Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams Project Location: Dermatology Department Rancho Cordova Medical Office

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

mailto:[email protected]

Overview of Presentation

• Setting the Stage– Organization/Location– Team Members– Context– Challenges

• The Project– Mission Statement– Project Process/Outcomes

• Key measures selected• Flow diagram• Fishbone• Hypothesis/Leverage Point• Aim Statement• Interventions

– Results

• Summary– Did we achieve our goals?

– Recommendations

– Closing systems and clinical teams perspective

• Special Thanks

• Questions???

• Upstream/Downstream Fable

Part One - the Project Part Two - In Closing…

“Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams”

Northern California Kaiser Permanente Medical Care Program

• Kaiser Foundation Health Plan– Non profit– Invests in non profit hospitals– Owns equipment, facilities,

including pharmacies– National Board of Directors

• The Permanente Medical Group, Inc.– For profit– Physicians and employees of

clinics– Private Corporation– Physician Board of Directors

• 3.3 million members• 19 Hospitals• 45 clinics

• 6500 physicians

Setting the Stage“Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams”

North Valley Region• Sacramento/Roseville

• Dermatology Services

• Dermatology Department at Rancho Cordova (site of project)

• 470,000 members• 2 Hospitals• 8 clinics• 900 physicians

• 3 Locations

• 12 physicians

• 3 Physicians, 1 Physician Assistant

• 3 Registered Nurses

• 2 Medical Asst per Physician

• Dedicated Call Center

• Support Staff


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


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


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


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


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


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


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.


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.


Flow of Patients in Clinic - time to see MD after Roomed

Baseline Average = 13.2 minutes Post Intervention Average= 9.0 minutesPercent Reduction = 32%

MA to MD Time Minutes

-20.00

-10.00

0.00

10.00

20.00

30.00

40.00

50.00

60.00

1 10 19 28 37 46 55 64 73 82 91 100 109 118 127 136 145 154 163 172 181 190 199 208 217 226 235 244 253 262 271

Consecutive Patients

Minutes

Minutes Mean Lower Control Limit Upper Control Limit

Intervention


Physician Unpaid Work Time

Baseline average = 102 min/calendar day Post intervention=90 min/calendar day Percent Reduction = 12%

Physician Unpaid Work Time

-50

0

50

100

150

200

250

300

350

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Days Worked Unpaid Time

Minutes Worked

Minutes Unpaid Overtime Mean Time Lower Control Limit Upper Control Limit

Intervention


Wait Time to See Physician in Outpatient Dermatology Clinic

Baseline Average = 40 minutes Post Intervention Average = 33 minutesPercent Reduction = 17.5%

Time Between Registration and Seeing Physician

-20.00

0.00

20.00

40.00

60.00

80.00

100.00

120.00

1 11 21 31 41 51 61 71 81 91 101 111 121 131 141 151 161 171 181 191 201 211 221 231 241 251 261 271 281

Consecutive Patient Wait Times

Time Waited in Minutes

Patient Wait to See MD Average Wait to See MD Lower Control Limit Upper Control Limit

Intervention


In Summary… Did we achieve our stretch goals?

Flow

of Patients50% 32% 64%

Physician Unpaid Work

Time

20% 12% 60%

Wait Time to See Physician

N/A 17% N/A

Measure Goal Achieved Percent of Goal

Almost… But we learned and significant progress was made!

Summary“Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams”

Next steps for Dermatology Service…

• Time required for appointment types– Structure half days with one type of appointment to determine realistic

times for appointments• Explore different scheduling options

– Block scheduling– Designated time for desk top duties

• Explore the best way to handle desk top duties– Review lab and pathology results– Review phone messages, emails, and correspondence

• Explore the appropriate use of the Physician Assistant– Could be used to see units of patients on wait lists for solar rechecks

and follow-up melanoma physical exams– After role is defined can consider hiring additional providers

• Set up project team on the recruitment of additional physicians• Explore the opportunities to develop projects with other members of the

department• Explore the single lesion clinic and needed follow-up using a different

project team including registered nurses

Summary“Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams”

Closing systems and clinical teams perspective

• CClinical teams as complex systems

• LLeverage points for significant change in complex systems.

• DDeveloping sustainable clinical teams

• MMoving to an improved healthcare model

Systems Perspective“Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams”

Outpatient Clinical Teams are similar complex systems…

Clinical Team

ProcedureReturns

Patients(Regular)

DischargeReferral

Patients(Future)

You build the foundation by starting with the smallestteam within the clinical team…


Then focus at the correct levels for significant change…

MINDSET

FUNCTION/PURPOSE

RELATIONSHIPS

ELEMENTS

BEHAVIOR

EVENTS

Systems Hierarchy for Intervention


Values, beliefs, paradigms

Results

Information flows structures

People, equipment

Observable actions

Occurrences

• Meaningful, satisfying moral goal with a sense of enough

• Protection of resource base• Positive feedback loops balanced by negative feedback

loops• Clean, clear, fast, compelling information flows• Successful over time

Aiming to Develop Sustainable Clinical Teams… Aiming to Develop Sustainable Clinical Teams…

which then begin changing the basis of our healthcare systems from…


Conventional Natural Capitalism Conventional Natural Capitalism

Unsustainable

Neglects natural & human capital

Human productivity

Price not cost

Financially profitable

Short term view

Sustainable

Values natural & human capital

Resource productivity

Cost not price

Restores capital

Long term view

“The stationary state would make fewer demands on our environmentalresources, but much greater demands on our moral resources. “

Herman Daly, 1971.


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…


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


Documents

Building the Foundation for Breakthrough Improvement In Outpatient Clinic Teams Project Location: Dermatology Department Rancho Cordova Medical Office