May 1999 Table of Contents

Improving Patient Care

Finding Diamonds in the Trenches With the Nominal Group Process

To harness the best ideas for improvement and to help build support for them, let everyone's voice be heard.

Fam Pract Manag. 1999 May;6(5):49-50.

When a practice begins to look for ways to improve patient care and service, ideas often flow only from the physicians or office manager — or from the staff member with the loudest voice. While this may produce decent ideas, the danger is that the rest of the staff has gone unheard. In turn, they may be less likely to embrace the process and less committed to working toward improvement. What's more, these individuals serving deep in the trenches of medical practice may actually have priceless ideas that no one has bothered to discover.

How, then, do you find these “diamonds”? Recently, I was introduced to the nominal group process.1 It is essentially a group brainstorming technique that can help you tap into an additional stream of ideas (from nurses, receptionists, clerks and so on) and then prioritize them as a group. Because each staff member sees a very different aspect of the practice, from scheduling to vital-signs taking, each has unique insights into how to strengthen the practice and improve care. When I used the nominal group process in my practice, I was struck by its effectiveness in eliciting individual input, stimulating group discussion, and developing consensus and group awareness.

The process

The nominal group process is a relatively simple but structured technique. It is designed to encourage each member of a group to contribute his or her ideas and to feel committed to the improvement process. The technique follows these steps:

  1. A question or issue is presented to the group, and each person silently generates his or her own ideas. This helps the group come up with many different ideas.

  2. The group members share their ideas and list them on a flip chart. This allows individuals to see others' ideas and helps validate their own ideas.

  3. The group discusses the ideas, which allows members to seek clarification, expand on their ideas or combine similar ideas.

  4. Everyone silently ranks the ideas from most to least important (this is a preliminary vote). If the group's idea list is short, members should rank all items; if the list is long, members should rank only their top five or 10 ideas, for example.

  5. Individuals display their rankings next to each item on the flip chart. Allowing each member to present his or her opinion helps to validate ideas and will help gain buy-in.

  6. Each member silently ranks the ideas again (a final vote), and the group counts the votes.

Our example

Our small group practice (two physicians, a physician assistant and 8.5 full-time-equivalent support staff) recently used the nominal group process to explore two important questions:

  1. What are five ways we could improve our current level of customer service?

  2. What are five things we should be doing to make our practice stand out?

The time required for the nominal group process is reasonable, but we modified the process slightly to make it more economical. (We estimated that the first and second steps would have cost us $450 to $800 per hour in lost production.) Rather than conducting the entire process in one long meeting, we completed some steps on individual time. We gave each staff member our two questions and asked them to return their ideas the next day. We combined their ideas into a master list, which we distributed to all employees, and the group met to discuss the ideas. Afterward, each person individually ranked his or her top five ideas. We met again to discuss our votes, and, afterward, each person ranked the ideas again and gave them to the physician manager. Then we met once again to discuss the results and our next steps.

How well did it work?

Our group of 13 (some of them part-time employees) came up with 47 different ideas.

In response to “What are five ways we could improve our current level of customer service?” the top five ideas were these:

  1. Work as a team. This includes helping in whatever way is needed, perhaps cross training individuals and allowing each person to describe at a staff meeting some unknown details of his or her job so that others can gain understanding.

  2. Reduce chart scatter. This involves filing more quickly, decreasing the possible locations for charts and eventually converting to computerized patient records.

  3. Return calls to patients sooner. The group mentioned using voice mail to help manage phone calls and allowing nurses to set time aside for returning calls.

  4. Make patients feel more welcome. For example, we'd like to spend more time with patients, and we want our lobby to be more patient friendly (perhaps by providing coffee, water, a TV and a phone for patient use).

  5. Reduce paperwork. In particular, we want to decrease the amount of paperwork patients have to complete.

Regarding “What are five things we should be doing to make our practice stand out?” these were our top five ideas:

  1. Have providers phone patients with their test results. Although our support staff thought providers should call all patients with all results, our providers preferred calling only with significant results. What we all agreed on, however, is that patients should receive timely feedback from the person most able to give them the information they need.

  2. Conduct special patient outreach. For example, we could easily send cards for birthdays and special events in our patients' lives (weddings, graduations, etc.). We may even want to make social phone calls to some patients (e.g., the homebound).

  3. Improve the referral process. First, we should make sure we send a copy of the note from the patient's last visit, including the problem list, with each referral. Also, we should let the consulting physician's office know at the time of the consult that we expect a timely note back (this reminder, we hoped, would prevent us from having to call later).

  4. Schedule longer appointments for new patients. New patients require extra time from all of us, and that first visit (their first impression) is critical.

  5. Decorate the office for various seasons of the year. This suggestion was not only to make patients feel more comfortable but to help staff members feel better about their workplace.

In addition to generating these ideas, the nominal group process has helped build buy-in. Although we haven't measured this objectively, my observation is that group members have developed a sense of ownership as we have tackled each area of improvement. What once would have been considered “the doctors' ideas” by certain staff members are now our ideas. For example, our doctors have always stressed the importance of promptly returning calls to patients. Some staff members had not responded enthusiastically to this suggestion coming from the doctors, but they now feel this is a group goal and can support it fully.

A tool for everyone

Small group practices, and even some larger ones, often face a dearth of management expertise. Unfortunately, few groups can afford to employ highly trained management professionals to develop new ideas and implement needed change. This makes simple, effective management techniques such as the nominal group process extremely valuable.

Dr. Moon is a family physician in Montgomery, Ala. This article is based on a self-directed management project he developed as part of the AAFP's Fundamentals of Management program.

1. Delbecq AL, Van de Ven AH. A group process model for problem identification and program planning. J Appl Behav Sci. 1971;7(4):466–492.

2. Gustafson DH, Shukla RK, Delbecq AL, Walster GW. A comparative study of differences in subjective likelihood estimates made by individuals, interacting groups, Delphi groups and nominal groups. Organ Behav Hum Decis Processes. 1973;9(2):280–291.

Copyright © 1999 by the American Academy of Family Physicians.
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