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Redesigning Specialty Practices from a Balanced Systems Perspective. 7 th International Summit of Office Redesign Institute for Healthcare Improvement March 20, 2006 9:30-12:30 Marjorie Godfrey, Carolyn Kerrigan, Barbara Rieseberg Dartmouth-Hitchcock Medical Center.

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Redesigning Specialty Practices from a Balanced Systems Perspective

7th International Summit of Office Redesign

Institute for Healthcare Improvement

March 20, 2006

9:30-12:30

Marjorie Godfrey, Carolyn Kerrigan, Barbara Rieseberg

Dartmouth-Hitchcock Medical Center

www.clinicalmicrosystem.org


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Aim & Objectives Perspective

  • This session will demonstrate how improving specialty practice requires theview of the system and all stakeholders.

  • Through applyingclinical microsystem thinking, balanced outcome measures, andsystems thinkingincluding inpatient and outpatient perspectives, significant gains can be achieved which benefit patients, staff, and organization strategies.

  • After this presentation you will be able to:

    • Develop a strategy to apply microsystem and organizational system tools and methods to improve clinical outcomes, patient, and staff satisfaction.

    • Create the local microsystem and the larger system view of specialty care to identify drivers of improvement.


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WELCOME! Perspective

  • Introductions

    • Name, Organization, Role

    • What you hope to gain from this morning


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Agenda Perspective

9:30-9:45 Welcome & Introductions MG

9:45-9:55An Overview of Plastic Surgery CK

9:55-10:15 The Facts BR

10:15-11:25 How to discover “The Facts” MG

The 5 Ps

11:25-12:25 The “Rest” of the Story CK & BR

Huddles, SMAs & SBITRs

12:25-12:30 Summary & Evaluation MG



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ADMIN Perspective


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Mission: Perspectivepurpose for which we exist

Partner with our customers to improve form and function for better living


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Vision: Perspectivehow we execute our mission

  • Maximize patient satisfaction in their health care experience by providing timely, courteous and compassionate care of the highest quality

  • Improve our patient's quality of life by incorporating the best medical evidence and technological resources available.

  • Involve the patient fully in their visit through shared decision making & comprehensive teaching

  • Appreciate the interdependence of our microsystem members – together we can achieve more than we can independently

  • Create a fulfilling work environment by initiating improvements in the work place

  • Train future physicians


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Our Professionals Perspective


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6 surgeons 2 residents Perspective

4 nurses 2 LNAs

  • Anesthesia

  • OR nurses

  • Coders

  • Research Assistants

5 secretaries

  • Practice Manager

  • Admin Supervisor


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Our Patients Perspective

  • 11,000 outpatient visits/year

  • 800 minor surgical procedures

  • 1,200 major surgical procedures


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The Facts – A Balancing Act Perspective

  • My role – 3 specialty practices

  • Painting the picture - 2003

    • health of our team

    • patient satisfaction

    • metrics that matter

    • measuring our success

  • Improvement needed


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My Role Perspective

  • Balancing between Macrosystem (administration), the Mesosystem (OR, other practices) and our own Microsystem


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My Role Perspective

  • Macrosystem pushing for

    • productivity, volume, more dollars – financial viability

  • Microsystem

    • too painful, can’t do our jobs well,we’ll never survive this - vitality


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My Partners PerspectiveSection Chief

  • On the same page

  • Open to learning & trying things

  • Questioning everything

  • Seeking constant input

  • Determined to paint a new picture


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My Partners PerspectiveAdmin SupervisorNurse Team Leader

  • Personnel issues all consuming

  • New, learning, not fully optimized

    • interest in learning and growing

    • bright, young, up and coming


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Health of our Team - 2002 Perspective

4.3 physician FTEs seeing ‘all comers’

…..wanting specialization

2.0 resident FTEs

…..workweek pains

.50 FTE nurse practitioner

…..underutilized, limited to wound specialty care

5.6 nurse FTEs – 4.60 RNs; 1.0 LPN

…..work not requiring their license/ training

3.7 secretarial FTEs – diversified work

…..appointments, surgeries, academic support, etc


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Metrics That Matter Perspective

  • Macro level thinking

    • financials

    • appointments

  • Micro level thinking

    • satisfaction

    • access

    • budget

    • OR cases; procedures


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2003 Patient Satisfaction – 80% minimum target Perspective

  • With whom you want - 97%

  • Provider rating - 87%

  • Courtesy of staff - 85%

  • Ease of coordinating care - 78%

  • Wait in waiting/exam room - 75%

  • Wait for appointment - 74%






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Areas Needing Improvement… well?

  • Understanding each others work

    • optimization of roles

  • Understanding processes

  • Professional development & growth

    • for all on the team

  • Building/maintaining safety and trust


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Areas Needing Improvement… well?

  • Timely access for our patients

  • Understanding & balancing the schedule

    • outpatient appointments, minor surgery cases and main operating room cases


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Engaging the “team” well?

“If you want to build a ship, don’t drum up the men to go to the forest to gather wood, saw it, and nail the planks together…

Instead, teach them the desire for the sea.”

-Antoine de Saint-Exupfery; French WWII Pilot


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Discover YOUR Microsystem well?5 “Ps”


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Introduction to well?Microsystem thinking

  • “Every system is perfectly designed to get the results it gets.”

Outpatient

Minor

OR


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Clinical Microsystem is… well?

The “Place” where patients, families and health care teams meet.


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A Picture of Embedded well?Systems

The Anatomy


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Patients well?

Purpose

Processes

Professionals

Patterns


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A Picture of a well?Microsystem

The Physiology


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Acute care well?

Chronic care

Preventive care

Palliative care

Functional

Biological

Expectations

Functional

Costs

Biological

Satisfaction

Costs

A “Generic” Clinical Microsystem model

Satisfaction of need, monitoring, assessment of outputs

Initial

Work-up,

Plan for care

Entry,

Assignment

Orientation

Disenrollment

Beneficiary knowledge, including knowledge of life

while not in direct contact with the health care system


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What is a “Clinical Microsystem?” well?

  • Small group of doctors, nurses, other clinicians

  • Some administrative support

  • Some information, information technology

  • A small population of patients

  • Interdependent for a common aim, purpose


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Assessing Your Microsystem well?

Use the Assess, Diagnose & Treat Your Specialty Practice Workbook to diagnose the strengths of your microsystem and to start identifying improvement opportunities.


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Patients well?

Purpose

Processes

Patterns

Professionals


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PATIENTS … well?

Assess

Diagnose

Treat

Involving the patient & family in the process

MICROSYSTEMS…

Assess

Diagnose

Treat

Involving the microsystem players in the process

Caring for Patients & Growing Microsystems



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Specialty Practice well?

PROFILE


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KNOW well?YOUR PURPOSE

  • Have you EVER discussed with your interdisciplinary team WHY your microsystem exists?

  • What is the purpose of your microsystem that everyone understands and supports?




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Professionals well?

“There are no inferior jobs in any organization. No matter what the assigned task, if it is done well and with dignity, it contributes to the function of everything around it and should be valued accordingly by all.”

Dr. Charles H. Mayo


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“The doctors often tell us that they couldn’t do their work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”

  • Toni Waalkens, Third Shift Lead, Environmental Services


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Specialty Practice Activity Survey work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”


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Know Your Processes work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”Cycle Time Tool


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Know Your Core and Supporting Processes work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”


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KNOW YOUR PATTERNS work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”


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Specialty Practice Metrics That Matter work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”


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EXERCISE work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”“Discovery of 5 Ps”

Aim: Practice “Assessing Your Specialty Practice” with a case study.

  • Chose roles

  • Set up your agenda

  • Review and complete 60 minute instruction sheet

  • Prepare a 5 minute report out


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REPORT OUTS work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”

  • What did you learn?

  • What can you apply at home?


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The “REST” of the Story work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”

  • Painting the rest of the picture

    • learning

    • leadership/structure

    • discipline

    • rhythm

    • pace

  • Our Future – moving into the Meso


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Learning work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”

  • Microsystems Class

  • IHI Access Teleconference Series

  • Noffsinger on SMAs

  • Think big, act small, fail fast… learn!


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A Personal FLOSS story work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”

“Our hunch is that changes are likely to last longer when they can be incorporated into the structures and habits of the way we work”

SHOWER

SINK


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Observation – work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”making the diagnosis


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Leadership/Structure work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”

  • Several restructuring meetings with representation on the team

  • Define the lead team

  • Collaborative leadership


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Discipline work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”

  • PDSA cycles

  • Infrastructure improvements:

    • Nursing reorganization

    • Secretarial restructuring

    • Physician ‘ideal’ practices

    • Protocol development

    • Standardization of scheduling


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Discipline: Focused Projects work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”

  • Reducing Return Rate

  • Shared Medical Appointments

  • Improving OR flow and volume

  • Standardizing Carpal Tunnel surgery

    (observation techniques)

  • Self-administered patient surveys


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Rhythm work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”

  • Daily “nano” team huddles

  • Weekly “mini” team huddles

  • Weekly access team meetings

  • Monthly section meetings

  • Annual section retreat

HUDDLES


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Pace work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”

  • Respect work week

  • Learn to work smarter, not harder

  • Carve out time for improvement work

  • Balance improvement work with demands of ongoing patient care


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Think out of the bowl! work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”


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What are the goals of an SMA? work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”

  • Promote patient understanding of disease/condition

  • Better inform medical decision making

  • Promote adherence to recommended treatments and therapies

  • Integrate peer support into health care experience

  • Better address psychosocial needs

  • Increase quality of care and outcomes


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Model Assumptions work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”

  • First Goal: increase quality of patient care and experience

  • Second Goal: increase provider efficiency and productivity

  • Requires additional resources

  • Target is a 3 fold increase in visit capacity


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Three Fold Increase work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”


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Is an SMA right for you? work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”

  • Can patients get in to see you as soon as they want?

  • Do you ever feel like a broken record?

  • Internists, are you looking for ways to better share disease management strategies with your patients and to improve adherence to recommended therapies?

  • Surgeons, are you looking for ways to improve your informed consent process?


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What is an SMA? work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”

  • 8-16 patients seen together

  • Not a seminar or lecture

  • Not group therapy

  • Individual care with observers

  • Creates an optimal learning environment


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What does it take? work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”

  • Assemble a team

  • Regular meetings (~ 6-9 sessions)

  • Schedule a mock visit

  • Schedule a start date


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Assemble a Planning Team work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”

  • Physician champion

  • Nurse manager

  • Practice manager

  • Scheduler

  • Documentation support person

  • Other


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Success Metrics work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”

  • Satisfaction (patient, support staff, provider)

  • Financial productivity

  • Time to 3rd available appointment

  • Census (booked and actual)


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http://www.claypaky.it/common/press/art_cirque.htm work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”

Choreography


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Our Experience with SMA’s work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”

  • Breast hypertrophy

  • Carpal tunnel & other common hand problems

  • Plagiocephaly

  • Panniculectomy


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BRITE work without us. Our custodial staff receives a lot of positive feedback. It makes us feel like equal members of the team.”

  • Private physical exams

  • Group education

  • Individual decision making

  • Target census: 12-14

  • Duration of visit for pts: 2.5 hours

  • Physician time: 2 hours


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Customer Knowledge: pre-visit mailing of comprehensive information

Detailed mock up of patient flow

Detailed mock up of provider flow

Changing role of RNs

Improvement Ideas:


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Secretarial scheduling/patient information information

Patient self-report of medical history using electronic survey tool

Space utilization and décor for group room

Modification of Patient Satisfaction Survey

Improvement Ideas (cont’d):


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Information/Survey Packets information

  • Information about SMA’s

  • Educational literature

  • Useful websites

  • General health survey

  • Condition specific survey

  • Must be returned 2 weeks prior to visit


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45 min information

90 min

135 min

N=3

90 -120 min

N=12


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Patient Attestation: information

To: Carolyn Kerrigan, MD, Elyse E. Pringle

Subject: Recent BRITE Appointment

Date: Wed, 24 Sep 2003

Hello - Thank you very much for making my recent visit with you and the staff so welcoming, informative, and worthwhile. I felt very comfortable in the group setting and think it is an excellent format for providing information and attention to women who have individual needs but shared concerns.

Thank you again…

excellent


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Breast Reduction Visit Satisfaction information(Shared N=27, Individual N=30)



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Main OR Efficiencies information

  • Felt like I was wasting time between OR cases, too much down time

  • If SMA’s were successful, did we have the parallel capacity in the main OR to accommodate patients?


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Surgeon booked in 1 room information

Surgeon booked in 2 rooms


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The bets were on! information


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Then & Now information

  • Leadership - interdisciplinary

  • Discipline – PDSA improvement

  • Rhythm – weekly & daily huddles, monthly section meeting

  • Pace – balanced practice and improvement



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Work Toxicity information

NOW

THEN


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‘Metrics That Matter’ information

  • Access

    • 3rd available

    • % booked

    • Future open capacity

  • OR

    • Cases/hours per case

    • % OR utilization

  • Financial

    • RVU productivity against benchmark

    • Variance from budget


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3 informationrd Available


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% Booked information


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Future Open Capacity information

THEN

NOW

available

booked


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Operating Room Utilization information

GEN

PLAST

VASC


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RVU Benchmark information

Provider 1

Provider 2

Provider 3

Provider 4

Provider 5

Provider 6


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Our Future information


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Moving into the Mesosystem information

  • Knowledge creates new challenges:

    • Hand-offs with adjacent microsystems

    • “Busting Silos”

      • Comprehensive Breast Program

      • Interdisciplinary Hand Program

  • Knowledge opens new doors:

    • Helping others with access issues

      • Work down backlog (eg Derm: laser, botox, etc)

      • Sharing resources (personnel, space)

      • Spread successes (eg SMAs)

  • Continuous journey…


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Questions information



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