The General Internal Medicine “All-Hands” Meeting

1. The General Internal Medicine “All-Hands” Meeting 4/6/06

2. Agenda • Intro / Future Meetings (Pignone)- 5 min • Same-Day Clinic (Pignone) – 10 min • Computer issues (Scurlock) – 10 min • Clinic Access (Miller/Malone) – 15 min • Orientation Visit (Palmer/Perry) – 10 min • Quality of care- examples of smoking cessation and Pneumovax (Whitney) – 10 min

3. M Runge Chair, Medicine Open Admin Officer III J Buse Div Chief M Pignone Assoc Chief T Miller Clinic Director E Mark R Malone Asst Clinic Director J Martin Clinic Staff Nurse Staff GIM Organizational Chart Admin Staff DM Enhanced Care

4. Same-Day Clinic

5. Urgent care  Same-day Clinic • Hospital decided to end support for hospital-based urgent care in 2006 • Financial issues • Space Issues • Current urgent care experience to be transformed to ACC-based “same-day clinic” within our Division starting July 2006

6. Same-day Clinic • Located at ACC Internal Medicine • 1 attending, 2-3 residents, 1-2 students • 1 nurse, 1-2 PBAs • Will see established Internal Medicine patients and referrals from within UNCH • Anticipate 20-40 patients per day • Scheduled appointment times • Replaces “walk-in doctor”

7. Computer Issues (Scurlock)

8. Computers • Computers required for clinical care • Ongoing problems with computers (hardware and software) have limited efficiency and quality • Challenge of working effectively with ISD

9. Report Issues with Computers • Report all issues to Tim Scurlock 6-0030 • Leave voicemail if necessary • Provide room number • Fixed asset number if possible • Describe the issue and report contents of the warning message • Do not ignore recurrent issues, even if occur frequently

10. Summary of Computer Issues • Tracking all reports of technical issues since 3/17/06 • 16 issues reported • 10 of these issues reported by clinic staff • 15 of these issues reported as urgent, directly impacting patient care • Most issues occur on 3100 side of clinic • Most issues relate to network connectivity, login problems, and printing issues

11. Reminder • Nursing staff are to restart computers each day at either the start or end of clinic

12. Clinic Access (Miller/Malone)

13. Access • Why is clinic access important? • Main driver of patient satisfaction • Important factor in staff satisfaction, too! • Access required for good clinical care • Financial stability requires efficient use of resources • Work at other practices shows that access is predictable and manageable • Health care system goal: all insured new patients seen within 2 weeks

14. Clinic Access- Changes in 2/06 • “E” (acute) slots eliminated • “N” slots were eliminated in favor of using two adjacent “R” slots for NEW patients • PBAs will manually note “N” or “R” status in A2K • PBAs when possible schedule adjacent appointments to preserve consecutive slots for NEW patients • PBAs will start scheduling with the first opening of the clinic • There is no limit to the number of NEW patients a provider can see in a clinic session

15. Summary of Changes to Scheduling Acute Visits • ATTENDINGS will see on average 10 slots per ½ day. • PBAs may add to the schedule 2 of the ATTENDINGS own patients, one in the middle and the other at the end • RESIDENTS will see on average 6 slots per ½ day • PBAs may schedule 2 add-on slots per ½ day • The RESIDENT in the on-call clinic can see fewer patients • Interns will not see add-ons for the first 3 months of the year • ALL future open slots can be utilized  • NEW patients seen in urgent care must schedule appointments on their own (through orientation visit) • Every AM templates will be reviewed

16. Scheduling Conflict Resolution • RESIDENTS should report conflicts that arise to Paul Chelminski • ATTENDINGS should report conflicts that arise to Tom Miller • PBAs should report conflicts that arise to Edna Mark and Robb Malone. • Paul, Tom, Edna, and Robb will facilitate resolution

17. Clinic Access: Further Interventions March 2006 • Began introductory group visits for new patients scheduled with residents • Increased Attendings who accept NEW patients • Significant limitations for next several months with several Attendings on leave

18. Residents: New Patient Availability Introduced NEW patient group visits late-March. Stopped scheduling NEW patients with Residents 3/13/06, patients must attend group visit first. Group visits started 3/22/06.

19. Attendings: New Patient Availability Decreased availability of new patient appointments due to several Attendings on leave

20. Resident Templates Templates for 2nd and 3rd year residents are currently being compiled. Our goal is to maintain at least 90 days to the end of resident templates, even during the months of June and July.

21. Orientation Visit (Palmer/Perry)

22. Goal of Orientation Visits for Resident New Patients • 40% No-show rates for resident new visits • Goal: Decrease no show rates for resident new patient appointments • Decrease wait time to new patient visits with residents • Other practices and our pain program have found introductory visits to help

23. Orientation Visits Can Decrease the Wait for Enrollment: The Pain Example Started New Patient Visit Before the Orientation Visit, patients were enrolled into the program by the care assistant and evaluated by the clinician on the same day. Now patients are only seen by the care assistant during their first appointment and then scheduled a later appointment for pain management.

24. Orientation Visits Can Improve Attendance Rates: The Pain Example Started New Patient Visit

25. What is the process for scheduling new patients with residents? • If patient is SELF-PAY or has MEDICAID only, schedule for residents • Patients with MEDICARE or PRIVATE INSURANCE patients should be offered choice of attending or resident • Hospital or ER follow-up: • In July, these will go to SDC • For now, preferentially schedule within 2 weeks, but if no appt is available schedule for Orientation Visit • If acute need, send to nurse triage • If new patient for coag clinic, refer to Angela, NO group visit

26. What Happens During the Visit? • Patients meet with member of nursing staff • Complete Personal Health Questionnaire • Financial counselor referral • Pharmacy assistance referral • Tour the clinic • Refills of non-controlled medications • Triage if acute need • Make appointment with new PCP

27. Orientation Visit Utilization Initiated new patient orientation group visit for resident patients 3/20/06. Reduced template from 10 to 8 slots late March.

28. Wait Time for an Orientation Slot

29. Quality of Care- Examples of smoking cessation and pneumovax (Whitney)

30. Quality measures • We have been tracking measures of the quality of our care in several areas • Helps determine success of programs • Guides improvement processes • May be used for “pay for performance” bonuses in future • Residents need to track performance and work on improvement as a core competency of training

31. Assessment of Pneumococcal Vaccination Status Among DM Patients

32. New Pneumovax Protocol • Through a new protocol, GIM Extenders, Nursing Staff, and Care Assistants are authorized to order Pneumococcal vaccination • Will be developing a process for ordering and administration • Care Assistants will identify patients, complete the order, and notify the nursing staff for administration

33. Assessment of Smoking Status Among DM Patients

34. Review of Counseling Sessions

35. ASK about tobacco USE ADVISE tobacco users to QUIT ASSESS readiness to make a QUIT attempt ASSIST with the QUIT ATTEMPT ARRANGE FOLLOW-UP care What Happens during the Visit: The Five A’s

36. Quick Resources for Patients • NC Tobacco Use Quitline • 1-800-QUIT-NOW • www.quitlinenc.com • www.quitnownc.org • NC Good Health Directory: sites in particular counties • Chewfree.com • Quittobacco.com • Cancer.gov/cancerinfo

37. Our next meeting:6/30/2006