It's an odd question: "How good could we get at office-based health care?" Other industries ask this sort of question all the time, yet in health care the question somehow feels uncomfortable. Perhaps it's because most of us are already working as hard as possible trying to provide the highest level of care possible to our patients -- and we're feeling financially squeezed. "Can practice get any worse?" seems the appropriate question. Why should we consider how good things could get? Might the answers from such an inquiry really help us work more efficiently, increase staff morale, improve health outcomes and stem the decline in our financial bottom line? In a word, yes.

In 1998, the Institute for Healthcare Improvement (IHI), a nonprofit organization, launched a national initiative to pursue the question of how good medical practice could get -- and how we could actually achieve that vision. Called the Idealized Design of Clinical Office Practices (IDCOP), the three-year initiative involves 42 prototype sites across the country in an effort to demonstrate that, through comprehensive redesign of the office system as a whole, clinical practices can achieve dramatic new levels of performance. In fact, we are already seeing exciting results just halfway through the initiative. As Donald M. Berwick, MD, MPP, president and CEO of IHI, has said, "We are on the threshold of remaking entire care systems -- beginning with the clinical office itself -- and the courageous among us will get there first. The changes we face have never been bigger ... or more exciting."

The inescapable need for change

If there's one certainty in health care today, it is this: Almost no one is happy with the current system -- not doctors, not patients, not staff members, no one. There is a clear, existing need for the fundamental redesign of all aspects of clinical practice.

The physician perspective. Ask yourself, "What bothers me most about my practice?" and "What gets in the way of creating a better practice?" These are some common answers:

• "The phone rings off the hook, and we don't know what to do about it."
• "We're buried in paperwork."
• "I know our office staff could be more efficient, but we're not sure how to do it."
• "The system doesn't make it easy to provide good patient care. It should be possible with normal effort, not continual heroic effort!"

Sound familiar? These answers underscore what we all know and yet feel unprepared to address: Medical practices are often inefficient, frustrating places to work. There is significant room for improvement.

What about the quality of our care? Is it as good as it could be? Interestingly, most physicians rarely express concern about the quality of their clinical care. We assume that our clinical outcomes are at or well above acceptable levels; however, our assumptions about the quality of our care are frequently just that -- assumptions, gut impressions. Most physicians practice in the dark, without the necessary data to help them know how well they are doing clinically.

KEY POINTS: The needs of physicians and patients cannot be met in the current practice design. The system must be rebuilt. A three-year initiative involving 42 prototype sites is attempting to design, test and deploy new ways of practicing office-based health care. In the idealized design, patients have improved access to care, the patient interaction is more meaningful and only safe, effective treatments are used.

Research data on our outcomes demonstrate that we are not as good as we could be.¹ We underuse valuable interventions such as immunizations; for example, only 28 percent of eligible patients get the pneumococcal vaccine.² We overuse useless interventions that can cause harm; for example, we frequently prescribe antibiotics for viral respiratory infections. And we misuse far too many interventions, including medications. For example, 3.7 percent of the hundreds of millions of patients hospitalized each year experience an avoidable adverse event such as being given the wrong drug dose, and emerging data on outpatient medication errors suggests a problem of the same or greater magnitude.³

The patient perspective. Honestly examined, it becomes clear that our offices embed many problems from the perspective of our patients as well. These include poor access, poor quality of provided information, a sense of uncertainty and unreliability, and a lack of respect for patients' time and needs. Most patients do not feel confident that our offices are adequately fulfilling their needs despite the fact that they typically give us high satisfaction ratings.

Our own experiences as users of offices and a growing body of literature suggest that clinical offices could be much better designed to meet patients' needs. A recent patient survey conducted by the Picker Institute revealed that large percentages of patients report problems in the following areas: access to care (23 percent), availability of reliable information and education (19 percent), respect for their preferences (13 percent), emotional support (19 percent), and coordination and continuity of care (19 percent).⁴

These important factors contribute to the migration of patients out of practices with these problems and into practices offering higher quality of care. A recent VHA Inc. (formerly Voluntary Hospitals of America) survey revealed that as many as 26 million, or one quarter, of U.S. households replaced their physicians within the last two years. Of those, 27 percent did so because they were dissatisfied with their physicians (this category included the responses "Did not like the physician," "Poor quality of care" and "Unable to communicate with physician") and 4 percent did so because they desired more flexible scheduling.⁵

These examples are not intended to place blame or to put physicians on the defensive. Instead, they provide an imperative for us to examine our systems of care and to provide the appropriate leadership toward the redesign of those systems. The message is this: With appropriate redesign of our office systems, we may be able to create office practices that provide much greater efficiency, better income, higher reliability and confidence in our systems, and better clinical outcomes simultaneously.

The idealized design

For just a minute, remove any preconception from your mind of what a "doctor's office" is or how it works. Contemplate the design of a system that allows you to give your patients the best possible health care and that fills you with joy in your work and confidence in its reliability, efficiency and high-quality outcomes. Think about this from a patient's perspective as well. What would such an office system look like?

The new office system you imagine probably looks nothing like the office of today. Indeed, today's office is largely a relic from decades past, and its design (from its scheduling system to its information management to its leadership structure) is not capable of achieving the needed performance. In order to achieve the highest level of performance, we cannot simply tweak the old system or "try harder" to make it work. Instead, we must fundamentally redesign all aspects of the practice, making sure all of its parts are working together toward a common purpose. When the parts act in conflict or without a common purpose, the system stumbles and falls.

Traditional practice vs. the ideal The practice design that the Institute for Healthcare Improvement is now working toward is fundamentally different than the traditional medical practice. Traditional practice Idealized practice Patients wait days or weeks for an appointment; work is delayed into the future. Patients are seen on the same day that they call for an appointment; practices do today's work today. Patients are "on their own" after they leave the physician's office. Patients can access information from their physician via e-mail or the practice's interactive Web site. Patients play a passive role; physicians make decisions about what is best for patients. Patients play an active role and take part in making decisions about their health care. Medical records are designed for compliance, are chronological and belong to the practice. Medical records are designed to be useable, are problem-oriented and belong to the patient. Clinical care is based largely on individual training and habit. Clinical care is based on continually updated scientific evidence. Patients are treated reactively and one at a time. Entire populations of patients are managed proactively through patient registries. Staff members develop new skills when it is imperative; job descriptions are fixed. Staff members are encouraged to broaden their skills and develop cross-functionality.

The system-wide redesign being pursued through the IDCOP initiative has essentially four themes:

1) Patients have unlimited access to the care and information they need when they need it.

2) The interaction between the patient and the care team is deep and personal.

3) The system exhibits high reliability in that it provides all the care known to be effective and only that care.

4) The practice has vitality -- financial stability, happy employees and a spirit of innovation.

More specifically, this is how good office-based practice could get. See if you can visualize it:

Access and efficiency. Your practice offers same-day appointments, rather than making patients wait days or weeks to be seen. Your waiting area is no longer a "holding" area but a patient education center. Patients are able to make their own appointments through your practice's own Web site. Visits for chronic diseases such as diabetes or asthma are held in groups, utilizing the full skill of your nursing staff. Patients can e-mail you and your staff with questions or for follow-up. There is no longer a registration desk, since patients are registered while in the exam room.

Clinical care. You maintain a patient registry for your patients with chronic diseases. Your specialist consultants communicate with you by e-mail and assist in care management using a commonly developed guideline. You follow up with patients and proactively reach out to them for needed services. Your practice encourages patients to be involved in their health care and promotes self-care through active patient education and training.

Leadership and human resource management. Your practice delivers care through the coordinated efforts of a functional care team in which every member's skills are optimally employed. Your staff members are encouraged to expand their skills and take on new responsibilities. Your practice engages in annual strategic planning fully integrating the "voice of the customer."

The IDCOP initiative The Idealized Design of Clinical Office Practices (IDCOP) is a three-year initiative headed by the Institute for Healthcare Improvement (IHI). It is aimed at radically redesigning the clinical office and involves three phases: Phase I: Design. In May 1998, IHI began working with a panel of experts to create flexible designs that could be applied across a broad range of practice settings. The designs are based on the work of modern pioneers in office-based care who have, one by one, substantially redesigned elements of the clinical office, often with stunning success. Phase II: Test. Beginning in January 1999, 42 prototype sites began 18 months of individually testing and refining those designs in an effort to prove their effectiveness. The prototype sites are also participating in six two-day meetings to discuss progress, barriers to improvement and plans for future action. Phase III: Deploy. The final year of the project, ending in July 2001, will be devoted to widespread organizational deployment along with continuing improvement of the prototype designs. Quarterly reports of IDCOP's progress are available as "pdf" files at www.ihi.org/idealized/projectinfo. To join the office improvement e-mail discussion list, send a message to ihi-icop-request@ls.ihi.org. In the body of the message type "subscribe ihi-icop" (without the quotes). You may leave the subject line blank.

Information management. Patients maintain their own "shadow chart." Results are available to patients 24 hours a day on an automatic voice message line or on your practice's Web site. Your group regularly seeks out new literature on the common problems in your practice and incorporates solutions in a timely way.

Measurement. Every member of the practice is engaged in gathering data about the collective work of the practice. A defined set of measurements that reflect a balance of activities in the practice is developed and displayed for all to see: measurements of health outcomes, cost of care, practice size, patient satisfaction and staff morale. Data from patients is collected in person and via e-mail or Internet surveys. Staff and patient focus groups provide important qualitative information.

Office management. Practice data serves as the basis for managerial decision making (management by fact). Costs are tracked by activity, not by supply inventories and charges. Every member of the practice has an opportunity for input in the annual strategic planning process.

Interacting with communities. Your practice recognizes that the care of patients includes those who don't come in for care. Community resources are fully used as elements of care. In turn, your practice actively participates with community programs to provide coordinated services such as immunization or cancer screenings.

Making change happen Every step toward the idealized design, whether it's instituting same-day scheduling or using e-mail to communicate with patients, requires a tremendous degree of change. How can you make change happen in your practice? Forget the status quo (i.e. "We've always done it this way"), and expect innovation. Find a leader who will champion the process and help you get the resources you need. Plan for change -- but get out of the planning mode as soon as possible. Test your ideas rapidly using a prototype or pilot group, which could range from one individual patient to one physician or one site within a group. Take what you've learned from your experiments and expand your work to the next level. Don't expect the process to be smooth or easy. Innovation requires trial and error.

How do we get there?

Remove any preconception from your mind of what a 'doctor's office' is or how it works.

Understanding the possibilities, or how good office-based practice could get, is only the beginning. The next step, which we are currently taking with the IDCOP initiative, is to test our strategies and begin making system-wide improvements. (See "Making change happen," page 51.) Many past "redesign" efforts have focused on parts or pieces ­ individual subsystems ­ without considering the system as a whole. While many such efforts have done wonderful work redesigning individual parts, the work has not added up to a fundamentally new system capable of fundamentally new results.

Our vision of a system that produces the best possible care as the default and that fully supports clinicians in their continual drive to improve patient care is being realized and is replicable in your practice. The task before us is not simple, but it is unbelievably exciting.

Editor's note: Over the coming months, FPM will be exploring in greater detail some of the key strategies involved in the idealized design, such as same-day scheduling, evidence-based medicine and group visits. Look for these articles, and visit the FPM archives (below) for other pertinent articles.

Further reading The following articles from the Family Practice Management archives address key components of the idealized practice design. Although they are not directly related to the Institute for Healthcare Improvement initiative described in this article, they can help you map out your route to the future. Clinical guidelines "How to Evaluate and Implement Clinical Policies." Gilbert TT, Taylor JS. March 1999:28-33. "Where to Look for Good Clinical Policies." Gilbert TT, Taylor JS. February 1999:28-32. E-mail with patients "Getting Patients Off Hold and Online," Spicer J. January 1999:34-38. Group visits "Making Good Time With Group Visits." Henry LA. July/August 1997:70-75. Open-access scheduling "Reducing Delays and Waiting Times With Open-Office Scheduling." Herriott S. April 1999:38-43. Patient-centered care "Helping Patients Take Charge of Their Chronic Illnesses." Funnell MM. March 2000:47-51. Patient registries "Building a Patient Registry From the Ground Up." White B. November/ December 1999:43-44. Population-based care "It's Time to Start Practicing Population-Based Health Care." Rivo ML. June 1998:37-46. Quality improvement "Improving Chronic Disease Care in the Real World: A Step-by-Step Approach." White B. October 1999:38-43. "Holding the Gains in Quality Improvement." Giovino JM. May 1999:29-32. "A Team Approach to Quality Improvement." Schwarz M, Landis SE, Rowe JE. April 1999:25-30. "Quality Improvement: First Steps." Coleman MT, Endsley S. March 1999:23-26.

Dr. Kilo is vice president and director of Idealized Design for the Institute for Healthcare Improvement, Boston. Dr. Endsley is an assistant professor in the Department of Community and Family Medicine at Dartmouth Medical School, Concord, N.H.

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REFERENCES

1. Chassin MR. Assessing strategies for quality improvement. Health Affairs. 1997;16(3):151-161.
2. Centers for Disease Control and Prevention. Influenza and pneumococcal vaccination coverage levels among persons aged >= 65 years ­ United States, 1973-1993. Morb Mortal Wkly Rep. 1995;44(27):506-515.
3. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324(6):370-376.
4. Gerteis M, Edgman-Levitan S, Daley J, et al. Through the Patient's Eyes: Understanding and Promoting Patient-Centered Care. San Francisco: Jossey-Bass; 1993.
5. Consumers and Their Doctors: How the Relationship Drives Perception. Dallas: VHA Inc; 1999.

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