October 5, 2001
Practice 2010
Now's the time for Practice 2010, says speaker
BY TONI LAPP
Although his main-stage "Practice 2010" lecture was subtitled "A Revolution in Office-based Care," it is revitalization -- not revolution -- that is needed, said Charles Kilo, M.D., M.P.H., at Assembly yesterday.
At any rate, changes are in the works. Consumers, especially baby boomers and Generation Xers, are just beginning to exert their influence, and they want change, he said. "They are activated, engaged and intolerant to paternalism."
The current system's flaws run deep, to the very core, Kilo said. "We are trained to focus on the individual and not on systems. To change, we must focus on systems."
Practice 2010 was designed to accelerate the change, said Kilo, director of the Idealized Design in Clinical Office Practice program of the Institute for Healthcare Improvement. His lecture was complemented by smaller presentations on implementing specific Practice 2010 concepts such as quality improvement and open-access appointment scheduling (see stories on page 2A).
Marc Harvey, M.D., of Charlotte, N.C. stays up to date with his personal digital assistant in the PDA chat room in the exposition hall.The idea is that by the year 2010, family practice will look very different from the way it looks today. But given what's known now, family physicians don't have to wait, Kilo said.
"Health care today is a jumble of Band-Aids, and no one knows what's at the core," he said.
Kilo suggested peeling away the Band-Aids to get to the solution.
Patients are frustrated; they wait on hold to set an appointment to see their doctor but are told the doctor is booked for weeks. Physicians are feeling dejected and overly managed by managed care. And clinical outcomes are worse than they should be.
With satisfaction over health care at an all-time low, there's never been more incentive to change, said Kilo.
He advised focusing on two things: relationships and knowledge.
Don't just know your patients by name -- know how to pronounce their names, he said, illustrating the point by showing an electronic record with the phonetic pronunciation of a patient's name.
When it comes to knowledge, learn to manage the vast amounts of it. Too often, standards of care aren't used, he said. Treatment for conditions as simple as sore throats vary from practice to practice.
He urged participants to evaluate their own methods of applying knowledge, admonishing that "collecting data and managing knowledge are two different things." In his practice, he has organized a chronic disease registry so he can identify his patients according to their conditions. This way, he can follow their progress and evaluate his treatment methods.
Start with the scientific sessions here, he said. Ask yourself how the knowledge you acquire will reliably be applied to your practice. "If the answer is you'll rely on memory," he said, "it's the wrong answer." *
Successful office changes can be made in small steps
BY COREY NASON REESE
Family physicians are working harder than ever, but they're not seeing the results they want in their practices. One key reason is that office design hasn't changed much in the past 100 years, some experts say.
But don't be overwhelmed -- just start making changes one small step at a time. That was the advice given to FPs by Glenn Rodriguez, M.D., and Bertha Safford, M.D., on Wednesday morning. The course, "Optimizing Clinical Care and Service in Your Practice," is part of the Academy's Practice 2010 initiative.
"Making changes in your office practice is hard. It takes passion, hard work and a vision, but despite the pressures and stresses, we have an unprecedented opportunity to be even better than ever before," said Rodriguez. "You have to really believe that there's a need to improve."
Rodriguez, a family physician and regional medical director for quality improvement at Providence Health System in Portland, Ore., introduced what he referred to as a "deceptively simple" model for change. The rapid-cycle improvement model for quality improvement contains three steps: setting the aim (defining the goal), defining the measure (analyzing the system), and testing improvements (utilizing rapid-cycle, small-scale tests).
Setting the aim involves taking a clear and deliberate look at what is to be accomplished. Physicians typically make this too complex, Rodriguez said. Write it, discuss it and make it measurable. A good aim will drive the next step -- defining the measure. Defining the measure will show what the project will look like if successfully changed.
The third aspect is to test the changes using a four-step, rapid-cycle process of Plan, Do, Study, Act -- PDSA. Select small, concrete goals and put them into action in a pilot situation that can be evaluated quickly -- perhaps in a day or week. If the changes don't work, go through PDSA again until a manageable solution is found.
Using the rapid-cycle model, Safford's practice of 41 physicians in 17 offices conducted a system-wide redesign on caring for their patients with diabetes. The project began in 1999 and has successfully improved care. Safford is a family physician and medical director of quality improvement for Family Care Network in Whatcom County, Wash. The project taught Safford many valuable lessons.
"Change is hard for most of us. It can be exciting if you're the driver, but if you're the recipient, you're probably resistant. Most of us perceive change negatively because we want to be in control. If you think it's easy, go back to your office and move the coffee pot!" she said.
To make significant changes, physicians need to think in terms of changing systems rather than simply concentrating on personal accountability for the quality of care that is delivered.
Safford used an example of a doctor ordering medicine in an emergency situation. The nurse mistakenly selects the wrong medicine, because the two bottles look alike. The incorrect medicine is administered. Both the physician and the nurse can be blamed, but blame won't change the likelihood of recurrence. To prevent that, the system is examined and the medicines are placed in different bottles.
Once a system has been changed, continued implementation is a challenge. Safford suggested ongoing reminder of why the change was needed and tying it back to the organization's values. Give people broad goals and the flexibility to make it work in their own office. Publicize the staff members involved in the change. Provide information about what worked and what didn't work. Continually celebrate your successes.
"Our goal is to give family doctors the tools to be able to make improvement changes in their practices and make those changes really stick. We don't want them to have little projects that then fade over time," Safford explained. *
FPs can improve patient satisfaction, bottom line by reducing wait times
It's no secret that the chief complaints from patients involve delays in scheduling appointments and long waits in the office. But what if you could see each patient on the day he or she calls and at the appointed time?
Impossible? Not at all, said Catherine Tantau, B.S.N., M.P.A., a practice management consultant with Murray, Tantau and Associates in Chicago Park, Calif.
Tantau spoke Wednesday at a Practice Management and Enhancement Course titled "Reducing Delays and Waiting Times: Open Access for Office Appointments." The course is part of AAFP's new Practice 2010 program designed to revolutionize traditional office practice.
"Long delays used to be a status symbol for some practitioners," Tantau said. "However, patients were saying that they loved their doctors but complained about the long delays in seeing them."
ADVANCED ACCESS
Tantau described the concept of "advanced access" to provider care as an alternative to the traditional system of long delays. "The idea is to offer patients an appointment with the provider of their choice at a time convenient to them," she explained.
The reasons for providing patients with advanced access to care include increasing patient and staff satisfaction, improving quality of care, growing the practice and reducing operational costs by improving resource utilization.
Under traditional systems, patients have to prove they are sick in order to see their physician right away or later that day. Sometimes they are sent to an urgent care clinic for treatment, or they may be referred to their family physician's colleague.
"Patients are most satisfied when they get to see their own primary care provider," Tantau maintained. "Satisfaction drops if they are referred to someone else in the practice they know, and satisfaction is the lowest when patients are forced to see a stranger."
Providing patients with advanced access to care requires a paradigm shift to a new way of doing business, she said. "In an advanced access scheduling system, there is no distinction between urgent and routine appointments. You should be able to offer every patient (who calls) an appointment today."
Future appointments, Tantau advised, should be made only for patients who request them and when the provider schedules a follow-up appointment.
BACKLOG REDUCTION
But how can a family physician get from here to there?
The first step is to understand the practice's demand for appointments every day of the week. The second step is to reduce the backlog of appointments scheduled two to three months in advance.
"For a time, you will need to increase capacity, and that means more work," Tantau said. "For example, if you normally see 20 patients a day, you may have to add five more a day to clear up the backlog. Set two dates for backlog reduction: a start date and a finish date. Look at how far out you have scheduled appointments, and determine realistically how long a time you need to reduce the backlog."
Other strategies include extending visit intervals for return visits from, for example, three months to four months, Tantau said.
To measure demand, family physicians should determine how many patients call for an appointment each day, how many walk in, how many are deflected to urgent care or a colleague, and how many go elsewhere if they can't be seen right away. *
FP Report is published by the AAFP News Department.
Copyright © 2001 by American Academy of Family Physicians.
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