Improving Academic Ambulatory Practices: Improving Quality and Efficiencies

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Improving Academic Ambulatory Practices
Improving Quality and Efficiencies

• ACGIM Leadership and Management Training
  Institute
• Christine Sinsky, M.D.
• Medical Associates Clinic, Dubuque, IA
• DC Dugdale, M.D. University of Washington
• Jim Bailey, M.D. University of Tennessee
• Kim Davis, M.D. Medical University of South
  Carolina
• April 25,2007

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Agenda

• Introduction
• An outsiders view looking in
• An insiders view transformation initiatives
• University of Washington
• University of Tennessee
• Medical University of South Carolina
• Introduction to SGIM-ACP Transforming Practice
  Project
• Panel Discussion

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• Focus How to structure office practice to
• Take best care of our patients
• Do it efficiently
• Be financially viable
• And enjoy it!

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Introductions

• One thing that is working well in your practice
• One thing you would like to improve
• 3x5 card and/or email csinsky1_at_mahealthcare.com
  
• Background
• Private practice
• Develop new practice model for ambulatory care
• Blue Ribbon Panel Report New Model of
  Coordinated Care
• Redesigning the Practice Model for General
  Internal Medicine A proposal for coordinated
  careJGen Intern Med 200722400409
• ACP-SGIM collaboration GIM practice redesign
• AMC consultant
• ABIM

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Saving Office Practice

• Doctors chief complaint is diminished pleasure
  in daily practice.
• Sox Annals 2004

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Saving Office Practice

• Medical students are taking notice, and more of
  them are choosing clinical specialties in which
  office practice plays a relatively small role.

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Productivity

• Need
• Quality
• Access
• Productivity
• MGMA benchmarks
• Clinical support
• Productivity

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Sufficient Space and Support

• Nurses
• 1.75 nurses vs 1.25
• 56 more production
• Exam rooms
• 3 rooms vs 2 rooms
• 34 more production

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AMC Consultations

• Rapid Access
• Pod Concept
• Mini-teams of nurse, 2 physicians, 4 exam rooms
• Workflow
• Series of minute details (post-it notes on door)
• Division of labor
• Consistency of nurse/physician team to counter
  inherent turbulence from rotation of faculty
• Establish infrastructure support for residents
  4.5 days not in clinic

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Observations from AMC site visits

• Different worlds
• Multiple responsibilities
• Teaching, research, clinical practice
• Primary professional home may be geographically
  and administratively separated from the
  ambulatory clinic
• Less ownership over clinic operations
• Vulnerable population

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Observations from AMC site visits

• Multiple organizations
• Hospital manages the clinic staff
• Faculty may not have direct authority over the
  resources that they need to practice.
• Given size of organization, GIM clinics may not
  be high priorities for hospital resources
• Intermittent clinic schedules for residents and
  faculty
• A challenge for continuity
• Residents outpatient clinic is add-on
• Consistent teamwork even more important

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Academic and private internists face many of the
same challenges

• Sufficient staffing
• Matching work responsibilities to skill set
• Eliminating re-work
• Timely access to care
• Maintaining continuity of care
• Medical information management
• Work previously done by others (transcriptionist,
  receptionist, pharmacist) is now displaced to
  physician

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• Work previously done by the physician is
  sometimes fragmented into separate silos of work
  by others
• hypertension clinic
• lipid clinic
• anticoagulation clinic
• diabetes clinic
• CHF clinic
• Physicians busy with clerical work, and turning
  clinical work over to others

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The majority of quality is related to clinic
operations.

• A well-trained, motivated, hard-working
  compassionate physician is not enough.
• This physician must practice in a functional
  system.

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Improving work flow

• Many generalists spend much of their day on
  non-physician level tasks
• Transcription
• Documentation
• Proofreading
• Paper work (FML, disability, insurance,
  pre-authorization)
• Data gathering
• Data entry
• Order entry
• Medication reconciliation
• Processing prescriptions

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• In few other sectors of the economy is the
  highest level professional responsible for the
  majority of production, customer service and
  clerical work.
• SGIM Blue Ribbon Panel Report
• Redesigning the Practice Model for General
  Internal Medicine. A Proposal for
  Coordinated Care
• J Gen Intern Med 200722400-109

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One key to improving quality and attractiveness
of GIM

• Minimize work physicians do that is within the
  skill set of other members of the team.
• Free up the physician for physician-level tasks
• Medical decision making
• Building a relationship with patient
• Present a more attractive model of GIM to
  residents and students

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• Standing orders
• Initial review of lab
• Pt education (Med. diet, BMI, Calcium)
• Immunizations
• Sx driven tests (PFT, EKG)
• Diabetic foot exam
• Diabetic eye exam
• (Colon screening)
• Nexus of organization of our practice
• Carol Smith

• More than an escort
• Integral member of the team
• Extension of me when dealing with patients
  patients recognize this.
• Manages returns most phone calls
• Does prescriptions
• Updates EHR
• Completes all paperwork

The Boss
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Information transfer

• Minimize information drop off
• Maximize efficiency

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SGIM-ACP Transforming Practice ProjectMichael
Barr, MD, ACPChristine Sinsky, MD, SGIMTracy
McKay, SGIM
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Planning Retreat 12.18.06

• ACP Michael Barr, Vincenza Snow, Paula
  Woodward, William Underwood, Mira Zirgani,Theresa
  Kanya
• ACP Center for Practice Innovation Rich Baron,
  Chuck Kilo, Michael Tooke, Nina Miles Everett
• SGIM Steve Fihn, John Goodson, Bruce Landon Rick
  Lofgren, Tracy McKay, Doriane Miller, James
  Richter, Christine Sinsky, Kevin Weiss
• MGMA Terry Hammons, Dave Gans

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SGIM-ACP Transforming Practice

• Hypothesis
• The quality of care, efficiency of practice, and
  levels of patient, staff and physician
  satisfaction can each be increased with
  innovative practice design.
• Background
• Quality ? and costs ? when care grounded in
  primary care (Starfield)
• ? ? physicians choosing GIM ambulatory care

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SGIM-ACP Transforming Practice

• Related Objectives
• Improve training environment for
  students/residents
• Develop critical performance standards for HIT
  that supports quality and efficiency
• Identify issues for further research that will
  support the practice of GIM, practice science
• Demonstrate the complexity of ambulatory GIM

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SGIM-ACP Transforming Practice Proposal

• Phase I
• Needs assessment survey 100
• Interview 10-15
• Site visits 5 AMC GIM clinics
• Based on this, develop tools, benchmarks,
  resources , strategies to create a better care
  environment for patients and a better training
  environment for students and residents
• Phase II
• 20 intervention sites

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SGIM-ACP Transforming Practice

• Foundation
• Patient-Centered Medical Home
• Blue Ribbon Panel Report on new model of chronic
  care
• Especially important in light of role of AMCs in
  attracting and educating future general
  internists.

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How can ACGIM make a difference?

• By contributing to a literature of "practice
  science?"
• By studying, publishing about, and articulating
  more clearly the components of a functional
  practice design
• By participating in the survey!
• By applying to be an intervention site