Key Principles• Planning• Education and

Communication• Measurement• Do Today’s Work Today• Continuity of Care• Understand Demand

and Capacity

• Work Down Bad Backlog• Standardize and Reduce

Appointment Types• Establish Contingency

Plans• Engage Providers• Daily Huddles• Process Redesign

• Tactics– Identify sponsors– Identify stakeholders– Create a planning team– Involve physicians and staff– Develop an Aim Statement (overall goals)– Identify priorities based on current performance– Define scope, tasks, and timelines– Identify resources needed

Planning

Education & Communication• Tactics

– Share best practice standards and data– Develop a communication strategy– Obtain buy-in from physicians and staff– Share resource availability

Measurement• Tactics

– Determine data needs and select appropriate tools– Identify and validate data sources– Identify data analysis resources– Share measurement results with stakeholders, providers,

and staff

Do Today’s Work Today• Tactics

– Define what this means by specialty– Create disease criteria

• Pre-assessment guidelines• Care bundles• templates

Continuity of Care• Tactics

– Set up care teams (Microsystems)– Identify use of mid-level and non-provider staff– Communicate with referring physicians– Identify patient’s responsibility to communicate– Physicians communicate with patient (after-visit

summaries)– Patient education (pre and post visit)– Define expectations for patients

Demand and Capacity• Tactics

– Measure demand and capacity by provider– Identify capacity constraints– Determine how to meet the demand and adjust capacity– Match demand with capacity

Reduce Bad Backlog• Tactics

– Define good and bad backlog– Measure by provider– Share data with providers– Identify steps to reduce bad backlog– Phased implementation with physician stories of success

Reduce Appointment Types• Tactics

– Evaluate existing visit types– Standardize appointment types and duration by specialty– Set up appointment type rules– Determine number of closed appointment slots (good

backlog)– Build scheduling template– Adjust scheduling process and staff

• Tactics– Measure demand and identify peak demand times– Establish rules to adjust capacity

Contingency Plans

Engage Providers• Tactics

– Identify physician champions– Involve physicians to educate physicians– Share patient experiences– Share referring physician experiences

Daily Huddles• Tactics

– Identify care team members– Select time and process for care team to meet– Share purpose, plan, and objective

Process Redesign• Tactics

– Engage providers through physician leadership– Create a blameless culture that fosters teamwork and

cooperation– Analyze processes – map current and future states– Understand what process capabilities exist– Train on new process design

“A Different System is Needed…… one that is reliable, proactive, efficient and engages patients in ways that ensure

the best outcomes” Institute for Healthcare Improvement, 2006

Care Team Objectives

• Micro team approach to care• Staff roles and responsibilities realigned• MA’s work in an expanded role• Patient centered, personalized, efficient visit• Cycle time reduced• Provider focus on patient• Patients develop relationship with care team• Increase in visits and WRVU’s• Patient, staff and provider satisfaction improved• Increase in market share and referrals

Care Team Configuration• Providers and MA’s work in teams• A small number of providers are supported by

a pool of medicals assistants - typical ratio is 2-2.5 MA’s per physician

• Two to three physicians work interchangeably with 5-7 MA’s

• Impact of increasing MA staffing offset by decreases in other support staff

Expanded Role of MA

• MA’s work in rotation – greeting, rooming and supporting the visit regardless of provider

• MA’s responsible for the “full cycle” of visit• MA acts as facilitator• MA documents the visit in the EMR – acts as

scribe during the exam• Patients develop a personal relationship • Allows physicians to focus on services they

uniquely provide – (cost of MA vs. Physician)

MA’s work in Rotation

• Greeting, rooming and supporting the visit for the next arriving patient (regardless of the provider they are seeing)

• Responsible for other support processes – messages, running lab tests, paperwork, stocking rooms etc.

• Rotation maximizes MA resources, reduces disruption and delays in patient flow

Standardization

• Standardized documentation templates• Condition-specific questionnaires• Order sets based on protocol• Exam rooms organized and stocked in a

standard manner – same place in each room• Printers are standard equipment in each room

Real-time Communication

• Communication enhanced between team members

• Use of technology – vocera, hand-held radios, white boards, electronic screens etc.

• Improves provider efficiency• Improves flow• Supports smooth transition from one patient to

another• Messaging through EMR – MA works the pool

Planning for Daily Work

• Share information about changes in schedule or staffing

• Identify opportunities to work in walk-ins or unscheduled patients with urgent needs

• Huddles – brief, stand-up care team meetings at the start of the day and after lunch

• Identify patients that need additional work-up prior to seeing the provider

Patient Accompanied at all Times• MA’s act as the facilitator of

the patient’s visit• Same MA with the patient

the entire visit• MA present during

assessment, diagnosis and treatment

• MA knows patient background and care plan

• MA answers appropriate questions and refer others to the provider

Waiting Times

• Patient does not wait – services brought to patient – do not move the patient

• MA facilitation reduces patient waiting times• MA anticipates and responds to service needs

of patient• Labs drawn in exam room by MA’s• Referral appointment made in exam room• Instructions and after-visit summaries given and

reviewed with patient in exam room

Call Management

• Centralized call center• Minimal telephone disruption – QUIET CLINIC• Call center does scheduling and registration –

streamlines check-in• Call center routes messages through EMR• Standards for response times set and monitored• Triage and escalation protocols used to address

urgent and emergent situations

Support Resources

• Electronic Medical Record– Access to complete medical record– Offers point of care reminders– Allergy and interaction alerts– Ability to export data

• Nursing resource pool

Planned Care“Currently Americans receive only about 55% of the recommended medical care they need, regardless of their race, gender, income, or where they live.”

“Studies show it would require 31.6 hours a day for a provider to manage the care needed for an average panel of 2,500 patients.”

Not Enough Time in the Day

Planned Care…The SolutionProvide all the recommended care and

services at the right timeSupports patients in maintaining or

improving their health statusCreates positive outcomes in quality,

satisfaction and financial performanceCompetitive advantages

Apply evidence-based guidelines to the individual needs of individual patients

Facilitate population management, coordination/ conformity of care, chronic disease management, and self-management

Relationships with Patients

Expected Outcomes of

Planned CareThe patient receives all recommended care

according to guidelinesAchieve care plan goalsIncrease in quality measures performancePersonalized, patient-centered careIncrease in patient satisfactionIncreased revenueIncreased referrals and market share

Elements of Planned Care

Population management

Coordination of carePre-visit planningCare managementSelf-management

support

Population ManagementAssessment of patients to identify groupsDetermine specific services and

notification to patients of services neededServices include preventive care/health

maintenance; follow-up visits; patient safety alerts; medication recalls

Outreach and reminders to patients

Coordination of Care

Management of the transition of care between facilities and external care sources

Providing clinical information at the time of admission

Contacting patients after dischargeCoordinating follow-up care & appointments

Pre-visit Planning

Pro-active management of scheduled appointments

Ensure effective use of time & activities associated with the patient’s visit

Medication managementArrangement of lab & preventive care orders

Care Management

Use of expanded team to develop individualized care plan

Individualized care plan to meet patient’s specific needs, treatments, and goals

Collaborative practice agreements

Referral coordination

Self Management SupportUse of resources and

tools to help patients and families manage their conditions outside the office visit

Use of technology resources such as MyChart

Group education classes and workshops

Expanded Team Members

Case managersPharmacistsSocial workersSelf management

facilitatorsOther support members

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