Commonly prescribed tests, treatments not always necessary

Do you practice care-appropriate, fiscally responsible medicine?

In mid-April, healthcare headlines buzzed about the “Choosing Wisely” initiative, established to spur discussion between patients and their healthcare providers by helping patients choose care that is:

• Evidence-based;

• Nonduplicative of care already received;

• Free from harm; and

• Necessary. 

Nine medical specialty organizations each offered a list of five tests or procedures used commonly in their fields that may not always be needed — and that contribute to our nation’s staggering healthcare bill. By bringing these services to the forefront, the organizations — American Academy of Allergy, Asthma & Immunology; American Academy of Family Physicians (AAFP); American College of Cardiology; American College of Physicians; American College of Radiology; American Gastroenterological Association; American Society of Clinical Oncology;
American Society of Nephrology; and American Society of Nuclear Cardiology — hope to promote more effective use of healthcare resources. “Choosing Wisely” sprang from an article published in an August 2011 issue of Archives of Internal Medicine.

The AAFP’s list of five things that primary care providers and patients should question encompasses:

• Imaging for low back pain within the first six weeks when no red-flag conditions exist;

• Antibiotics for acute mild-to-moderate sinusitis;

• Dual-energy X-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors;

• Annual electrocardiograms (EKGs) or other cardiac screening for low-risk, asymptomatic patients; and

• Pap smears on women younger than 21 or who have had a hysterectomy for noncancer disease. 

To that list we would add certain treatments for headache and enlarged prostate. The complaint of headache rarely warrants costly imaging studies such as sinus X-rays, CT scans and MRIs. The patient’s headache history is often the clinician’s best diagnostic tool — the headaches’ frequency, duration, associated symptoms, location of the pain, severity, family history, etc. Imaging tests are called for only after the patient’s headaches don’t respond to lifestyle changes and standard analgesic medications or physical and neurological examinations lead the clinician to suspect a serious underlying cause.

An enlarged prostate should not spur the clinician to order a prostate-specific antigen (PSA) test immediately. The most recent evidence suggests that PSA testing does not lower the risk for death from prostate cancer.1 A 13-year follow-up report published in the Journal of the National Cancer Institute concluded that there is no evidence of benefit from PSA screening. The test can, in fact, cause harm because of false-positive tests and overdiagnosis. This finding extends the trial's 10-year results, which also showed no mortality benefit.

Martha Johns, MD, MPH, FACPM, HealthTeamWorks medical director for Guidelines and Implementation, notes, “Many studies have now demonstrated that evidence-based healthcare recommendations such as the ones discussed above are not only better for patients but can help avoid needless expense. This is good news for our healthcare system.”

Source
1. Andriole GL, et al. Prostate cancer screening in the randomized prostate, lung, colorectal, and ovarian cancer screening trial: Mortality results after 13 years of follow-up. http://jnci.oxfordjournals.org/content/early/2012/01/06/jnci.djr500.abstract JNCI J Natl Cancer Inst (2012)doi: 10.1093/jnci/djr500First published online: Jan. 6, 2012

HealthTeamWorks Coach University grad discusses her take-aways

“At [HealthTeamWorks] Coach University, you begin with data, with assessments of the practice. I’ve never seen anything like that. It’s is empowering to the clinic. You give them a snapshot of where they are and show them how to make measurable, meaningful changes [in processes and systems] to push their performance forward. The training is based on clinical guidelines and best practices. You build from these using the science of change,” says Kate Coburn, MS, MPH.

Coburn is HealthTeamWorks’ new Patient-Centered Medical Home (PCMH) manager, responsible for overseeing practice transformation work, coaching coaches, assessing medical practice systems and “making change happen.” She attended HealthTeamWorks’ Coach University in December 2011. She and nine other students spent a week in Lakewood, Colo., learning from HealthTeamWorks’ experienced quality improvement coaches in the classroom and on site in medical practices.

Most practices that make the transformation from traditional medical care to the patient-centered medical home (PCMH) model of care do it with the help of a trained facilitator or coach.^1,2,3 HealthTeamWorks Coach University is one of only a few places in the United States that trains quality-improvement coaches to develop PCMHs.

Curriculum covers all aspects of PCMH transformation

“You can’t ever get enough information in what it takes to facilitate a practice — in systems redesign, systems improvement, IT, data collection and application, population management, patient self-care facilitation, NCQA* certification requirements — every aspect of this complex process,” Coburn says. “HealthTeamWorks manages PCMH transformation by coaching coaches, assessing systems, leading initiatives that make change happen. HealthTeamWorks has an unbelievable ability to assess a practice’s current state, address gaps in performance, and enable the practice to set and reach ambitious goals.”
The Coach University curriculum includes: 

• The model for improvement;

• The chronic-care model;

• Evidence-based guidelines;

• Leadership development and the dynamics of the team approach to care;

• Quality measures and population management;

• Patient engagement and self-management support; and

• Technology to support the delivery of patient care.

Unlike many Coach University trainees, Coburn arrived with an extensive background in health system transformation. Since 2008 she had coached practices of Fletcher Allen Health Care, Vermont’s academic medical center, in achieving NCQA PCMH recognition.

Use of data, culture change enable practice transformation

Coburn notes that the HealthTeamWorks’ coaching approach is steadfastly patient-focused and connects with the three credos she stands by:

• Words create worlds;

• You can’t manage what you don’t measure; and

• Every system is perfectly designed to get the results it does.

Guided by these beliefs, “I focus on growing from a positive core,” Coburn says. “In every practice we will assess what they have, determine opportunities for change and learn what data are measurable and available. Then we identify the practice superstars. Who embraces patient advocacy? Who understands the data? Who are the leaders and who are the doer-bees?”

The leaders — who can exist at all levels of a practice — will help establish the new practice culture. “You might find a practice leader at the front desk,” Coburn says. “A leader might be a medical assistant. Part of our work in transforming healthcare is to get a feeling for people’s strengths.” Ultimately, she believes, everyone must share data and move in the same direction to transform care delivery to be patient-centered and driven by best practices.

*National Committee for Quality Assurance

Sources
1. Baskerville NB, Liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. doi: 10.1370/afm.131 2 Ann Fam Med January/February 2012 vol. 10 no. 1 63-74.
2. Nutting PA, Crabtree BF, Miller WL, Stange KC, Stewart E, Jaén C. Transforming physician practices to patient-centered medical homes: lessons from the national demonstration project. Health Aff (Millwood). 2011 Mar;30(3):439-45.
3. Crabtree BF, Chase SM, Wise CG, et al. Evaluation of patient centered medical home practice transformation initiatives. Med Care. 2011 Jan;49(1):10-6.

Care management, one of the cornerstones of the patient-centered medical home (PCMH), focuses on both wellness and illness. Directed at patients with long-term and/or complex care needs, it encompasses prevention and patient education, as well as treatment of acute sickness and/or injury. Care management means comprehensive care, addressing a person’s psychosocial and spiritual well-being, as well as physical health.

A PCMH that manages patients’ care ensures that:

• Every patient  has an individualized care plan;

• Each care team member has access to patients’ care plans;

• Care is standardized according to clinical guidelines;

• Care team members work as a group; and

• Each team member knows her/his role in providing care.
   

Care management aims to turn acute, episodic care into planned care. For example, to forestall breathing difficulties in an asthmatic patient and potential visits to the emergency room, the PCMH care team carefully monitors her medications. They work with her to determine her asthma triggers so she can avoid them, and teach her self-management techniques. The care team establishes regular office visits to assess the patient’s lung function and the effectiveness of her medications. The goal of both the team and the patient is to help her attain control over her condition and enjoy a high quality of life.

Thus, care management:

• Turns acute, episodic care into planned care;

• Focuses on high-risk, high-cost patients; and

• Emphasizes prevention, disease management and patient engagement.

Technology assists care management. A patient registry allows a practice to identify all patients needing care management, such as those with asthma, high blood pressure, diabetes or coronary artery disease. Clinicians can devise and apply care plans for these populations, including regular office visits, screenings, medication monitoring, tests and appointments with specialists. The registry helps them schedule and track this care. An electronic health record (EHR) allows the care team immediate access to patient data and secure sharing with other providers.

Top care-management practices include:
 

• Multidisciplinary care teams;

• Pop-ups on the EHR to alert the care team about patients due for exams, lab work, etc.;

• Staff roles adjusted to give patients focused, personalized care;

• Online patient portal allowing quick access to the care team, scheduling and test results;

• Labs drawn in advance so the care team can focus appointment time on treatment and patient education;

• Team huddles prior to appointments, so all members know the care plan and their roles in promoting it;

• Checklists to ensure thorough care; and

• Program evaluations to ensure quality care.

The National Committee for Quality Assurance lists care management requirements in its 2011 PCMH standards.¹ To identify and manage patient populations, a practice must:
 

• Collect demographic and clinical data for population management;

• Assess and document patient risk factors; and

• Identify patients for proactive and point-of-care reminders.

For individual patients, a practice must:
 

• Perform previsit planning;

• Assess progress toward treatment goals;

• Address barriers to achieving treatment goals;

• Reconcile medications at each visit and after hospitalization; and

• Use e-prescribing.

Care management, integrated into a practice’s daily flow, will produce better outcomes, more satisfied patients and providers, and reduce the frequency of costly emergency room visits and hospitalizations.

Source
1. National Committee for Quality Assurance. Comparison: PPC-PCMH 2008 with PCMH 2011.  www.ncqa.org/LinkClick.aspx?fileticket=RdzaHTOsgxI%3D&tabid=1412, pp. 3-4.

By Allyson Gottsman, HealthTeamWorks executive vice president

A medical practice does not become a patient-centered medical home (PCMH) overnight. The move from traditional healthcare to the PCMH model of care requires a cultural shift for everyone: providers, staff, patients and payers.

Too often, we focus on new processes and new technologies and expect the people who will use them to change accordingly. However, organizations change only when the people in them change. Making change is easy, but making change stick is difficult.

Change means that people will need to follow new processes, cooperate in new ways and behave differently. If you want to ensure that PCMH concepts take hold in your practice, ensure that people understand why changes are necessary.

For example, in traditional medical care, patients’ chief complaints determine the care they receive. Thus, care is reactive. In the PCMH, caregivers systematically assess all a patient’s health needs and plan her or his care accordingly. Care is comprehensive, coordinated, evidence-based and multidisciplinary. All members of the practice must understand that the PCMH delivers care proactively and addresses all of a patient’s medical conditions — not just those presenting acutely. This is a major cultural and process shift.

Change management is all about leadership and culture. Don’t underestimate the importance of culture — your practice’s mission, its use of resources, the involvement of its people and their responsiveness to patients. Create the vision for your practice as a PCMH: why it’s important to patients, the practice, the community — and each individual in the organization. The PCMH rests on a culture of continuous improvement and commitment to pursue excellence.

The key to success and commitment in PCMH transformation is involving others in designing and implementing changes. Just as patient care becomes team-based and patient-centric, rather than physician-based and physician-centric, so should decision-making around new systems and processes become team-based and patient-centric. Look to the strengths of those in your practice in establishing new protocols, processes and job descriptions.

It’s natural for people to resist change. Identify barriers to PCMH evolution, including:

• Fear – Wanting to avoid the unknown;

• Communication – Lack of understanding of changes’ purpose and value;

• Inadequacy – Worry over meeting new goals and expectations;

• Control – Personal agendas; and

• Inconsistency – In how staff members understand the medical home philosophy, adopt patient-centered processes and present the PCMH message to each other and beyond the practice. 

Clear communication and data can overcome these barriers and allay anxiety. As you undergo transformation, make sure that providers and staff see progression in quality measures, practice efficiencies and patient satisfaction scores. Reflect on the changes. Celebrate successes. Transformation requires letting go of the familiar and leaving the comfortable behind.

The result? A patient-centered practice driven by data, a focus on quality and satisfaction in delivering care.
 

Among the primary care practices seeking to evolve into patient-centered medical homes (PCMHs) are residency practices — those that train the next generation of physicians in family medicine, internal medicine and pediatrics. Fundamental, patient-centered changes to a residency practice’s processes and mind-set must encompass the education provided to doctors in training.

To greater or lesser degrees, every medical practice will face challenges on the journey to the PCMH. Residency practices, however, have particular hurdles, including the regular rotation of residents, residents’ schedules, regulatory requirements and the practices’ obligations to sponsoring organizations.

New paper details barriers in residency practices

A recent paper in the journal Family Medicine described nine barriers faced by residency practices trying to adopt PCMH improvements. The article*was authored by faculty in the Department of Family Medicine at the University of Colorado and two HealthTeamWorks Quality Improvement Coaches: Nicole Deaner, MSW, and Caitlin O’Neill, MS, RD.

The paper draws its conclusions from the Colorado Family Medicine Residency Patient-Centered Medical Home Project, a collaboration among the state’s nine family medicine residen¬cy programs and 10 residency prac¬tices supported by the Colorado Health Foundation. The project aims to transform the Colorado Family Medicine Residency programs into PCMH practices and train residents in the PCMH model of patient care. HealthTeamWorks’ practice-improvement coach¬es work with curriculum special¬ists to integrate the key components of the PCMH into these programs.

Deaner’s and O’Neill’s field notes about the residency practices they coach provided the basis for the list of nine common barriers to PCMH improvement in these settings:

1. Negative past expe¬riences with quality improvement or attempts at  transformative change;
2. Unprepared practice leaders;
3. Resistance to change and skepticism by members of the practice;
4. Unproductive team processes, such as frequent canceled meetings, absent leaders or lack of accountability;
5. Lack of knowledge about the PCMH, shown by in¬complete dissemination of information;
6. Implementation of an electronic health record distracts the focus from the PCMH or stalls improvement ac¬tivity;
7. Staffing rules and differing priorities by the residency’s sponsoring organization that constrain PCHM transformation;
8. Lack of staff participation; and
9. Poor communication from ineffective methods and part-time faculty and residents. 
 

Interventions can overcome barriers

On the positive side, specific interventions by practice coaches can often overcome these barriers. “Cultural changes take time, in practices as elsewhere …” the authors write. “… many of the barriers that slow the alignment of priorities in a practice or hamper the ability to make changes can be remedied by active interventions by coaches in the form of leadership training, fa¬cilitation, identifying gaps, and pro¬viding techniques and tools to mark and encourage progress, engage staff, and build leadership.”

The progress underway in the Colorado family medicine residency practices demonstrates that barriers to PCMH adoption are surmountable. “Resident, faculty and staff leadership development and the ability to work in effective teams has been a very exciting part of working on this project,” Deaner says. “This has required a significant cultural shift. Traditionally, practices use a hierarchical culture where the provider directs the patient and the practice team. The PCMH model emphasizes a culture of engaging and activating both nontraditional staff leaders and patients as partners in their care.”

O’Neill says, “We hope that this paper helps guide other organizations that want to help residency practices adopt PCMH principles. If the next generation of physicians understands the value of this model, they will apply it in practice and continue to disseminate patient-centered, value-based care.”

Read the complete article in Family Medicine.

* Fernald, DH, Deaner N, O’Neill C, Jortberg BT, deGruy FV, Dickinson WP. Overcoming early barriers to PCMH practice improvement in family medicine residencies. Fam Med Jul-Aug 2011; 43(7): 503-509.

Shared medical appointments (SMAs), also called group visits, can provide many benefits to your patients and your practice. They promote efficiency in busy primary care offices with many chronically ill patients, and give patients peer support and a venue to exchange ideas, problems and successes.

“Physicians want to give every patient with a chronic condition the education and self-management skills that are part of comprehensive medical care, but they just don’t have the time,” says Brent Jaster, MD, a family physician, consultant, and senior clinical instructor at the University of Colorado School of Medicine. He notes that to meet recommendations by the U.S. Preventive Services Task Force, a physician would need to spend an estimated 7.4 hours a day providing preventive services.¹

Given this unrealistic expectation, many primary care practices assign preventive care services to nonphysician providers or health educators. Their efforts are undoubtedly beneficial, but SMAs represent another strategy that can provide deeper and more lasting changes in patients’ self care, self confidence and self image.

Characteristics of the SMA

SMAs typically involve a medical provider, a facilitator (a nurse, behaviorist or health educator) a documenter (optional but cost-effective), an educator as needed, and one or two medical assistants (MAs) to check in patients. Administrative support is essential to ensure access, document and code patients’ visits, obtain confidentiality waivers, check in patients and prepare the room.

SMAs may be continuous, occurring at regular days and times and encouraging patients to form a cohesive group. A continuity group comprises the same people with the same physician and the same or similar conditions, or people who share a demographic characteristic, such as postmenopausal women. Membership changes occasionally through attrition or additions, but ongoing attendance is assumed.

On-demand SMAs

In an on-demand SMA model, patients — often with different medical conditions — see their physicians only when they have a medical need. The physicals SMA is an on-demand model that includes a private physical exam followed by group education, discussion and a question-and-answer session that allows patients to learn with and from peers.

Family members and other support people are welcome at the SMA. Sessions last 90 minutes and include these features: 

• Check-in

• MAs record chief complaint and take vital signs

• Introductions

• Education by provider and/or educator

• One-on-one patient care observed by the group

• Questions

• Patients state self-management goals

The features can be integrated so the group follows a patient-driven, rather than preplanned, agenda. Private exams can occur before or after the group visit, if necessary.
To succeed at SMAs, Jaster says, a practice needs to:

• Have providers personally invite participants

• Ensure administrative support

• Define outcome measures from the start

• Consider offering a broad array of on-demand and continuity SMAs for well-child, pregnancy, chronic disease and preventive care to improve multiple health care measures

“The therapeutic potential of one-on-one visits will nearly always be inferior to shared medical appointments because of the healing power of group interaction. It is well documented in the psychiatric literature4 that groups are inherently therapeutic, from the obvious —‘I realized I was not alone’— to the existential. Imagine your patient telling you, ‘I love this.’ Shift the paradigm, see the magic,” Jaster says.

References
1. Yarnall KS, Pollak KI, Ostbye T, Krause KM, Michener JL.  Primary care: is there enough time for prevention? Am J Public Health. 2003;93:635-641.
2. Ostbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005;3:209-214.
3. Noffsinger EB. Will drop-in group medical appointments (DIGMAs) work in practice? The Permantente Journal. http://xnet.kp.org/permanentejournal/fall99pj/digma.html
4. Yalom I. The Theory and Practice of Group Psychotherapy. New York: Basic Books; 1995.

By Elaine Skoch, RN, MN, EMBA, NEA-BC, HealthTeamWorks Director of Systems Transformation
 

Every practice will have its own response to balance patient demand and provider supply. Practices with more than two types of appointments have more challenges in scheduling,  especially when different providers have different visit types and require schedulers to use slots exactly as intended.

Using two visit types increases flexibility in scheduling — say one short visit (15-20 minutes) and one long visit — a multiple of the short visit (30-40 minutes).

Re-designing roles and responsibilities is another way a practice can equalize supply and demand, particularly in managing preventive services and tests for chronic-disease management. Written protocols directing support staff to deliver these services frees up providers’ time to meet the needs of other patients.

Consolidate appointment types, “max pack” appointment times

Increase the efficiency of appointments with pre-visit scheduling reviews. As part of routine morning and afternoon huddles, the care team ensures that charts for the day contain all necessary information before patients arrive. Pre-visit reviews also allow the team to anticipate preventive services, such as immunizations and screenings.

“Max packing” describes the process of putting as many services as possible into a visit to increase convenience for the patient. The point is not to perpetuate a volume-based healthcare system, but rather to establish a value-based, more efficient system that consolidates services and provides comprehensive patient care.

Develop options for patients to obtain your services 

To increase access to your practice, establish open-access scheduling to accommodate same-day appointments and eliminate backlog. Start the process slowly and begin to open slots from the end of the day to the beginning, one slot per hour. Progress to multiple slots per hour as your providers and patients adjust to the new schedule and the opportunity to get appointments on the day they call. For greatest flexibility, move appointments into blocks of time.

Work down the backlog of filled appointments slots you want to leave open. When that occurs, you are no longer deflecting today’s work. Then you can begin to accommodate patients the day they call.

You can also:

• Extend practice hours into evenings and weekends to open more appointment slots;
• Use team members in new capacities;
• Add mid-level providers; and
• Add e-visits and/or group visits.

By managing the supply of patients with the capacity of your providers and your practice, you’ll maximize ability to serve the community, please your patients, improve the morale of your staff and support a sound bottom line.

By Elaine Skoch, RN, MN, EMBA, NEA-BC, HealthTeamWorks Director of Systems Transformation

Every medical practice wants enough patients to keep caregivers busy and revenue steady, but backlogs in the waiting room benefit no one. Patients kept waiting may seek another practice or go to the emergency room — at higher cost to the healthcare system. A full waiting room may keep providers and staff in a rush, which may result in less-than-optimal care.
 
Well-run practices balance supply and demand. They establish processes to match their patient-panel size with their capacity to deliver care effectively and efficiently. To use an old saw, they “do today’s work today,” instead of constantly playing catch-up with tasks left over from the day — or days — before.

Doing today’s work today hinges on improving access to care. You want enough patients visiting and calling (and e-mailing) your practice to keep staff busy and revenue flowing, but you don’t want to be overwhelmed by “bad backlog.” To improve  access and gain an understanding of your practice’s supply of and demand for services:

• Calculate  the practice’s ideal panel size;
• Equalize supply and demand;
• Consolidate appointment types; and
• Develop options for patients to obtain your services.

Open-access scheduling relies on the theory that demand is predictable and may vary seasonally. (You may need to monitor seasonal changes in demand to fill down-time with preventive or follow-up services.) You want to match your appointment supply to demand.

Calculating panel size
 

To determine how many patients your practice can see comfortably and thoroughly, figure the number of unique visits you’ve had over a certain time period — say 18 months. Then figure the average number of provider visits a day in your clinic and the clinical days worked per year. Use this formula to figure your ideal panel size:

Provider visits per day x clinical days worked
                    Visits per patient
 
For example, let’s say your practice had 6,300 patient visits over the last 18 months made by 2,000 individuals. Your providers see an average of 24 patients a day and put in 240 clinical work days annually (this number takes into account vacation time and holidays): 6,300 ÷ 2,000 = 3.15 visits per patient per period. Your panel size formula looks like this:

24 visits per day x 240 days worked
           3.15 visits per patient

You can meet the demand of 1,829 patients comfortably. (The age and gender breakdown of your panel can influence this number. Breaking down panel demographics could make the calculation more precise. For example, we know that panels with more women of child-bearing age or with large pediatric or elderly populations average more visits per person.)

Calculating supply

Next, determine your practice’s capacity, or supply. Get the number of available appointment slots by multiplying 20 (the average number of slots available per day without overbooking or double-booking) by 240 clinical work days to get 4,800 visits. That’s the number of appointments your practice has available in a year. As things stand, you’re 961 slots short of capacity, because 1,829 x 3.15 = 5,761 visits.

Less clear-cut are considerations about your practice’s efficiency and access. How effective is your work flow? How well do providers and staff communicate? How do you manage no-show patients? How often do providers get interrupted in the exam room? Do you emphasize prevention and patient self-care? A host of variables affects your clinic’s ability to see patients efficiently and provide high-quality care.
 

Next week: Part 2

Brief daily meetings keep care team informed, focused on patient service

The care team forms the heart of the patient-centered medical home (PCMH). Daily team huddles serve as strategy sessions to keep that heart functioning at optimum capacity. The PCMH care team — usually a physician, a nurse and/or medical assistant(s) and a front-desk employee — use huddles to plan their approach for the next segment of the day and prepare for challenges, such as complex patients who require additional time.

Huddles are frequent, brief “check-ins” related to specific actions and goals. The physician and his/her staff review the schedule and patient charts before each morning session and afternoon session in the clinic. They then plan the agenda for each patient’s visit.

Huddles:

• Promote communication among team members;
• Avoid duplicated work;
• Ensure that members plan tasks with necessary input from others; and
• Promote teamwork.

In general, care team huddles should:

• Occur twice a day – before morning and afternoon patient appointments;
• Be kept to less than 10 minutes;
• Become established in the practice’s routine;
• Stay focused and pertinent; and
• Allow no interruptions.

The morning huddle should start with a review of the previous day and the status of unfinished medical work, such as calls to consultants, review of lab and X-ray results and patient follow-up. The huddle should also cover the status of clinic operations, including staffing, equipment and computer operability, patients with unexpected hospital visits, meeting and special events or external issues.

Team members then should identify:

• Patients with chronic disease;
• Patients who that have been in the emergency roomER or hHospitalized;
• Patients who are often late, problematic or have high service needs;
• Canceled appointments; and
• Patients for whom the provider will need assistance.
   

At the afternoon huddle, the team evaluates the appointments scheduled for the second half of the day. Members may also exchange information about the patients seen that morning.
Huddles also serve a team-building function. Members should be encouraged to maintain a positive, collegial attitude. Everyone should seek to learn from mistakes and review what went right, as well as what went wrong, so the practice can adopt more efficient processes.
If you’re not already using huddles in your practice, try ithem. Used properly, they smooth clinic functions for providers and patients alike.

Huddle Resources

Huddle video

Article: Huddles: Improve Office Efficiency in Mere Minutes. Family Practice Management, June 2007.

Article: The Teamlet Model of Primary Care. Annals of Family Medicine. Bodenheimer, T. (2007)

Every medical practice wants to implement the safest, most efficient, most cost-effective procedures possible. But knowing how to close the gap between how you want to provide care and how you currently provide care isn’t always obvious.

“Care can be thought of as a series of tasks and processes – systems of care,” says Kathleen Reims, MD, a family medicine physician and quality expert. “Healthcare systems are affected by patient factors, care team factors and health system factors.”

To improve performance in your practice, Reims recommends the Plan, Do, Study, Act (PDSA) approach advocated by the Institute for Healthcare Improvement. The institute calls PDSA “a useful tool for documenting a test of change. The PDSA cycle is shorthand for testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act).”

To start improving performance, Reims says, look at the practice’s core measures report each month. What procedures need improvement? Choose a measure and, with key staff members:

• Brainstorm why the practice’s performance is not what you would like it to be
• List the changes you think might help
• Prioritize the changes
• Pick your top change and figure out a plan to test whether it makes an improvement
• Make the steps small: one patient, one provider, one day. You’ll likely need multiple PDSA cycles to test one change
• Reflect and discuss the results of your test with your team
• Use what you learned to guide your next change 
• As you test changes, monitor the measure performance. If your changes are improving the system, the measure performance will improve
• Establish the new processes as the standard

Here’s an example. A primary care practice wants to know that patients with asthma get flu shots. The care team debates why their flu shot rate is so low and decides that many patients likely receive the vaccine elsewhere, but the practice hasn’t captured this information. They decide to test this assumption and, if it’s correct, whether they can improve documentation. 

• Plan: Medical assistant (MA) will ask the next three patients with asthma about a flu shot if the practice hasn’t documented it this season.

Prediction: Patients will be able to indicate where and when they received the shot. Many patients will be current on their shot but will have been immunized elsewhere.

• Do: MA asks three patients with asthma about a flu shot, as it was not documented for the 2010-2011 flu season.

Results: Two patients received flu shots elsewhere. Third patient needs shot. MA checks with provider and gives shot.

• Study:  The team was correct that flu shots given elsewhere were not captured. Additional lessons learned: MA is not clear on how to document a shot given outside of the office, and provider input is required when patient needs a flu shot.
• Act: The team persists as its members recognize that documenting flu shots given elsewhere will better reflect asthmatic patients who are up to date on those shots. They make two other changes as a result of this small test:
  • The provider team clarifies how to standardize documentation of flu (and other) shots given elsewhere.
  • The practice creates ttanding orders (best practice!) to give a flu shot if there is no record that the patient received it elsewhere and has no contraindications for receiving the vaccine.

The practice performs another PDSA to test the revised process with the next three patients. It works well, and the practice drafts a new procedure. In the third PDSA, other MAs test the procedure and suggest improvements. The refined procedure is finalized and documented. The team moves on to the next priority and anticipates seeing an improvement in the flu shot measure.

Try the PDSA approach, Reims says, and you’ll develop best practices for your clinic. You’ll start to close the gap between how you want to provide care and how you currently provide care.