This questionnaire was completed by leaders at Clinica Campesina in Denver, Colorado, USA.  It is taken from the chapter on Case Studies from the book What Works:  Effective Tools and Case Studies to Improve Clinical Office Practices by Suzanne Houck.

Clinica Campesina
Denver, Colorado

1. What was the impetus for deciding to initiate improvement at your site?

We wanted a program to help our diabetic patients.

2.  Has leadership been important to your efforts? If so, please describe the role of leadership in improvement.

Yes, from the very beginning, it was an Executive Team decision to apply for our first IHI Diabetes Collaborative and the Executive Team has been involved since then.

3.  In your opinion, what activities have been especially important to sustaining improvement?

Commitment from the Executive Team; the demonstration of significant impact; the excitement of the improvement process; involvement of middle managers, providers, and front line staff. The improvement sequence varied among sites. At one site we initiated alternate visits; at another, office efficiency; and at a third, open access. At one site, we worked on redesigning the physical structure first and at another, staff attitudes. It took about three years to get all three sites redesigned, from attitudes to infrastructure to physical structure.

4.  How important have core values been to your improvement work?

Once the improvement efforts demonstrated benefit to our patients and staff, the improvement itself became a core value. Our other core values were quite important in guiding our efforts in the sense that we knew our efforts had to stay true to our values.

5.  How are core values communicated to staff?

Newly hired staff receive an orientation that includes a review of core values. Clinica is a culture of collaboration so there are many meetings in which important leaders are a part of the group where values are communicated. Values are also communicated in how we go about our business as well as how we take care of patients and staff.

6.  Do you have an ongoing team that leads improvement in your organization? If so, please describe who is on it, how often they meet, and the structure for initiating improvements.

We had distinct teams do the disease Collaboratives. When we started our office redesign in March of 2000, we put together an organization-wide team consisting of the VP of Clinical Affairs, VP of Operations, the Operations and Clinical site managers (from each of 3 sites), an Assistant Medical Director, and IS staff. This team we call ORDC (Organizational Redesign Committee). There was a Redesign Team also established at each site to lead the efforts at the site level. These committees exist today. Along the way, we established the Health Outcomes Committee, chaired by an Assistant Medical Director. The charge of this committee is to lead the efforts on spreading and sustaining Clinica’s improvement efforts using the Chronic Care Model. The ORDC also works with the collaborative issues as they relate to office redesign.

7.  Have there been specific processes or ways of using resources that you have focused on, such as leadership development, access, teams, or chronic care?

We have focused on diabetes, depression, asthma, prenatal, and chronic pain patients using the Chronic Care Model. We have also embraced three concepts from the IHI’s Office Redesign material: office efficiency, alternative visits, and open access scheduling. We have used IHI’s Quality Improvement Model for all of our work. There has been lots of leadership development through all levels of the organization as a result of our work.

8.  Does your site vary the ways that patients can access care, such as group visits, nurse clinics, phone care, and email with patients? If yes, please describe.

Yes, we have group visits for diabetic patients, OB group visits, initial prenatal group visits, newborn group visits, and we have worked on redesigning the role of the nurse so that the nurse could be a provider of care. We are in the middle of a management transition and organizational restructuring to create care teams managed by nurses. We also have worked with our scheduling to decrease triage so that nurses can nurse. One provider does a very limited amount of e-mail care.

9.  How do you track and post results or outcomes? (These include operational, clinical, satisfaction, and financial.) How do you select which metrics to use?

Have you found it important to limit the number of metrics used? What metrics do you use?

We track measures monthly and have them posted on data walls at each site. In addition, we are working on publishing measures monthly that will relate to an incentive plan for all staff. We select metrics based on evidence (when there is some), importance of the measure to what we are trying to accomplish, and the ability to set up a system to gather and report the measure. We are measuring time to third available appointment, continuity, panel size, no shows, unbooked appointments, productivity per pod and per provider and a variety of outcome measures for diabetes, asthma, depression, immunizations, and prenatal care.

Since we began improvement efforts, average HbA1c levels for diabetic patients have dropped from 10.5 to 8.2. In the last year, the percentage of diabetic patients with a foot exam has increased form 44 percent to 65 percent and our registry that tracks diabetic patient care has increased from 275 to 505 patients.

10.  Does your site do any structured population management such as tracking patients with chronic disease?

Yes, we have registries for diabetes, depression, asthma, chronic pain, and prenatal care.

11.  Do you regularly measure patient satisfaction? If so, how often is it measured?

How are satisfaction results shared with staff? Have you tracked patient response to specific improvement efforts such as cycle time or access?

We have measured patient satisfaction on a quarterly basis. We ask patients to “give us a grade” on a variety of things. We have enough data for run control charts to be useful. At times, through our QI efforts we have also developed different patient satisfaction tools to measure specific things. The results of the quarterly data are presented to our TQM committee who shares it with all staff.

12.  If you were starting your improvement work now, what would you do differently?

What would you do the same way?

 I would institutionalize the things we decided to do right away, making sure we developed the scripts, training materials, changes in job descriptions, skills checklists, etc. I would also go for the whole thing, instead of doing improvement in parts.

13.  What advice would you give to others embarking on sustainable improvement?

Improve at a rate you can sustain and be sure to do enough to actually make a difference.

14.  Please describe your organization:

Community health center 

15.  Are you part of an integrated delivery network?

No

16.  Approximately how many patients are cared for at your site/organization?

20,000 unduplicated users

17.  On average, approximately how many patient visits occur at your site weekly, monthly or yearly?

1,800 weekly, 7,200 yearly

18.  How many FTE physicians and mid-levels (nurse practitioners and/or physician assistants) are employed at your site?

8 physicians 16 midlevels

19.  If you’re using formal care teams, what is the makeup of your  team(s) (e.g., 1 FTE MD, 1 mid-level, 2 MAs, 1 clerk, etc.)?

1 MD, 2 mid-level practitioners, 1 nurse, 3 MAs, 1 financial screener, 1 case manager, 4 office techs. We all have 1 LCSW per site and an RD for all 3 sites.

20.  Do you use an electronic medical record?

No

21.  What is your average cycle time for a patient visit?

45 minutes

22.  How are physicians compensated?

Salary.  However, a new incentive program adds bonus incentives to all staff when visits exceed an average of 17/day for a month in a given team or pod. When visits exceed the average, everyone receives an additional $1. If all 8 pods exceed average number of visits for a given month, everyone receives an additional eight dollars. We also have the following outcome goals: 

• Percent of patients with persistent asthma on steroid inhalers
• Percent of patients with 2 HbA1c’s drawn per year
• Percent of patients with depression on new meds that get a phone call
• Percent of 2-year-olds who are totally immunized
• Smoking cessation goal for pre-natal patients

While the amounts seem small, staff members can make an additional $2,000 per year. Staff has already responded very positively to the incentive. It has also provided a way for teams to share performance information. Teams also get credit for hospital encounters. The program has taken three months to get rolling, with data collection the greatest challenge.