American College of Physicians: Internal Medicine — Doctors for Adults ®

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Improving access tops list of small-office tips

Tackle practice improvements one at a time and make sure someone is in charge of tracking progress

From the June ACP Internist, copyright © 2008 by the American College of Physicians.

By Jessica Berthold

For some the biggest issue was recalcitrant staff. For others, it was scheduling logjams, documentation lapses, or computer systems that didn’t mesh with those of hospitals and pharmacies.

Every internal medicine practice has its own unique set of problems—and strengths. What all the internists in the above examples had in common, however, was the opportunity to have their practices observed and evaluated by professionals at the ACP’s Center for Practice Innovation, and to be advised on how to make constructive changes.

Overwhelmingly, they said the experience was a positive one.

“The whole process was really eye-opening for us,” said Cecile Muehrcke, ACP Member, a general internist in Euclid, Ohio. “Often you have a sense of things that are or are not working in your practice, but to have someone watch and make suggestions really helps.”

Improving access tops list of small-office tipsOthers noted that while having the CPI advise them was highly motivating, it might be difficult for practices to generate the same enthusiasm for improvement without an outside group offering advice. The sheer number of changes a practice often needs to make can seem too great to tackle on one’s own, said Georgia Newman, FACP, an Oberlin, Ohio general internist.

“When I try to put myself in the shoes of a physician not involved in continuous improvement, there are so many things to do that it seems overwhelming,” Dr. Newman said.

Practices which were the most successful at making lasting changes were the ones that addressed one or two problems at a time, rather than trying to make sweeping changes, said Michael Barr, FACP, CPI director. They also had one person in charge of tracking the improvement process for the office—often a practice manager or a physician.

“No practice could do every single thing we recommended right away,” Dr. Barr said. “By design, the CPI practices picked areas that were most important for them to start with, and went from there. I’d advise the same approach for others.”

Two standout issues

Each CPI practice’s dynamics and goals were different, but some common problems emerged that were important to address from the start, Dr. Barr said.

“If I were to pick one thing a practice should focus on, it would be providing good access to the practice for patients, families and other physicians—really anyone who needs to contact the office,” Dr. Barr said. “You can’t provide patient-centered care if your patients can’t reach you.”

Access has many components, such as the ability to reach a physician’s office via telephone, e-mail or text message; to come in for an appointment in a reasonable amount of time; and to get lab results back promptly, Dr. Barr said.

Keeping clinical data organized and updated is another important area for practices to improve upon, he added. In a poorly organized practice, everything from refills to patient self-management suffers. (See sidebar for tips on access and organization.)

“How can a nurse do refills in a practice where the medication record is inconsistent or incomplete? How does a doctor track the goals developed between a patient and family, if these goals aren’t recorded appropriately in the clinical record?” Dr. Barr said.

Indeed, access and organization are really two sides of the same coin, since they both deal with communication, he added.

“Referrals, lab tracking, patient management … all are really dependent on a smooth, organized flow of information,” Dr. Barr said.

Improvements, and a few surprises

The CPI is now analyzing and writing up the reams of data collected during its site visits. Already, however, it’s clear that several practices saw rapid and significant change in adhering to safety practices, said Jill Marsteller, PhD, assistant professor of health policy and management at Johns Hopkins Bloomberg School of Public Health, who is consulting and crunching numbers for the CPI project.

“There were improvements in several safety measures, like correctly placing sharps boxes and storing hazardous waste. There was also solid improvement in storing medicine and vaccines,” Dr. Marsteller said. “Soon after they were made aware of a safety problem, these practices fixed it.”

Certain clinical measures seemed to improve as well, with CPI practices reporting that their numbers of diabetic patients who got yearly eye exams, and who successfully kept their LDL below 100, had increased during the project. More women between age 50 and 69 years old got mammograms within one year, too, said Dr. Marsteller.

One of the more surprising things the CPI learned during its project was the extent to which small practices are run either by members of the same family, or comprise employees who have been together for so long that they have become like family.

“There were these long-term relationships where you had the same doctor with the same nurse for 20 years. You don’t see that with the larger, multispecialty practices,” Dr. Marsteller said.

Another surprise: The most technologically innovative tactic wasn’t always the best. Certain practices were better off with a paper system than with an electronic health record, for example.

“Some had such a good paper system that using an EHR would screw things up,” Dr. Marsteller said. “There are plenty of small practices for whom EHRs don’t affect or improve efficiency, especially since it’s such a substantial investment.”

Physicians don’t always know a great deal about the business aspect of running a practice, she added.

“It’s not just the accounting, but issues like safety protocols with sharps containers—where exactly were the physicians supposed to have picked that up? It’s not something people automatically know, or are explicitly taught in medical school,” she said.

Next steps

Within the coming months, the CPI plans to publish papers on some of the lessons it learned. These will evaluate not only how successful the practices were in making improvements, but how well the CPI did in providing guidance for change. The information on the latter will help the CPI determine its role in the future, Dr. Barr said.

One change has already come to pass: the CPI has merged with the College’s Practice Management Center and become the Center for Practice Improvement and Innovation. Together, they are considering ways to provide new services and support for ACP member practices, based on an expansion of the CPI model and experience, Dr. Barr said.

For now, however, practices interested in helping themselves can access a wealth of materials and tools through ACP at www.acponline.org/running_practice.

“In the end, I hope what we’ve done is help practices recognize they can make changes in a non-threatening way with the support of their colleagues and the ACP staff,” Dr. Barr said.

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Ways to make patient management better

Improving access to your office

  • Cross-train front and back office staff, so they can fill in on phones, refills or scheduling when needed.
  • Schedule patients based on how long visits actually run, not how long you wish they ran.
  • Leave open spots in the schedule for sick visits.
  • Identify your busiest phone times and develop a staffing strategy.
  • Consider an automated phone system, with voice mail and a refill line, which routes calls to the correct people.

Improving organization of data in the office

  • Consider getting an electronic health record, or using standard sheets provided by the CPI, to keep data concise and current. (Sheets available at www.acponline.org/running_practice).
  • Use two identifiers on all patient information.
  • Document everything, including all non-prescription and prescription medications, vaccinations, educational information given to patients and plans for self-management.
  • Make sure every single staff member is aware of standard procedures regarding data documentation and storage.

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No one said it would be easy …

One physician had such trouble with his EHR system that he went back to a paper-based system.

Two practices relocated, one expanded its space, and two solo physicians sold their practices to hospitals and became employees.

Three practices had huge difficulties with connectivity between their EHRs and billing systems.

Five practices experienced significant turmoil due to staff changes, including a death, a maternity leave, and an employee who left because she didn’t want to deal with office improvements.

Nine practices wanted to use EHR software to create reports on clinical indicators, but found it impossible to do so without a substantial financial investment.

Ten practices that tried to use electronic prescribing had to abandon their efforts due to pharmacy and state regulations.

Twelve practices said they were unable to connect with lab vendors in any computer-based manner.

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By the numbers

Practices on the Eastern seaboard: 18
Practices in the Western U.S. and Texas: 10
Practices in the Midwest: 6
Average number of physicians per practice: 1.55
Average number of clinicians (including PAs and NPs): 2.0
Average number of examination rooms: 4.5
Average number of patients: 3,175
Clinical staff to clinician ratio: 16:1
Administrative staff to clinician ratio: 14:1

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About this series

On a quest to unveil common problems for small practices and offer solutions, the College’s Center for Practice Innovation visited 34 practices across the United States over a two-year period. Members of the center’s three-person team assessed each practice on a variety of factors, such as scheduling, work flow, documentation and safety. They offered individual recommendations and resources for improvement, then returned to the practices a year later to see how they did.

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