Criteria for Excellence | Chapter 9A: Principles grounding the family medicine practice

Explore the core principles of an excellent family medicine residency practice.

The following principles of excellence should be at the core of any residency practice and drive the form and function of the care delivered by residents, faculty, and team members:

  • Community context

  • Accessible care

  • Comprehensive care

  • Continuous care

  • Coordinated, team-based care

  • Sustainability and innovation

Background and justification for the metrics for excellence listed in this section can be found in Appendix 1.

Understand and serve your family medicine practice community

A Program of Excellence should clearly define the community it serves. This includes a process by which the program identifies the key attributes of that community, engages with key stakeholders, and specifically applies data-driven strategies to its practice. At a minimum, considerations include race, ethnicity, primary language(s) spoken, and social characteristics, as well as identified community assessments and partnerships. Patients with complex needs should be identified so that specialized care plans can be developed and accommodations take into account social determinants of health.

  • On an annual basis, at a minimum, residents, faculty, the care team, and leadership analyze key demographics of the population served.
    • Age
    • Sex
    • Race
    • Ethnicity
  • The program identifies the top priorities for the defined community it serves, engages with community-based organizations, and leads efforts for programming to better address community needs.
  • The program utilizes registries to identify and stratify patient cohorts based on disease states, social factors, and utilization patterns.
  • The program prioritizes diverse strategies and collaborations to enhance access and compassionate care for the most vulnerable populations, including:
    • Frail and elderly patients
    • Patients who have severe mental illness
    • Patients who have intellectual and developmental disabilities
    • Unhoused individuals
    • Patients who are “high utilizers” of emergency and hospital care

Improve access to care in the family medicine practice

Prompt access to care is of utmost importance to patients and must remain a top priority for the FMP. Family physicians should also be recognized as the point of first contact for the individuals served and the health system. Advances in technology can change care delivery and the way patients access care, but in all cases, prompt access should be balanced with prioritizing physician-patient continuity.

Care access metrics define how easy it is for patients to get the care they need. For needed care to be provided in a timely fashion, patients must have access to their continuity resident physician during every workday, whether in person or by video, phone, or email.² Residency programs must restrict rotation demands that prevent residents from responding to patients within one business day.

  1. The practice has same-day access for established patients available.
  2. The practice actively tracks metrics such as the time to third next available appointment and the percentage of slots open.
    1. The time to third next available appointment goal is less than seven days.
  3. The types of visits offered include person-centered, alternative formats (e.g., e-visits, group visits, virtual encounters, shared medical appointments).
  4. Phone response rates are tracked and a system of surveillance ensures timely responses based on triaged urgency.

Deliver comprehensive, whole-person care

Comprehensive care focuses on the whole person, including family, social, and environmental contexts. At the physician level, this means that most health problems patients have should be cared for in the primary care setting, except when referral to a subspecialist is appropriate. Trusting patient-physician relationships are central to comprehensive care because they give physicians the best understanding of both what care matters to their patients and what care is needed. Comprehensive care services include wellness promotion and disease prevention, such as programs to screen for issues related to exercise, nutrition, and mental health and promote healthy lifestyle choices. Evidence-driven, person-centric, team-based chronic disease management should be coordinated across the continuum of care. Comprehensive care must be delivered in a way that continually evaluates and improves quality.

0

  1. The program tracks practice and individual clinician referral rates and provides normative data to residents and FMP leadership.²
    • Goal of less than 20% per year for population
  2. The program maintains diverse resident panels that represent the population served and include multimorbid conditions.
    • By the second year, each resident’s panel includes at least 50 patients with two or more chronic diseases.²
  3. The program uses a preventive services index to track receipt of immunization, screening, counseling, and chemoprophylaxis services recommended by the U.S. Preventive Services Task Force (USPSTF).
  4. The program’s formative resident evaluation process includes discrete quality of care metrics for chronic conditions such as:
    • Major depressive disorder: screening, treating, tracking
    • Diabetes
    • Hypertension
  5. Residents have the opportunity to be directly involved in the care of conditions currently amenable to primary care that were previously in the realm of subspecialists (e.g., hepatitis C, HIV, substance use disorder).²

Strengthen continuity of care in family medicine residency

Continuity allows patients to establish knowledge, trust, and an understanding of the situational context with a physician as their usual source of care. A residency practice’s ability to foster patient-physician relationships over time remains core to providing the opportunity to develop skills in trust building and compassion.

Programs should take advantage of this opportunity to model and teach skills in actively listening, expressing empathy, and connecting in meaningful ways with a diverse panel of patients to help them engage in improved health behaviors and self-care.

Furthermore, during residency training, the emphasis on continuity across time and settings provides essential exposure to observing the course of disease and health and reaping the rewards of the vital patient-physician partnership.

Emerging evidence reinforces that higher primary care continuity leads to improved outcomes for individuals and the health system.³ Successful residency practices balance their service commitment to patients with the education of their learners.

0

  1. Health care visits result in the outcomes that are most important to the patient.
    • Patients are offered the opportunity to set SMARTIE (strategic, measurable, ambitious, realistic, time-bound, inclusive, and equitable) goals.
    • Individual success is tracked over time to achieve patient-directed outcomes.
  2. The program routinely evaluates continuity at the patient and physician levels.
    • Physician-level continuity rates
      • Goal of 70% for faculty
      • Goal of 50% for PGY-2
      • Goal of 60% for PGY-3
  3. The program maintains a curriculum introduced early in residency to promote mastery of active listening skills, expression of empathy, and person-centered goal setting.

Build coordinated, team-based care in the residency practice

Coordination of care involves leading, organizing, and integrating patient care across various locations, specialties, and phases of care. The core location of care is the residency practice. Given the complexities of primary care, family physicians ideally work in the context of a larger care team. Teams that include registered nurses (RNs), pharmacists, and behavioral health professionals, as well as non-licensed team members such as medical assistants (MAs) and community health workers/peer support, add to family physicians’ capacity to see more patients, manage increasing stress, and coordinate care beyond the walls of the practice. Residency programs should strive to develop a culture that promotes learning and continually improves the quality of patient care delivered. Adequate time for practice team activities must be built into the residency schedule.

Safety is a key element of excellent care. Reporting near misses and maintaining a culture of safety are useful methods to discover and correct potentially unsafe processes and practices before patients are harmed. Programs should use simulation to train residents so they can develop competency to perform procedures safely before they are allowed to perform them on patients.

0

  1. The FMP uses co-empanelment to provide resident and faculty coverage for one another and define team member roles and expectations.
  2. The FMP tracks staffing ratios and turnover.
    • The MA-to-physician ratio is 1:1 during clinic sessions for all faculty and upper-level residents.
    • Team continuity is 90% for care provided during usual office hours (excludes after-hours or urgent care).
    • The turnover rate for staff is below the median for support staff in the region or based on industry trends.
  3. The FMP utilizes standardized protocols to coordinate clinical care.
    • The FMP has protocols for refills, appointment access to re-engage patients, and prior authorizations.
    • When residents are away or on busy rotations, the FMP has reliable systems in place for team staff, resident practice partners, or faculty to support electronic health record (EHR) inboxes and urgent patient issues.
    • The FMP has clear protocols for transitioning patients to new physicians when residents graduate so that patients are not lost in transition and complex patients are handed off effectively.⁴
    • The FMP clearly defines roles of team members who provide external care coordination for subspecialty referrals and transitions after hospitalizations and emergency department (ED) visits.
  4. Care management services are integrated into the FMP and the flow for patients.
    • Social support services are immediately available at the time of care.
    • The FMP has systems in place to support chronic disease management, preventive care registries, and self-management education.
  5. The program collaborates with public health and community-based organizations.
    • The program tracks the number of projects and community organizations engaged.
  6. The FMP is co-located and integrated with key interprofessionals.
    • Behavioral health professionals and continuity physicians are able to directly coordinate with each other, whether in person or virtually.²
    • The FMP is able to provide or directly coordinate treatment for substance use disorder.²
    • The FMP promotes integrated care delivery and group visits that are offered in partnership with the team for RN, pharmacist, and behavioral health visits.
  7. Leadership promotes an open and empowering culture for residents and clinic teams.
  8. The FMP has an organized process for staff to report near-miss events, and staff are assured that reporting an error does not have negative consequences.
  9. Early in residency training, the program uses simulation to train residents to perform invasive procedures, examinations, and uncomfortable interviews.

Promote sustainability and innovation in the family medicine practice

Although finances and payment systems often dominate definitions of value, the greater purpose of the FMP—which is to improve health outcomes for the community served—should be emphasized. Desired health outcomes should be evaluated and shared with key stakeholders on an annual basis to best demonstrate the overall value of the program. Residency programs should sustain a learning culture and show willingness to innovate and change. These qualities separate average programs from those that achieve excellence.

In order for the rest of the system to follow their lead, practices undergoing innovative transformation will need to demonstrate their value by improving patient health status, as well as demonstrating fiscal stability and growth. To understand health outcomes that matter to patients, the FMP needs to include patients in some meaningful way in the planning and innovation process.

Designing methods to promote health behavior changes and improve integration of mental and physical health can go a long way toward improving overall health outcomes and patient satisfaction.

It remains essential for leadership, residents, faculty, and staff to be directly engaged with sustainability, strategic visioning, and planning. Inclusion and transparency in this process promotes not only practice management education but also equity and empowerment. A Program of Excellence creates a vibrant culture that empowers the team to be a part of the creative process of working toward more positive clinic experiences for all involved. Continually improving the FMP serves as a reminder to residents of the greater purpose of care delivery and ingrains the attitudes necessary for a successful career in family medicine.

0

  1. The program has an inclusive strategic planning process with an annual review of progress toward its goals.

  2. The program is financially viable within the context of its health system, and it receives regular financial data and can make practice-specific changes to maintain viability.

  3. Residents are encouraged to engage in community and practice improvement projects that test new models and processes to improve health outcomes and the practice’s efficiency.

  4. The FMP’s overall decision-making process is inclusive, and diverse ideas from all levels of the practice are encouraged.

Assess your residency program

Put what you’ve learned into practice. Complete the corresponding self-assessment to evaluate your program’s current practices, identify opportunities for improvement and help guide your next steps.
Take this section's self assessment