Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams Project Location: Dermatology Department Rancho Cordova Medical Office Building Kaiser Permanente Medical Care Program Rancho Cordova, CA 95670 Project lead: Donald Forrester BSChE MD CPE Position at time of project: Staff physician, former Physician in charge Retired: 11/2008 Current position/contact information: Sole Proprietorship Federal Service Trademark = Clinical Catalyst Presentations, Seminars, Clinical Care 841 La Sierra Drive Sacramento, CA 95864 Email: [email protected]Phone: 916-420-0244 www.DonForresterMD.com
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Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams Project Location: Dermatology Department Rancho Cordova Medical Office.
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Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams
Project Location:Dermatology Department Rancho Cordova Medical Office BuildingKaiser Permanente Medical Care ProgramRancho Cordova, CA 95670
Project lead: Donald Forrester BSChE MD CPE
Position at time of project:Staff physician, former Physician in chargeRetired: 11/2008
Current position/contact information:Sole ProprietorshipFederal Service Trademark = Clinical CatalystPresentations, Seminars, Clinical Care841 La Sierra DriveSacramento, CA 95864Email: [email protected]: 916-420-0244 www.DonForresterMD.com
Setting the Stage“Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams”
Team Members for Project
• Management Guidance Team– Dr. Rozance: Physician in
Chief
– Dr. Palkowski: Physician in Chief
– Dr. Haynes: Asst Physician in Chief
– Dr. Kidwell: Asst Physician in Chief
– Dr. Forrester: Project Lead
• Project Team – Dr. Anderson: Chief,
Dermatology
– Ms. McAllister: Medical Assistant
– Ms. Cianci: Medical Assistant
– Dr. Forrester: Project Lead
Setting the Stage“Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams”
Context for the Dermatology Services • Regional mandate for improving access for consults to specialties to
less then 2 weeks led to increased scheduled patients with focus on new consults
• Focus on new patients has led to wait lists for return patients • Department survey showed physicians are suffering from burn out • Work load has led to turnover of physicians and reduction in days
worked by those who have stayed• Department having difficulty hiring new physicians(5 open positions)• Some Innovations have helped:
– Single lesion clinic with RN’s has streamlined the majority of consults– Primary Care Dermatology Fellow Training program has helped with
referrals
• Proposed innovation using an additional Medical Assistant to assist physicians was funded 3 months ago
Setting the Stage“Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams”
Challenges • Skills
– No baseline training or awareness of TQM/SPC• Administrative
– Infrequent meetings with staff and physicians– Taylor management style is the norm– IT has not responded to requests for assistance– Roll out of a new coding system on October 20th
• Cultural– Lodge culture– Craft of medicine is supported
Setting the Stage“Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams”
Mission Statement
Building the foundation for breakthrough improvement in outpatient clinical teams requires an understanding and valuing of how healthcare professionals use their time. Using a quality improvement approach our pilot takes an initial step toward this understanding by improving the efficiency and effectiveness of two medical assistants and a dermatologist working as a team to treat patients. We hope to contribute to a world-class sustainable work environment which would allow the clinical team to cope with the demands and complexity of today's healthcare industry.
The Project“Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams”
Key Measures Selected
• Medical Assistants were most concerned with the flow of patients through the clinic:– They selected the time that the patient waits in the exam room
before the physician entered as the key measure of flow
• Physician was most concerned about the amount of time spent outside scheduled clinic time working to catch up and the delay in charting:– He selected the amount of time outside scheduled clinic time as
the key measure reflecting on delay in charting and leading to burnout among physicians
The Project“Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams”
Conceptual Flow DiagramPatient
Registers
Put Slip in box
Medical Assistant Physician
New or return patient ?
Prepare consult or review old chart
Medical Asst escorts patient into exam room
Prepares room and instructs patient
Exits Exam Room
Enters Exam Room
Places Chart on Physician’s Desk Reviews Chart
Enters Exam Room
History and Exam
Biopsy &/or Picture ?Enters Room and Assists Physician
Exits Exam Room
Yes
No
Diagnosis And Disposition
Enter Diagnosis and Rx on Computer
Leaves Room and completes chart later
Exits Exam Room to see Medical Assistant
Instructs and arranges follow-up if needed
Leaves Clinic
Desk Work
Cause and Effect(Fish bone diagram)
Reduce Work Time Outside of Standard Clinic Hours
Work Complexity System Complexity
Desktop Work Absence Coverage
Phone messages
Pathology results
Lab Results
Email
Secure messages
Elderly Patients
Unexpected Biopsy Complexity of Derm illness
Orders
Progress Notes
Consults
Coding?
Work schedules
Cover messages, lab & pathology
Drop-in patients
Nurse consults
New patients
The Project“Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams”
Hypotheses/Leverage Point
1. Number of appointments per day
2. Type of appointments per day
3. Sequential versus Block booking
4. Amount of support staff per physician
5. Number of exam rooms per physician
6. Roles of personnel supporting physician
7. Amount of unbooked clinic time for physician
8. Number of providers
The Project“Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams”
Aim Statement
By October 20th we will compare a new system of care to measured baseline data for a clinical team composed of 2 medical assistants and one physician. We will demonstrate a 20% reduction of work outside clinic hours by the physician and a 50% reduction in time that patients wait to be seen by the physician after being roomed by the medical assistant. We will also report the change in the total time the patient spends in waiting to see the physician.
Data collection will be with tally sheets at Medical Assistant’s work stations and physicians desk and personal calendar.
The Project“Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams”
Interventions
1. Medical Assistants enter room with the physician providing support by scribing the progress note and supporting biopsies. After physician leaves the room the medical assistant is able to schedule appointments and answer patient questions in the exam room.
2. An additional ½ hour of unscheduled patient time is given to physician.
The Project“Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams”
Flow of Patients in Clinic - time to see MD after Roomed
Baseline Average = 13.2 minutes Post Intervention Average= 9.0 minutesPercent Reduction = 32%
“The stationary state would make fewer demands on our environmentalresources, but much greater demands on our moral resources. “
Herman Daly, 1971.
Systems Perspective“Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams”
In closing… • Special thanks go to…
– Sponsor – Jack Rozance MD– Project Team Members – Randall Anderson MD, Debbie
McAllister & Cathy Cianci– Physician Leader Educator - Brent James MD – Consultant - Ann Ward RN – Intermountain Healthcare Staff – TQM/Excel Expert - Peter Higgins
• Questions???• Leave you with a fable or story to ponder…
“Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams”
It was many years ago that villagers in Downstream recall spotting the first body in the river. Some old timers remember how Spartan were the facilities and procedures for managing that sort of thing. Sometimes, they say, it would take hours to pull 10 people from the river, and even then only a few would survive.
Though the number of victims in the river has increased greatly in recent years, the good folks of Downstream have responded admirably to the challenge. Their rescue system is clearly second to none: most people discovered in the swirling waters are reached within 20 minutes – many in less than 10. Only a small number drown each day before help arrives – a big improvement from the way it used to be.
Talk to the people of Downstream and they’ll speak with pride about the new hospital by the edge of the waters, the flotilla of rescue boats ready for service at a moment’s notice, the comprehensive health plans for coordinating all the manpower involved, and the large number of highly trained and dedicated swimmers always ready to risk their lives to save victims from the raging currents. Sure it costs a lot but, say the Downstreamers, what else can decent people do except to provide whatever is necessary when human lives are at stake.
Oh, a few people in Downstream have raised the question now and again, but most folks show little interest in what’s happening Upstream. It seems there’s so much to do to help those in the river that nobody’s got time to check how all those bodies are getting there in the first place. That’s the way things are, sometimes.
Ardell, Donald B., “High Level Wellness: An Alternative to Doctors, Drugs and Disease”, Rodale Press, 1977.
A CONTEMPORARY FABLEUPSTREAM/DOWNSTREAM
“Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams”