Office Redesign:Office Redesign:Improving Clinic Practice Improving Clinic Practice

EfficiencyEfficiency

Dave Eitrheim MDDave Eitrheim MDRed Cedar Medical Center-Red Cedar Medical Center-

Mayo Health SystemMayo Health SystemMenomonie, WIMenomonie, WI

Patient Centered Medical HomePatient Centered Medical Home Personal physicianPersonal physician who provides continuity of care. who provides continuity of care. A A whole person orientationwhole person orientation where the patient is where the patient is

not dealt with as an organ system.not dealt with as an organ system. Advanced access schedulingAdvanced access scheduling where patients are where patients are

not put off and are seen when they would like to be not put off and are seen when they would like to be seen.seen.

Care managementCare management that coordinates a complex that coordinates a complex healthcare system and uses evidence-based healthcare system and uses evidence-based guidelines.guidelines.

Self management principles taught to patients Self management principles taught to patients through increased through increased patient educationpatient education..

Use of Use of registriesregistries for improved chronic care with for improved chronic care with searchable databases.searchable databases.

Quality improvementQuality improvement measures to measure and measures to measure and improve clinical outcomes.improve clinical outcomes.

Health information transformation which includes Health information transformation which includes electronic medical recordselectronic medical records..

PCMH FrustrationsPCMH Frustrations

Infrastructure costInfrastructure cost: EMR, : EMR, registries, QI initiatives, patient registries, QI initiatives, patient education.education.

Increased timeIncreased time needed for needed for comprehensive care provided at comprehensive care provided at clinic visits: Is the 15 minute office clinic visits: Is the 15 minute office visit still possible in the PCMH?visit still possible in the PCMH?

The 15 minute office visitThe 15 minute office visit

Nurse tasks in Nurse tasks in rooming a patient rooming a patient 21 years ago:21 years ago:

1) Weight.1) Weight.

2) Blood pressure.2) Blood pressure.

3) Chief complaint.3) Chief complaint.

The 15 minute office visitThe 15 minute office visit Nurse tasks when rooming a diabetic patient Nurse tasks when rooming a diabetic patient

today:today: Weigh patient.Weigh patient. Take and record BP, pulse, temperature if needed, O2 Take and record BP, pulse, temperature if needed, O2

sat if needed, LMP if applicable.sat if needed, LMP if applicable. Record tobacco use and offer cessation counseling.Record tobacco use and offer cessation counseling. Review and update all allergies and medications listed Review and update all allergies and medications listed

on the Current Medication List and see if refills are on the Current Medication List and see if refills are needed.needed.

Counsel preventative services and give appropriate Counsel preventative services and give appropriate immunizations, help schedule pap, mammogram, lipid immunizations, help schedule pap, mammogram, lipid testing, and colonoscopy.testing, and colonoscopy.

Diabetic care includes doing annual diabetic foot exam Diabetic care includes doing annual diabetic foot exam and recording information that is used by our diabetic and recording information that is used by our diabetic registry. Review diabetic knowledge assessment registry. Review diabetic knowledge assessment worksheet and provide education or make needed worksheet and provide education or make needed referrals to the dietician or diabetic educator.referrals to the dietician or diabetic educator.

Provide and review patient education materials.Provide and review patient education materials.

Red Cedar Medical Center StoryRed Cedar Medical Center Story

Providers are busy – Providers are busy – but not seeing more patientsbut not seeing more patients

Visits Per Provider-FP and PA/NP 1997-2006

0

1,000

2,000

3,000

4,000

5,000

6,000

1 2 3 4 5 6 7 8 9 10

Year

Volum

eDr. Mark Deyo-Svendsen

Dr. David Eitrheim

Dr. Michael Feigal

Dr. Joseph Heimler

Dr. Tw yla Ostercamp

Dr. Michael Phillips

Dr. Nathan Rich

Dr. Steven Rosas

Dr. Hank Simpson

Dr. Kyja Stygar

Dr. James Walker

Amy Burns, PA

Jody Chilsen, PA

Anna Haus, PA

Rose Keys, NP

Dennis Ryan, PA

Barb Tysdahl, PA

Lucinda Ughetti, PA

Mary Beth Waldo, NP

New physicians graduate-New physicians graduate-but not in primary carebut not in primary care

Significant competition forSignificant competition for Primary Care Specialists Primary Care Specialists

Why Clinic EfficiencyWhy Clinic Efficiencyat Red Cedar Medical Center?at Red Cedar Medical Center?

Patient visit numbers rising.Patient visit numbers rising. Provider visits per day dropping.Provider visits per day dropping. Can’t recruit new primary care Can’t recruit new primary care

physicians.physicians. No place to put them even if we did.No place to put them even if we did.

My office practiceMy office practice

Problem: Behind in Problem: Behind in schedule.schedule.

Solution: See fewer Solution: See fewer patients or add more patients or add more nursing staff.nursing staff.

Patient visits per provider per weekPatient visits per provider per week

0102030405060708090

100

27 24 18

Contact hours

15/30 20/40

Structure office practice to: Structure office practice to: Take the best care of our patients.Take the best care of our patients. Do it efficiently.Do it efficiently. Be financially viable.Be financially viable. Enjoy it!Enjoy it!

Focus Focus

Office RedesignOffice Redesign

Office Efficiency LEAN teamOffice Efficiency LEAN team New Model of Nursing CareNew Model of Nursing Care Adaptive DesignAdaptive Design

Office RedesignOffice Redesign

LEAN team recommendationsLEAN team recommendations made to made to every primary care provider/nurse team every primary care provider/nurse team that can be implemented immediately.that can be implemented immediately.

New Model of Nursing CareNew Model of Nursing Care: 2 nurses : 2 nurses working with one physician to create a working with one physician to create a very high level of efficiency where nurses very high level of efficiency where nurses are empowered to work to the full scope of are empowered to work to the full scope of their practice.their practice.

Adaptive DesignAdaptive Design: Encourage innovation : Encourage innovation among physician/nurse teams as they try among physician/nurse teams as they try new ways to increase practice efficiency.new ways to increase practice efficiency.

Preplan planned care visitsPreplan planned care visits by pre- by pre-ordering labs and sending automated ordering labs and sending automated reminder letters for the next scheduled reminder letters for the next scheduled visit.visit.

Refill all medsRefill all meds on the chronic medication on the chronic medication list for up to one year whenever possible.list for up to one year whenever possible.

Use Use dictation templatesdictation templates.. Emphasis on rooming and starting Emphasis on rooming and starting first first

patientpatient of the morning and afternoon of the morning and afternoon schedules schedules on-timeon-time..

Recommendations for all Recommendations for all provider/nurse teamsprovider/nurse teams

Preplan planned care visitsPreplan planned care visits Annual physical exams, 6 month diabetic Annual physical exams, 6 month diabetic

visits and other planned chronic care visits visits and other planned chronic care visits should be “preplanned”.should be “preplanned”.

The preplanned visit is either scheduled The preplanned visit is either scheduled when the patient leaves the clinic or a when the patient leaves the clinic or a reminder letter is sent 2 weeks before the reminder letter is sent 2 weeks before the preplanned follow-up visit.preplanned follow-up visit.

Labs are pre-ordered on the follow-up Labs are pre-ordered on the follow-up planner order sheet so the appointment planner order sheet so the appointment scheduler can enter it into our scheduler can enter it into our computerized lab system for the next computerized lab system for the next planned clinic visit.planned clinic visit.

Dear _______________________,Dear _______________________,

This is to inform you that your next physical exam with lab work is due This is to inform you that your next physical exam with lab work is due soon. It works well if you can have your blood drawn a few days before soon. It works well if you can have your blood drawn a few days before your exam so that you and your provider can discuss the results at your exam so that you and your provider can discuss the results at your visit. Since most tests require 12 hours of fasting, please do not your visit. Since most tests require 12 hours of fasting, please do not eat or drink for 12 hours (except for water) before coming. Ideally, you eat or drink for 12 hours (except for water) before coming. Ideally, you should do this no more than 3 days prior to your physical exam should do this no more than 3 days prior to your physical exam appointment. An order has been sent to the lab for you.appointment. An order has been sent to the lab for you.

Lab hours:Lab hours:Monday 6 a.m. – 8 p.m.Monday 6 a.m. – 8 p.m.Tuesday through Thursday 6 a.m. – 6 p.m.Tuesday through Thursday 6 a.m. – 6 p.m.Friday 6 a.m. – 5 p.m.Friday 6 a.m. – 5 p.m.Saturday and Sunday 9 a.m. – 3 p.m.Saturday and Sunday 9 a.m. – 3 p.m.

Report to the Urgent Care registration desk for your lab work.Report to the Urgent Care registration desk for your lab work.Please call 715-233-7777 to schedule an appointment for your physical Please call 715-233-7777 to schedule an appointment for your physical exam.exam.

Thanks you,Thanks you,

Medication refillsMedication refills

Whenever possible, all meds should be Whenever possible, all meds should be refilled together for up to one year.refilled together for up to one year.

When a med refill request comes into the When a med refill request comes into the clinic, the entire CML is printed and all meds clinic, the entire CML is printed and all meds refilled rather than a single med refilled.refilled rather than a single med refilled.

A footing has been added to the CML and A footing has been added to the CML and “Yes” circled when one year of refills are “Yes” circled when one year of refills are needed. The footing reads, needed. The footing reads, “Refill all “Refill all medications above for up to 90 days medications above for up to 90 days with one year of refills unless indicated with one year of refills unless indicated differently above”.differently above”.

Dictation templatesDictation templates

A standard dictation template is A standard dictation template is developed for physical exams and developed for physical exams and available to all providers to use or available to all providers to use or modify for their own use.modify for their own use.

Development of templates for Development of templates for repetitive dictations are encouraged repetitive dictations are encouraged and are shared when appropriate so and are shared when appropriate so others can use or modify any others can use or modify any templates that are developed.templates that are developed.

First patient rooming First patient rooming

The first patient of the morning and The first patient of the morning and afternoon are scheduled 15 minutes afternoon are scheduled 15 minutes early so nursing will have time to room early so nursing will have time to room patient.patient.

If the physician can start the first patient If the physician can start the first patient of the schedule on-time, it can prevent of the schedule on-time, it can prevent falling and staying behind in the falling and staying behind in the schedule through the rest of the day.schedule through the rest of the day.

New Model of Nursing CareNew Model of Nursing Care

New Model of Nursing CareNew Model of Nursing Care

Nursing staff Nursing staff empowered to work to empowered to work to the fullest level of their the fullest level of their licensure in the New licensure in the New Model of Nursing Care.Model of Nursing Care.

Patient, physician and Patient, physician and nurse satisfaction nurse satisfaction increased.increased.

Wait times for patients Wait times for patients decreased.decreased.

Productivity increased.Productivity increased.

““In few other sectors of the economy is the In few other sectors of the economy is the highest-level professional responsible for highest-level professional responsible for the majority of production, customer the majority of production, customer service, and clerical work.”service, and clerical work.”

SGIM Blue Ribbon Panel Report. Redesigning the Practice SGIM Blue Ribbon Panel Report. Redesigning the Practice Model for General Internal Medicine: A Proposal for Model for General Internal Medicine: A Proposal for

Coordinated Care. Coordinated Care. J Gen Intern MedJ Gen Intern Med 2007;22:400-109 2007;22:400-109

Physicians are doing nursing tasksPhysicians are doing nursing tasks Patient satisfaction is heavily determined by Patient satisfaction is heavily determined by

the patient’s interaction with their physician.the patient’s interaction with their physician. Physician should maximize the time spent on Physician should maximize the time spent on

the patient’s chief complaint.the patient’s chief complaint. DMS, accreditation standards and increasing DMS, accreditation standards and increasing

documentation have led to appointments documentation have led to appointments where the physician is handling the patients’ where the physician is handling the patients’ medical concerns plus many other tasks that medical concerns plus many other tasks that take time away from the primary purpose of take time away from the primary purpose of the visit.the visit.

Each part of the office visit should be Each part of the office visit should be done by the most appropriate employee. done by the most appropriate employee. Nurses should be empowered to work Nurses should be empowered to work to the fullest level of their abilities and to the fullest level of their abilities and training. Minimize physician tasks that training. Minimize physician tasks that are in the skill set of others.are in the skill set of others.

New Model of Nursing CareNew Model of Nursing Care

Nurse rooms patient and includes certain Nurse rooms patient and includes certain tasks such as preventative medicine tasks such as preventative medicine counseling that had previously been done counseling that had previously been done by the physician.by the physician.

Nurse returns to the room after the Nurse returns to the room after the physician is done to complete any patient physician is done to complete any patient education recommended by the physician education recommended by the physician or initiated by the nurse.or initiated by the nurse.

Nurse dictates everything that she does so Nurse dictates everything that she does so the physician doesn’t need to document the physician doesn’t need to document her work.her work.

Nursing Tasks in the New Model of Nursing Tasks in the New Model of Nursing CareNursing Care

Chart prep: Make sure that the chart is thoroughly prepped Chart prep: Make sure that the chart is thoroughly prepped for each patient visit. All recent labwork, x-rays, visits to for each patient visit. All recent labwork, x-rays, visits to specialists, UC/ER and clinic is available and turned sideways specialists, UC/ER and clinic is available and turned sideways in chart so physician has immediate access to this information.in chart so physician has immediate access to this information.

Counsel and record preventative services: all immunizations, Counsel and record preventative services: all immunizations, mammogram, pap smear, colon CA, lipids. ?PSA, BMD.mammogram, pap smear, colon CA, lipids. ?PSA, BMD.

Reconcile current medication list, update CML when necessary Reconcile current medication list, update CML when necessary and alert physician about needed refills at each patient visit.and alert physician about needed refills at each patient visit.

Dictation: Nurse dictates everything that she does.Dictation: Nurse dictates everything that she does. Irrigate ears including use of liquid colace when needed to Irrigate ears including use of liquid colace when needed to

soften cerumen.soften cerumen. X-rays: When the patient returns from radiology, the nurse X-rays: When the patient returns from radiology, the nurse

will get the x-ray up on computer so it is immediately available will get the x-ray up on computer so it is immediately available to the physician.to the physician.

Dictated letters: When the physician dictates a letter to a Dictated letters: When the physician dictates a letter to a patient, he/she dictates any needed enclosures at the end of patient, he/she dictates any needed enclosures at the end of the letter. The nurse adds the needed enclosures which may the letter. The nurse adds the needed enclosures which may include a prescription, future labwork or patient ed materials.include a prescription, future labwork or patient ed materials.

RN does nurse-only 99211 visits: Currently visits for RN does nurse-only 99211 visits: Currently visits for hypertension and dyslipidemia.hypertension and dyslipidemia.

Nursing Tasks in Diabetic CareNursing Tasks in Diabetic Care Fill out diabetic flow sheet Fill out diabetic flow sheet

for the diabetic registry.for the diabetic registry. Do annual diabetic foot Do annual diabetic foot

exam and schedule diabetic exam and schedule diabetic eye exams or make referral eye exams or make referral to referral specialist.to referral specialist.

Review diabetic knowledge Review diabetic knowledge assessment worksheet and assessment worksheet and offer education or referral to offer education or referral to dietician or diabetic dietician or diabetic educator.educator.

Nursing Tasks in the New Model of Nursing Tasks in the New Model of Nursing CareNursing Care

Order annual or diabetic exam labwork off of Order annual or diabetic exam labwork off of protocol.protocol.

Order medication refills per protocol.Order medication refills per protocol. Fill out prescriptions for refills so the physician Fill out prescriptions for refills so the physician

only has to review and sign the prescription.only has to review and sign the prescription. Form completion: Leave of absence, disability Form completion: Leave of absence, disability

forms and prior authorizations are sent straight forms and prior authorizations are sent straight to the referral specialist and bypass the to the referral specialist and bypass the physician. Nursing completes all forms or physician. Nursing completes all forms or portions of forms that they are able to complete portions of forms that they are able to complete (ex) daycare physical forms.(ex) daycare physical forms.

Additional tasks done by nursing when nurse has Additional tasks done by nursing when nurse has additional time such as during no-show additional time such as during no-show appointments: Nurse can help other nurses in appointments: Nurse can help other nurses in the nursing station.the nursing station.

ProceduresProcedures

All procedures All procedures scheduled for 15 scheduled for 15 minutes.minutes.

Procedures performed Procedures performed same day as office same day as office visit: no rescheduling.visit: no rescheduling.

Thorough prep by Thorough prep by nursing minimizes nursing minimizes physician time in physician time in performing procedure.performing procedure.

Patient EducationPatient Education

Nursing staff or physician can find good Nursing staff or physician can find good patient ed materials and handouts.patient ed materials and handouts.

Nurse teaches off of handouts.Nurse teaches off of handouts. Nursing staff can run their own health Nursing staff can run their own health

maintenance programs and use the program maintenance programs and use the program with appropriate patients without physician with appropriate patients without physician prior approval for each patient. (ex) prior approval for each patient. (ex) pedometer program or portion control pedometer program or portion control program.program.

Wait timesWait times

ProductivityProductivity

See 2.7 more patients per workday (17.9 See 2.7 more patients per workday (17.9 increased to 20.6) = 15.2 % increase.increased to 20.6) = 15.2 % increase.

Productivity increased by 17.9 %.Productivity increased by 17.9 %. The addition of a LPN is The addition of a LPN is

fully covered by seeing fully covered by seeing 3-4 more patients per day. 3-4 more patients per day.

SatisfactionSatisfaction

PhysicianPhysician spends less time on spends less time on dictation and can focus visit on dictation and can focus visit on patient’s chief complaint.patient’s chief complaint.

NursingNursing isn’t overwhelmed and does isn’t overwhelmed and does more interesting and challenging work.more interesting and challenging work.

PatientPatient wait times are decreased and wait times are decreased and they are receiving more education, they are receiving more education, more time with nursing staff and a more time with nursing staff and a more focused time with their physician.more focused time with their physician.

Adaptive DesignAdaptive Design

MHS grant for 6 months.MHS grant for 6 months. Starts with several physician/nurse Starts with several physician/nurse

teams that are interested in using teams that are interested in using adaptive design to improve care and adaptive design to improve care and increase efficiency in office practice.increase efficiency in office practice.

Teams trained to do “work on their Teams trained to do “work on their work” every day.work” every day.