Improving Primary Care Access
Optimizing the care team is critical to maximizing the supply of the clinic and improving the daily flow of work. The specific mix of staff (number of physicians, nurses, assistants, technicians, clerks, etc.) will vary from clinic to clinic and determines the extent and type of work that can be driven away from the physician (the constraint). The care team composition of each clinic emerges from a discussion of how the clinic (and ultimately the facility) decides to balance its supply and demand. The clinic has to understand the types of services it provides, and then decide who should be involved in the work and how the work should be divided among the care team. This approach begins with demand and adjusts supply to meet the demand (within the limits of clinic resources). This is different from an approach that sets an arbitrary care team mix and then tries to fit the demand into the supply.
Changes for Improvement
Cross-training enables staff to assume different duties as needed. The ability of a clinic to respond to expected or unexpected surges in demand or unexpected, yet predictable events depends to a large extent on the flexibility of the staff to adjust their responsibilities during these periods.
Cross-training does not negate the concept of each care team member working to his or her highest level. It provides another option to smooth the flow and support the providers.
To develop a flexible and effective care team, provide some degree of cross-training so that the team as a whole can respond quickly to minute-to-minute variations in demand and supply, or to unexpected events. The following are examples of useful cross-training for care teams.
- A float team that is trained to cover responsibilities throughout the clinic when needed.
- Scheduling staff that can clean instruments and set up rooms for procedures.
- Nursing staff that can do scheduling, if necessary.
- Scheduling or reception staff that can obtain patient information and assign patients to exam rooms.
- Check-in and check-out staff that can fill in for each other.
Reduce Variation in Provider Styles
Variation in how office visits are conducted by different providers (e.g., use of other providers and staff members, documenting notes, etc.) can add complexity to the flow of patients and staff. An open discussion about how the "work gets done" can help identify opportunities for standardized approaches that promote efficiency across the larger care team.
Use Team Communication Methods
In order to optimize communication, care teams should plan to meet regularly through huddles, team meetings, and staff meetings (see Use Regular Huddles and Staff Meetings to Plan Production and Improve Team Communication). These change ideas (i.e., using huddles and meetings) apply logically to several of the ten ideas for improving access. For example, a huddle can be used by a team working to improve their communication, or by a team that needs to better manage its supply and demand. The creation of communication short-cuts and flexible cues and sequencing can also optimize team communication.
Communication short-cuts are visual displays of information that provide effective ways to make adjustments in the schedule, coordinate emerging patient needs, or reassign staff responsibilities. For example, use a large board in the clinic workroom to note daily patient appointments (including special needs) by provider along with nursing staff assignments. This provides staff with the "big picture" of what’s going on in the clinic each day so that the care team can help where needed.
Flexible cues and sequencing are a type of communication that keep a practice flowing smoothly without the need for verbal or face-to-face communication. Here are some examples:
- A chart in the blue basket means that the patient has arrived and is ready for rooming, and a chart in the red basket means that the patient has gone for testing.
- Flags on the room indicate which member of the care team is in the room, or if the patient is ready for the next stage of the visit.
- Paper tasks that will take longer than one minute to complete are placed in an in-basket for the physician, while tasks that are quick (and will contribute to continuous flow) are placed in a prearranged "hot-spot" for immediate attention
Ensure That Clinicians and Staff Work to Their Highest Level of Experience, Skills, and Licensure
A key concept to remember when assigning clinic responsibilities to optimize the care team is to have all staff members working to the highest level of their expertise and ability. Work must be matched to each staff member's licensure, experience and abilities, including physicians, mid-level providers, nurses, and other staff members. Staff satisfaction also tends to increase when they feel comfortable with their assigned roles and responsibilities.
Maximizing staff roles requires a clear understanding of the needs of the clinic and patient demand so that the work (demand) and the care team member (supply) can be matched appropriately. It also requires the creation and use of clear job descriptions with specific competencies outlined, and possibly some additional training or refresher courses. It is important to research the scope of licensing with the state regulatory agencies to be sure that staff are not inadvertently asked to work beyond the scope of their license.
Establish Standard Protocols to Move Work Away from the Provider
One way to optimize staff abilities is to establish protocols for conditions and processes that can be clearly delineated. The following are some examples:
- Develop a standard process for flu and pneumococcal vaccinations so that a nurse or other appropriate provider can administer shots according to established guidelines.
- Develop nurse-run or pharmacist-run hypertension, allergy, or INR clinics based on protocols.
- Ask physicians to sign off on standard advice protocols for home care.
- Write protocols for ordering an initial lab or radiology for certain symptoms (such as urinary tract infection, strep throat, or suspected broken bone) at the office visit, or to replace a physician visit with a nurse visit.
Interruptions create unnecessary variation in the flow of tasks, disrupt the coordination of work among staff, and contribute to patients waits for services or treatment. For example, when a provider is interrupted during a patient visit for a phone call, or when patient information or exam room supplies and equipment are missing, all can lead to delays. To decrease these common types of interruptions, have physicians track the number of times and reasons why they leave the exam room for missing items to identify what equipment is needed in the room at all times. Clinics can also establish telephone call policies to mitigate interruptions by phone.
Manage Contracted Supply
Some practices discover a gap between the expected amount of time providers have on their schedules for direct patient care and the time stipulated in contracts. Correcting this mismatch can often result in increased supply.
Primary care practices often work with external supports for their patients, such as home health agencies, community support agencies, and care management companies. Lack of clarity around roles and responsibilities results in time wasted.