Encouraging System Thinking in the Office

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Encouraging System Thinking (in the Office!)

• Supporting Improvement and Innovation Learning
  Series
• Connie Sixta, RN, PhD, MBA

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Use of three sets of change concepts

• Expanded Chronic Care Model
• Advanced Access
• Office Redesign

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BCs Expanded Care Model
Build Healthy Public Policy
Community
Create Supportive Environments
Strengthen Community Action
Health System
InformationSystems
Self-Management Support/Develop Personal Skills
Delivery System Design/Re-orient Health Services
Decision Support
Prepared, Proactive Community Partners
Productive Interactions and Relationships
Prepared, Proactive Practice Team
Informed, Activated Patient
Activated Community
Population Health Outcomes Functional and
Clinical Outcomes
http//www.healthservices.gov.bc.ca/cdm/cdminbc/ch
ronic_care_model.html
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Foundation of access and redesign changes

• Physician/provider panel of patients
• Continuity of care for patients

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The facts about improving access

• Occurs within each providers practice.
• Improves one provider at a time.
• Requires Medical Director and Management
  leadership and support.
• Depends on clinical and support team involvement.

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Access changes

• Patients get appointments when they request it
• Patient illness/concern managed promptly
• Decrease in ER visits and hospitalizations
• No need to book unnecessary future appointments
• No need for resource intensive telephone triage
• Necessary follow-up appointments are scheduled
• Clinical Outcomes and Satisfaction improve
• No Show rate decreases
• Wasted appointments minimized (capacity
  increases)
• Decreased waste of resources (rooms, staff,
  provider)
• Productivity and cost per case improve

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Access changes

• Demand and supply of providers is monitored and
  managed
• Continuity of care is managed to increase
  efficiency, decrease rework, increase patient
  safety
• The visit is maxpacked at point of service
• Contingency planning by providers and
  administration is proactive
• Maintain the supply of providers
• Plan for attrition, vacations, and medical leave
• Partnership aimed at meeting patient demand

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How do we improve access eliminate the backlog

• The increase in backlog stops when demand and
  supply are balanced
• The backlog scheduled beyond today is eliminated
  (this does not include provider scheduled follow
  up appointments).

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Shape the demand for patient visits

• Decrease demand for an appointment by
• Phone follow up instead of visit follow-up can
  be done per protocol by nurse/Medical Assistant
• Extend the time between follow up visits as
  appropriate
• Institute new processes and protocols to manage
  routine activities (i.e. nurse-managed medication
  refill, referral mechanisms)

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Shape the demand for patient visits

• Stretch the constrained resource (provider)
  Group Visits
• Can be condition-specific (diabetes, cardiac)or
  general
• Provider sees his or her own patients
• Behavioral health specialist can facilitate
• Nurse for patient education topics
• Incorporate individual, private exams(makes the
  visits billable)

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Shape the demand for patient visits

• Group visits Results
• Patients learn from one another
• Self-care improves
• Provider can take care of more patients (see 12
  patients in a 2-hour slot)

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Shape the demand for patient visits

• Reduce the time gap from booked to visit Visit
  reminders
• Do you book returns 4 weeks away? Risky!
• Will the patient keep the appointment?
• Our patients lives can change a lot in 4-6 weeks
• Will the day time still be convenient?
• Some will initially accept, then cancel or
  no-show
• Appointment in the books false sense of security
• Dont book remind

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Shape the demand for patient visits

• Reduce the number of visits needed
• Visit alternatives (phone, e-mail)
• Check-in with patient when exam isnt needed
• Should consider secure e-mail
• Unfortunately, not reimbursed
• Benefits convenient for patient, productive for
  provider, use time saved to see more patients in
  the community

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Shape the demand for patient visits

• Visit reminders
• Reduce the number of visits needed
• Extend return intervals
• Get the most from every visit Maxpacking
• Grow the nursing role

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Access redesign improves effectiveness and
efficiency at the practice level

• Increases provider and team capacity
• Gets the waste out of the system
• Improves patient continuity and related clinical
  outcomes
• Increases patient access to care
• Increases the efficiency of the patient visit
• Improves provider, staff, and patient
  satisfaction
• Gets the waiting time out of the system

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Redesigning the clinic visit

• We redesign processes to
• Decrease the length of the visit (cycle time),
  getting the waste out of the clinic visit
• Increase efficiency, getting the wait out of
  the patient visit stand
• Increase productivity and throughput without
  working harder
• Increase provider, team, and room capacity
• Increase care effectiveness

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Patient enters clinic
Registration
Pre-Red Zone
Clinic Room
Cycle time
Provider-Patient Interaction
Red Zone
Completion of procedures/orders
Post-Red Zone
Checkout
Non-appointment time
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Patient Flow through the Clinic
Patient enters clinic
Registration
Pre-Red Zone
Clinic Room
Cycle time
Provider-Patient Interaction
Red Zone
Completion of procedures/orders
Post-Red Zone
Checkout
Non-appointment time
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Begin process redesign by mapping out the
process

• Complete a process walk-through (example clinic
  processes)
• Have a staff member pose as a patient and
  walk-through a clinic process
• Tell the staff about the walk-through and ask
  them to act normally
• Start the process with the pre-process step and
  continue the process through to completion
• Document the starting time of each step in the
  process, what works well, what does not work
  well, what thoughts you have for improvement,
  what feelings you experienced during the process
  
• Map the process

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Clinic walk-through data collection form
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Key
Process
Key
Process
Key
Process
Key
Process
Key
Process





 
 
 
 
 
Beginning
Beginning
Beginning
Beginning
Beginning
Process flow
mapped
Step 1
Step 2
Step 3
 First Step
Step 4
Decision
Step 5
Step 6
Last Step
Step 7
 
 
 
 
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Example getting an appointment
Patient calls the Centers main to make an appt.
Automatic recording answers, pt. inputs 4
Registration answers, asks questions, and puts
the pt on hold

Checks with MA for next possible appt time

Registration tells pt that the MA will talk with
him to discuss his symptoms/related appt and puts
pt on hold
MA interviews pt to determine need for appt
Checks with RN for next possible appt time
MA tells pt that the RN will talk with him, puts
the pt on hold
RN talks with pt about his symptoms, says he will
get an appointment, puts pt on hold
Tells registration to give pt an appt
Registration gives patient an appt time
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Use redesign principles

• Do tasks in parallel
• Use multiple processes
• Minimize handoffs
• Synchronize
• Use a pull system
• Move steps closer together
• Use automation
• Consider people to be in the same system
• Use multiple processing units
• Have specialists do only the tasks that require
  their specific skills
• Convert internal steps to external steps that do
  not require direct provider supervision

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Do tasks in parallel

• To complete a process correctly, most tasks or
  steps of the process do not need to be done
  sequentially
• Examples
• Have the patient fill out the self-assessment
  form while the front office staff is pulling the
  chart
• Have the patient review the billing and income
  qualification information while the staff is
  updating the registration information

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Use multiple processes

• Use multiple processes to handle patient needs
  according to age, condition, and presenting
  problem
• Examples
• Physical exams
• Immunizations
• Group visits for patients with chronic illness
• Education sessions for new patients that need to
  fill out forms and be oriented to the clinic
  processes
• Special education sessions

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Minimize handoffs

• Minimizing the number of staff that is involved
  with a visit process decreases process time, and
  errors
• Accomplish this by consolidating tasks,
  decreasing handoffs, and cross training the staff
  so that one person can handle as many
  non-provider tasks as possible
• Examples
• During the visit have a consistent staff member
  room the patient, gather clinical data, hand
  patient to the provider, and receive patient from
  the provider to complete the visit process
• Have a staff member complete the entire chart
  preparation process including identification of
  individual patient needs

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Synchronize

• All steps of the clinical process are
  synchronized around one point when the patient
  is ready in the room for the provider
• Example If clinic visit starts at 100 pm, the
  following actions should occur
• 1) The patient should arrive right before 100
  pm,
• 2) The registration person should greet the
  patient at 100 pm, ask for any updates in
  information, and get the patients chart,
• 3) At 105 pm the registration person should
  handoff the patient and chart to the MOA who
  takes the patient to the room, takes the
  patients BP and weight, confirms the patients
  medications
• 4) At 115 pm the MOA patient takes and hands off
  the patient to the provider.
• 5) The synchronization point is 115 pm the
  patient is ready for the provider and the
  provider is ready for the patient at 115 pm.

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Use a pull system

• Use a strategy that pulls the patient into and
  through the clinic in deference to pushing the
  patient from the waiting room
• Pushing denotes pushing against all kinds of
  resistance and bottlenecks
• Example The Medical Office Assistant lets the
  front office know when the room is ready so that
  when the front office completes the sign-in
  process, the Medical Office Assistant is right
  there to greet the patient and escort them back
  to the clinic room

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Move steps closer together

• If support departments are geographically far
  apart from each other, moving them closer
  together save time
• Example
• The laboratory is moved closer to clinic rooms
• The laboratory technician comes into the patient
  room to draw the specimen
• The business office is located close to the
  clinic rooms, so that insurance verification can
  be expedited

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Use automation

• Use a computerized system to manage a process
• Example
• Electronic Medical Records interfaces with the
  laboratory and radiology and reports are
  automatically generated
• Clinic room documentation is done by the provider
  to prevent double charting and errors

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Consider people to be in the same system

• All staff are accountable for a smooth and
  efficient flow process whether they work in
  clinical or support departments
• Example
• All support departments are represented on the
  access and redesign improvement team
• All staff have an important and valuable role to
  play
• All staff must work together to coordinate the
  process and care

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Use multiple processing units

• Using a number of clinical care units or teams to
  manage components of the patient load
• Examples
• Three pods within a large clinic
• Admission is a process separate
• Chronic disease management is done in group visits

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Have specialists do only the tasks that require
their specific skills

• Each team member needs to work to the highest
  level related to their education, training, and
  capability so the work of the team and each team
  member can be maximized
• Providers should do provider tasks, nurses do
  nurse tasks, Medical Assistants do Medical
  Assistants tasks, etc.
• Example Licensed Practical Nurses doing
  immunizations, Medical Assistants doing LEAP
  exams

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Redesign roles of the provider and staff

• Aim
• Protect provider-patient interaction (the Red
  Zone)
• Increase provider capacity

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How do we maximize the clinical team?

• Assign team members to a consistent provider
• Schedule weekly team meetings to design/discuss
  team development-- expect presence of all team
  members
• Define the objectives/purposes of the team
• Develop team member roles/expectations
• Maximize each team members role
• Use protocol, policies, and procedures
• Teach and Train
• Synchronize the team
• Establish daily communication session to
  discuss/finalize the days plan
• Care coordination
• Problem-solving
• Huddle format
• Evaluate team progress on an ongoing basis

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Develop the consistent provider team

• Assign consistent team members to each provider
• Define the purpose of the clinical team
• Schedule routine, consistent team meetings
• Establish team communication
• openness
• valuing of team members
• Begin the work of the team
• Evaluate roles and processes
• Promote problem-solving approach
• Initiate performance improvement

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Maximize the role of each team member

• Agree to maximize the role of each team member to
  the highest level of education/license
• Evaluate the role (tasks done) by each team
  member
• Evaluate the non-appointment tasks
• Who is doing them?
• Can the tasks be batched?
• What is the Demand and Supply around the task?
• Evaluate the provider interruptions that occur
  during the Red Zone and evaluate tasks that
  can be delegated to prevent interruptions

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Maximize the role of each team member Cont

• Re-assign non-provider tasks to non-providers
• Re-assign non-nursing tasks to non-nurses
• Re-assign non-Medical Office Assistant (MA) tasks
  to a non-Medical Office Assistant (a non-clinical
  person)
• Re-assign or batch non-appointment tasks and
  assign to appropriate staff

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Flow improvement outcomes

• Ensure value-added time for the patient
  (interaction time)
• Decrease wasted time for the patient (wasted time
  is not value-added time)
• Protect the red zone the value
• Prevent interruptions
• Make sure provider is only doing provider tasks
• Add capacity for more red zones

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Managing non-appointment work

• What is the non-appointment work?
• Documenting
• Refilling medications
• Reviewing labs/x-rays
• Taking and returning messages
• Making referrals
• Managing forms
• Can the non-appointment work be batched?
• When can the non-appointment work be scheduled?

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Managing non-appointment work

• Identify clinic support processes contributing to
  delays
• Determine what the work is and who is doing it
• Measure how much work there is (measure demand)
• Determine how many resources are available
  (measure supply)
• Redesign the processes to balance demand and
  supply

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Synchronize the clinical team

• Start on time and stay on time
• Complete Pre-red Zone work on time
• Synchronize Red-Zone
• Synchronize Patient
• Synchronize Room
• Synchronize Equipment
• Synchronize Provider
• Synchronize Information
• Document real time

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Synchronization of the clinic visit

• Room
• Staff
• Equipment
• Information (Chart)
• Patient
• Provider

9 am
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Synchronization example
When the clinic visit starts at 100 pm, the
following actions should occur 1) The patient
should arrive right before 100 pm2) The
registration person should greet the patient at
100 pm, ask for any updates in information, and
get the patients chart 3) At 105 pm the
registration person should hand-off the patient
and chart to the MOA who takes the patient to the
room, takes the patients BP and weight, confirms
the patients medications 4) At 115 pm the MOA
hands the patient off to the provider 5) The
synchronization point is 115 pm the patient is
ready for the provider and the provider is ready
for the patient at 115 pm
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The truth about synchronization

• The visit can only go as fast as the slowest step
• If the visit starts 15 minutes late each
  session (AM and PM), a clinic can waste 400 15
  minute appointments per year
• You need to work backwards from sync time to
  make sure everything/everyone is ready on time

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Teamwork during a patient visit

• Maintain continuity of care with provider and
  team to promote efficiency and effectiveness
• Use the registry to identify and manage patient
  needs
• Use data to predict and manage the unexpected
• Make sure the team is prepared to handle common
  procedures
• Plan the visit, utilize the team and team member
  expertise

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Predict and anticipate patient needs at time
of visit

• Maintain continuity of care to promote efficiency
  and effectiveness
• Use the registry to identify and manage needs
• Use data to predict and manage the unexpected
• Make sure the team is prepared to handle common
  procedures
• Plan the visit, utilize the team and team member
  expertise

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The clinical team must talk about patients
needs

• Discuss, plan, coordinate the clinic day or
  half-day
• Team Huddle
• Team communicates to get everyone on the same
  page
• Team meets for 5 minutes or less
• Team members bring information to the team
• Patients with special needs
• New admissions
• Procedures
• Tasks are assigned to team members so that
  patient needs are managed effectively
• Team members know the expectations
• Teamwork is enhanced

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Changes that make the visit efficient

• Measure the cycle time
• Provider does provider work
• Clinical team roles are maximized
• Non-provider work is batched and is done by
  non-providers
• Non-visit Provider work is batched
• Clinical processes are timely
• The clinical visit is synchronized

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Identify and manage constraints

• Provider Constraints
• What non-provider tasks in the Provider doing?
• Make sure non-providers are doing non-provider
  work
• Cross train the clinical team members
• Maximize team member roles
• Add an evaluation step in front of the provider
  constraint (triage)
• Develop protocols
• Process constraint
• Eliminate wasted time
• Separate phone flow, patients flow, and paper
  flow
• Work toward continuous flow
• Build specific processes to manage the constraint

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Impact of maximizing the red zone and care team

• Enhancement of patient-centered care
• Improved through put
• Decreased waste
• Increased availability of provider time (able to
  manage more appointments)
• Improved patient outcomes
• Patient, provider, and staff satisfaction
• Decrease in cost per visit

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Maximizing the office system

• Increased Provider, Patient, and Staff
  Satisfaction
• Improved clinical measures
• Improved access
• Decreased waste (no shows)
• Increased office efficiency and effectiveness
• Increased physician capacity