Melissa Stratman

04 Dic, 2012
Follow Coleman!

Melissa Stratman

04 Dic, 2012
Follow Coleman!

Small Office Redesign

This is the story of a small faculty practice within a hospital system. This patient visit redesign model is probably the most efficient we’ve seen implemented.

Something had to change. It was a familiar story: patients placed on hold for interminably long times; lack of available and convenient appointment slots; a crowded waiting room with lengthy delays before patients were called back into the clinical area to see their doctors. But Bob Schwartz, M.D., the Medical Director, and Anique Bryan, M.D., the Assistant Medical Director were burning with impatience to change this typical but unsatisfying scenario.

The clinic is the clinical home to nine part-time University of Miami faculty. The practice felt the pressure of modern health care economics and sought to increase patient volume and revenue to avoid staff cuts or closing the practice. Schwartz and Bryan had a solution in mind, inspired by results that they had seen at Jefferson-Reeves Health Center, another ambulatory clinic in the Jackson Health System, which had been trained in Patient Visit Redesign™, and which had been able to significantly lower patient wait times and increase provider productivity.

The Family Medicine Faculty Practice decided to participate in an accelerated redesign process conducted by Coleman Associates called RealTime Redesign™.

Three Coleman Associates trainers arrived on-site on a hot August Monday afternoon, and by Friday morning the Faculty Practice was operating in a whole new way. Gone were the stacks of messages that used to keep Bryan busy for hours after the clinic closed for the day. No longer were there piles of medical charts waiting for the posting of lab results or visit notes.

Instead, staff were surprised find the waiting room empty as they exited for lunch or at the end of the day. Clinic sessions began promptly on time and ended on time. And every staff member became a crucial part of this success. Patients were effusive with compliments and appreciated the newfound respect for their time. In short, the patient visit experience was transformed.

The Redesign Model

The Family Medicine Faculty Practice redesign model demonstrates the power of working in teams, especially when staffing is lean. The Medical Group Management Association (MGMA) national statistical average for a single-specialty family practice clinic is 4.8 support staff FTEs per physician FTE. The Faculty Practice had three MD FTEs, which by MGMA average would translate into 14.8 FTE support staff. The practice had only nine FTE support staff. With this degree of leanness, work processes need to be ruthlessly streamlined and staff organized into very tight teams.

A medical records staffer, a phone attendant, and a “greeter” were the only three staff not assigned to one of the three Patient Care Teams (PCTs). They were “utility players” that supported all the teams. Each PCT consisted of a clinician, a medical assistant, and a receptionist. Those were the old roles though. The new roles extended the range of what each person could do so that each team player had a broad role.

A PCT is considered a clinical home for a set of patients (the clinician’s patient panel). Continuity of care is a huge outcome of redesign, so all “business” pertaining to all patients in the panel becomes the responsibility of the PCT: phone calls, walk-ins, collection of co-pays, filing of medical charts, confirming next day appointments, checking insurance eligibility, and any other patient transactions. In other words, a PCT is a semi-autonomous, small practice. The PCT structure means the organization (of any size) is team-based with a “small is beautiful” mentality.

If a patient phoned the practice for an appointment, the call would be answered by the phone attendant. The attendant would quickly ascertain which PCT was responsible for the patient and immediately relay that call to the appropriate receptionist. (In the future, direct lines to each PCT would eliminate the traffic to the phone attendant.) The receptionist may or may not be at the front desk. Why? Because the receptionists wear wireless phone receivers and can pick up patient calls even as they file medical charts from visits already completed. There’s no reason to have immobile workers in 2005.

If the patient wanted an appointment, it would be booked by the receptionist. If the patient had a question the receptionist could not answer, she would communicate directly, via walkie-talkie, with the PCT’s medical assistant to get an immediate answer. This system meant that incoming work was handled on a real time basis and not stacked up for someone to get to after the clinic session ended.

New tools and equipment helped stretch the available resources. Digital floor scales were placed in every exam room to weigh adult patients quickly and privately, eliminating the extra stop at a vitals station. In fact, all work was done in the exam room reflecting the redesign principle “Organize our work around the patient, not the patient around our work”.

PCT members used walkie talkies so they could quickly and directly communicate with each other throughout the day. The physician no longer had to hunt for the medical assistant, who now could be summoned to the exam room quickly.

Each PCT was provided with fast and reliable wrist blood pressure gauges which the medical assistants kept in the pocket of their scrubs. That ended innumerable searches for that elusive large blood pressure cuff.

The flowmaster, phone attendant, and a medical records staffer formed the Logistics Team, which worked supported all three Patient Care Teams. The medical records expert was responsible for pulling medical charts 24 hours in advance of clinic sessions and filing lab results in charts on a real time basis. Lab results were not allowed to pile up for batch processing—a source of errors and rework. PCT receptionists were responsible for filing charts after visits (and for looking for “lost” charts” since they had filed them—which reduced the incidence of lost charts.)

The flowmaster is a position that requires some explanation. This is not a “greeter” who would merely greet patients as they arrive. This is a drive gear of a position. This is the person who is absolutely obsessed with moving patients from the front waiting room and into the exam rooms, and equally obsessed about patients exiting the exam rooms without the typical long waits for a clinician or an ancillary staff member to wrap up a visit.

The best flowmaster knows the front desk operations, has some clinical experience (usually as a medical assistant), and enjoys an easy rapport with both patients and staff. It’s a lot to ask for in one person, but it is what is required to do this role well, and there was such a person on staff at this clinic.

The flowmaster was stationed in the front of the clinic to greet and expedite arriving patients. The flowmaster would move the patient to the appropriate front desk person to be processed immediately (no sign in sheet), while communicating the PCT’s medical assistant to get an accurate estimate of the wait time for this patient. The flowmaster relayed that information to the patient, made sure the patient was comfortable with the wait time, and then proceeded to “debug” any flow problems occurring in the clinic to keep visit cycle time within 45 minutes for 90% of all visits.

The Logistics Team provided the support which enabled the PCTs to focus entirely on their patients. The flowmaster knew which patients were waiting for how long to see which Patient Care Teams and worked to alleviate flow problems, the phone attendant picked up all the outside calls and relayed patient calls to the right PCT, and the medical records expert kept the charts well maintained and prepared for each clinic session.

What was so impressive about this practice model is that was so efficient and utilized so few personnel. Each Patient Care Team became, in essence, a “mini practice” which was able to take care of all of the needs of the patients assigned to it. As staff gained more experience working together every day in their PCTs, they also became stronger and more adept in handling curve balls and variations in patient flow. Stacks of paper seemingly melted during the RealTime Redesign week. Staff worked hard but were thrilled with the results because their patients were delighted with the patient visit redesign.

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