Practice Improvement: One Physician’s Experience.

1. Practice Improvement: One Physician’s Experience. Microsystems Approach to Improvement Douglas G Couper MDJanuary 22. 2009

2. Team Couper Introductions Dr Couper, MD– 1 FTE 36 contact hours Trisha Welch, MA – 1 FTE, “Roomer” Patti O’ Reagan, RN – 1 FTE, “Desktop Manager” Janet Aquilar ,PSR –1 FTE, Front desk Clinical Support Doris Valente, LPN – Nursing Lead, provides additional support for desktop if needed. K. Schnupp, RN – .2 FTE, Provides evening Queue support Other support: Referrals (IM & FP3) , Medical Records, Radiology, Nordx labs

3. Weekly Meetings What do we measure, and how do team meetings keep us focused? • Weekly Improvement Team Meeting • Improvement, Preparation, and Follow Up, with Coaching Support. • All team members attend. • Developing plans to test change ideas and monitor results. • Use a GANTT chart to drive agenda.

6. What we measured • Measuring Cycle Time • 15 patients monthly, random sample, use worksheet and timer to track visit cycle time. • Adequate sampling of data to analyze reasons for long waits. goal:1.5x appointment length Or a 15 minute appt would run 24 minutes long

7. Fishbone Diagram Where is the leverage for improvement of cycle time? Patients Have Too Many Issues for Appointment Length Missing Information in Logician Exam Room Interruptions ..stocking ..BP cuff function ..getting handouts/lab letters Appointments often do not Start on Time

8. What ideas did we test, monitor, and standardize? • Reduced interruptions by: • developing reliable stocking room standards • eliminating BP rechecks due to equipment defects • working on delays caused by leaving room for handouts/letters • Improved pre-visit preparation by: • Developing MA standards for visit pre-work • Started to review the weekly schedule to better manage ‘today’s schedule’ • Implementing pre-visit patient communication tool • Monitored AM and PM start times and time to home for provider. • Developed a Risk Assessment tool.

9. What are some avoidable roomer interruptions?

10. Are we making progress eliminating equipment related BP rechecks?

12. Time to Third

14. Interruptions for Dr Couper

15. What are the room stocking standards and how is reliability achieved?

16. PREWORK by MA done about 2 weeks in advance: • Preloads Chart for new patients • Prints Chart Summaries • Orders labs for PE • Reminds patient to bring BP or Glucose logs • Determines if PHQ-9 is needed • Determines if there are specific room needs (wound care, biopsy, wheelchair)

17. Risk Assessment Tool

18. The patient communication tool was developed to facilitate communication from patient to doctor, nurse to doctor, and doctor to nurse.

19. Tracking data (start times in this case) is not always pretty:

20. What are we learning from Start times & Time to Home May 08?

21. What are we learning from Start times & Time to Home Sept 08?

22. Measuring and Improving 15 min Appt Cycle TimeAim: Reduce cycle time to 24 minutes for 15 minute appointment over 6 months.

23. What have we learned from microsystem improvement work that others might benefit from? • Team Lessons Learned: • Reducing Waits, Waste, & Delaysin Daily Work, and Sustainingthe gains takes effort, and is accomplished by small gains in many areas. • . Weekly meetings are important to sustain gains, keep momentum • Staffing changes have a huge impact on gains! • Patient’s feel that they get better care when staff are satisfied with their roles, and staff are satisfied when they have more control. • Proactive planned care means better care delivery and reduction in back log

24. Challenges • Momentum takes a long time to get going. • Team Buy in was necessary for all members. • Time limitations need to be overcome. The process of improvement needs to be a priority. • Resource limitations (Printers, space) were sometimes insurmountable. • Staff Turnover had a HUGE impact on my practice.

25. Summary of Tips for Improving Cycle Time

27. What are we working on now? • We have chosen to focus on several areas: • Access • Optimizing Visit Flow • Optimizing Chronic Disease Management (Diabetes was chosen) • Identifying patients not being seen / overdue for visits/PE.

28. ACCESS • Start Times • Study and revise Stocking time frame for exam rooms and Procedure room. • Collect deferred • Implement vacation coverage criteria • Study 3 months of backlog to determine who can be brought forward • Research options to working down backlog or provided care through alternative means (Email/Phone call f/u) • Implement test of change

29. Optimize pt visit flow • Patient reminders for medications and BP logs (only for physicals?) • New Pt records • Lab consults & signing off on mammos, paps and stool cards • Track Cycle time for 15 & 30 min appts

30. Optimize Chronic Disease Management • Invite HED staff to Couper team meeting, to review roles and insurance coverage. • Establish process for following up on self management goals • Finding self management goals in centricity. • Define team process with care manager, pcp team and HED to review plan for patients with A1C>9 • Implement test of change to integrate HED • Identify pts with A1C/DM -define process for ordering A1C prior to visit • Measure effectiveness of A1C ordering process .

31. Diabetes Goals • Increase the percentage of Diabetics with A1C under 7.0 form 65% to 70%. • Decrease the number of Diabetics with an A1C over 9.0 from 9 to 6.

32. Utilize EHR database to identify overdue visits • E.H.R. Dept to develop new Patient population tables to capture Preventative health population based on IM Criteria. • b. Study Couper pt count that are overdue for preventative care appointments. • c. Flowchart out current process. • d. Brainstorm best practice. • e. Implement test of change idea

33. OPTIMIZING TEAM CARE • Collaborate with Teams Shepp and Talon (2 other teams that cover team Couper) • Teams to define optimal model • This is our plan/goal for later this year.

35. Summary • You need to have a vision of where you want to be in order to get there. • Achieving substantial goals can be reached through incremental gains. • Start with the obvious and the easy, and work down from there. • You can’t do it alone; it is a team process. • Measure, intervene, and remeasure. • For every advance there will be setbacks. Perseverance is mandatory.

36. Thank You