With the release of the Future of Family Medicine (FFM) report last year, the AAFP helped articulate a clear vision of the specialty as being patient centered, systems focused and quality oriented.1 The New Model of Care proposed by the project defines in broad brush a redesigned practice that is just invented today. It includes ideas as the following:
Advanced access scheduling,
Online appointment scheduling,
Planned care for patients with chronic diseases,
Clinical practice guidelines software,
Standardized order sets,
E-mail communication with patients,
Practice-based measurement systems.
These ideas aim to improve office efficiency, service excellence and clinical outcomes, and are being tested in practices throughout country. (See “Cases in point.”) Yet we are only at the tip of the iceberg of new ideas for improving practice. Getting to the future of family medicine will require continued innovation, not from a few family but also from community of family academic, managed practices.
In the sections that follow, we describe tested methods for optimizing the creativity and innovation of your practice to improve patient care.
To continue meeting the needs of patients, family physicians must embrace innovation and reinvent their practices.
Great ideas can be adapted from neighboring practices or from businesses outside of health care.
Putting ideas into action, and testing their impact, is the heart of innovation.
Don't be afraid to fail.
Six steps to innovation
Innovation is not the exclusive province of eccentric geniuses but is open to anyone with a desire for change and a willingness to challenge existing ways of working. For those courageous family physicians ready to start the transformation of their practices, we offer a six-step process for successful innovation.
Step one: Set your aims. The first step in all improvement efforts in your practice should be to clearly identify your aims for change. These should summarize what your practice intends to achieve in terms that are specific, measurable, relevant to your practice and time-bound. Write them down and use them to keep your efforts focused on the goal.
For example, the aims for an asthma improvement project might be “to improve the health of our asthma patients by implementing a systems-based approach to their care. Our success will be evidenced by a 60-percent reduction in ER visits, at least 90 percent of patients with persistent asthma being treated with anti-inflammatory medications, at least 90 percent of patients having an up-to-date asthma flow sheet in their chart and at least 60 percent of patients having an asthma-trigger-avoidance plan. The project will last until December 2005.”
Step two: Put together a team. Innovation is a team sport. While everyone in the practice can contribute ideas and should be kept informed of any changes, you'll need a smaller group to carry out the bulk of the work. Assemble a team representing the different functions in your practice (e.g., clinical, clerical and administrative). Allow for changes to the team if new skills or perspectives are required. To help the team members succeed, make sure your leadership supports and rewards their ideas and initiative.
CASES IN POINT
Many family physicians have heard the call for change and are becoming innovators by testing and implementing a wide range of practice redesigns. The recent Family Practice Management “Big Idea” contest (FPM, September 2004) highlighted 18 examples of forward-thinking family physicians putting new ideas into practice. Below are three additional examples:
South Jordan Health Center
This two-physician family practice, operated by the University of Utah, has dramatically redesigned the office visit. Patients make same-day appointments by calling an off-site call center. The phone rarely rings at South Jordan, creating a tranquil environment. On arrival, patients are greeted and immediately escorted to the exam room by one of five medical assistants (MAs) who stays with the patient throughout the visit. The MA documents the history using one of 100 templates in the electronic health record, documents the physician's physical findings, draws needed blood work, obtains X-rays and checks out the patient. The MA and the physician stay in constant contact through a two-way radio system. Patient cycle time (that is, the length of time from check-in to check-out) is reduced dramatically, while physician-patient interaction is increased and patients are continually delighted with the efficient, attentive care.
Dupage Family Medicine
Jim Cunnar, MD, is a family physician in Naperville, Ill. He has implemented an electronic health record and streamlined his work processes to meet the needs of his patients. He adopted an online insurance verification process that saves both patient and staff time. He also uses e-mail to communicate with his patients. When asked why he works so hard to put new ideas to work, he replies, “Why not? Wouldn't you want your mother to have this kind of care?”
The SPARC Clinic
The SPARC clinic at the Mayo Clinic in Rochester, Minn., was established to identify, build and test prototypes of new strategies for care delivery. Short for “See, Plan, Act, Refine and Communicate,” SPARC develops team-based programs, with emphasis on regular brainstorming and generation of ideas for prototyping. For example, upon identifying long lines at patient registration, the SPARC team designed a prototype and tested a self-check-in process using kiosks placed in the waiting room, all within a two-week period.
Step three: Seek ideas from outside the practice. In many cases, you don't have to reinvent the wheel. Look for great ideas from external resources such as a neighboring practice, your own health care organization, the AAFP Quality Initiative (https://www.aafp.org/quality) and the Institute for Healthcare Improvement (http://www.ihi.org), to name just a few. You may even want to look beyond medicine at how other service industries are able to increase efficiency and meet their customers' needs. For example, how does your favorite hotel register its customers in a timely way? How does a leading hardware chain keep customers fl owing through its stores? How do the best airlines maintain loyal customers with excellent service? Support the team in brainstorming about these ideas and how they could be adapted for your practice.
Step four: Generate new ideas. One of the best ways to generate innovative ideas is to engage in activities that force you to think beyond the status quo. Consultant Paul Plsek suggests that “anything that helps us pay attention in a different way, escape our current mental patterns and maintain movement in our thoughts will support our efforts at innovation.”2
Here are just a few ideas: Spend time observing the processes in your practice related to your aim, draw a “map” of the steps involved and challenge the assumptions associated with each step. Collect your staff's observations as well, and possibly even those from an outside observer. Try to experience your practice as your patients do (e.g., call your receptionist and ask for an appointment). Photograph or videotape your work, particularly from the perspective of the patient. Ask radical “what if” questions to jolt your group out of its current mental models. For example, “What if we had no time constraints during patient visits?” or “What if patients set the price of an office visit based on their satisfaction with the encounter?”
Another useful activity is brainstorming – bringing the team together for one to two hours and simply generating as many ideas as possible. Tom Kelley, general manager of the product design firm IDEO, suggests some basic guidelines for a good brainstorming session:3 Start with a well-crafted statement of the problem you are trying to solve. As individuals share their ideas, avoid critiques by following simple ground rules such as “go for quantity” and “encourage wild ideas.” Look for opportunities to take promising ideas and build upon them. For instance, “An electronic registration kiosk is a great idea. What are other ways of getting patients out of line and into exam rooms?” Provide plenty of writing and drawing materials. Encourage participants to move around the room, to mark ideas down on flip charts and to use pictures or other visual displays to express their ideas.
TIPS FOR INNOVATION
Aim for simplicity. The best ideas are usually easy to understand, easy to explain to others and relatively easy to implement.
Think in verbs, not nouns. Focus on the action or experience (e.g., “teach patients to manage their diabetes” vs. “diabetes education”).
Build on the ideas of others. Do not hesitate to borrow ideas from your competitors or adapt ideas from businesses outside of medicine.
Create an idea “treasure box.” When you find great ideas, write them down and save them in one place so you can recall them when needed.
Think spatial change, as well as process change. You may need to make physical changes to your practice, such as redesigning the layout for better flow or relocating employees to optimize efficiency and communication.
Brainstorm often. It takes practice, but as your group becomes comfortable with the process, great ideas will surface.
Bring people together. Encourage your staff and colleagues to share problems and potential solutions, and support the natural teams or alliances that develop around shared passions.
Reward ideas. To keep your team members motivated, acknowledge their hard work even if their idea wasn't a complete success. A failed idea is better than inaction, as long as you learn from it.
Step five: Test the innovation on a small scale. Putting ideas into action, and testing their impact, is the heart of innovation. Work with your team to turn ideas into prototypes, showing how they might work in practice. Build models, draw pictures or create service scenarios. Test your prototype on a small scale using rapid cycle testing methods.4,5 For example, ask one physician to try it for one week or with a small group of patients, and see what you learn. Don't be afraid to fail. As Kelley has said, “Fail often to succeed sooner.”3
Step six: Evaluate the success of your prototype. Make sure that every test measures key outcomes. For instance, if you are testing electronic patient registration, consider measuring both patient and staff satisfaction, number of registration errors and registration time. Based on what you learn from the test, revise your idea and then test it again. Gradually, you'll introduce the idea to a larger test group and then to the entire practice. But practice-wide implementation isn't the end. Ongoing evaluation and improvements are critical to long-term success.
The following articles from the Family Practice Management archives can help you experiment with new practice designs.
Open (advanced) access
E-mail with patients
Planned care for chronic diseases
Electronic health records
Family physicians as innovators
The nature of family medicine, with its breadth and unpredictability, has historically fostered innovative thinking in the content of clinical care. We can build upon this innovation capacity to transform how we deliver care, as well. A clear aim, a small team, some basic innovation tools and the willingness to experiment can produce some remarkable ideas and prototypes. If family physicians are to achieve the clinical, service and financial goals defined by the New Model of Care, we will need to engage actively in innovation. It will require nothing less than the reinvention of our workplaces, our practice culture and our fundamental care delivery processes.