© 2004 Institute for Healthcare Improvement High functioning clinical teams are extremely efficient: How to get one and achieve advanced access L. Gordon Moore MD Bertha Safford MD

© 2004 Institute for Healthcare Improvement Objectives Explain what care teams are Explain the attributes of a care team Explain how care teams can reduce demand and increase supply Develop a care team

© 2004 Institute for Healthcare Improvement Definition A care team is the right mix of people coming together with the right tools to deliver the right care for a defined population of patients.

© 2004 Institute for Healthcare Improvement Attributes of a Highly Functional Care Team (p<.01) Clear expectations and available tools Easy to understand and discuss processes of care Information is available when needed Everyone on the staff is valued; Respect and sharing Feedback of performance and opportunities to grow Positive attitudes of co-workers (24 Practices) from John H. Wasson - Dartmouth

© 2004 Institute for Healthcare Improvement Do Patients Notice Good Teams? From John H. Wasson MD - Dartmouth

© 2004 Institute for Healthcare Improvement Does Patient Perception Matter? From John H. Wasson MD - Dartmouth

© 2004 Institute for Healthcare Improvement Not perfect in Patient Perception Looks Scary From John H. Wasson MD - Dartmouth

© 2004 Institute for Healthcare Improvement Why do this? Up to 40% of the work we do is re- work: Hand-offs Repetitive patient calls & messages Staff salary & benefits makes up 70% of overhead

© 2004 Institute for Healthcare Improvement High functioning teams can accomplish more in less time Better balance between work and life Reduced overhead Advanced access is less work for us and serves our patients well

© 2004 Institute for Healthcare Improvement Process for making an appoint- ment From Catherine Tantau,

© 2004 Institute for Healthcare Improvement Rx refill process

© 2004 Institute for Healthcare Improvement Optimize the Care Team to Increase Supply Ensure that all roles in the practice are maximized to meet all patient needs Co-locate staff Cross-train staff Reduce variation Provider styles Rooms How we talk to patients Use standard protocols to optimize use of other providers Separate flows for paper, patients, etc.

© 2004 Institute for Healthcare Improvement How Can a Team Reduce Demand? Promote self-care – Nurse interaction in office or on phone with some patients Alternatives to face-to-face (phone contact if a visit is not clinically necessary) Nurse visit for BP check, sore throat, weight management, smoking cessation (allowing for State Licensure and individual capability) Provider extends re-visit intervals Max-pack visits

© 2004 Institute for Healthcare Improvement How do you Get There? Ideally, start with resource planning Then define the team necessary to meet the needs of your patients All staff meet regularly Get the data you need to inform you of your results What is your teams demand? What is your teams capacity? Where is the constraint?

© 2004 Institute for Healthcare Improvement

Objectives Apply the change concepts of Optimizing the Care Team from the Care Model Use the key changes from the Care Model

© 2004 Institute for Healthcare Improvement Delivery System Design Improve efficiency

© 2004 Institute for Healthcare Improvement Strategy: Improve Efficiency Change Concept Optimize the Care Team and Staff

© 2004 Institute for Healthcare Improvement Change Concept: Optimizing Care Team and Staff Key Changes Match the work to the individuals licensure and capability Cross train staff Define and develop the team as unit

© 2004 Institute for Healthcare Improvement Content review: Traditional Roles in Clinical Office Practices Roles held by tradition Authority held by few Function Focus Members of the team

© 2004 Institute for Healthcare Improvement Redesign Concepts for Care Teams Co-location of people and resources Cross-functioning and cross-training of staff Self-organization & sharing of work Weekly team meetings Visit planning Self-measurement for improvement Care team huddles

Assess Your Current Team What are current roles & responsibilities of team members? Review hours of operation Typical hours of operation Staff Who, what capabilities, times they work Capacity of the clinicians Where are your constraints? Who is doing what work now? What would be the ideal match between individuals and work?

© 2004 Institute for Healthcare Improvement Work Analysis example…. TaskWho does it nowIn a perfect world who would do it Book apptsRNs and clericalClerical support Take incoming calls EveryoneClerical support Chart prepMAsClerical support TriageRNs and MDsRNs Med refills requests RN, MD, clericalClerical with MD sig. Check inReceptionists Suture removalMDRN Dressing changeMDMA Flu shotsRNMA Etc. © Tantau & Associates, LLC

Define the Activities: Visit and Non-Visit

© 2004 Institute for Healthcare Improvement What Should the Care Team be Doing? Explore the Mismatch : Between role and activity State/Professional guidelines and current role Between activity and patient needs Between volume of resources and Between staffing and demand by hour of day, days of week, month of year Things to look for: Where do you see variation? Are the right people doing the right things? Are roles commensurate with education, training and licensure? Are staff trained to the highest level of capability? Are there systems to support and monitor performance?

© 2004 Institute for Healthcare Improvement Examples of Waste at the Constraint (Providers) Interruptions and distractions (telephone, nurses, messages, etc.) Providing care, answering phone calls, completing paperwork or other items that others such as nurses could perform Waiting for medical records Waiting to get patients in rooms

© 2004 Institute for Healthcare Improvement Examples of waste at constraint (Front office) Multiple repeat patient phone calls due to office policy of we need five days notice for Rx refills Access delays Provider schedule is not available Sorting calls by urgent vs routine Inaccurate PCP listed Every patient signs waiver form at every visit

© 2004 Institute for Healthcare Improvement A team is a small number of people with complimentary skills who are committed to a common purpose, set of performance goals, and an approach for which they hold themselves mutually accountable. Wisdom of Teams by Katzenbach Building the Right Team

© 2004 Institute for Healthcare Improvement High functioning team Defined patient population Vertical slice of the office Defined team members Defined back-up Data to inform team of their results Dartmouth - Microsystems

© 2004 Institute for Healthcare Improvement Vertical slice of office Their own space Data on their processes & outcomes Their own patients MD/NP/PA Nurse/MA Receptionist

© 2004 Institute for Healthcare Improvement An office practice MD/NP/PA Nurse/MA Receptionist MD/NP/PA Nurse/MA Receptionist MD/NP/PA Nurse/MA Receptionist

© 2004 Institute for Healthcare Improvement Mutual Accountability Know whats expected Capability Feedback Volunteer

© 2004 Institute for Healthcare Improvement Successful team behaviors Daily: Review days schedule Is there anyone on the schedule who should not be/ Anticipate equipment needs, visit length problems Manage all patient demand within the team – e.g. see all visit demand that day Weekly Review future schedule for gaps in capacity Im at a conference next Wednesday all day Review team data: access delays, cycle time, clinical process & outcomes Define # of new patients (if any) team can accept

© 2004 Institute for Healthcare Improvement More team behaviors Create and manage a contingency plan list For the expected unexpected 15 min visit for chest pain, rectal bleeding, three kids Gaps between capacity and demand Coordinating team activities across the practice We need to hold three appointments for Dr. Joness patients as shes on the labor deck probably all day.

© 2004 Institute for Healthcare Improvement Successful practice behaviors Correctly identify provider/team on patient charts and in the system Separate work flow for various teams Separate check in and check out window Separate phone number Teams wear color stickers Were the Red team Triage becomes work flow backup for absent providers/teams

© 2004 Institute for Healthcare Improvement Resources Clinical Microsystems Action Guide – Advanced access: Access Senge P.M The Fifth Discipline Fieldbook. Doubleday. Presentation is on Gordons web site: