1. www.pspbc.ca Group Medical Visits For Specialists

2. 2 Aim  Improve patient access to and increase efficiency of care and follow-up through shared medical appointments, a time-efficient method of treatment Group Medical Visits

3. 3  Identify suitable patient populations and best suited practice approach  Plan, implement and evaluate shared medical appointments Focus on

4. 4  Improve access (decrease waiting time)  Improve efficiency  Integrate health services – ‘wrap the services around the patient’  Improve patient and provider satisfaction  Improve health outcomes SMA Aims

5. 5  Baseline data  Endoscopy: Approximately 300 scopes per year  Individual consult appointments  Average wait time for consult – 8 weeks  Average wait time for scope 6-8 weeks  Procedure appointments booked by hospital staff via phone calls What are the best patient populations for SMAs?

6. 6  TIME 1 – referral letter to group visit  TIME 2 – group visit to scope procedure  Number of patients seen  Physician and staff work hours Scenario – Defining the Measures

7. 7  Establish the team – including hospital staff  Determine objectives  Formulate a process  Set a date, time and location  Initiated group consults June 25 2008 Scenario – The Plan

8. 8  ↓TIME 1 to 4 weeks (50% reduction)  ↓TIME 2 to 4 - 6 weeks (30% reduction)  ↓consult time by 52%  ↑number of patients seen by 29%  ↓hospital staff booking time by 64% Scenario – Summary of Measures

9. 9  Met objectives and measures  Group visits held twice a month  Process embedded in the clinic  Cross-training of clinic staff  Hospital staff continue to be involved  Lead physician promoting group visits with other physicians  Patient satisfaction  Provider and staff satisfaction How do we know we have achieved positive sustainable change?

10. 10  Decreased wait time  Improved health maintenance  Enhanced services and quality of care  Improved patient and physician relationships  Improved patient and provider satisfaction  Cost savings Group Medical Visit Benefits

11. 11  Specialist  MOA  PSP Coordinator  RNs/other health care providers Group Medical Visits Roles

12. 12  1 to 1 Specialist/patient appointment done in a Group  Share patient clinical data (flip chart, overhead)  Charting during the group meeting  Order lab/diagnostics  Prescriptions  Chart notes  Patients that need to be seen privately can do so at the end  Arrive on time  Leave on time  Participates in short debriefing at the end of GMV Specialist Role

13. 13  Organize the group space  Working with the Specialist to ID good time and how often GMVs will be held  Overbook by 25% (stats show 81% of pre-registered actually show up)  Telephone bookings and patient invite and/or send out invitation letter  Make a patient information package › Confidentiality form › Evaluation form › Flow sheets › Handouts doctor wants  Track data/narrative reports/measures i.e. module measurements, completion and target rates  As patients arrive assist with BP, weight, etc. and document  Participates in short debriefing at the end of GMV MOA or office staff

14. 14  Facilitates learnings for GMV for each team member  Encourages role maximizing, and role expansion training  Assists with finding a suitable behaviourist  Attends GMVs until independent  Facilitates team debrief after each GMV  Continues to keep in touch for support  Facilitates model for improvement testing and evaluating  Writes PDSA Coordinator role

15. 15  Shared physicals appointment  They reduce repetitive information  8-12 patients  90 minutes long  First half of the session is a private physical exam by doctor - while other group members are sharing & learning with behaviourist  Second half is doctor patient interactions in a group Physicals Shared Medical Appointments

16. 16  The care of patients requiring specialty services will be redesigned to increase access, capacity and efficiency in specialty practices.  Advanced Access, Efficiency change packages, including Group Medical Visits will be used to decrease the wait time of patients for and at appointments in specialty practices.  Change will be evidenced by improved 3rd next available appointment, or improved cycle time, or the implementation of a minimum of two Group Medical Visits. Aim Statement: Increased access, capacity and efficiency in specialty practice

17. 17  What are we trying to accomplish? › Aim  How do we know a change is an improvement? › Measures  What changes can we make that will result in an improvement? › Are the small test of changes showing improvement? The Model for Improvement Source: The Improvement Guide (Langley, Nolan, Nolan, Norman, and Provost, Jossey-Bass, 1996).

18. 18 The PDSA cycle Act What changes are to be made? Next cycle? Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Study Complete the analysis of the data Compare data to predictions Summarize what was learned Do Carry out the plan Document problems and unexpected observations Begin analysis of the data

19. 19 Repeated use of the PDSA cycle Changes that result in improvement AP SD A P S D AP SD D S P A DATA Very small scale test Follow-up tests Wide-scale tests of change Implementation of change Hunches theories ideas

20. 20 Reduce backlog: Goal is 5 days Improved access = better patient outcomes AP SD A P S D AP SD D S P A DATA D S P A Cycle 1: Measure 3 rd Next Available Cycle 2: Work 1 hour later each day to work down backlog Cycle3: Group Medical Visit 2 X per month to work down backlog Specialty: Improving access

21. 21 Kelowna’s Aim: Reduce use of Foley catheters following joint arthroplasty surgery Idea: Don’t insert at all or else remove catheters Day 1 Standing orders do not include catheters AP SD A P S D AP SD D S P A DATA D S P A Cycle 1: On male pt. of Dr. O’C’s, with no hx of urinary problems, Foley is d/c’d POD1 with order to perform in and out catheter if unable to void Cycle 2: Dr. O’C trials no Foley insertion on pt. with no hx of urinary problems. In and out catheter if unable to void Cycle3: Second surgeon trials no Foley and in and out PRN

22. 22  Action-oriented – “What are you going to test next Tuesday?”  Rapid-cycle testing of changes  Evaluation and revision of all changes before implementation  Testing and implementing the changes in small populations, then spreading to the larger population  Impact evaluated using annotated run charts  Monthly reporting of tests and outcomes Characteristics of the Model for Improvement

23. 23 Planning for Action Period “Fail to plan, plan to fail.” Carl W. Buechner

24. www.pspbc.ca For more information Practice Support Program 115 - 1665 West Broadway Vancouver, BC V6J 5A4 Tel: 604 736-5551 www.pspbc.ca