Re-engineer your practice—starting today

Improve access and efficiency, and your patients and staffwill have something to smile about. Here's how some medical offices aredoing it.

By Ken Terry, Managed Care Editor

Something amazing happened to FP Greg Long last February. That was whenhis four-doctor practice in Appleton, WI, began offering patients appointmentsthe same day they called. Previously, they'd had to wait 10 to 14 days fora nonurgent appointment, and up to six months for a physical. Now, Longand his colleagues can see their patients when they want to be seen—andwithout working longer hours.

"My job satisfaction has increased, because I know I'm giving mypatients better service," says Long. "And I know they're happier,because they're telling me they are."

The nurses are happier, too. "They don't have to sit on the phonetrying to keep people out of the office," notes Long. "Nursescan put patients in appointment slots when they need to be seen. That givesthe nurses time to do more patient care."

Long's practice is one of two offices in the ThedaCare health care systemtrying out re-engineering techniques that will eventually affect all 100of the system's primary care physicians. Same-day access is only part ofthe comprehensive redesign going on in those two sites. Another strategyaffects triage nurses: Instead of having one for each physician, Long'sclinic plans to let any available nurse take calls from any doctor's patients.The calls will also be routed directly to the nurses, rather than beingscreened by receptionists, as they are now. The twin goals are to streamlinescheduling and to free the receptionists for other duties.

PeaceHealth, an integrated delivery system based in Bellevue, WA, hastraveled further down the re-engineering road. One-third of the 50 primarycare physicians employed by the system are offering same-day scheduling,and one 10-doctor office has fundamentally reorganized its clinical workprocesses.

Internist Frank H. Littell, one of several physicians who's orchestratingthe changes at PeaceHealth, works in the prototype site in Eugene, OR. He'spart of a "care team" that includes two other internists and thefive staffers who interact with their patients, including medical assistantsand an LPN. (The FPs and pediatricians in the office also belong to careteams.) What makes these teams so efficient and boosts their productivityis their physical proximity and the cross-training of staff members.

This strong, flexible staff support has been a key to making same-dayaccess feasible in Littell's practice. Another factor was the internists'decision to expand appointment slots from 15 to 20 minutes each.

"That's allowed us to dictate the chart right after each visit,grab the piles of things in the inbox, and deal with any phone calls asthey arise," explains Littell. "So it's a function of being realisticabout the other work that we do beyond seeing patients. That's been thekey. I have added some time to my bookable hours. On the other hand,my total in-office time has shrunk, because I'm not batching stuff at theend of the day or at lunch."

A national initiative aims to improve outpatient care

The redesign projects at ThedaCare and PeaceHealth aren't isolated efforts.These organizations are among two dozen group practices and IPAs participatingin a national re-engineering program. The three-year initiative at morethan 40 practice sites—both large and small—was organized by the Boston-basedInstitute for Healthcare Improvement, which has been promoting clinicalquality improvement for a decade.

The overarching goal of the institute's Idealized Design of ClinicalOffice Practices (IDCOP) program is to upgrade the quality of outpatientcare. The program proposes to remove barriers to patient access, reducewaste and inefficiency, improve patient-doctor communications, expand linkswith the community, and help physicians gain access to clinical knowledgeat the point of care.

IHI, which isn't blind to today's financial realities, also stressesthat re-engineering needs to improve a practice's bottom line. PediatricianDonald M. Berwick, president of the institute, notes this is especiallyimportant for the health care systems that form the bulk of the program'sparticipants. A lot of them, he says, "are losing tens or hundredsof millions of dollars on infrastructures they can't support."

Nevertheless, IDCOP organizations say that placing excessive emphasison profitability can be counterproductive. "When there's too much pressureto improve the bottom line, it subverts the redesign effort," saysFP Gordon Moore, associate chief medical officer for Strong Health in Rochester,NY. "It makes people grumpy and reduces morale. You really need tohave an all-encompassing focus. That's what gets the doctors and the officesaboard."

Having seen many quality improvement programs come and go, physiciansare naturally skeptical of this one, too. When Moore talks about raisingthe number of patients seen, he says, some doctors accuse him of tryingto turn their offices into health care mills. "What I say is, 'If youthink that's a problem, let's measure patient satisfaction every week. Andif it starts to dip, we'll back off.' " So far, he adds, patient satisfactionis rising with improved access and efficiency.

The Latham Medical Group, a nine-doctor primary care practice in Latham,NY, joined the IDCOP collaborative mainly because Latham's leaders recognizedthat patients weren't being treated right. "Based on the number ofpatient complaints we were getting, we felt that our overall quality ofservice was poor," says Ed Enos, the group's administrator. "Andthat tends to spill over to the staff and the docs, because a lot of timeis spent explaining to patients what our service limitations are. So poorservice diminishes staff satisfaction, as well."

Berwick says these kinds of problems are endemic to most medical offices.If a practice is functioning properly, he says, its patients should be ableto say, "'They give me the help I want and need when I want and needit.' There is no way this can be done in the current office environment."

To turn this situation around, says internist Charles M. Kilo, directorof IDCOP, the collaborative is trying to "redesign all components ofthe office, assuring that we not only have the best components, but thatthey interact together in a way that produces the best possible performance."

IDCOP organizations are trying to help each other reach that goal byattending quarterly conferences, visiting other medical offices, and networkingby phone and over the Internet. Eventually, they'd like to spread theirinnovations to all practice sites within their groups.

Size does matter, but small practices can do it, too

If you're in a small, independent practice, re-engineering may seem likean impossible dream. You probably wonder how you can revamp your whole practicewithout outside help, not to mention big bucks for a world-class computersystem. But many of the sites involved in IDCOP aren't highly computerized;in fact, Kilo warns against waiting for an electronic medical record systembefore you re-design your practice.

"Certainly, the office of tomorrow will be more computerized thanit is today, and that will make many things easier and increase the reliabilityof medical diagnoses and treatments," he says. "But the transitionisn't easy, and we shouldn't wait for it, because there's too much we cando today."

The IDCOP groups and parent organizations are spending $25,000 per siteper year to participate in the program. But you don't have to duplicatetheir work to benefit from it, notes FP Bruce Bagley, leader of the LathamMedical Group and president of the American Academy of Family Physicians.

"The purpose of IDCOP is to figure out what the right template is,and that's extremely labor- and resource-intensive," he notes. "Oncethe collaborative comes up with the theoretical right answer about how torun an office—how the telephone system, the appointment scheduling system,and the billing system should work—everybody else just has to implementit."

Bagley says he wants the AAFP to spread the re-engineering gospel toits members. He and other leaders of the society plan to meet with IHI officialsin February to map strategy. In addition, Kilo says, the American Academyof Pediatrics has an internal office redesign program parallel to IHI's.And a number of practices not involved in IDCOP are engaged in redesignprojects of their own.

To its proponents, re-engineering is an urgent mission for all doctors."The market's going to demand consistent quality in diagnosis and treatment,and it's going to demand service," says Bagley. "Physicians whodon't meet those demands are going to be like the local hardware store whenThe Home Depot comes in. They're just not going to make it."

Hazards on the re-engineering highway

One year into the redesign project, IDCOP is still grappling with fundamentals.Even those organizations that are furthest along are still focused mainlyon improving access and efficiency. And, while some are spreading the gospelto physicians outside their prototype sites, it's a struggle for these otherdoctors to reach open access without adequate internal support systems.That's a prime reason why only 30 percent of PeaceHealth's primary carephysicians offer open access now, vs 75 percent several months ago. "Someof them backslid," says Littell.

Another obstacle: how physicians are paid. Production-based salaries,for instance, don't motivate doctors to pack as much as they can into eachvisit and to discourage non-essential visits—key redesign goals. Whilemany IDCOP participants are highly capitated, all of them are strugglingwith the question of how to compensate physicians in ways that promote re-engineering.

There's also a question of physician leadership. Doctors with the kindof vision required to champion re-engineering can't be found in every office.That's why in larger, multisite groups, physicians like Littell have togive up some of their practice time to help implement changes both withintheir practices and beyond.

Then there are extra costs, including staff training and, in some cases,the hiring of additional workers. At ThedaCare, for example, the busy physicianswouldn't have been able to maintain same-day scheduling without adding anextra midlevel practitioner, notes Long. The reason was contingency planning:A doctor who takes time off needs another physician and a PA or an NP tocover for him while he's gone.

Moreover, while re-engineering aims to give staffers more responsibilityand increase their job satisfaction, it can also be frustrating, confusing,and time-consuming, especially at the outset. At Strong Health's prototypesites, for instance, "there have been changes in job descriptions androles, and some staffers have been uncomfortable. Some have left,"says FP Gordon Moore. Overall, though, Moore says re-engineering has ledto skyrocketing morale.

Open access need not overwhelm your practice

When busy physicians think about going to same-day scheduling, theirbiggest fear is that they'll be inundated with patient visits. But thatshouldn't happen, unless a doctor's panel is too big. According to CharlesKilo of IHI, 0.7 to 0.8 percent of a doctor's patients will call for anappointment each day, on average, and 80 percent of those who call willaccept same-day appointments if they can get them.

Since Littell sees patients only three days a week, he keeps his panelsmall. He gets about 15 visits daily, rising to a peak of 25 on some days.On most days, however, he's able to leave work an hour earlier than he didbefore. That's partly because he now does all his dictation, phone calls,and refills between appointments. His full-time colleagues also tend toleave earlier. While they could see more patients, he notes, they valuetheir lifestyles more than extra income.

In contrast, some physicians are using open access to expand their practices.At Fairport (NY) Internal Medicine, which is owned by Strong Health, visitsare up 40 percent since last January, when the practice introduced same-dayscheduling. Each of the two doctors in the 2-year-old practice is bringingin 15 to 20 new patients a week—which internist Wallace E. Johnson attributeslargely to open access.

FP Greg Long of ThedaCare, who has a relatively large panel, sees about28 patients a day, compared with 32 before his office went to same-day scheduling.When most of his appointments were prebooked, he'd leave four slots opendaily for urgent cases. Now he goes into each day with 15 open appointments."I'm able to see all my patients who call on any given day. But ona light day, I might not fill all my open slots. And there are days whenI fill all 15 plus a couple more. So it's less predictable than it usedto be," he observes.

Nevertheless, open access has decreased the stress on Long. Like Littell,he does most of his patient-related work during and after visits, so itdoesn't pile up at the end of the day. "It also seems that the nursesare getting done a bit earlier, because we're able to get through phonemessages faster and more efficiently. Before, if I was running behind becauseI had everybody double-booked, I'd want to keep doing patient care. So messageswould be the last thing I'd take care of."

Care teams free doctors to make the best use of time

The IDCOP participants are still trying to work out the right size andcomposition of a care team. But the consensus seems to be that it shouldinclude two or three physicians and four or five staff members who shouldbe cross-trained to back each other up. That flexibility saves time andprevents work from slowing down or halting when a key person is missing.

In the past, notes Frank Littell, the staffers in his practice did theirown jobs and ignored everyone else's. Scheduling, for example, was the provinceof phone receptionists, not nurses. But it's the nurses who know more aboutpatient needs. Under the new system, they can schedule, and the receptionists(all LPNs or medical assistants), who now sit in the back office, can orderrefills with the help of protocols. (The few greeters left in the frontoffice just collect copayments and alert the care team when patients arrive.)Having the receptionists do 75 percent of refills, he adds, has greatlyreduced the number of charts he has to look at.

While nonphysician members of the care team rotate through jobs otherthan their own, they primarily focus on one thing at a time. This, he says,produces greater efficiency and fewer errors than the previous system, inwhich his nurse often got backed up and would be rushing between differenttasks.

Although ThedaCare hasn't yet formed care teams like those at PeaceHealth,it's changing staffers' job descriptions. Instead of Greg Long's nurse handlingreferrals to specialists and labs between her other duties, as she doesnow, receptionists will be in charge of referrals. They'll have time todo them once incoming phone calls are routed directly to the triage nurses.

Other staffers now do paperwork that used to drain hours from Long'sschedule each week. The radiology technician fills out patient reports fornormal mammograms, and Long's nurse does the same for normal Pap smears.A medical-records clerk has been trained to complete disability forms, eachof which used to take Long 15 to 20 minutes.

FP Gordon Moore of Strong Health notes that even small time wasters canadd up to gross inefficiency. At Fairport Internal Medicine, for instance,the day's appointment schedule was posted on a piece of paper between thefront office and back offices. "Whenever a patient called to changean appointment, the receptionist would have to get up from her desk, walkback to look at the schedule, get back to the patient on the phone, thengo back to see if another appointment was available," Moore says. "Thenurses also had to walk back and forth to look at this piece of paper."The solution was to use the practice's computerized scheduling system notonly for booking patients ahead, but also for adding and dropping appointmentson the day's schedule.

Some simple changes can not only improve efficiency but raise staff morale,as well. At the Latham Medical Group, for instance, charts used to be filedin a small, cramped area upstairs, and the doctors would be furious because,half the time, they couldn't find charts in time for appointments. The situationwas so frustrating that about two-thirds of the medical-records staff quitlast year. After the practice created a better record room downstairs andrelabeled the charts by number instead of name, doctors were able to gettheir hands on most charts, and the staff turnover stopped.

Greater efficiency also pays off in terms of patient satisfaction. Priorto the redesign of Frank Littell's office, for example, patients complainedthey couldn't get through to the office by phone. Afterward, the percentageof callers who hung up or were cut off dropped from 35 to 8 percent, hesays.

Not all care requires an office visit

The idea of caring for some patients without seeing them may appeal moreto physicians in highly capitated practices than to those who depend mainlyon office visits for income. But to IHI president Don Berwick, "Themore you can move demand away from office visits, the more time you'll haveto deal with patients who really need personal interaction."

Ed Enos of the Latham Medical Group points out, "Patients don'talways want to come to the office. Sometimes they just want advice fromone of our triage nurses." A woman with a urinary tract infection,he adds, can drop off a urine specimen and, depending on the test result,might receive a prescription for an antibiotic without seeing a physician.This option, he notes, "is very convenient for working women."

Now that the triage nurses in Greg Long's practice spend less time onroutine visit scheduling, "they're able to do more active managementof diabetics over the phone," he says. "They're instructing patientson diet and exercise, getting them scheduled for their eye exams, and soon."

Long believes this kind of activity limits return visits. "We'vealways assumed that people have to get their care in face-to-face visits.But a big part of IDCOP is getting people to do more care management overthe phone or the Internet. That's going to decrease the need for visits."

A growing number of physicians, both inside and outside IDCOP, are communicatingwith patients by e-mail. A few doctors are even using e-mail to handletheir patients' simpler health problems.

For AAFP President Bruce Bagley, this approach is "a bit of a stretch."On the other hand, he points out, "We're doing a lot more telephonemedicine now than we did five or six years ago. That doesn't necessarilymean we're diagnosing and treating over the phone, but we're giving outhealth advice that people used to come to the office for."

The toughest obstacle: Cultural change

Ultimately, the biggest challenge to re-engineering is not technological,but behavioral. Physicians aren't used to thinking of themselves as partof a team; and, even if they see the need for change, Bagley points out,"they're fearful it's going to interfere with their patient focus."

For example, Latham's patients can call after hours and on weekends toget prescriptions refilled, says Enos. If they leave a message, the prescriptionwill be phoned to a pharmacy within 24 hours. But if they want to speakwith a physician, they might be on hold for a while. Although physicianstake turns providing urgent care during off hours, some resent being interruptedat those times.

"The question is, should we gear up to provide customer serviceat all hours of the day, or should we inform patients that we're here afterhours for acute care only? Some of our docs believe we should be providingall services at all times, and others tend to resist that." Latham'ssolution: Put on extra nurses to take routine calls in the evening, andask physicians to respond to insistent callers only. The doctors have complied,and Enos believes this has raised patient satisfaction.

Physicians are also reluctant to take responsibility for problems theycreate with their staff, contends Gordon Moore of Strong Health. "Inthe typical doctor's office, the staff views the customer as the doctor,not the patient," he says. "If an employee angers the doctor,she's in trouble. And that's wrong. So you get into a re-engineering workshopand you try to figure out why so many patients are complaining that they'renot getting test results on time. It's because Dr. So-and-So sits on hishands, not getting the forms back in time to patients. The secretaries knowthis. They're the ones getting the heat. But the patients won't say booto the doctor; he walks on water. That puts the secretaries in the middle,and it's a miserable position.

"So when we're getting ready to switch to same-day scheduling, wetell the doctors, 'You've got to take responsibility and be available tosign the forms.' When you do that, you take away a lot of pressure and makeit easier for the secretaries to do their jobs."

Knee-deep in the redesign process at PeaceHealth, Frank Littell findsthat "stress is up, but satisfaction is up. We hope the stress levelwill come down." Before that happens, though, the group will have todo a better job of planning for contingencies. Some of the pressure wouldbe relieved if PeaceHealth hired more midlevels, he says. But just as important,he emphasizes, the physicians need to start planning their vacations cooperatively."Traditionally, doctors just sign out. That doesn't work in a groupdoing open access. They have to be more cooperative. We're still dealingwith some of the realities of culture and history."

This is the first article in a monthly series on re-engineering office-basedpractices. Other installments will cover such topics as same-day scheduling;care teams; redesign of office space; phone systems; how to make the mostof each visit; telephone treatment and other nonvisit care; measurementof how changes improve care, efficiency, and satisfaction; and the financialimplications of re-engineering.

Ken Terry. Re-engineer your practice--starting today.

Medical Economics

2000;2:174.