Advanced Clinic Access and the Case for Quality

1
Advanced Clinic Access and the Case for Quality

• Jeffrey Murawsky, MD
• Chief Medical Officer, VISN 12
• Associate Professor, Medicine

2
Welcome to My First Day Full Time at Hines

• August 14, 2002
• New associate program director
• Member of local pi/advance clinic access team
• Consumer complaint on day 1
• Dear doctor, I tried to schedule a visit in the
  general medicine clinic to establish care and was
  told it would be 1 year before I could be seen
  and

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So Where Were We

• Average Waiting Time for New patients
• 148 days
• Average Waiting Time in Clinic
• 45 minutes
• Quality Measures Benchmarks
• Tobacco Screening 72 45
• HTN control 73 52
• Pneumovax 76 30

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Whats the Problem With Waiting?

• Health care should be timely- reducing waits and
  sometimes harmful delays for both those who
  receive care and those who give care.
• Institute of medicine crossing the quality
  chasm.
• Delays result in reduced quality of care and
  quality of life.
• Impact of waiting time on the quality of life of
  patients awaiting coronary artery bypass
  grafting. Sampalis J CMAJ 2001 165 429-33.
• Picker institute report access.
• Business concern.
• Increased no-show/inefficiency.
• Delays in diagnosis.

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The Problem With Inadequate Access

• No preventative services
• Presentation at later stage of disease
• Colon Cancer Diagnosis Lancet 1979, Eur J Surg
  1985
• Lung Cancer Treatment Clin Oncology 2000
• Re-work
• Toyota re-engineering (15 increased resources)
• No one waits quietly!
• Provider dissatisfaction

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The Risks of Waiting for Cardiac Catheterization

• Prospective study of event rates of MI, CHF,
  Death while awaiting cardiac catheterization
• 57 of all events occurred within the waiting
  time felt appropriate, 43 after waiting time
  elapsed
• Appropriate waiting times could not be accurately
  predicted

Natarajan M, et al. CMAJ 2002 167(11)
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Colorectal Cancer Screening-Florence Hutchison,
MD, COS, Charleston

• CRC performance measure 30
• 24 month backlog for colonoscopy
• 2850 patients waiting
• High no-show rate for colonoscopy
• The majority of colon cancer diagnosed at stage
  3-4
• Delay in diagnosis of cancer 1 tort claim for VA
  region

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ResultsImprovement in CRC Screening
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Results Impact of Focus on High Risk Patients
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Crossing the Quality Chasm

• IOM
• Effective
• Safe
• Timeliness
• Patient Centered
• Efficient
• Equitable

• VHA
• Quality
• Access
• Satisfaction
• Functional Status
• Cost Effective
• Community/Home Based

Institute of Medicine Report 2001 Crossing the
Quality Chasm
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Idealized Design of the Clinical Office Practice

• Institute for Healthcare Improvement project, VA
  partnership 1999
• Office practice is the interface between patients
  and health care services
• Patients report 40 unaware of emotional issues,
  15 medication side effects
• Preventive services rates poor
• Office Practice of 1964 versus 2004

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Patient-centered Access

• Availability
• Geographic and Financial
• Appropriateness
• Want What you know to ask for
• Need What you do not know to ask for
• Preference
• Who and What
• Timeliness
• Services when services are desired

Innovations in Access to Care A
Patient-Centered Approach Ann Intern Med
2003139568-74
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Advanced Clinic Access

• A system to redesign office practice in order to
  provide the patient with ability to receive
  quality care when the patient wants and needs it.
• Based in Queuing Theory and Industrial
  Engineering.
• Rejects many tenants of traditional office
  practice.
• Demand for care services in infinite.
• Triage of demand into urgent and non urgent visit
  types.
• Best care is always provided by person with the
  highest level of expertise (physicians).

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Existing Model of Office Practice

• Traditional model
• Triage of demand into urgent and non urgent
• Permission to overbook sick patients
• Excess demand diverted to urgent care, ED
• Each visit to an alternate setting generates
  another routine clinic visit
• Carve out model
• Reserves some time for sick patient only
• Can be individual or group
• Creates excess demand
• Worried well versus stoic sick
• Will ensure mismatch of services

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Advanced Clinic Access

• Understanding Demand
• Predictable
• Modifiable
• Removing the backlog
• Created by both Provider and Patient
• Understanding Supply
• Queuing Theory
• Alternatives to Providers
• Physician Extenders
• Clinical Nurse Specialists
• Telephone Contact
• Clerical and Nursing Support

• Matching Supply and Demand
• Panel Size Equity for Primary Care
• Input Equity for Specialty Clinics
• Planning for Contingencies
• Anticipate variability
• Staff participation

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Advanced Clinic Access

• Redesign the System to Increase Supply
• Define and Modify any Constraints
• Usually Provider Time
• Drive work away from constraint Work at the High
  End of Expertise
• Separate Parallel Processes
• Patient flow, Telephone triage, Paper flow
• Standardize Protocols for office processes
• Synchronize Patient Provider and Information
• All is ready Chart, Patient, Provider
• All is done Health Prompts

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VA Connecticut
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VA Connecticut
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ACA Implementation Association With Performance
and Resource Utilization

• The Milwaukee Experience

Dr. Gordon Schectman VAMC Milwaukee Veterans
Integrated Service Network 12
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Implementing ACA in Milwaukee

• Providers instructed to lengthen the RVI when
  medically feasible.
• Providers instructed to share burden of care with
  clinic staff.
• LPNs taught to perform routine laboratory and
  blood pressure monitoring tasks.
• Nurses trained to assist providers in disease
  management.
• Provider feedback of their access and performance
  data provided quarterly.

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Milwaukee ACADeveloping Clinic Infrastructure

• Presentations to primary care teams.
• Biweekly meetings to include participating
  providers and team representatives.
• Redefine role of all personnel.
• Emphasize disease management to promote
  teamwork and reduce clinic visits.
• Review and implement change ideas.
• Begin to build access.

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The RVI in VISN 12 Scheduling gt Six Months
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Success of ACA Implementation in Milwaukee VA
(Primary Care)
Includes all primary care clinics (even
residents!)
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Achieving Performance GoalsMilwaukee Providers
and Residents
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ACA Implementation and Ambulatory Care Resource
Utilization

• Does ACA implementation in primary care merely
  shift the burden of care and resource utilization
  away from the primary care provider to.
• RN and other primary care staff?
• Emergency room and urgent care clinics?
• Specialty care including medical and surgical
  specialty clinics?
• Can Milwaukee data address these questions?
• Manual audit of random sample of 1000 patients
  during three different time periods before,
  during and after ACA implementation.

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ACA Implementation and Primary Care Resource
Utilization
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ACA Implementation and Non-primary Care Resource
Utilization
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Transforming Primary Care and Resource
Utilization Milwaukee

• Improvements in access and performance were
  associated with reduced provider visits, and
  shifting of care from the primary provider to the
  RN.
• Reduced visits to the provider were not replaced
  by increased visits to either urgent or specialty
  care.

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Hines Access to Primary Care
Backlog Reduction
Increased Panel Size
Redesigned System with Provider Education
Now it is 2 days with 50 of providers an opening
within 7 days
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Hines VA Access
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Hines VA

• Inpatient Care
• Decreased bed days by 3 in FY04 YTD
• Readmission rates below benchmark
• LOS CHF/COPD .7/.5 days less than Medicare
• Decreased bed days by 5 in FY03
• Continuity of Care Group Model
• Emergent Care
• 11 of all care episodes to Internist/ED
• Decreased from 32
• Group Care
• 94 of all primary care visits with PC Team
  versus 71
• 82 to individual PCP versus 60

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Hines VA Quality
Over this period there were 4000 patients added
to the system without additional provider
resources
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Patient Perspective
FY02 Q4- 57, FY02 Q1- 45
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The Mission of the VA

• Quality Patient Care
• Research
• Education
• Affiliations with medical schools since 1946
• VA affiliations 107 of 126 US medical schools
• 8,852 residents (9) are supported by VA at any
  time
• 70 MD program residents rotate through VA
  facilities
• 47 accredited programs represented

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My First Job As Associate Program Director

• Competency Based Medical Education
• System to address not the potential of a
  physician but to address actual demonstrable
  accomplishments
• Six general competencies
• Patient Care
• Medical Knowledge
• Interpersonal Skills and Communication
• Professionalism
• Practice Based Learning and Improvement
• Systems Based Practice

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Systems Based Practice

• Residents must demonstrate an awareness of and
  responsiveness to the larger context and system
  of health care and the ability to effectively
  call on system resources to provide care that is
  of optimal value. Residents are expected to
• understand how their patient care and other
  professional practices affect other health care
  professionals, the health care organization, and
  the larger society and how these elements of the
  system affect their own practice
• know how types of medical practice and delivery
  systems differ from one another, including
  methods of controlling health care costs and
  allocating resources
• practice cost-effective health care and resource
  allocation that does not compromise quality of
  care
• advocate for quality patient care and assist
  patients in dealing with system complexities
• know how to partner with health care managers and
  health care providers to assess, coordinate, and
  improve health care and know how these activities
  can affect system performance

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Two Problems One Solution

• Waits and delays
• Improve system designed to deliver care
• Use principles of advanced clinic access
• Resident clinics and understanding of the
  dynamics of system crucial part of system change
  and reaching the critical mass necessary to
  change the VA way

• Competency based education
• Systems based competency addresses need to
  demonstrate understanding of health care systems
  and effective utilization of the resources
• Demonstration of understanding of differences
  between health care systems (university and VA)

Ever Seen Herding Cats
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Teaching ACA Principles

• Educate within the context of systems of
  practice core competency used in graduate
  medical education
• Educate using the problem based method of
  learning
• Case series
• Journal based discussion of an ideal office
  practice design
• Present and develop material as a collaborative
  effort with affiliates, Office of Academic
  Affairs
• Council of Teaching Hospitals
• Group on Resident Affairs

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Case Studies and Teaching Materials Are Available
At

• http//vaww.va.gov/oaa/teaching_tools
• Or
• http//www.med.va.gov/oaa/teaching_tools

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Curriculum Summary

• Concepts in advanced access- case lecture series
• Maximizing activity at clinical appointments
• Effect on supply of future visits
• Effect on revenue and availability
• Understanding the return visit interval
• Evidence based approach (CPG)
• Providing care if and not when
• Planning for contingencies
• Understanding the consequences of resident
  practice
• Dynamic practice planning
• Understanding the care team
• Developing the roles of physician extenders

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Faculty Resources

• Answer guides for resident educational materials
  on the key concepts of ACA curriculum
• Provide a general awareness of ACA principles
• Foundation of ACA as a best practice
• Reference materials with an academic focus
• Journal articles
• IHI materials
• Build to improve attending understand of ACA with
  a system that is familiar (evidence based
  medicine)

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Example Learning Session

• A 57 year old man presents to your clinic for an
  initial visit for low back pain. This symptom
  has been present for two weeks and was
  precipitated by lifting a heavy object. He has
  not been to a primary physician for at least 5
  years. In his review of symptoms he denies any
  symptoms not related to his complaint and is
  focused on this issue. His physical examination
  is unremarkable, expect for minor left lumbar
  paraspinal tenderness. In review of his records
  from specialty clinics his last 3 blood pressures
  have all been greater than 145/90. 
• What are your goals for this visit?

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Discussion

• What are your goals for this visit?
• Lead a discussion about max packing. Have the
  residents discuss the need to make the most of
  each encounter. Areas of concern could be
  focused on value placed on the patients time (not
  having to present for multiple visits), cost
  (multiple co-pays) ,or quality of care (not
  following the clinical practice guideline for
  hypertension). Focus the discussion on the
  creation of demand for visits by the provider
  (not addressing the hypertension today would
  create an extra visit and delay care for others
  in the providers panel).

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Competency Demonstration

• Teaching is not enough
• PDSA modeling in residents
• Integration of structure and teaching
• Taught but does it change practice?
• Demonstration in an objective method with
  directed feedback and planning

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Evaluation Process Continued

• PGY 2 and PGY 3
• Case series on advanced clinic access continued
• Performance improvement data review
• Improvement in care metrics linked to evaluation
  of outpatient care
• Evaluation of panel of patients
• Project on access and its effect on patient care
• Journal review of advanced clinic access as best
  practice
• Self directed chart review to evaluate strengths
  and weaknesses in
• Chronic disease management
• Preventive medicine
• Clinical access

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Example Performance Report
85 Total Patient Visits Clinic Access Average
Days to 3rd Next Available Appointment
28 (Acceptable lt 14 days Benchmark lt 7
days) STANDARDS Your
VA-EPRP Peer Comparison
Measure N at Goal FS
EX Median 90tile BP in
HTN 42 74 70 75 63 84 IHD
LDLlt120 35 73 71 74 89 97 MI on
ASA 14 50 93 95 42 96 MI on
BetaBlock 16 83 84 89 75 100 BP in
DM 21 71 70 75 67 88 HgbA1c lt
9 9 65 83 86 81 94 DM Foot
Exam 15 60 68 75 68 94 Colorectal
Ca 41 87 72 75 76 94 Pneumovax 41 85
85 90 89 99 Flu Vax 61 88 79 82 77 91
Hep C Screening 25 100 90 95 97 100 Mamm
ogram 0 NA 85 90 83 100 Pap 0 NA 85 9
0 89 100
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Systems-based Practice Competency

• Evaluation of residents action plans for
  improvement over time in
• Chronic disease management
• Preventive services
• Clinical access
• Demonstrates understanding of the relationship
  between clinical access and quality assessed
  during clinical preceptorship
• Gap between resident clinics and attending
  practices for quality measures undetectable

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Resident Practice Quality Indicators
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Comparisons to Attending Care
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Advanced Clinic Access

• A new system grounded in a patient centric model
  of care based on principles of just in time
  engineering.
• Systemizing Quality Based Improvement is
  effective within VHA.
• Jha AK, Perlin J, Kizer KW, Dudley RA NEJM 2003
  3482218-27.
• Kerr EA, et al. Ann Internal Med1131272-81.
• Promotes Understanding of how individual
  decisions about care relate to the system in
  which the care is provided.
• Provides a framework for accessing a core
  competency in resident education.

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Thank You

• Jeffrey Murawsky, MD
• jeffrey.murawsky_at_va.gov