Redesigning Specialty Practices from a Balanced Systems Perspective

1. 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

2. Aim & Objectives • 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.

3. WELCOME! • Introductions • Name, Organization, Role • What you hope to gain from this morning

4. Agenda 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

5. Plastic Surgery Overview

8. ADMIN

9. Mission: purpose for which we exist Partner with our customers to improve form and function for better living

10. Vision: how 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

11. Our Professionals

12. 6 surgeons 2 residents 4 nurses 2 LNAs • Anesthesia • OR nurses • Coders • Research Assistants 5 secretaries • Practice Manager • Admin Supervisor

13. Our Patients • 11,000 outpatient visits/year • 800 minor surgical procedures • 1,200 major surgical procedures

15. The Facts – A Balancing Act • My role – 3 specialty practices • Painting the picture - 2003 • health of our team • patient satisfaction • metrics that matter • measuring our success • Improvement needed

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

17. My Role • Macrosystem pushing for • productivity, volume, more dollars – financial viability • Microsystem • too painful, can’t do our jobs well,we’ll never survive this - vitality

18. My PartnersSection Chief • On the same page • Open to learning & trying things • Questioning everything • Seeking constant input • Determined to paint a new picture

19. My Partners Admin SupervisorNurse Team Leader • Personnel issues all consuming • New, learning, not fully optimized • interest in learning and growing • bright, young, up and coming

20. Health of our Team - 2002 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

21. Metrics That Matter • Macro level thinking • financials • appointments • Micro level thinking • satisfaction • access • budget • OR cases; procedures

22. 2003 Patient Satisfaction – 80% minimum target • 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%

23. Staff Satisfaction - 2002

24. Are increased demands at work making you frustrated and angry?

25. Do you have so much work that it’s impossible to do it all well?

26. Measurements…

27. Areas Needing Improvement… • Understanding each others work • optimization of roles • Understanding processes • Professional development & growth • for all on the team • Building/maintaining safety and trust

28. Areas Needing Improvement… • Timely access for our patients • Understanding & balancing the schedule • outpatient appointments, minor surgery cases and main operating room cases

29. Engaging the “team” “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

30. Discover YOUR Microsystem5 “Ps”

31. Introduction to Microsystem thinking • “Every system is perfectly designed to get the results it gets.” Outpatient Minor OR

33. Clinical Microsystem is… The “Place” where patients, families and health care teams meet.

34. A Picture of EmbeddedSystems The Anatomy

35. Patients Purpose Processes Professionals Patterns

36. A Picture of a Microsystem The Physiology

37. Acute care 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

38. What is a “Clinical Microsystem?” • 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

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

40. Patients Purpose Processes Patterns Professionals

41. PATIENTS … 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

42. Assessing & Improving Your Specialty Practice

43. Specialty Practice PROFILE

44. KNOW 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?

45. KNOW YOUR PATIENTS

46. KNOW YOUR PROFESSIONALS

47. Professionals “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

48. “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

49. Specialty Practice Activity Survey

50. Know Your ProcessesCycle Time Tool