many other integrated delivery systems, the medical group has lost money ever since the development of the integrated system. We had an opportunity to look at the redesign of the medical group."
The first sites began examining their processes in January 1999. They are collecting data every six months and anticipate having significant improvements to reveal within three years, says project manager Mora Babineau, MHP.
Some benefits are readily apparent, Littell says, pointing out that initial changes have boosted the morale of staff and physicians and increased patient satisfaction.
Scheduling and access are areas that plague staff, physicians, and patients alike. So the "Idealized Design" practices began by trying to improve patient flow and scheduling, often moving toward open access that allows same-day scheduling and attempts to match physician supply with patient demand.
"What are the one or two areas that people are disgruntled about on a daily basis? Their schedules," says Babineau. "People felt they had no time."
So practices greatly reduced scheduling types and, in some cases, added hours. "It also helps you when people are in for an appointment to max-pack’" by addressing preventive needs even though the patient came in for an acute problem, she explains.
For Peacehealth, open access went hand in hand with another innovative change — care teams. The medical group moved schedulers and clerks to the back of the office into the doctor-nurse care teams. Each team now has a dedicated scheduler who answers a separate phone number for one team. The nurses and medical assistants have been cross-trained to handle patient phone calls and paperwork.
The changes correspond to a business model called "Lean Thinking," based on a book by the same name written by James Womack and Daniel Jones.
"Most clinics have a lot of inefficiency," says Littell. "Nobody in the front knows what the people in the back are doing. Nobody in the back knows or appreciates what the people in the front are doing. "We decided to combine the front and the back office, to create three teams with three or four providers per team," he says. "The people involved in the delivery of health care should all work together, and that includes the front office."
The change improves patient flow because the cross-trained staff can now support each other.
Test new ideas with leaders’ support
Peacehealth has just begun considering other changes using a rapid cycle process of quality improvement that allows the medical group to test ideas and expand or discard them. For example, Peacehealth is creating a software-based registry of diabetic patients to help the medical group track their care.
"Some of us in the group are experimenting with audiotaping the visit and giving it to the patient to improve compliance with instructions," says Littell, who adds that written instructions also are provided.
The medical group also may add some lab capabilities that would allow for "real-time" results to increase efficiency in patient care.
Other IHI project participants are adopting other innovations, but it’s still too early to capture many lessons from the practices that seek to redefine how they provide care, says Babineau. "It takes a long time to make change. We’re facing that reality as we’re heading to our second year."
Yet one fact is clear: Success relies largely on the commitment the project receives, she says. "It’s important to have leadership from the CEO level and leadership at the site. We’re seeing success where the leadership is coming from the physicians. Putting them back in charge of this work is the right way to go."
IHI also requires the sites to devote a half-time or full-time employee as a project manager. Each quality improvement team sets specific aims, and the project manager coordinates monthly data collection and a monthly report to senior leadership, staff, and IHI.
"If you’re really serious about doing this, you need someone who is collecting information, getting your data walls up [to track trends using charts], making sure everyone is staying focused," Babineau says.