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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

Redesigning Specialty Practices from a Balanced Systems Perspective

7th International Summit of Office Redesign

Institute for Healthcare Improvement

March 20, 2006


Marjorie Godfrey, Carolyn Kerrigan, Barbara Rieseberg

Dartmouth-Hitchcock Medical Center

aim objectives
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.
  • Introductions
    • Name, Organization, Role
    • What you hope to gain from this morning

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

mission purpose for which we exist
Mission: purpose for which we exist

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

vision how we execute our mission
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

6 surgeons 2 residents

4 nurses 2 LNAs

  • Anesthesia
  • OR nurses
  • Coders
  • Research Assistants

5 secretaries

  • Practice Manager
  • Admin Supervisor
our patients
Our Patients
  • 11,000 outpatient visits/year
  • 800 minor surgical procedures
  • 1,200 major surgical procedures
the facts a balancing act
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
my role
My Role
  • Balancing between Macrosystem (administration), the Mesosystem (OR, other practices) and our own Microsystem
my role1
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
my partners section chief
My PartnersSection Chief
  • On the same page
  • Open to learning & trying things
  • Questioning everything
  • Seeking constant input
  • Determined to paint a new picture
my partners admin supervisor nurse team leader
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
health of our team 2002
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

… not requiring their license/ training

3.7 secretarial FTEs – diversified work

…..appointments, surgeries, academic support, etc

metrics that matter
Metrics That Matter
  • Macro level thinking
    • financials
    • appointments
  • Micro level thinking
    • satisfaction
    • access
    • budget
    • OR cases; procedures
2003 patient satisfaction 80 minimum target
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%
areas needing improvement
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
areas needing improvement1
Areas Needing Improvement…
  • Timely access for our patients
  • Understanding & balancing the schedule
    • outpatient appointments, minor surgery cases and main operating room cases
engaging the team
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

introduction to microsystem thinking
Introduction to Microsystem thinking
  • “Every system is perfectly designed to get the results it gets.”




clinical microsystem is
Clinical Microsystem is…

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








Acute care

Chronic care

Preventive care

Palliative care









A “Generic” Clinical Microsystem model

Satisfaction of need, monitoring, assessment of outputs



Plan for care





Beneficiary knowledge, including knowledge of life

while not in direct contact with the health care system

what is a clinical microsystem
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
assessing your microsystem
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.







caring for patients growing microsystems




Involving the patient & family in the process





Involving the microsystem players in the process

Caring for Patients & Growing Microsystems
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?

“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

“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
exercise discovery of 5 ps
EXERCISE “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
report outs
  • What did you learn?
  • What can you apply at home?
the rest of the story
The “REST” of the Story
  • Painting the rest of the picture
    • learning
    • leadership/structure
    • discipline
    • rhythm
    • pace
  • Our Future – moving into the Meso
  • Microsystems Class
  • IHI Access Teleconference Series
  • Noffsinger on SMAs
  • Think big, act small, fail fast… learn!
a personal floss story
A Personal FLOSS story

“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”



leadership structure
  • Several restructuring meetings with representation on the team
  • Define the lead team
  • Collaborative leadership
  • PDSA cycles
  • Infrastructure improvements:
    • Nursing reorganization
    • Secretarial restructuring
    • Physician ‘ideal’ practices
    • Protocol development
    • Standardization of scheduling

Discipline: Focused Projects

  • Reducing Return Rate
  • Shared Medical Appointments
  • Improving OR flow and volume
  • Standardizing Carpal Tunnel surgery

(observation techniques)

  • Self-administered patient surveys
  • Daily “nano” team huddles
  • Weekly “mini” team huddles
  • Weekly access team meetings
  • Monthly section meetings
  • Annual section retreat


  • Respect work week
  • Learn to work smarter, not harder
  • Carve out time for improvement work
  • Balance improvement work with demands of ongoing patient care
what are the goals of an sma
What are the goals of an SMA?
  • 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
model assumptions
Model Assumptions
  • 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
is an sma right for you
Is an SMA right for you?
  • 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?
what is an sma
What is an SMA?
  • 8-16 patients seen together
  • Not a seminar or lecture
  • Not group therapy
  • Individual care with observers
  • Creates an optimal learning environment
what does it take
What does it take?
  • Assemble a team
  • Regular meetings (~ 6-9 sessions)
  • Schedule a mock visit
  • Schedule a start date
assemble a planning team
Assemble a Planning Team
  • Physician champion
  • Nurse manager
  • Practice manager
  • Scheduler
  • Documentation support person
  • Other
success metrics
Success Metrics
  • Satisfaction (patient, support staff, provider)
  • Financial productivity
  • Time to 3rd available appointment
  • Census (booked and actual)
our experience with sma s
Our Experience with SMA’s
  • Breast hypertrophy
  • Carpal tunnel & other common hand problems
  • Plagiocephaly
  • Panniculectomy
  • Private physical exams
  • Group education
  • Individual decision making
  • Target census: 12-14
  • Duration of visit for pts: 2.5 hours
  • Physician time: 2 hours
improvement ideas
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:
improvement ideas cont d
Secretarial scheduling/patient 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):
information survey packets
Information/Survey Packets
  • Information about SMA’s
  • Educational literature
  • Useful websites
  • General health survey
  • Condition specific survey
  • Must be returned 2 weeks prior to visit

45 min

90 min

135 min


90 -120 min


patient attestation
Patient Attestation:

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…


main or efficiencies
Main OR Efficiencies
  • 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?

Surgeon booked in 1 room

Surgeon booked in 2 rooms

then now
Then & Now
  • Leadership - interdisciplinary
  • Discipline – PDSA improvement
  • Rhythm – weekly & daily huddles, monthly section meeting
  • Pace – balanced practice and improvement
metrics that matter1
‘Metrics That Matter’
  • Access
    • 3rd available
    • % booked
    • Future open capacity
  • OR
    • Cases/hours per case
    • % OR utilization
  • Financial
    • RVU productivity against benchmark
    • Variance from budget
future open capacity
Future Open Capacity





rvu benchmark
RVU Benchmark

Provider 1

Provider 2

Provider 3

Provider 4

Provider 5

Provider 6

moving into the mesosystem
Moving into the Mesosystem
  • 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…