Ed Millermaier, MD, MBA, COO and CMO, Borgess Ambulatory Care
Cindy Buckner, RN, Executive Director of Operations Design and Quality Improvement, Borgess Ambulatory Care
Beth Lipscomb, Project Assistant, Borgess Ambulatory Care
Pat Dyson, Executive VP, Corporate Services, Borgess Health
Carole Black, MD, Director, Navigant Consulting
Louise Bedard, RN, Director, Navigant Consulting
Lisa Rolfe, Managing Director, Navigant Consulting
John McHugh, Associate Director, Navigant Consulting

***Watch a video clip of Borgess Ambulatory Care's improvement work shared at IHI’s 19th Annual National Forum.***

To deliver the Borgess Promise through improved processes and throughput, meeting leading practice benchmarks for ambulatory care (i.e., on-time starts, “behind time,” appointment and telephone access, time spent with patients); and to utilize this exceptional care experience to provide the foundation for delivery system growth to achieve the goal of 1,000,000 ambulatory patient “touches” by 2012, a 23 percent increase in outpatient volume.

• Patient “touches”
• Behind time
• On-time starts
• Appointment access
• Telephone access

In the context of developing a strategic plan for Borgess Health, Borgess Ambulatory Care was identified as a key driver in meeting strategic objectives: future system growth, patient loyalty, and quality care delivery. A comprehensive strategy and operational assessment and program planning project followed that identified opportunities and challenges/imperatives, creating a prioritized framework for implementation. Using “lean” methodology, multiple improvement initiatives were then planned and interventions introduced. 

Changes included:

• To meet the health system objective, identified Borgess Ambulatory Care (BAC) strategic objectives, including breakthrough quality, system growth and patient loyalty
• Collected extensive baseline practice process measurements, interviews, and case/chart reviews to identify opportunities for process improvements and gaps compared with leading practices — a “deep data dive”
• Validated the metrics and assessments using time studies, patient surveys, in-clinic observations, interviews, chart reviews, and customer focus groups
• Completed a comprehensive data collection and analysis to understand and display current state practice operations
• Shared assessment findings broadly within the practice and health system to capture attention and engagement
• Created the Borgess Promise to capture the derived principles — Our Commitment to Patients:
  • Your care will be safe
  • We know who you are and are ready for you
  • We will see you when you want to be seen
  • You will know what to expect
  • We will be your trusted partner in health
  • We will exceed your expectations
• Presented the “BAC Promise” to the system leaders, leading to its formal adoption as a system-wide commitment
• Engaged physician leaders and senior system executives in crafting and delivering the change message and garnering support
• Assessed the current network and market, developed a plan for practice site reconfiguration, and focused recruitment to reach growth objectives of 1,000,000 touches by 2012
• Determined that infrastructure and process improvement were the immediate priorities to build the foundation for growth
• Formally presented results of the initial assessment data to all practice physicians to enlist them in the change effort
• Developed an operational infrastructure to drive the improvement agenda and prioritized interventions at both the BAC and system levels
• Leveraged experience from previously successful programs to address prioritized programmatic interventions such as diabetes care
• Chartered local practice pilots to test proposed operational interventions with modest success — learned that in some cases pilots were less effective because broader change was needed to achieve impact
• Reorganized support staff to match skill sets and roles, fully deploying clinical staff to clinical tasks
• Revised phone triage processes and redeployed several nurses as Care Coordinators for Disease Management with initial focus on Diabetes and Preventive Services
• Created a diabetes registry to track care for the practice’s 5,000 diabetics, catching up outstanding services in the process
• Expanded the group visit approach to support longitudinal care for diabetics
• Identfied opportunity for enhanced pediatric preventive care
• Increased pediatric well child appointments by 200 percent with clinician buy-in and support
• Planned and implemented a robust Family Practice site practice/process reconfiguration to deliver leading practice performance: phones reconfigured to provide live answer; decreased abandonment rate; consistent provider pods to improve staffing and office cross-coverage consistency
• Improved scheduling and schedule prep to increase follow-up appointment scheduling before leaving the clinic, decreasing incoming calls
• Completed training of all staff in customer service with scripting
• Implemented concurrently at Borgess Health: 30-minute Emergency Department guarantee program and imaging clinician recruitment and service improvements, also enhancing access and service for Borgess Ambulatory Care patients

During the eight months since the assessment and implementation planning project were completed, implementation efforts have begun and progressed significantly. Total ambulatory touches increased by 3.8 percent to 858,514, driven by increases in primary care practice, Emergency Department, and Imaging visits.  Multiple redesign and process interventions are collectively yielding promising improvements in access and service to patients. 

Lessons Learned:

• Engage physicians early and often in strategic reviews and planning discussions to foster buy-in and support.
• Dive deeply into data and measurements to fully understand challenges and obstacles and to support the imperative, thus more fully engaging leaders, clinicians and staff in improvement efforts; this extensive initial “deep data dive” was essential to reflect a current picture of “what is.”
• Utilize the “data dive” results proactively to capture physician attention generating positive energy for change; to foster buy-in, the BAC physician leader shared data, implications, and future plans with all physicians via an extensive road show to the practice sites. 
• Solicit broad-based feedback to ensure that all perspectives are, and feel, included and heard.
• Dare to consider bold moves — the Promise seemed lofty and perhaps overly expansive at first, but gradually momentum built so that ultimately it was embraced as a system-wide vision for all services.
• Provide training to support improvement objectives — the Ambulatory Care leadership has participated in trainings and “lean” planning sessions to develop skills, momentum and program plans to drive process improvement efforts.
• Develop plans based on pilots designed to test interventions locally.
• Create an implementation venue which is sufficiently broad to give the planned interventions an opportunity to succeed. In one situation where initial small pilots were tried, modest improvements were suggested, but were of limited impact; in order to truly test implementation, a broader and more comprehensive site-wide intervention was required to fully test all aspects of the planned process changes.
• Tackle the priorities first — fixing the basics was the initial primary priority, which could then provide the platform for successful growth and expansion while also improving current operations and patient/staff/clinician satisfaction.

Carole Black, MD
Director
Navigant Consulting
cblack@navigantconsulting.com

[Posterboard presentation at IHI's December 2007 National Forum]