Office Redesign: Improving Clinic Practice Efficiency Dave Eitrheim MD Red Cedar Medical Center- Mayo Health System Menomonie, WI

Patient Centered Medical Home Personal physician who provides continuity of care. A whole person orientation where the patient is not dealt with as an organ system. Advanced access scheduling where patients are not put off and are seen when they would like to be seen. Care management that coordinates a complex healthcare system and uses evidence-based guidelines. Self management principles taught to patients through increased patient education. Use of registries for improved chronic care with searchable databases. Quality improvement measures to measure and improve clinical outcomes. Health information transformation which includes electronic medical records.

PCMH Frustrations Infrastructure cost: EMR, registries, QI initiatives, patient education. Increased time needed for comprehensive care provided at clinic visits: Is the 15 minute office visit still possible in the PCMH?

The 15 minute office visit Nurse tasks in rooming a patient 21 years ago: 1) Weight. 2) Blood pressure. 3) Chief complaint.

The 15 minute office visit Nurse tasks when rooming a diabetic patient today: Weigh patient. Take and record BP, pulse, temperature if needed, O2 sat if needed, LMP if applicable. Record tobacco use and offer cessation counseling. Review and update all allergies and medications listed on the Current Medication List and see if refills are needed. Counsel preventative services and give appropriate immunizations, help schedule pap, mammogram, lipid testing, and colonoscopy. Diabetic care includes doing annual diabetic foot exam and recording information that is used by our diabetic registry. Review diabetic knowledge assessment worksheet and provide education or make needed referrals to the dietician or diabetic educator. Provide and review patient education materials.

Red Cedar Medical Center Story

Providers are busy – but not seeing more patients

New physicians graduate- but not in primary care

Significant competition for Primary Care Specialists

Why Clinic Efficiency at Red Cedar Medical Center? Patient visit numbers rising. Provider visits per day dropping. Can’t recruit new primary care physicians. No place to put them even if we did.

My office practice Problem: Behind in schedule. Solution: See fewer patients or add more nursing staff.

Patient visits per provider per week

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

Office Redesign Office Efficiency LEAN team New Model of Nursing Care Adaptive Design

Office Redesign LEAN team recommendations made to every primary care provider/nurse team that can be implemented immediately. New Model of Nursing Care: 2 nurses working with one physician to create a very high level of efficiency where nurses are empowered to work to the full scope of their practice. Adaptive Design: Encourage innovation among physician/nurse teams as they try new ways to increase practice efficiency.

Recommendations for all provider/nurse teams Preplan planned care visits by pre-ordering labs and sending automated reminder letters for the next scheduled visit. Refill all meds on the chronic medication list for up to one year whenever possible. Use dictation templates. Emphasis on rooming and starting first patient of the morning and afternoon schedules on-time.

Preplan planned care visits Annual physical exams, 6 month diabetic visits and other planned chronic care visits should be “preplanned”. The preplanned visit is either scheduled when the patient leaves the clinic or a reminder letter is sent 2 weeks before the preplanned follow-up visit. Labs are pre-ordered on the follow-up planner order sheet so the appointment scheduler can enter it into our computerized lab system for the next planned clinic visit.

Dear _______________________, 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 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 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 appointment. An order has been sent to the lab for you. Lab hours: Monday 6 a.m. – 8 p.m. Tuesday through Thursday 6 a.m. – 6 p.m. Friday 6 a.m. – 5 p.m. Saturday and Sunday 9 a.m. – 3 p.m. Report to the Urgent Care registration desk for your lab work. Please call 715-233-7777 to schedule an appointment for your physical exam. Thanks you,

Medication refills Whenever possible, all meds should be refilled together for up to one year. When a med refill request comes into the clinic, the entire CML is printed and all meds refilled rather than a single med refilled. A footing has been added to the CML and “Yes” circled when one year of refills are needed. The footing reads, “Refill all medications above for up to 90 days with one year of refills unless indicated differently above”.

Dictation templates A standard dictation template is developed for physical exams and available to all providers to use or modify for their own use. Development of templates for repetitive dictations are encouraged and are shared when appropriate so others can use or modify any templates that are developed.

First patient rooming The first patient of the morning and afternoon are scheduled 15 minutes early so nursing will have time to room patient. If the physician can start the first patient of the schedule on-time, it can prevent falling and staying behind in the schedule through the rest of the day.

New Model of Nursing Care

New Model of Nursing Care Nursing staff empowered to work to the fullest level of their licensure in the New Model of Nursing Care. Patient, physician and nurse satisfaction increased. Wait times for patients decreased. Productivity increased.

“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 2007;22:400-109

Physicians are doing nursing tasks Patient satisfaction is heavily determined by the patient’s interaction with their physician. Physician should maximize the time spent on the patient’s chief complaint. DMS, accreditation standards and increasing documentation have led to appointments where the physician is handling the patients’ medical concerns plus many other tasks that take time away from the primary purpose of the visit. Each part of the office visit should be done by the most appropriate employee. Nurses should be empowered to work to the fullest level of their abilities and training. Minimize physician tasks that are in the skill set of others.

New Model of Nursing Care Nurse rooms patient and includes certain tasks such as preventative medicine counseling that had previously been done by the physician. Nurse returns to the room after the physician is done to complete any patient education recommended by the physician or initiated by the nurse. Nurse dictates everything that she does so the physician doesn’t need to document her work.

Nursing Tasks in the New Model of Nursing Care Chart prep: Make sure that the chart is thoroughly prepped for each patient visit. All recent labwork, x-rays, visits to specialists, UC/ER and clinic is available and turned sideways in chart so physician has immediate access to this information. Counsel and record preventative services: all immunizations, mammogram, pap smear, colon CA, lipids. ?PSA, BMD. Reconcile current medication list, update CML when necessary and alert physician about needed refills at each patient visit. Dictation: Nurse dictates everything that she does. Irrigate ears including use of liquid colace when needed to soften cerumen. X-rays: When the patient returns from radiology, the nurse will get the x-ray up on computer so it is immediately available to the physician. Dictated letters: When the physician dictates a letter to a patient, he/she dictates any needed enclosures at the end of the letter. The nurse adds the needed enclosures which may include a prescription, future labwork or patient ed materials. RN does nurse-only 99211 visits: Currently visits for hypertension and dyslipidemia.

Nursing Tasks in Diabetic Care Fill out diabetic flow sheet for the diabetic registry. Do annual diabetic foot exam and schedule diabetic eye exams or make referral to referral specialist. Review diabetic knowledge assessment worksheet and offer education or referral to dietician or diabetic educator.

Nursing Tasks in the New Model of Nursing Care Order annual or diabetic exam labwork off of protocol. Order medication refills per protocol. Fill out prescriptions for refills so the physician only has to review and sign the prescription. Form completion: Leave of absence, disability forms and prior authorizations are sent straight to the referral specialist and bypass the physician. Nursing completes all forms or portions of forms that they are able to complete (ex) daycare physical forms. Additional tasks done by nursing when nurse has additional time such as during no-show appointments: Nurse can help other nurses in the nursing station.

Procedures All procedures scheduled for 15 minutes. Procedures performed same day as office visit: no rescheduling. Thorough prep by nursing minimizes physician time in performing procedure.

Patient Education Nursing staff or physician can find good patient ed materials and handouts. Nurse teaches off of handouts. Nursing staff can run their own health maintenance programs and use the program with appropriate patients without physician prior approval for each patient. (ex) pedometer program or portion control program.

Wait times

Productivity See 2.7 more patients per workday (17.9 increased to 20.6) = 15.2 % increase. Productivity increased by 17.9 %. The addition of a LPN is fully covered by seeing 3-4 more patients per day.

Satisfaction Physician spends less time on dictation and can focus visit on patient’s chief complaint. Nursing isn’t overwhelmed and does more interesting and challenging work. Patient wait times are decreased and they are receiving more education, more time with nursing staff and a more focused time with their physician.

Adaptive Design MHS grant for 6 months. Starts with several physician/nurse teams that are interested in using adaptive design to improve care and increase efficiency in office practice. Teams trained to do “work on their work” every day.