Criteria for Excellence | Chapter 9B: Form and function of the family medicine practice site

The form and function of the family medicine practice (FMP) site is made up of various elements, including the facility’s physical design, the practice’s staffing model, the flow of patients, and the model of care used to provide services in a truly patient-centered way.

Background and justification for the metrics for excellence listed in this section can be found in Appendix 2.

A Program of Excellence should maintain a family medicine residency practice with enough volume and diversity that no resident will have any difficulty achieving minimum training requirements, including the minimum volume of pediatric and elderly patients. Residents should receive regular encounter volume reports, and faculty advisors should intervene early to ensure adequate volume performance so there will be no need for special catch-up electives during the PGY-3 year.

Overall rotation design for the duration of residency should provide enough clinic session opportunities that each resident can easily have over 2,000 face-to-face visits. Some residents may require fewer visits to achieve competency in ambulatory family medicine care, and some may require more. However, without a structure in place to provide at least 2,000 face-to-face encounters for each resident, it will be nearly impossible to achieve this number by modifying schedules late in the residency. The projected annual goal number of face-to-face visits for all clinicians at the FMP site is an important metric. It should be calculated and monitored for all clinicians who require the use of exam rooms.

At least 10% of face-to-face encounters should be with patients who have complex medical and social needs that are co-managed by an interdisciplinary team.

The FMP site should be inviting to patients and to clinicians and staff. It should have enough exam rooms to accommodate all physician time assigned to the site. Facilities should have core components that include procedure rooms, a precepting area (adequate in size to accommodate the teachers of interprofessional learners), counseling and education space, and adequate space for group visits. In addition, it should offer opportunities to use technology for direct observation of encounters. There should be faculty offices, resident and team workspace, a library (electronic and/or hard copy), and support staff offices, as well as a well-appointed reception area and laboratory.

Residency Program Solutions (RPS) has tools to help determine the number of exam rooms needed based on the number of residents, faculty, and advanced practice providers (APPs) at the FMP site and their clinical job descriptions. In most cases, the FMP should have a minimum of one exam room per 1,000 patient visits per year.

Family physician faculty who are fully engaged with the clinical and academic operation of the residency are fundamental to the quality of the residency education and clinical care provided (Table 1).

Residents should have a panel of sufficient size and diversity for them to gain broad clinical experience. In general, residents should have the following panel sizes:

A resident’s panel should allow them to have the recommended number of continuity encounters and give them maximum opportunities to develop meaningful relationships during training. Panel size considerations include hours of availability, patient expectations, and average number of annual visits projected or derived from current practice. The earlier residents can grow their panel, the more opportunities they will have to develop these relationships. Programs of Excellence should consider models such as Clinic First to provide opportunities to build a patient panel early in training.

Additionally, the program curriculum should require sufficient time for residents to care for their panel of patients, establish relationships, maintain continuity, and provide comprehensive services. A reasonable expectation for continuity experience cannot be met by fulfilling the ACGME requirements for each family medicine resident to provide patient care in an FMP for at least 40 weeks per program year and for each graduate to complete a minimum of 1,000 hours caring for FMP patients.⁵ A curriculum map with at least 1,600 to 2,000 total clinic hours is desirable to attain program goals.

There are evolving questions about the technology, payment model, and patient desire for telemedicine versus face-to-face care. However, it is clear that telemedicine visits will be a part of all family medicine practices. The capacity for privacy-assured video visits with simultaneous electronic health record (EHR) documentation should be available to all clinicians who are scheduled for telemedicine visits. In addition to the skills required for excellent face-to-face care, education in telemedicine should be emphasized for residents and medical students.

A clinic management team should be responsible for ensuring that the FMP provides safe, accessible, high-quality, person-centered care. This team is composed of the program director, a core faculty member who serves as clinic medical director, the clinic manager, and other team leaders. It should meet regularly to review clinic operations and provide support for continuous performance review and improvement.

All members of the FMP (i.e., staff, faculty, and residents) should understand their role in improving patient care and have the opportunity to work with team members to solve problems and discuss how to make improvements. Patient safety must be prioritized in a manner that promotes patient-centered care and transparent relationships across the complex medical environment. The values of trust, justice, and accountability must be fundamental to efforts for continual improvement.

A high-functioning patient advisory committee (PAC) meets at least every two months, has a set agenda, and shares patient satisfaction comments relevant to practice improvement. It also creates space for all group members to have their voices heard and help steer the direction of care at the FMP. The PAC should have clearly defined roles, expectations, established guidelines, and goals. It should include residents, staff, medical leadership, and a diverse group of patients who have knowledge of the community and are invested in the health and education of family physicians. A mission statement is helpful, and the PAC should agree upon values to guide discussion and a method to handle disagreement. Community members can be rotated off after a set term, but the term should be long enough to give the group stability.

Programs need to manage data for each resident to ensure breadth and depth of educational experiences, QI, and safety. This includes the demographic makeup of each resident’s panel (i.e., age, race, ethnicity, gender identity), as well as the diagnoses and care complexity of patients on each panel. Additional quality metrics for all clinicians in the FMP and patient satisfaction/feedback data should be available. Most of this information will be embedded in the practice EHR or in the hospital data system. Extracting the needed reports in a timely fashion to allow FMP leaders to monitor panel assignment/quality metrics and clinical productivity is key to providing data-driven care and meeting ACGME requirements. It is also helpful to have at least one faculty member with informatics training who can communicate the educational needs and intention of the reports to the data analysts.

The FMP should have robust revenue stream management. Financial reports should be given to all clinicians, including residents, on a regular basis so that they can discuss practice goals and their performance. These reports should be paired with a continuous QI process to address adverse findings or expand on areas for improvement identified throughout the reports.

A financial assessment resource from RPS and the National Institute for Program Director Development (NIPDD) is available with an RPS consult or through NIPDD participation.

The FMP is the curriculum, but it is not the sole source of resident education. Family medicine residents learn to be family physicians in the FMP through caring continuity relationships with patients. Residents learn the skills they will bring into the FMP for their patients by rotating with other specialties in the community. They also need educational opportunities to care for their patients in a range of settings. For example, residents need to know when a patient on their panel is admitted to the hospital so they can maintain contact during the hospitalization. Other opportunities may include caring for patients when they become homebound, are in rehabilitation facilities or at pediatric care facilities, or are admitted to the maternity ward.

1. Residents average approximately 2,000 continuity encounters (face-to-face or telemedicine) in the FMP or alternative practice sites by the end of three years, including the required number of pediatric, geriatric, and complex patients.
2. The program has a sufficient number of faculty members for its size, with sufficient protected administrative and program/faculty development time.
   1. The program maintains a low faculty turnover rate (goal of less than 20% over three years), with compensation that is competitive with the local physician employment market. Each faculty member has a professional development plan that is updated annually and includes sufficient time and resources to accomplish the stated objectives.
   2. The program mean for the annual ACGME faculty survey consistently exceeds the national mean.
3. The clinic has a minimum of 3.0 to 5.0 support staff per FTE clinician.
   1. Staff should reflect the diversity of the patients and community served.
   2. The turnover rate for staff is below the median for support staff in the region or based on industry trends.
4. The FMP has at least one available exam room per 1,00 patients seen per year.
5. Residents have the following panel sizes:
   1. PGY-1: 120-160 patients
   2. PGY-2: 270-330 patients
   3. PGY-3: 450-520 patients.
   4. The curriculum requires sufficient time in continuity practice to care for empaneled patients, establish relationships, maintain continuity, and provide comprehensive care.
   5. The minimum threshold to accomplish these goals over three years is 1,600 to 2,000 hours.
6. The FMP maintains telemedicine and portal options with secure technology, appropriate space within the FMP to provide these visits, and a curriculum to train residents in the skills required to provide diligent care using these options.
7. The FMP has a functional management team to provide direction for clinic operations and perform improvement, and engages all residents in staff-and team-based performance improvement activities.
8. The practice has an efficient means of collecting important practice and individual performance data and has sufficient information technology (IT) resources to generate reports and produce changes to support practice improvement.
9. Practice leadership has input into determining the annual budget to maintain a vibrant teaching practice. They also have access to monthly practice finance reports and regularly share portions of the reports with staff to improve efficiency, as appropriate.
10. Residents can provide continuity care in more than one setting, and care across settings is coordinated.