Practice Innovations: Translating Ideas from Conference to Clinic

1. Practice Innovations:Translating Ideas from Conference to Clinic PRISM 7 Working Smarter not Harder MaineHealth Learning Community Freeport, ME January 22, 2009 Christine Sinsky, MD Thomas Sinsky, MD csinsky1@mahealthcare.com Medical Associates Clinic and Health Plans Dubuque, Iowa

2. Agenda: Bringing About Change • Group Introductions • Planned Care Appointments 10 min • Building Teamwork 15 min • Streamlined Prescription Mgm’t 10 min • In-room Dictation 5 min • In Their Own Voices (5 min) • Reflections of patients, staff, physicians • One Idea to Take Away5 min • Discussion throughout

3. Time spent on results reporting? Lab ahead of appt?

4. “If you can’t describe what you’re doing as a process… … you don’t know what you are doing” W. Edwards Deming Process Mapping Change Management

5. Process Mapping: Post-appt Lab • Post-appt lab MD contacts patient with management advice Pt Appt (review lab from 6 mo ago A1c) MD reviews lab, pulls up record and reconstructs context Lab Done Lab results to Work List Outdated lab Fragmented bits of data Re-work Extra work Calls office Pt left with questions Extra work Diminished communication • For each step ask • Can it be eliminated? • Can it be done in a different order? • Is it being done by the most appropriate person? Patient inconvenienced Non- adherence

6. Process Mapping: Pre-appt Lab • Pre-appt Lab (Planned Care Appt) Appt Book lab ahead Automated Reminder Call Pt goes to Lab Appt (w/current lab) • Current data for visit • Increases patient involvement • Eliminates re-work

7. Questions or Comments?

8. What does your team look like? What is working? What would you like to change?

9. Task Allocation 40 min Check-in Vital Signs Med reconciliation Update PFSH 3 min 1 min MD-Patient Bonding/History/Exam/Plan Mini-huddle 15 min 1 min Operationalize Decisions Documentation Follow-up 10 min 5 min 6 min

10. Teamwork at the Point of Care Check-in Vital Signs Med reconciliation Update PFSH MD-Patient Bonding/History/Exam/Plan Mini-huddle Operationalize Decisions Documentation Follow-up

11. Teamwork at the Point of Care Check-in Vital Signs Med reconciliation Update PFSH MD-Patient Bonding/History/Exam/Plan Mini-huddle Operationalize Decisions Documentation Follow-up

12. Teamwork at the Point of Care Check-in Vital Signs Med reconciliation Update PFSH MD-Patient Bonding/History/Exam/Plan Mini-huddle Operationalize Decisions Documentation Follow-up

13. Teamwork at the Point of Care Check-in Vital Signs Med reconciliation Update PFSH MD-Patient Bonding/History/Exam/Plan Mini-huddle Operationalize Decisions Documentation Follow-up

14. Teamwork at the Point of Care Do Today’s Work Today Check-in Vital Signs Med reconciliation Update PFSH Pre-appt lab MD-Patient Bonding/History/Exam/Plan Mini-huddle Operationalize Decisions Documentation Follow-up Follow-up

15. Teamwork at the Point of Care Do Today’s Work Today Check-in Vital Signs Med reconciliation Update PFSH Pre-appt lab MD-Patient Bonding/History/Exam/Plan Mini-huddle Operationalize Decisions Documentation Follow-up

16. Teamwork at the Point of Care 20 min Check-in Vital Signs Med reconciliation Update PFSH MD-Patient Bonding/History/Exam/Plan Mini-huddle Operationalize Decisions Documentation Follow-up

17. Value Case Work Patients and MDs most value Check-in Vital Signs Med reconciliation Update PFSH 3 min 1 min MD-Patient Bonding/History/Exam/Plan Mini-huddle 15 min 1 min Operationalize Decisions Documentation Follow-up 5 min 6 min 10 min

18. Value Case Squeezed out when insufficient support 1.5 nurse: MD Check-in Vital Signs Med reconciliation Update PFSH 3 min 1 min Mini-huddle MD-Patient Bonding/History/Exam/Plan 15 min 1 min Operationalize Decisions Documentation Follow-up 5 min 6 min 10 min

19. Value Case More time when more teamwork 1.5 nurse: MD Check-in Vital Signs Med reconciliation Update PFSH 3 min 1 min MD-Patient Bonding/History/Exam/Plan Mini-huddle 1 min 15 min Operationalize Decisions Documentation Follow-up 5 min 6 min 10 min

20. Access Case Improved Access and Capacity 1.5 nurse: MD Check-in Vital Signs Med reconciliation Update PFSH 3 min 1 min MD-Patient Bonding/History/Exam/Plan Mini-huddle 1 min Operationalize Decisions Documentation Follow-up 5 min 6 min 10 min

21. Satisfaction Case: Staff Deeper level of engagement 1.5 nurse: MD Check-in Vital Signs Med reconciliation Update PFSH 3 min 1 min Prevention Coordinator Health Coach Case Management MD-Patient Bonding/History/Exam/Plan Mini-huddle 1 min Operationalize Decisions Documentation Follow-up 5 min 6 min 10 min

22. Satisfaction Case: Physician Continuity Less clerical work ↓ After hours work 1.5 nurse: MD Check-in Vital Signs Med reconciliation Update PFSH 2 min 1 min MD-Patient Bonding/History/Exam/Plan Mini-huddle 1 min Operationalize Decisions Documentation Follow-up 4 min 6 min 6 min

23. The Business Case for Sufficient Support • Doctor-does-it-all • 0.5 MA • 16 patients/day • Empowered Teamwork • 1.5 MA • 20 patients/day • The Business Case for support • 4 more pt/d = $86,000/yr • net benefit of $36,000/year Assumptions: 4 visits (two 99213, two 99214)MA works 48 weeks/year; payer mix generates $40/RVU; non-facility 99213 = 1.71, 99214 = 2.58 tRVUs; MA salary and benefits = $50,000/yr;

24. Sufficient Space and Support • Nurses • 1.75 nurses vs 1.25 • 56% more production • Exam rooms • 3 rooms vs 2 rooms • 34% more production

26. The Business Case: More Staff →More Net Revenue Net Revenue after Operating Costs per FTE MD MGMA Cost Survey: 2007 Report Based on 2006 data

27. Questions or Comments?

28. Staff time on prescriptions? System for renewals?

29. Synchronized, Bundled Renewals all prescriptions renewed 90 days + 4 refills (15 months) Maggie’s observation: only 25% of time spent in previous practice Planned Care Appt Order sets Empowered Nursing Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors Prescription Management

30. The Business Case:Nursing Time Lost • Primary care providers: 27 • Nursing time Lost $99,000/yr • 27 primary nurses x 4 d/wk x ½ hr/d x 46 wk/yr x $33/hr • 1 on-call nurse 2 hr/ d x 5 d/wk x 52 wk/yr x $33/hr • Physician Productivity Lost $240,000/yr • 46 weeks/year • Two fewer 99214 visits/week • $97 x 2 x 27x 46 = Total$339,000/yr

31. Time Study:Nurses with Stopwatches • One week of data collection • Receiving faxes • Talking on the phone to patients or pharmacies • Reviewing the chart • Addressing concerns with physicians • Returning faxes • Documenting the prescription in EHR (narcotics, benzodiazepines excluded)

32. Prescription Renewal Time Study Nursing Time min/wk • Total 998 (17 hr) • Our partners: 62 • T+C Sinsky: 12 (20%)

33. Questions or Comments?

34. Do you dictate in the room? Have you been a patient when the physician dictated in the room?

35. Dictation with Patient • Good for physician • Complete work before leaving room • Minimize distractions, interruptions, forgetting Dr. John Beasley

36. Dictation with Patient “This documentation done in partnership with the patient” • Good for patients • Respectful • Reinforce the plan • Realize we listen, think • Increases face time

37. Dictation with Patient • 57 yo annual exam • Declined colonoscopy x 7 • “pt declines colonoscopy” • After dictation in room pt said • “Well, maybe I could think about that colon test….but not till after the harvest.” • Another means of communication • Increases adherence

38. Questions or Comments?

39. In Their Own Voices

40. I assume the years of effective work are limited, so I do not hold back. This is more liberating Than earlier years When a bit of open mindedness Seemed terribly daring, Or a sense of abundance of time Slowed inquiry. Thank you for being interested. Carolyn Handy, artist, age 82

43. I’m trying to think of questions doctors ask. “How have your blood sugars been?” Always that question. The question I would rather hear or would like to hear in addition to that, is about non-medical stuff. It’s like they could simply ask, “How was your trip here? I think that’s all I crave, you know, not everything revolving around diabetes.

44. It would seem really easy for the doctor to jot any simple personal anecdote, In my chart and ask about it. It really connects me with them And I’m much more able to receive advice From people I feel are thinking of me as a person rather than just the next patient. Andie Dominick in Patient Listening: A Doctor’s Guide, Loreen Herwaldt

46. She is more than her fibromyalgia

47. 99 Years Old and Still Running

48. When I get bored with my work I realize I’m not paying attention to my patients and their stories. Family Physician, WI, 2008

50. I have to keep reminding doctors, As well as myself, Not to let illness define me. It’s in attendance, but it’s not all I am. Marva Dawn in Patient Listening: A Doctor’s Guide, Loreen Herwaldt