Improving Patient Care Efficiency and Effectiveness: Team Care and - - PowerPoint PPT Presentation

Improving Patient Care Efficiency and Effectiveness: Team Care and the Use of Scribes

Michael Rabovsky M.D. Interim Chairman, Family Medicine Vice Chairman, Medicine Institute Cleveland Clinic

TeamCare Model

• 1 Doctor
• 2 Medical assistants

Clinical Workflow

• Medical assistant completes all intake

requirements

• Reason for visit
• Note template is loaded in the progress

note

• Collecting and documenting the History of

Present Illness and ROS

• Medication refill requests discussed

Clinical Workflow

• Medical assistant gives oral

presentation to provider on waiting patient

• Medical assistant enters room with

provider

Clinical Workflow

The physician; with the medical assistant in the room and SCRIBING

• Confirms the history
• Performs the physical exam
• Makes medical assessment and

management decisions

• Articulates treatment plan to the patient

and medical assistant

Clinical Workflow

• The physician leaves the exam room of the

completed patient.

• Orders pended by the clinical staff are filed

by the provider.

• The physician signs any prescriptions that are

not electronically transmitted.

• Physician starts the process with the next

patient prepped by the medical assistant

Clinical Workflow

• The medical assistant reviews the After Visit

Summary with the patient along with any prescriptions or ordered tests.

• Patient education is given and reviewed.
• The patient is escorted to the appointment

desk by the clinical staff.

Documentation

• If the clinical staff has a question about

medical terminology they will place three *** as a place holder.

• The chart can not be closed without these

variables (***) being satisfied.

Documentation

• The documentation for this note was completed by (name of

MA) acting as scribe for (Name of physician) June 3, 2016 8:31 AM.

• Notes have been reviewed and edited.

I agree with the Chief Complaint, ROS, and Past Histories independently gathered by the clinical support staff and the remaining scribed note accurately describes my personal service to the patient.

• Name of physician

Key Metrics

• Increase volume of patients seen
• Increase efficiency/decrease scheduling wait

time

• Increase accessibility to quality physician care
• Increase patient satisfaction
• Improve quality of patient care
• Increase clinical employee satisfaction
• Increase physician satisfaction

Access – Patients Added

May 2011 – December 2012

20 40 60 80 100 120 140 53 116 83 106 66 80 97 66 72 123 140 113 94 104 130 137 32 24 30 32

Ramp Up Team Care Missing MA

Nurse Assistant Friendliness /courtesy of nurse/asst. Concern of nurse/asst for problem Care Provider Time CP spent with patient Patient’s confidence with CP Likelihood of recommendi ng CP Rating of CP CP respect for questions 2Q 2011 83.8% 85.0% 82.6% 83.4% 71.3% 89.8% 89.8% 89.8% 77.1% 2 Q 2012 87.3% 88.8% 85.6% 93.3% 87.7% 93.8% 92.8% 95.8% 92.6% 84% 85% 83% 83% 71% 90% 90% 90% 77%

87% 89% 86% 93% 88% 94% 93% 96% 93%

0.0% 20.0% 40.0% 60.0% 80.0% 100.0% 120.0% Score

Outcomes: Press Ganey Patient Experience

Quarter 2-2011 v Quarter 2-2012

Outcomes: Press Ganey Patient Experience

Quarter 4-2011 through Quarter 4-2012

Nurse Assistant Friendliness/ courtesy of nurse/asst. Concern of nurse/asst for problem Care Provider Time CP spent with patient Patient’s confidence with CP Likelihood of recommendi ng CP Rating of CP CP respect for questions 2Q 2011 84% 85% 83% 83% 71% 90% 90% 90% 77% 3Q 2011 88% 88% 88% 92% 84% 96% 96% 96% 96% 4Q 2011 93% 94% 92% 93% 91% 92% 93% 94% 95% 1Q 2012 88% 87% 89% 90% 89% 87% 97% 97% 97% 2 Q 2012 87% 89% 86% 93% 88% 94% 93% 96% 93% 4Q 2012 75% 75% 75% 83% 63% 75% 88% 88% 75% 93% 94% 92% 93% 91% 92% 93% 94% 95% 75% 75% 75% 83% 63% 75% 88% 88% 75% 0% 20% 40% 60% 80% 100% 120%

Percent Very Good

Outcomes: Press Ganey Patient Experience

Quarter 4-2011 v Quarter 4-2012

Nurse Assistant Friendliness/ courtesy of nurse/asst. Concern of nurse/asst for problem Care Provider Time CP spent with patient Patient’s confidence with CP Likelihood of recommendi ng CP Rating of CP CP respect for questions 4Q 2011 93% 94% 92% 93% 91% 92% 93% 94% 95% 4Q 2012 75% 75% 75% 83% 63% 75% 88% 88% 75% 93% 94% 92% 93% 91% 92% 93% 94% 95% 75% 75% 75% 83% 63% 75% 88% 88% 75% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Percent "Very Good"

Outcomes

Quality Indicators Chosen for Improvement

Team Care started 2Q 2011

Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012 Q3 2012

Blood Pressure Control

74% 76% 81% 79% 79% 78% 78%

A1c Diabetics

96% 96% 98% 96% 98% 97% 99%

Diabetes Screening

89% 90% 90% 90% 91% 91% 93%

Hyperlipid- emia Screening

79% 80% 80% 74% 77% 79% 81%

Mammogram Completed

77% 78% 78% 75% 78% 79% 78%

*Days not worked not considered 283 554 570 526 414 440 539 576 488 460 470 488

219 269 319 369 419 469 519 569 619 WRVU's Month

Productivity WRVU's 2010-2011-2012

2010 2011 2012

Sensitivity Analysis Potential Financial Impact

Per Day 6 8 10

Annual Add 1,338 1,784 2,230 Revenue $156,546 $219,024 $273,780 Expenses $61,992 $61,992 $61,992 EBIDA $94,554 $157,032 $211,788

Financial Impact from Strongsville Team Care

Annualized Average: August 2011-July 2012

Average Slots Added per Month 102 Average Additional Revenue per Month $11,952 Average Monthly Additional Expenses $5,196 Average Monthly EBIDA $6,756

Planning & Implementation

• A multi-disciplinary project team was formed
• Process map of desired workflow completed
• Workspace modified
• MAs educated in the physician’s EPIC smart

tools

• Standard work for clinical assistants

approved by nursing leadership………… AND OUR LAWYERS (AND THEIR LAWYERS)

Planning and Implementation

• Time set aside weekly for doctor to

educate and communicate with MAs about any issues

• Outside Consultants in Change

Management

• Hiring New Staff

CHALLENGES

• CHANGE IS TOUGH
• Doctors
• Existing Medical Assistants

“more work” “ another way to make money”

• Applicant Pool and Finding Qualified

People

Key Success Factors

• Support from Leadership
• Point Person for Startup : Physician Leader
• Project Manager
• Selection and Education of the MA’s

training

simulations

. Pay Differential for MA’s

Taking It to the Next Level

• Expand Team Care at Site

4 Teams Currently

• Expanding to Other Sites
• Hired RN Care Coordinator
• Pre-Visit Planning
• Chronic Disease Registries
• Population management
• Clinical Pharmacy Support in place

Taking It to the Next Level

• CEO and Executive Team Support
• Medicine Institute Wide Roll-Out 2013
• Setting and Meeting Metrics
• Access
• Productivity
• Quality
• GC-CHAPS

Press Ganey Staff Engagement

Team Care Non-Team Care Engagement Score 4.45 (+0.23) 4.21 (-0.01) Tier 1 2 Safety Perceptions 4.67 (+0.30) 4.39 (+0.02) Organization 4.30 (+0.34) 3.93 (-0.03) Manager 4.38 (+0.29) 4.04 (-0.05) Employee 4.26 (+0.19) 3.99 (-0.08)

• 25 Doctors Started TeamCare

9 still active

• Medical Assistant Dependent
• Productivity Goal : (3) Additional slots per half day

session Sweetspot : (2) Additional slots

TeamCare: Lessons Learned

2 6