Improving Patient Care Efficiency and Effectiveness: Team Care and - PowerPoint PPT Presentation

Improving Patient Care Efficiency and Effectiveness: Team Care and the Use of Scribes Michael Rabovsky M.D. Interim Chairman, Family Medicine Vice Chairman, Medicine Institute Cleveland Clinic

TeamCare Model • 1 Doctor • 2 Medical assistants

Clinical Workflow • Medical assistant completes all intake requirements • Reason for visit • Note template is loaded in the progress note • Collecting and documenting the History of Present Illness and ROS • Medication refill requests discussed

Clinical Workflow • Medical assistant gives oral presentation to provider on waiting patient • Medical assistant enters room with provider

Clinical Workflow The physician; with the medical assistant in the room and SCRIBING • Confirms the history • Performs the physical exam • Makes medical assessment and management decisions • Articulates treatment plan to the patient and medical assistant

Clinical Workflow • The physician leaves the exam room of the completed patient. • Orders pended by the clinical staff are filed by the provider. • The physician signs any prescriptions that are not electronically transmitted. • Physician starts the process with the next patient prepped by the medical assistant

Clinical Workflow • The medical assistant reviews the After Visit Summary with the patient along with any prescriptions or ordered tests. • Patient education is given and reviewed. • The patient is escorted to the appointment desk by the clinical staff.

Documentation • If the clinical staff has a question about medical terminology they will place three *** as a place holder. • The chart can not be closed without these variables (***) being satisfied.

Documentation • The documentation for this note was completed by (name of MA) acting as scribe for (Name of physician) June 3, 2016 8:31 AM. • Notes have been reviewed and edited. I agree with the Chief Complaint, ROS, and Past Histories independently gathered by the clinical support staff and the remaining scribed note accurately describes my personal service to the patient. • Name of physician

Key Metrics • Increase volume of patients seen • Increase efficiency /decrease scheduling wait time • Increase accessibility to quality physician care • Increase patient satisfaction • Improve quality of patient care • Increase clinical employee satisfaction • Increase physician satisfaction

Access – Patients Added May 2011 – December 2012 140 137 140 Ramp Up Team Care 130 123 116 120 113 106 104 97 100 94 83 80 80 72 66 66 60 53 Missing MA 40 32 32 30 24 20 0

Outcomes: Press Ganey Patient Experience Quarter 2-2011 v Quarter 2-2012 120.0% 96% 100.0% 94% 93% 93% 93% 87% 89% 90% 90% 90% 86% 88% 85% 84% 83% 83% 77% 80.0% 71% Score 60.0% 40.0% 20.0% 0.0% Friendliness Concern of Time CP Patient’s Likelihood of CP respect Nurse Care Rating of /courtesy of nurse/asst spent with confidence recommendi for Assistant Provider CP nurse/asst. for problem patient with CP ng CP questions 2Q 2011 83.8% 85.0% 82.6% 83.4% 71.3% 89.8% 89.8% 89.8% 77.1% 2 Q 2012 87.3% 88.8% 85.6% 93.3% 87.7% 93.8% 92.8% 95.8% 92.6%

Outcomes: Press Ganey Patient Experience Quarter 4-2011 through Quarter 4-2012 120% 100% 95% 94% 94% 93% 93% 93% 92% 92% 91% 88% 88% 83% Percent Very Good 80% 75% 75% 75% 75% 75% 63% 60% 40% 20% 0% Friendliness/ Concern of Time CP Patient’s Likelihood of Nurse Care CP respect courtesy of nurse/asst spent with confidence recommendi Rating of CP Assistant Provider for questions nurse/asst. for problem patient with CP ng CP 2Q 2011 84% 85% 83% 83% 71% 90% 90% 90% 77% 3Q 2011 88% 88% 88% 92% 84% 96% 96% 96% 96% 4Q 2011 93% 94% 92% 93% 91% 92% 93% 94% 95% 1Q 2012 88% 87% 89% 90% 89% 87% 97% 97% 97% 2 Q 2012 87% 89% 86% 93% 88% 94% 93% 96% 93% 4Q 2012 75% 75% 75% 83% 63% 75% 88% 88% 75%

Outcomes: Press Ganey Patient Experience Quarter 4-2011 v Quarter 4-2012 100% 95% 94% 94% 93% 93% 93% 92% 92% 91% 88% 88% 90% 83% 80% 75% 75% 75% 75% 75% Percent "Very Good" 70% 63% 60% 50% 40% 30% 20% 10% 0% Friendliness/ Concern of Time CP Patient’s Likelihood of Nurse Care CP respect courtesy of nurse/asst spent with confidence recommendi Rating of CP Assistant Provider for questions nurse/asst. for problem patient with CP ng CP 4Q 2011 93% 94% 92% 93% 91% 92% 93% 94% 95% 4Q 2012 75% 75% 75% 83% 63% 75% 88% 88% 75%

Outcomes Quality Indicators Chosen for Improvement Q1 Q2 Q3 Q4 Q1 Q2 Q3 2011 2011 2011 2011 2012 2012 2012 Blood 74% 76% 81% 79% 79% 78% 78% Pressure Control A1c 96% 96% 98% 96% 98% 97% 99% Diabetics Diabetes 89% 90% 90% 90% 91% 91% 93% Screening Hyperlipid- 79% 80% 80% 74% 77% 79% 81% emia Screening 77% 78% 78% 75% 78% 79% 78% Mammogram Completed Team Care started 2Q 2011

Productivity WRVU's 2010-2011-2012 619 576 570 569 554 539 526 519 488 488 470 469 460 440 WRVU's 419 414 2010 2011 369 2012 319 283 269 219 Month *Days not worked not considered

Sensitivity Analysis Potential Financial Impact Per Day 6 8 10 Annual Add 1,338 1,784 2,230 Revenue $156,546 $219,024 $273,780 Expenses $61,992 $61,992 $61,992 EBIDA $94,554 $157,032 $211,788

Financial Impact from Strongsville Team Care Annualized Average: August 2011-July 2012 Average Slots Added per 102 Month Average Additional $11,952 Revenue per Month Average Monthly Additional $5,196 Expenses Average Monthly EBIDA $6,756

Planning & Implementation • A multi-disciplinary project team was formed • Process map of desired workflow completed • Workspace modified • MAs educated in the physician’s EPIC smart tools • Standard work for clinical assistants approved by nursing leadership………… AND OUR LAWYERS (AND THEIR LAWYERS)

Planning and Implementation • Time set aside weekly for doctor to educate and communicate with MAs about any issues • Outside Consultants in Change Management • Hiring New Staff

CHALLENGES • CHANGE IS TOUGH • Doctors • Existing Medical Assistants “more work” “ another way to make money” • Applicant Pool and Finding Qualified People

Key Success Factors • Support from Leadership • Point Person for Startup : Physician Leader • Project Manager • Selection and Education of the MA’s training simulations . Pay Differential for MA’s

Taking It to the Next Level • Expand Team Care at Site 4 Teams Currently • Expanding to Other Sites • Hired RN Care Coordinator • Pre-Visit Planning • Chronic Disease Registries • Population management • Clinical Pharmacy Support in place

Taking It to the Next Level • CEO and Executive Team Support • Medicine Institute Wide Roll-Out 2013 • Setting and Meeting Metrics • Access • Productivity • Quality • GC-CHAPS

Press Ganey Staff Engagement Team Care Non-Team Care Engagement Score 4.45 (+0.23) 4.21 (-0.01) Tier 1 2 Safety Perceptions 4.67 (+0.30) 4.39 (+0.02) Organization 4.30 (+0.34) 3.93 (-0.03) Manager 4.38 (+0.29) 4.04 (-0.05) Employee 4.26 (+0.19) 3.99 (-0.08)

TeamCare: Lessons Learned • 25 Doctors Started TeamCare 9 still active • Medical Assistant Dependent • Productivity Goal : (3) Additional slots per half day session Sweetspot : (2) Additional slots 2 6