American College of Physicians: Internal Medicine — Doctors for Adults ®

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Teamwork is the new mantra for quality improvement

Getting staff working to the 'top of their license' can make or break quality and pay-for-performance projects

From the April ACP Observer, copyright 2006 by the American College of Physicians.

By Janet Colwell

Last year, Michael A. Hennigan, FACP, instructed the nurses and assistants in his office to schedule appointments for screenings or lab work according to evidence-based guidelines. It was a critical part of the solo practitioner's strategy to implement quality improvement and pay-for-performance initiatives, without getting bogged down in all the administrative details those initiatives can bring.

Now, if a woman patient over age 50 has not had a mammogram for more than a year, the nurse or assistant fills out the necessary referral form before the patient sees the doctor. Dr. Hennigan, an internist at Decatur Internal Medicine Associates (also known as the Diabetes and Lipid Center) in Decatur, Ala., only has to sign the forms in the exam room.

"I may physically have to sign a form but it's not a matter of me remembering to order the tests," said Dr. Hennigan, who also has nurses print out patients' medication list from the electronic health record (EHR) and hand it to patients as they check in. That way, he spends his time discussing information with patients, not compiling it.

The ability to delegate can make the difference between hitting quality improvement targets and falling short. While some look only to EHRs to get organized, experts say the truly efficient office also makes the most of its personnel.

All office staff members should be "working to the top of their license," doing what they are qualified to do, no more and no less. That means doctors, the most skilled and highly compensated members of the team, should stick to those tasks they are uniquely qualified to do and delegate the rest.

"Physician practices in the future will be based on teamwork," said David B. Reuben, FACP, director of the geriatrics program at the David Geffen School of Medicine at the University of California, Los Angeles. "It's absolutely critical to think about the workflow and how it's structured."

Hand off paperwork

As the only physician in his practice, Dr. Hennigan has been forced to delegate to stay afloat. As long as you have employees you can trust, he said, delegating maximizes your time with patients.

When nurses bring in a diabetes patient who has normal hemoglobin A1c, controlled cholesterol and normal liver function, for example, "it's pretty predictable that we are going to refill the same medications," he said. "When I walk in the room, those prescriptions are printed out and awaiting my signature."

Similarly, a trusted nurse alerts him when medications might need to be adjusted. He also delegates tracking down patients' old chest X-rays to an in-house transcriptionist.

To jumpstart more delegation, UCLA's Dr. Reuben recommends imagining your office as a series of concentric circles with the most expensive care at the center. The time physicians spend in the exam room with patients is the most expensive. Less expensive, but still significant, is the time patients spend in the office with other staff. The outermost and least costly circle is the time the patient spends at home.

"To run an efficient office, you always push whatever you can out of that inner circle," explained Dr. Reuben, who is one of three clinical leaders heading up an ACP project to test redesign strategies for geriatric practices. "Any work the physician doesn't need to do should be done by someone else who can do it equally well."

At Physician Health Alliance, a 44-member physician group with 18 locations in northeast Pennsylvania, receptionists and schedulers try to schedule tests or screenings before patients come for a visit. They attach HEDIS measurement sheets to all patient charts so staff members can see what tests or screenings are due before they schedule an appointment.

After consulting the HEDIS sheet, "the receptionist or nurse might ask, 'do you want to schedule that before your next visit?' "said Karen M. Murphy, the group's chief executive. The office is in the process of implementing the chronic care model, developed by Seattle's Group Health Cooperative, and is in the first year of a pay-for-performance program initiated by two major health plans.

In New Brunswick, N.J., Kim M. Dixon, ACP Member, makes sure that registered nurses perform a variety of functions that they are qualified to do, including refilling prescriptions; providing patient education and triage; administering immunizations; checking blood pressure; giving patients test results; and addressing patient concerns or questions.

Dr. Dixon has also boosted the responsibilities of two patient care technicians who work in her six-physician hospital-based practice. The technicians, who have always drawn blood and taken vital signs, now calculate patients' body mass index (BMI) and waist circumference, which the office is tracking as part of its participation in the College's "Closing the Gap: Cardiovascular Risk" project. (More information is online.)

"It's a lot cheaper for the technicians to do these things than for the physician, and you don't need a physician to calculate a BMI," Dr. Dixon said. Delegating that task has also led to much better tracking, she added, because the technicians are more reliable. Leaving the BMI up to doctors, "it doesn't get done."

Learn to delegate

Most physicians, anxious to reduce their workload, embrace delegating. Others, however, are afraid of overburdening already busy medical assistants or believe the physician ought to do the full evaluation, said Dr. Reuben, who has advised primary care internists on the subject.

He has found, for instance, that some physicians resist having staff members take over parts of the routine geriatric falls evaluation, such as orthostatic blood pressure measurement, brief mental status exams and eye exams. "The ironic thing," he said, "was that physicians who said they didn't want to delegate turned out to be the same ones who didn't do the task themselves."

Dr. Reuben, who is also president of the American Geriatrics Society, routinely delegates most aspects of the initial history taking to patients and their families through an extensive pre-visit questionnaire. And in his office, anticoagulation is primarily managed by nurses using a computer-guided program.

Because you need to delegate to get the most out of any quality improvement project, here are some tips to make it easier:

  • Pre-plan. Spend time on the front end structuring new workflow and ensuring that there is enough staff to support it, said Ms. Murphy at Physicians Health Alliance. "We have to have the infrastructure to support physicians so they feel confident patients will be taken care of," she said. Plan effectively and make physicians part of the planning.

  • Set parameters. Clearly delineate the responsibilities of assistants and nurse practitioners. Ms. Murphy said that nurses and physicians need to work together to identify situations where the doctor should be consulted. A registered nurse might renew routine prescriptions for a diabetic patient independently, for instance, but consult the physician on increasing dosages or starting new medications.

  • Look outside your practice. Consider others who can help your practice. Although Dr. Dixon's practice currently has no physician extenders, it does work with a hospital-based nurse practitioner to improve care for patients with diabetes, a relationship that's led to "marked improvement" in the care of diabetic inpatients, Dr. Dixon said. The nurse also checks in with patients between visits, encouraging them to comply with their treatment plans and addressing any questions they have.

"I think it is the wave of the future to have physician extenders," Dr. Dixon said. "The current environment doesn't really allow doctors to do everything they should be doing for patients—and still get reimbursed enough to survive."

The big picture

Despite some physicians' concerns about overburdening staff, it turns out that broadening everyone's responsibilities—from schedulers all the way to billing and technical support staff—not only improves efficiency but can boost morale.

At Physicians Health Alliance, for example, the billing office is now involved in quality measurement. If an insurer reports that 70% of the group's diabetes patients have their blood sugar under control, the billing department analyzes claims data to verify or dispute those figures. Even the information technology staff has become familiar with the group's clinical goals to best determine how data should be entered into the electronic record, said Ms. Murphy.

In Dr. Hennigan's office, all staff members attend semi-annual meetings, where different individuals agree to take the lead to improve areas where the practice needs to perform better. Front desk staff now know, for instance, the clinical goals the practice has set to maintain its status as an American Diabetes Association (ADA) certified diabetes education site. They now monitor patients' records during checkout and remind them to schedule past-due tests or appointments.

The practice also plans to implement an internal pay-for-performance program to reward employees for helping achieve benchmarks. So far, employees have won gift certificates for referring patients who are not meeting ADA goals to the certified diabetic educator for foot care, education or nutritional counseling. Dr. Hennigan said he may offer larger cash incentives as the program grows.

Some rewards for better quality are already being shared: The practice recently ranked among the top three of 105 practices in a U.S. public health service-funded project that gauged practice progress on 80 different clinical quality measurements. All the employees, Dr. Hennigan said, felt they shared that credit.

For Dr. Dixon, getting the entire staff working as a team has given employees more interest in patients' progress."

"Everyone gains from it—-the physician has some of the burden lessened and can be more efficient," Dr. Dixon said, "while nurses can do what they're trained to do."

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.

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