Emory Healthcare is a participant in IHI’s Learning and Innovation Community on Redesigning the Clinical Office Practice.

Richard Gitomer, MD – Team Sponsor
Jeff Lesesne, MD – Lead Physician
Linda Couture, MD – Project Leader
Karlene Wortham, MA – Team Leader
Victoria Taylor, LPN – Planned Care Coordinator
Trina Pitts, RN – Clinical Supervisor

Providers:
H. Anthony Carter, MD
Jennifer Smith, MD
Tiffany Vetter, MD

Clinical Staff:
Twila White, RN
Jacki Williams, LPN
Twyla Thomas, LPN
Toni Johnson, LPN
Angela Forbes, LPN, MAS
Davida Palmer
Rachel Owens
Demetria Thompson
Kim Hightower
Danielle Price
Tequilia Sledge
Eshna Patel

Medical Records: Eveline Mensah

Front Desk:
Dulcie Broomfield
Penny Lewis
Philonda Bell
Lakisha Lee
Sherry Mayes

Clinic Manager: Myrna Cott

Clinic Ambassador: Allison Brown

• To improve access and efficiency over the next 12 months by reducing cycle times, increasing access, and ensuring patient-physician continuity in an effort to improve patient satisfaction and outcomes.
• To deliver comprehensive, high-quality medical care for our patients with diabetes. We will achieve this aim by using the Chronic Care Model to create a collaborative partnership with these patients over the next year.

• Measure and balance supply and demand [*Demand is measured by hours of patient time appointed in a given day regardless of the day on which the time is actually scheduled. Supply is measured each day by the number of bookable physician hours.] (This measure is shown in the Results section below)
• Reduce days to third next available appointment to zero by April 2008 (This measure is shown in the Results section below)
• Maintain 93 percent patient/primary care physician (PCP) continuity through September 2008
• Reduce cycle times by 20 percent by April 2008 [*Cycle time goal = 42 minutes] (This measure is shown in the Results section below)
• Improve score on “Office is efficient and doesn’t waste my time most of the time” question on patient survey from 70 percent to 85 percent by September 2008 (This measure is shown in the Results section below)
• 60 percent of diabetic patients with HbA1c less than 7
• 60 percent of diabetic patients with LDL less than 100
• 60 percent of diabetic patients with BP less than 130/80

• Implemented open-access scheduling for four doctors.
• Simplified scheduling: Fewer appointment types. Protocol for call center with two care teams consisting of nurse practitioner and open-access doctor and nurse practitioner plus doctors not participating in open access.
• Balanced supply and demand: Over-extended MD closed to new patients for two months. Limited in-office scheduling of return visits to Wednesday-Friday. Contingency planning for vacation time.
• Used rooming board for one medical assistant/physician (MA/MD) to identify points of delay. Use of walkie-talkies for improved MA/MD communication regarding patient arrival. Spaghetti-diagrammed session for one MD to identify issues causing cycle time delays. Moved charts from exam room doors to chart rack near computer for one MD to save steps.
• Instituted standardized policy for late patients (script for front desk). All patients offered option of being worked in same-day or rescheduling.
• Developed standardized process for timely handling of faxed prescription refills.
• Assessed blood pressure measurement skills for all staff. Developed standardized blood pressure treatment protocol.
• Staff trained in helping patients set self-management goals. Outline for mentors to use in follow-up of self-management goals with diabetics.
• Implemented diabetic group visits.
• Note: Planned care results are not included with this report.

 Key Lessons:

• Current supply exceeds demand, but is not balanced on day-to-day basis
• Major interruptions to office visits are caused by missing supplies and lack of printers in exam rooms
• Monitoring days to third next available appointment and limiting scope of practice for over-extended MDs was critical in working down the backlog

Barriers:

• Difficulty obtaining continuing demand and cycle time data
• Lack of printing capability in exam rooms and lack of standardization in exam rooms
• Electronic registry still unavailable
• Point-of-care A1c test results not captured in database

Next Steps:

• Measure capacity for four doctors on monthly basis
• Test real-time referrals for two doctors
• Conduct 5-S* audit of exam rooms to facilitate standardization [*5-S (Sort, Simplify, Sweep, Standardize, Self-Discipline) is a visually-oriented system for organizing the workplace to minimize the waste of time]
• Formalize staff recognition process
• Implement protocol for blood pressure management
• Improve communication on waits and delays
• Test pre-visit planning with lab work prior to visits
• Maximize team huddles
• Increase involvement of care team members in patient education