1. Office Redesign: The Planned Care Model Dave Eitrheim MD Red Cedar Medical Center- Mayo Health System Menomonie, WI eitrheim.david@mayo.edu

2. Red Cedar Medical Center: Providers are busy, but not seeing more patients

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

5. The 15 minute office visit Nurse tasks when rooming a diabetic patient today: Nurse tasks when rooming a diabetic patient today: Weigh patient. Weigh patient. Take and record BP, pulse, temperature if needed, O2 sat if needed, LMP if applicable. Take and record BP, pulse, temperature if needed, O2 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 on the Current Medication List and see if refills are needed. 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. 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. 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. Provide and review patient education materials.

6. Planned Care Visits Most chronic care visits are not preplanned. Most chronic care visits are not preplanned. Provider lacks necessary information. Provider lacks necessary information. Patient has different expectations for visit. Patient has different expectations for visit. Staff isn’t fully utilized. Staff isn’t fully utilized. EMR can make the situation worse if more tasks and clicks are put on to the provider. EMR can make the situation worse if more tasks and clicks are put on to the provider. “Systems are perfectly designed to get the results they receive.” Dr. Don Berwick “Systems are perfectly designed to get the results they receive.” Dr. Don Berwick

7. Physicians are doing nursing tasks Patient satisfaction is heavily determined by the patient’s interaction with their provider. Patient satisfaction is heavily determined by the patient’s interaction with their provider. Set an agenda: Providers should maximize the time spent on the patient’s reason for the visit. Set an agenda: Providers should maximize the time spent on the patient’s reason for the visit. DMS, accreditation standards, EMRs and increasing documentation have led to appointments where the provider is handling the patients’ medical concerns plus many other tasks that take time away from the primary purpose of the visit. DMS, accreditation standards, EMRs and increasing documentation have led to appointments where the provider 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. 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.

8. Preplanned Chronic Care Patients want to discuss and ask questions about labwork and test results at their clinic visit. Patients want to discuss and ask questions about labwork and test results at their clinic visit. Physicians are more efficient when they have all the info that they need at a visit. Physicians are more efficient when they have all the info that they need at a visit. Preplanning the next chronic care visit prevents rework before the next visit. Preplanning the next chronic care visit prevents rework before the next visit. Techniques such as goal-setting and motivational interviewing lead to better outcomes. Techniques such as goal-setting and motivational interviewing lead to better outcomes. It doesn’t take a village, but it takes a team. It doesn’t take a village, but it takes a team.

10. Planned Care Model Preplanning Patient self management data Preplanned Care Coordinator contacts patient to pre- plan appointment Registry database shows most recent patient data and trends Post Planning Nurse patient education/coaching Appointments next planned care visit setup with pre- labs Community Resource communication to nursing homes, caregivers, home health nurses Registry database updated Nurse -chart prep -reconcile current medicine and allergy list -tobacco use -preventative medicine measures -additional tasks determined by team Physician -SOAP -focus on patient’s reason for visit -access to evidence-based guidelines -goal setting -preplan next visit -post-planning Planned Care Visit Physician-Nurse Team

11. Preplanning: Patient Responsibilities Work on goals established at last visit Work on goals established at last visit Bring self-management data to visit and act on data that is out of range (blood pressure, blood glucose, peak flows, diet and exercise, etc.) Bring self-management data to visit and act on data that is out of range (blood pressure, blood glucose, peak flows, diet and exercise, etc.)

12. Preplanning: Preplan Care Coordinator Letter or phone call to patient instructing patient to… Letter or phone call to patient instructing patient to… Update current medication list Update current medication list Pre-labs: Preorder labs to be done right before clinic visit per protocol (if not already ordered) Pre-labs: Preorder labs to be done right before clinic visit per protocol (if not already ordered) Self management data: Bring home BPs, glucose, weight, exercise log, peak flows,etc. to appointment Self management data: Bring home BPs, glucose, weight, exercise log, peak flows,etc. to appointment

14. 3. PSA 3. PSA a. All men age 50-70 should have screening PSA a. All men age 50-70 should have screening PSA b. Men with history of PSA’s elevated above normal (or 4.0) should have a Free & Total PSA b. Men with history of PSA’s elevated above normal (or 4.0) should have a Free & Total PSA c. Men with history of prostatectomy, brachytherapy, or radiation therapy as treatment for prostate cancer now have very lowPSAs and should have a diagnostice PSA c. Men with history of prostatectomy, brachytherapy, or radiation therapy as treatment for prostate cancer now have very lowPSAs and should have a diagnostice PSA 4. Diabetic Flow Sheet Labs – Indicated for: 4. Diabetic Flow Sheet Labs – Indicated for: Diagnosis – Diabetes Mellitus I and II Diagnosis – Diabetes Mellitus I and II If on these Medications If on these Medications Insulin Oral Agents Insulin Oral Agents Humalog Glypizide Humalog Glypizide Novolog Glyburide Novolog Glyburide Lantus Glimepiride (Amaryl) Lantus Glimepiride (Amaryl) Levemir Metformin Levemir Metformin Humulin Pioglitozone (Actos) Humulin Pioglitozone (Actos) Novolin Rosiglitazone (Avandia) Novolin Rosiglitazone (Avandia) a. Annual labs include Glucose, Creatinine, Urine Microalbumin, Lipid Profile; (Glucose and a. Annual labs include Glucose, Creatinine, Urine Microalbumin, Lipid Profile; (Glucose and creatinine are included in fasting basic profile if on hypertension meds noted above) creatinine are included in fasting basic profile if on hypertension meds noted above) b. HgbA1c – every 6 months b. HgbA1c – every 6 months 5. Fasting Blood Glucose, HgbA1c – 8 hour fast 5. Fasting Blood Glucose, HgbA1c – 8 hour fast a. Diagnosis – Prediabetes, impaired glucose tolerance (previous FBS 100 or greater) a. Diagnosis – Prediabetes, impaired glucose tolerance (previous FBS 100 or greater) b. Medications – only diet and exercise b. Medications – only diet and exercise 6. TSH 6. TSH a. Diagnosis – Hypothyroidism a. Diagnosis – Hypothyroidism b. Medications – Levothyroxine b. Medications – Levothyroxine c. Screen all women over age 50 every 5 years c. Screen all women over age 50 every 5 years 7. Diabetes Screen – FBS every 5 years after age 45 7. Diabetes Screen – FBS every 5 years after age 45

15. Preplanning: Registry Searchable database Searchable database Most recent data Most recent data Trends in data Trends in data Improves population care Improves population care Motivational tool Motivational tool

16. Planned Care Visit: Provider/Nurse Team

17. Planned Care Visit: Nurse Chart prep (EMR included) Chart prep (EMR included) Reconcile current medication and allergy list Reconcile current medication and allergy list Tobacco use discussed and counseling offered Tobacco use discussed and counseling offered Preventative medicine measures counseled and ordered Preventative medicine measures counseled and ordered Mammography, pap, colon CA screens Mammography, pap, colon CA screens Immunizations Immunizations Additional tasks determined by team Additional tasks determined by team

18. Planned Care Visit: Physician Focus on patient’s agenda or reason for visit Focus on patient’s agenda or reason for visit Access to evidence-based guidelines Access to evidence-based guidelines Goal-setting with motivational interviewing Goal-setting with motivational interviewing Set up post-planning including preplanning next visit Set up post-planning including preplanning next visit

19. Post-planning: Physician Additional orders: Labs can usually be added to blood drawn before planned care visit (lab stores blood for 6 days) Additional orders: Labs can usually be added to blood drawn before planned care visit (lab stores blood for 6 days) Follow-Up Planner Order Sheet Follow-Up Planner Order Sheet Preplan next visit with pre-labs ordered Preplan next visit with pre-labs ordered

20. Post-planning: Nurse Patient education or coaching Patient education or coaching Teach off of patient education handouts or websites Teach off of patient education handouts or websites Patient education materials don’t need to be physician driven (ex) pedometer program Patient education materials don’t need to be physician driven (ex) pedometer program Diabetes knowledge worksheet used to make dietician and diabetic educator referrals Diabetes knowledge worksheet used to make dietician and diabetic educator referrals

21. Post-planning: Appointments or scheduling Follow-Up Planner Order Sheet Follow-Up Planner Order Sheet Sets up: Sets up: Next planned care visit with any prelabs or x-ray (appointment set up or reminder letter sent) Next planned care visit with any prelabs or x-ray (appointment set up or reminder letter sent) Referral visits to other clinic physicians, dietician, diabetic educator, PT/OT/ST, nurse Referral visits to other clinic physicians, dietician, diabetic educator, PT/OT/ST, nurse Referral visits to outside specialists done by routing order sheet to specialty care coordinator Referral visits to outside specialists done by routing order sheet to specialty care coordinator

23. 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,

24. Post-planning: Registry Database updated for next planned care visit Database updated for next planned care visit Patient notified if next planned care appointment is missed or labs not done Patient notified if next planned care appointment is missed or labs not done Providers receive monthly reports that shows their own population data compared to other providers and benchmarks (unblinded) Providers receive monthly reports that shows their own population data compared to other providers and benchmarks (unblinded)

25. Post-planning: Community Resources Good communication to home health nurses, nursing homes and caregivers Good communication to home health nurses, nursing homes and caregivers Referrals to community health programs: Referrals to community health programs: Department of Human Services: Birth to 3, WIC, County Office on Aging Department of Human Services: Birth to 3, WIC, County Office on Aging Know community resources and provide info on them Know community resources and provide info on them

26. Planned Care Model Preplanning Patient self management data Preplanned Care Coordinator contacts patient to pre- plan appointment Registry database shows most recent patient data and trends Post Planning Nurse patient education/coaching Appointments next planned care visit setup with pre- labs Community Resource communication to nursing homes, caregivers, home health nurses Registry database updated Nurse -chart prep -reconcile current medicine and allergy list -tobacco use -preventative medicine measures -additional tasks determined by team Physician -SOAP -focus on patient’s reason for visit -access to evidence-based guidelines -goal setting -preplan next visit -post-planning Planned Care Visit Physician-Nurse Team

27. Pursuing Ideal … Through Frontline Solutions

28. Frontline Solutions is a simplifying, enabling methodology based on the Toyota Production System that gets the patient exactly what they need at continually lower costs.

29. Toyota Production System Principles Problem recognition and understanding begins with direct observation. Problem recognition and understanding begins with direct observation. Problems are best solved by those actually involved in the work, with assistance from management/leadership. Problems are best solved by those actually involved in the work, with assistance from management/leadership. Everyone is responsible for problem identification and solution. Everyone is responsible for problem identification and solution.

30. Comments about Frontline Solutions “This is changing the culture one problem at a time” (Learning Line Trainer) “This is changing the culture one problem at a time” (Learning Line Trainer) “Its more efficient – within a couple of days of identifying a problem, a solution is available to try” (office nurse) “Its more efficient – within a couple of days of identifying a problem, a solution is available to try” (office nurse) “I am constantly thinking how we can do things better for our patients or how we can do things more efficiently for our Dr./Nurse teams The great thing is that these are often things that we can change immediately and we do not have to wait weeks or even months to get approval from someone.” “I am constantly thinking how we can do things better for our patients or how we can do things more efficiently for our Dr./Nurse teams The great thing is that these are often things that we can change immediately and we do not have to wait weeks or even months to get approval from someone.” “The nice thing is that the people who are doing the work are actually finding the solutions to problems.” “The nice thing is that the people who are doing the work are actually finding the solutions to problems.”

31. Many healthcare systems and processes are so complex that top- down design will inevitably lead to defects, breakdowns, and work- arounds. ------------------------------------------ Frontline Solutions is a methodology that can address these breakdowns with frontline level problem solving.

32. How Does Frontline Solutions Actually Work? Direct observation as the method of problem identification Direct observation as the method of problem identification Involve frontline staff in problem identification and solution as a “Learning Line” with assistance from LLTs and management Involve frontline staff in problem identification and solution as a “Learning Line” with assistance from LLTs and management The rules in use The rules in use

33. Problem Solving with Frontline Solutions The A3 Frame the Problem in the Context of Ideal Patient Care Frame the Problem in the Context of Ideal Patient Care Map the Current Condition Map the Current Condition Find the Root Cause(s) Find the Root Cause(s) Propose a Solution (Target Condition) Propose a Solution (Target Condition) List the Steps Needed (Counter-Measures). Who does What, When, etc.? List the Steps Needed (Counter-Measures). Who does What, When, etc.? How do you know if the counter-measure failed (Test)? How do you know if the counter-measure failed (Test)?

35. How is this different? NNNNot just another improvement tool AAAA different way of thinking and acting –A–A Culture shift

36. Additional Resources: Frontline Solutions Designed to Adapt: Leading Healthcare in Challenging Times; John Kenagy, M.D. Designed to Adapt: Leading Healthcare in Challenging Times; John Kenagy, M.D. Jim Haemmerle, M.D.; Red Cedar Medical Center-Mayo Health System: haemmerle.james@mayo.edu Jim Haemmerle, M.D.; Red Cedar Medical Center-Mayo Health System: haemmerle.james@mayo.edu haemmerle.james@mayo.edu Rule 4 Consulting: www.rule4consulting.com Rule 4 Consulting: www.rule4consulting.com