**Clinical Microsystems**

**"The Place Where Patients, Families and**

**Clinical Teams Meet"**

**Assessing, Diagnosing and Treating**

**Your Outpatient Primary Care Practice**

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**www.clinicalmicrosystem.org**

+-----------------------------------------------------------------------+
| **Strategies for Improving "The place where patients, families and    |
| clinical teams meet."**                                               |
+-----------------------------------------------------------------------+
| **A Microsystem Self-Assessment, Diagnosis and Treatment Plan**       |
+-----------------------------------------------------------------------+
| Clinical microsystems are the front-line units that provide most      |
| health care to most people. They are the places where patients,       |
| families and care teams meet. Microsystems also include support       |
| staff, processes, technology and recurring patterns of information,   |
| behavior and results. Central to every clinical microsystem is the    |
| patient.                                                              |
|                                                                       |
| The microsystem is the place where:                                   |
|                                                                       |
| -   Care is made                                                      |
|                                                                       |
| -   Quality, safety, reliability, efficiency and innovation are made  |
|                                                                       |
| -   Staff morale and patient satisfaction are made                    |
|                                                                       |
| Microsystems are the building blocks that form practices. The quality |
| of care can be no better than the quality produced by the small       |
| systems that come together to provide care. Here is the quality       |
| equation:                                                             |
|                                                                       |
| Health System Quality = Quality of Microsystem ~1~ + Quality of       |
| Microsystem ~2~ + Quality of Microsystem ~3-n~                        |
|                                                                       |
| All health care professionals---and we believe all front line         |
| clinical and support staff are professionals---have 2 jobs.\          |
| Job 1 is to provide care. Job 2 is to improve care.                   |
|                                                                       |
| Finding time to improve care can be difficult, but the only way to    |
| improve and maintain quality, safety, efficiency and flexibility is   |
| by blending analysis, change, measuring and redesigning into the      |
| regular patterns and the daily habits of front-line clinicians and    |
| staff. Absent the intelligent and dedicated improvement work by all   |
| staff in all units, the quality, efficiency and pride in work will    |
| not be made nor sustained.                                            |
|                                                                       |
| This workbook provides tools and methods that busy clinical teams can |
| use to improve the quality and value of patient care as well as the   |
| work-life of all staff who contribute to patient care. These methods  |
| can be adapted to a wide variety of clinical settings, large and      |
| small, urban and rural, community-based and academic.                 |
+-----------------------------------------------------------------------+
| **The Path Forward**                                                  |
+-----------------------------------------------------------------------+
| This workbook provides a guide for making a path forward towards      |
| higher performance. Just as you can assess, diagnose and treat        |
| patients; you can assess, diagnose and treat your clinical            |
| microsystem. This workbook is designed to guide your clinical         |
| microsystem on a journey to develop better performance. There are     |
| many good ways to improve performance; research shows that this is    |
| one of those good ways.                                               |
|                                                                       |
| You can access more examples, tools and blank forms to customize at   |
| **www.clinicalmicrosystem.org**                                       |
+-----------------------------------------------------------------------+
| **Note:** We have developed this workbook with tools to give ideas to |
| those interested in improving healthcare. "Dartmouth-Hitchcock        |
| Medical Center and the developers of this workbook are pleased to     |
| grant use of these materials without charge, providing that           |
| recognition is given for their development, that any alterations to   |
| the documents for local suitability and acceptance are shared in      |
| advance, and that the uses are limited to their own use and not for   |
| re-sale."                                                             |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **The Path Forward**                                                  |
+-----------------------------------------------------------------------+
| **A Microsystem Self-Assessment, Diagnosis and Treatment Plan**       |
+-----------------------------------------------------------------------+
| **Step 1: Organize a "Lead Team"**                                    |
+-----------------------------------------------------------------------+
| **Successful, sustainable cultural change requires the commitment and |
| active involvement of all members of the clinical microsystem. To     |
| keep the microsystem on track and focused, a "Lead Team" of           |
| representatives of all roles should be formed.**                      |
+-----------------------------------------------------------------------+
| **Step 2: Do the Assessment**                                         |
+-----------------------------------------------------------------------+
| **Assess your microsystem using the "5Ps" as your guide. Review your  |
| current performance metrics.**                                        |
|                                                                       |
| -   **Purpose**                                                       |
|                                                                       |
| -   **Patients**                                                      |
|                                                                       |
| -   **Professionals**                                                 |
|                                                                       |
| -   **Processes**                                                     |
|                                                                       |
| -   **Patterns**                                                      |
|                                                                       |
| -   **Metrics That Matter**                                           |
+-----------------------------------------------------------------------+
| **Step 3: Make a Diagnosis**                                          |
+-----------------------------------------------------------------------+
| **Based on Step 2, review your assessment and Metrics That Matter to  |
| make your diagnosis. You should select a "Theme and Aims" for         |
| improvement based on this diagnosis and your organization strategic   |
| priorities.**                                                         |
+-----------------------------------------------------------------------+
| **Step 4: Treat Your Microsystem**                                    |
+-----------------------------------------------------------------------+
| **Use scientific improvement methods and tools.**                     |
+-----------------------------------------------------------------------+
| **Step 5: Follow-up**                                                 |
+-----------------------------------------------------------------------+
| **Design and execute monitoring processes, outcomes and results. Move |
| to your next improvement themes.**                                    |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **STEP 1: Organize a "Lead Team"**                                    |
+-----------------------------------------------------------------------+
| Assemble a "Lead Team" to represent all disciplines and roles in your |
| practice. Include MDs, RNs, NPs, clinical support staff, clerical     |
| staff, patients and families along with any other professionals who   |
| are regularly in the practice providing care and service.             |
+-----------------------------------------------------------------------+
| Must dos:                                                             |
|                                                                       |
| -   Lead Team should meet weekly to maintain focus, make plans and    |
|     oversee improvement work                                          |
|                                                                       |
| -   Effective meeting skills should be used in the weekly meetings    |
|                                                                       |
| -   Monthly ALL staff meetings should be held to engage and inform    |
|     all members of the practice                                       |
|                                                                       |
| -   Explore creative ways to communicate and stay engaged with all    |
|     staff on all shifts and all days of the week Use email,           |
|     newsletters, listservs, paper, verbal, visual displays,           |
|     communication boards and buddy systems                            |
|                                                                       |
| -   Remember true innovation is achieved through active engagement of |
|     the patient and family with the Lead Team                         |
+-----------------------------------------------------------------------+
| **STEP 2 Assess Your Primary Care Practice**                          |
+-----------------------------------------------------------------------+
| *Complete the "5Ps" assessment.* This process needs to be completed   |
| by the interdisciplinary team. Building common knowledge and insight  |
| into the microsystem by all members of the practice will create a     |
| sense of equal value and ability to contribute to the improvement     |
| activities.                                                           |
|                                                                       |
| ***Start with Purpose.*** Why does your practice exist?               |
|                                                                       |
| Raise this question to EVERYONE in your practice to create the best   |
| statement of purpose that everyone can buy into.                      |
|                                                                       |
| *Assess Your Patients, Professionals, Processes and Patterns* using   |
| the worksheets in the "Greenbook." The aim is to create the "Big      |
| picture" of your system to see beyond one patient at a time.          |
| Assessing the "5Ps" and then reflecting on their connections and      |
| interdependence often reveals new improvement and redesign            |
| opportunities.                                                        |
|                                                                       |
| *Create a timeline for the assessment process.* The whole workbook    |
| DOES NOT need to be completed within 2 weeks. Some microsystems have  |
| the capacity and resources to move quickly through the workbook in a  |
| short period of time. Many microsystems need to pace themselves       |
| through the workbook and complete the worksheets and assessment       |
| through a longer timeline. Some microsystems may need to start an     |
| important improvement immediately while starting the assessment       |
| process. In this case, the ongoing assessment will give you needed    |
| context and will help you make better improvements.                   |
|                                                                       |
| ***Remember however you choose to progress through the workbook, it   |
| MUST be done within the context of your interdisciplinary team.***    |
+-----------------------------------------------------------------------+
| Use the Data Review sheet to help outline and track which data and    |
| information will be retrieved in current systems and which data/info  |
| will be measured through a worksheet. Review the worksheets of the    |
| Assess, Diagnose and Treat Your Primary Care Practice workbook.       |
| Determine which worksheets you will copy and use to collect new data  |
| and information. Which worksheets will you NOT use because you have   |
| data systems that can provide useful, timely data for you without a   |
| special effort?                                                       |
+-----------------------------------------------------------------------+

+--------------------------------------+----------------+-------------+
| **Microsystem Assessment of Data     |                |             |
| Sources and**                        |                |             |
|                                      |                |             |
| **Data Collection Actions**          |                |             |
+--------------------------------------+----------------+-------------+
| -   With your interdisciplinary      |                |             |
|     team, review the Assess,         |                |             |
|     Diagnose and Treat workbook-"The |                |             |
|     Greenbook". Use this form to     |                |             |
|     determine which measures you can |                |             |
|     obtain from your organization    |                |             |
|     and therefore, don't need to use |                |             |
|     the worksheets. Be sure the data |                |             |
|     is current and not months old.   |                |             |
|                                      |                |             |
| -   Determine which worksheets will  |                |             |
|     be used. Plan who, when and how  |                |             |
|     the worksheets will be           |                |             |
|     completed.                       |                |             |
|                                      |                |             |
| -   Decide who oversees the          |                |             |
|     compilation of each worksheet or |                |             |
|     [alternative data                |                |             |
|     source]{.underline}.             |                |             |
+--------------------------------------+----------------+-------------+
| **Page/Type of Data**                | **Data         | **D         |
|                                      | Source/Data    | ate/Owner** |
|                                      | Collection     |             |
|                                      | Action**       |             |
+--------------------------------------+----------------+-------------+
| Page 6 B Know Your Patients          |                |             |
+--------------------------------------+----------------+-------------+
| B1. Estimated Age Distribution of    |                |             |
| Patients                             |                |             |
+--------------------------------------+----------------+-------------+
| B2. Estimated Number of Unique       |                |             |
| Patients in Practice                 |                |             |
+--------------------------------------+----------------+-------------+
| B3. Disease Specific Heath Outcomes  |                |             |
+--------------------------------------+----------------+-------------+
| B4. List Your Top                    |                |             |
| Diagnosis/Conditions                 |                |             |
+--------------------------------------+----------------+-------------+
| B5. Top Referrals                    |                |             |
+--------------------------------------+----------------+-------------+
| B6. Patients Who Frequent Practice   |                |             |
+--------------------------------------+----------------+-------------+
| B7. Clinical Microsystems            |                |             |
+--------------------------------------+----------------+-------------+
| B8. Patient Satisfaction Scores      |                |             |
| (Patient Survey pg 7)                |                |             |
+--------------------------------------+----------------+-------------+
| (Chronic Care Survey pg 10-11)       |                |             |
+--------------------------------------+----------------+-------------+
| B9. Patient Population Census        |                |             |
+--------------------------------------+----------------+-------------+
| ("Walk Through" pg 9)                |                |             |
+--------------------------------------+----------------+-------------+
| B10. Out of Practice Visits          |                |             |
+--------------------------------------+----------------+-------------+
| Page 6 C Know Your Professionals     |                |             |
+--------------------------------------+----------------+-------------+
| C1. Current Staff                    |                |             |
+--------------------------------------+----------------+-------------+
| > Float Pool                         |                |             |
+--------------------------------------+----------------+-------------+
| > On-Call                            |                |             |
+--------------------------------------+----------------+-------------+
| C2. 3^rd^ Next Available             |                |             |
+--------------------------------------+----------------+-------------+
| C3. Days of Operation                |                |             |
+--------------------------------------+----------------+-------------+
| C4. Hours of Operation               |                |             |
+--------------------------------------+----------------+-------------+
| C5. Appointment Type                 |                |             |
+--------------------------------------+----------------+-------------+
| C6. Appointment Duration             |                |             |
+--------------------------------------+----------------+-------------+
| C7. Staff Satisfaction Scores (Staff |                |             |
| Survey pg 12)                        |                |             |
+--------------------------------------+----------------+-------------+
| (Personal Skills Assessment pg 13 -- |                |             |
| 14)                                  |                |             |
+--------------------------------------+----------------+-------------+
| (Activity Survey pg 15)              |                |             |
+--------------------------------------+----------------+-------------+
|                                      |                |             |
+--------------------------------------+----------------+-------------+
| Page 6 D Know Your Processes         |                |             |
+--------------------------------------+----------------+-------------+
| D1. Create Flow Charts of Routine    |                |             |
| Processes                            |                |             |
+--------------------------------------+----------------+-------------+
| D2. (Patient Cycle Time Tool pg      |                |             |
| 16/17)                               |                |             |
+--------------------------------------+----------------+-------------+
| D3. (Core and Supporting Processes   |                |             |
| pg 18)                               |                |             |
+--------------------------------------+----------------+-------------+
| D4. (High Level Flowchart pg 19)     |                |             |
+--------------------------------------+----------------+-------------+
|                                      |                |             |
+--------------------------------------+----------------+-------------+
| Page 6 E Know Your Patterns          |                |             |
+--------------------------------------+----------------+-------------+
| E1. Most Significant Pattern         |                |             |
+--------------------------------------+----------------+-------------+
| E2. Successful Change                |                |             |
+--------------------------------------+----------------+-------------+
| E3. Most Proud of                    |                |             |
+--------------------------------------+----------------+-------------+
| E4. Financial Picture                |                |             |
+--------------------------------------+----------------+-------------+
| (Unplanned Activity Tracking Card pg |                |             |
| 20)                                  |                |             |
+--------------------------------------+----------------+-------------+
| (Telephone Tracking Log pg 21)       |                |             |
+--------------------------------------+----------------+-------------+

<table>
<colgroup>
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<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 4%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="35"><strong>Primary Care Practice Profile</strong></td>
</tr>
<tr class="even">
<td colspan="35"><p><em><strong>A. Purpose:</strong></em></p>
<p>Why does your practice exist?</p></td>
</tr>
<tr class="odd">
<td colspan="7">Site Name:</td>
<td colspan="14">Site Contact:</td>
<td colspan="14">Date:</td>
</tr>
<tr class="even">
<td colspan="7">Practice Manager:</td>
<td colspan="14">MD Lead:</td>
<td colspan="14">Nurse Lead:</td>
</tr>
<tr class="odd">
<td colspan="35"><em><strong>B. Know Your Patients:</strong></em> Take a
close look into your practice, create a “high-level” picture of the
PATIENT POPULATION that you serve. Who are they? What resources do they
use? How do the patients view the care they receive?</td>
</tr>
<tr class="even">
<td><strong>Est. Age Distribution of Patients:</strong></td>
<td colspan="2"><strong>%</strong></td>
<td></td>
<td colspan="11"><strong>List Your Top 10
Diagnoses/Conditions</strong></td>
<td colspan="3"><strong>Top Referrals (e.g. GI Cardiology)</strong></td>
<td colspan="2"></td>
<td colspan="11"><strong>Patient Satisfaction Scores</strong></td>
<td colspan="4">% Excellent</td>
</tr>
<tr class="odd">
<td>Birth-10 years</td>
<td colspan="2"></td>
<td></td>
<td colspan="5">1.</td>
<td colspan="6">6.</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="11">Experience via phone</td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td>11-18 years</td>
<td colspan="2"></td>
<td></td>
<td colspan="5">2.</td>
<td colspan="6">7.</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="11">Length of time to get your appointment</td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td>19-45 years</td>
<td colspan="2"></td>
<td></td>
<td colspan="5">3.</td>
<td colspan="6">8.</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="11">Saw who patient wanted to see</td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td>46-64 years</td>
<td colspan="2"></td>
<td></td>
<td colspan="5">4.</td>
<td colspan="6">9.</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="11">Satisfaction with personal manner</td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td>65-79 years</td>
<td colspan="2"></td>
<td></td>
<td colspan="5">5.</td>
<td colspan="6">10.</td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="11">Time spent with person today</td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td>80 + years</td>
<td colspan="2"></td>
<td></td>
<td colspan="8" rowspan="4"><strong>Patients who are frequent users of
your practice and their reasons for seeking frequent interactions and
visits</strong></td>
<td colspan="6" rowspan="4"><strong>Other Clinical microsystems you
interact with regularly as you provide care for patients (e.g. OR,
VNA)</strong></td>
<td colspan="2"></td>
<td colspan="9" rowspan="2"><strong>Pt Population Census: Do these
numbers change by season? (Y/N)</strong></td>
<td colspan="4" rowspan="2"><strong>#</strong></td>
<td colspan="2" rowspan="2"><strong>Y/N</strong></td>
</tr>
<tr class="odd">
<td>% Females</td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td rowspan="2"><strong>Est. # (unique) pts. In Practice</strong></td>
<td colspan="2" rowspan="2"></td>
<td rowspan="2"></td>
<td colspan="2" rowspan="2"></td>
<td colspan="9">Patients seen in a day</td>
<td colspan="4"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="9">Patients seen in last week</td>
<td colspan="4"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="3" rowspan="2"><strong>Disease Specific Health Outcomes, pg
24</strong></td>
<td rowspan="2"></td>
<td colspan="8"></td>
<td colspan="6"></td>
<td colspan="2" rowspan="2"></td>
<td colspan="9">New patients in last month</td>
<td colspan="4"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="8"></td>
<td colspan="6"></td>
<td colspan="9">Disenrolling patients in last month</td>
<td colspan="4"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="3">Diabetes HgA1c =</td>
<td></td>
<td colspan="8"></td>
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="8">Encounters per provider per year</td>
<td colspan="4"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="3">Hypertension B/P =</td>
<td></td>
<td colspan="8"></td>
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="15"><strong>Out of Practice Visits</strong></td>
</tr>
<tr class="even">
<td colspan="3">LDL &lt;100 =</td>
<td></td>
<td colspan="8"></td>
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="10">Condition Sensitive Hospital Rate</td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="3"></td>
<td></td>
<td colspan="8"></td>
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="10">Emergency Room Visit Rate</td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="35"><em><strong>*Complete “Through the Eyes of Your
Patient”,15 7 &amp;
:s0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000
pg 9</strong></em></td>
</tr>
<tr class="odd">
<td colspan="35"><em><strong>C. Know Your Professionals:</strong></em>
Use the following template to create a comprehensive picture of your
practice. Who does what and when? Is the right person doing the right
activity? Are roles being optimized? Are all roles who contribute to the
patient experience listed? What hours are you open for business? How
many and what is the duration of your appointment types? How many exam
rooms do you currently have? What is the morale of your staff?</td>
</tr>
<tr class="even">
<td colspan="2"><strong>Current Staff</strong></td>
<td colspan="3"><strong>FTEs</strong></td>
<td colspan="5"><strong>Comment/<br />
Function</strong></td>
<td colspan="6"><strong>3<sup>rd</sup> Next Available</strong></td>
<td><strong>Cycle Time</strong></td>
<td colspan="8"><strong>Days of Operation</strong></td>
<td colspan="10"><strong>Hours</strong></td>
</tr>
<tr class="odd">
<td colspan="2" rowspan="2">Enter names below totals<br />
Use separate sheet if needed</td>
<td colspan="3" rowspan="2"></td>
<td colspan="5" rowspan="2"></td>
<td colspan="3" rowspan="2">PE</td>
<td colspan="3" rowspan="2">Follow-up</td>
<td rowspan="2">Range</td>
<td colspan="8">Monday</td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td colspan="8">Tuesday</td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="2">MD Total</td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="8">Wednesday</td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="8">Thursday</td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="8">Friday</td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="8">Saturday</td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="2">NP/PAs Total</td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="8">Sunday</td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="18">Do you offer the following? Check all that apply.</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="12">Group Visit</td>
</tr>
<tr class="even">
<td colspan="2">RNs Total</td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="12">E-mail</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="12">Web site</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="12">RN Clinics</td>
</tr>
<tr class="odd">
<td colspan="2">LPNs Total</td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="12">Phone Follow-up</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="12">Phone Care Management</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="12">Disease Registries</td>
</tr>
<tr class="even">
<td colspan="2">LNA/MAs Total</td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="12">Protocols/Guidelines</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="7"><strong>Appoint. Type</strong></td>
<td colspan="3"><strong>Duration</strong></td>
<td colspan="8"><strong>Comment:</strong></td>
</tr>
<tr class="even">
<td colspan="2">Secretaries Total</td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="7"></td>
<td colspan="3"></td>
<td colspan="8"></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="7"></td>
<td colspan="3"></td>
<td colspan="8"></td>
</tr>
<tr class="even">
<td colspan="2">Others:</td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="17"><strong>Staff Satisfaction Scores</strong></td>
<td><strong>%</strong></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
<td colspan="9" rowspan="2">How stressful is the practice?</td>
<td colspan="8" rowspan="2">% Not Satisfied</td>
<td rowspan="2"></td>
</tr>
<tr class="even">
<td colspan="2">Do you use Float Pool?</td>
<td colspan="3"><strong>____</strong></td>
<td>Yes</td>
<td colspan="2"><strong>____</strong></td>
<td colspan="3">No</td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="2">Do you use On-Call?</td>
<td colspan="3"><strong>____</strong></td>
<td>Yes</td>
<td colspan="2"><strong>____</strong></td>
<td colspan="3">No</td>
<td colspan="6"></td>
<td colspan="9" rowspan="2">Would you recommend it as a good place to
work?</td>
<td colspan="8" rowspan="2">% Strongly Agree</td>
<td rowspan="2"></td>
</tr>
<tr class="even">
<td colspan="17"></td>
</tr>
<tr class="odd">
<td colspan="35"><strong>*Each staff member should complete the Personal
Skills Assessment and “The Activity Survey”, pgs 13-15</strong></td>
</tr>
<tr class="even">
<td colspan="35"><em><strong>D. Know Your Processes:</strong></em> How
do things get done in the microsystem? Who does what? What are the
step-by-step processes? How long does the care process take? Where are
the delays? What are the “between” microsystems hand-offs?</td>
</tr>
<tr class="odd">
<td colspan="35"><ol type="1">
<li><p><strong>Track cycle time for patients from the time they check in
until they leave the office using the Patient Cycle Time Tool. List
ranges of</strong></p></li>
</ol>
<p><strong>time per provider on this table, pg 16/17</strong></p></td>
</tr>
<tr class="even">
<td colspan="35"><strong>2. Complete the Core and Supporting Process
Assessment Tool, pg 18</strong></td>
</tr>
<tr class="odd">
<td colspan="35"><em><strong>E. Know Your Patterns:</strong></em> What
patterns are present but not acknowledged in your microsystem? What is
the leadership and social pattern? How often does the microsystem meet
to discuss patient care? Are patients and families involved? What are
your results and outcomes?</td>
</tr>
<tr class="even">
<td colspan="7" rowspan="2"><ul>
<li><p>Does every member of the practice meet regularly as a
team?</p></li>
</ul></td>
<td colspan="15" rowspan="3"><ul>
<li><p>Do the members of the practice regularly review and discuss
safety and reliability issues?</p></li>
</ul></td>
<td colspan="13"><ul>
<li><p>What have you successfully changed?</p></li>
</ul></td>
</tr>
<tr class="odd">
<td colspan="13"><ul>
<li><p>What are you most proud of?</p></li>
</ul></td>
</tr>
<tr class="even">
<td colspan="7"><ul>
<li><p>How frequently?</p></li>
</ul></td>
<td colspan="13"><ul>
<li><p>What is your financial picture?</p></li>
</ul></td>
</tr>
<tr class="odd">
<td colspan="14"><ul>
<li><p>What is the most significant pattern of variation?</p></li>
</ul></td>
<td colspan="21"><strong>*Complete “Metrics that Matter”, pgs
23-24</strong></td>
</tr>
</tbody>
</table>

+-------------------------------------------------------+------------+---+
| **Patients**                                          |            |   |
+-------------------------------------------------------+------------+---+
| -   Patients have valuable insight into the quality   |            |   |
|     and process of care we provide. Real time         |            |   |
|     feedback can pave the way for rapid responses and |            |   |
|     quick tests of change. This "Point of Service"    |            |   |
|     Survey can be completed at the time of the visit  |            |   |
|     to give real time measurement of satisfaction.    |            |   |
|                                                       |            |   |
| -   Use the Primary Care Profile to review *"Know     |            |   |
|     Your Patients."* Determine if there is            |            |   |
|     information you need to collect or if you can     |            |   |
|     obtain this data within your organization.        |            |   |
|     Remember the aim is to collect and review data    |            |   |
|     and information about your patients and families  |            |   |
|     that might lead to a new design of process and    |            |   |
|     services.                                         |            |   |
|                                                       |            |   |
| -   Conduct the Patient/Family Satisfaction Survey    |            |   |
|     for 2 weeks with families if you currently DO NOT |            |   |
|     have a method to survey families. If you have a   |            |   |
|     method, be sure the data is up to date and        |            |   |
|     reflects the current state of your practice.      |            |   |
+-------------------------------------------------------+------------+---+
| **Patient/Family Satisfaction with Primary Care       |            |   |
| Practice Access Survey\                               |            |   |
| "Point of Service"**                                  |            |   |
+-------------------------------------------------------+------------+---+
| **Date:**                                             |            |   |
+-------------------------------------------------------+------------+---+
| **Think about this visit.**                           |            |   |
+-------------------------------------------------------+------------+---+
|                                                       |            |   |
+-------------------------------------------------------+------------+---+
| > **1. How would you rate your satisfaction with      |            |   |
| > getting through to the office by phone?**           |            |   |
| >                                                     |            |   |
| > ** Excellent  Very Good  Good  Fair  Poor**    |            |   |
| >                                                     |            |   |
| > **2. How would you rate your satisfaction with the  |            |   |
| > length of time you waited to get your appointment   |            |   |
| > today?**                                            |            |   |
| >                                                     |            |   |
| > ** Excellent  Very Good  Good  Fair  Poor**    |            |   |
| >                                                     |            |   |
| > **3. Did you see the clinician, or staff member,    |            |   |
| > that you wanted to see today?**                     |            |   |
| >                                                     |            |   |
| > ** Yes  No  Did not matter who I saw today**     |            |   |
| >                                                     |            |   |
| > **4. How would you rate your satisfaction with the  |            |   |
| > personal manner of the person you saw today         |            |   |
| > (courtesy, respect, sensitivity, friendliness)?**   |            |   |
| >                                                     |            |   |
| > ** Excellent  Very Good  Good  Fair  Poor**    |            |   |
| >                                                     |            |   |
| > **5. How would you rate your satisfaction with the  |            |   |
| > time spent with the person you saw today?**         |            |   |
| >                                                     |            |   |
| > ** Excellent  Very Good  Good  Fair  Poor**    |            |   |
| >                                                     |            |   |
| > **Comments:**                                       |            |   |
+-------------------------------------------------------+------------+---+
| **Thank You For Completing This Survey**              |            |   |
+-------------------------------------------------------+------------+---+
|                                                       |            |   |
+-------------------------------------------------------+------------+---+

<table style="width:100%;">
<colgroup>
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 9%" />
<col style="width: 6%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 11%" />
<col style="width: 2%" />
<col style="width: 8%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 2%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="36"><strong>Patients</strong></td>
</tr>
<tr class="even">
<td colspan="36"><strong>Primary Care Practice Patient Viewpoint
Survey</strong></td>
</tr>
<tr class="odd">
<td colspan="36"><em><strong>Today’s Office Visit</strong></em></td>
</tr>
<tr class="even">
<td colspan="36">Please rate the following questions about the visit you
just made to this office.</td>
</tr>
<tr class="odd">
<td colspan="18"></td>
<td colspan="3"><strong>Excellent</strong></td>
<td colspan="6"><strong>Very Good</strong></td>
<td colspan="2"><strong>Good</strong></td>
<td colspan="2"><strong>Fair</strong></td>
<td colspan="5"><strong>Poor</strong></td>
</tr>
<tr class="even">
<td colspan="19"><ol type="1">
<li><p>The amount of time you waited to get an appointment.</p></li>
</ol></td>
<td colspan="2"></td>
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="19"><ol start="2" type="1">
<li><p>Convenience of the location of the office.</p></li>
</ol></td>
<td colspan="2"></td>
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="19"><ol start="3" type="1">
<li><p>Getting through to the office by phone.</p></li>
</ol></td>
<td colspan="2"></td>
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="19"><ol start="4" type="1">
<li><p>Length of time waiting at the office.</p></li>
</ol></td>
<td colspan="2"></td>
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="19"><ol start="5" type="1">
<li><p>Time spent with the person you saw.</p></li>
</ol></td>
<td colspan="2"></td>
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="19"><ol start="6" type="1">
<li><p>Explanation of what was done for you.</p></li>
</ol></td>
<td colspan="2"></td>
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="19"><ol start="7" type="1">
<li><p>The technical skills (thoroughness, carefulness, competence) of
the person you saw.</p></li>
</ol></td>
<td colspan="2"></td>
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="19"><ol start="8" type="1">
<li><p>The personal manner (courtesy, respect, sensitivity,
friendliness) of the person you saw.</p></li>
</ol></td>
<td colspan="2"></td>
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="19"><ol start="9" type="1">
<li><p>The Clinician’s sensitivity to your special needs or
concerns.</p></li>
</ol></td>
<td colspan="2"></td>
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="19"><ol start="10" type="1">
<li><p>Your satisfaction with getting the help that you needed.</p></li>
</ol></td>
<td colspan="2"></td>
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="19"><ol start="11" type="1">
<li><p>Your feeling about the overall quality of the visit.</p></li>
</ol></td>
<td colspan="2"></td>
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="19"></td>
<td colspan="2"></td>
<td colspan="6"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="5"></td>
</tr>
<tr class="even">
<td colspan="36"><em><strong>General Questions</strong></em></td>
</tr>
<tr class="odd">
<td colspan="36">Please answer the general questions about your
satisfaction with this practice.</td>
</tr>
<tr class="even">
<td colspan="36"><ol start="12" type="1">
<li><p>If you could go anywhere to get health care, would you choose
this practice or would you prefer to go someplace else?</p></li>
</ol></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="5">Would choose this practice</td>
<td colspan="2"></td>
<td colspan="3">Might prefer someplace else</td>
<td colspan="2"></td>
<td colspan="6">Not sure</td>
<td colspan="8"></td>
<td colspan="5"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="36"><ol start="13" type="1">
<li><p>I am delighted with everything about this practice because my
expectations for service and quality of care are exceeded.</p></li>
</ol></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="5">Agree</td>
<td></td>
<td colspan="5">Disagree</td>
<td colspan="2"></td>
<td colspan="7">Not sure</td>
<td colspan="8"></td>
<td colspan="2"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="36"><ol start="14" type="1">
<li><p>In the last 12 months, how many times have you gone to the
emergency room for your care?</p></li>
</ol></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="5">None</td>
<td></td>
<td colspan="5">One time</td>
<td colspan="2"></td>
<td colspan="7">Two times</td>
<td colspan="3"></td>
<td colspan="10">Three or more times</td>
<td></td>
</tr>
<tr class="even">
<td colspan="36"><ol start="15" type="1">
<li><p>In the last 12 months was it always easy to get a referral to a
specialist when you felt like you needed one?</p></li>
</ol></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="5">Yes</td>
<td></td>
<td colspan="5">No</td>
<td colspan="2"></td>
<td colspan="7">Does not apply to me</td>
<td colspan="8"></td>
<td colspan="4"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="36"><ol start="16" type="1">
<li><p>In the last 12 months how often did you have to see someone else
when you wanted to see your personal doctor or nurse?</p></li>
</ol></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="5">Never</td>
<td></td>
<td colspan="5">Sometimes</td>
<td colspan="2"></td>
<td colspan="7">Frequently</td>
<td colspan="8"></td>
<td colspan="4"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="36"><ol start="17" type="1">
<li><p>Are you able to get to your appointments when you
choose?</p></li>
</ol></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="5">Never</td>
<td></td>
<td colspan="5">Sometimes</td>
<td colspan="2"></td>
<td colspan="7">Always</td>
<td colspan="8"></td>
<td colspan="4"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="36"><ol start="18" type="1">
<li><p>Is there anything our practice can do to improve the care and
services for you?</p></li>
</ol></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="5">No, <strong>I’m satisfied</strong> with everything</td>
<td></td>
<td colspan="5">Yes, <strong>some things</strong> can be improved</td>
<td colspan="2"></td>
<td colspan="7">Yes, <strong>many things</strong> can be improved</td>
<td colspan="8"></td>
<td colspan="4"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="5">Please specify improvement:</td>
<td colspan="31"></td>
</tr>
<tr class="odd">
<td colspan="36"><ol start="19" type="1">
<li><p>Did you have any good or bad surprises while receiving your
care?</p></li>
</ol></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td colspan="5">Good</td>
<td></td>
<td colspan="5">Bad</td>
<td colspan="2"></td>
<td colspan="7">No surprises</td>
<td colspan="8"></td>
<td colspan="5"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="3">Please describe:</td>
<td colspan="33"></td>
</tr>
<tr class="even">
<td colspan="36"></td>
</tr>
<tr class="odd">
<td colspan="36"><em><strong>About You</strong></em></td>
</tr>
<tr class="even">
<td colspan="36"><ol start="20" type="1">
<li><p>In general, how would you rate your overall health?</p></li>
</ol></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="2">Excellent</td>
<td colspan="2"></td>
<td colspan="4">Very good</td>
<td></td>
<td colspan="5">Good</td>
<td></td>
<td colspan="6">Fair</td>
<td colspan="3"></td>
<td colspan="9">Poor</td>
<td></td>
</tr>
<tr class="even">
<td colspan="36"><ol start="21" type="1">
<li><p>What is your age?</p></li>
</ol></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="5">Under 25 years</td>
<td></td>
<td colspan="5">25 – 44 years</td>
<td colspan="2"></td>
<td colspan="7">45 – 64 years</td>
<td colspan="2"></td>
<td colspan="11">65 years or older</td>
<td></td>
</tr>
<tr class="even">
<td colspan="36"><ol start="22" type="1">
<li><p>What is your gender?</p></li>
</ol></td>
</tr>
<tr class="odd">
<td></td>
<td></td>
<td colspan="5">Female</td>
<td></td>
<td colspan="5">Male</td>
<td colspan="2"></td>
<td colspan="7"></td>
<td colspan="8"></td>
<td colspan="5"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="36"><p>Sources: Medical Outcomes Study (MOS) Visit-Specific
Questionnaire (VSQ), 1993</p>
<p>Patient Utilization Questions, Dartmouth Medical School</p></td>
</tr>
</tbody>
</table>

<table style="width:100%;">
<colgroup>
<col style="width: 7%" />
<col style="width: 12%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 12%" />
<col style="width: 6%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 11%" />
<col style="width: 4%" />
<col style="width: 16%" />
<col style="width: 15%" />
<col style="width: 4%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="13"><strong>Patients</strong></td>
</tr>
<tr class="even">
<td colspan="13"><ul>
<li><p>Gain insight into how your patients experience your practice. One
simple way to understand the patient experience is to experience the
care. Members of the staff should do a "Walk Through" in your practice.
Try to make this experience as real as possible, this form can be used
to document the experience. You can also capture the patient experience
by making an audio or videotape.</p></li>
</ul></td>
</tr>
<tr class="odd">
<td colspan="13"><strong>Through the Eyes of Your Patients</strong></td>
</tr>
<tr class="even">
<td colspan="13"><strong>Tips for making the "Walk Through" most
productive:</strong></td>
</tr>
<tr class="odd">
<td colspan="6"><p>1. Determine with your staff where the starting point
and ending points should be, taking into consideration making the
appointment, the actual office visit process, follow-up and other
processes.</p>
<blockquote>
<p>2. Two members of the staff should role play with each playing a
role: patient and partner/family member.</p>
<p>3. Set aside a reasonable amount of time to experience the patient
journey. Consider doing multiple experiences along the patient journey
at different times.</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="5"><p>4. Make it real. Include time with registration, lab
tests, new patient, follow-up and physicals. Sit where the patient sits.
Wear what the patient wears. Make a realistic paper trail including
chart, lab reports and follow-up.</p>
<p>5. During the experience note both positive and negative experiences,
as well as any surprises. What was frustrating? What was gratifying?
What was confusing? Again, an audio or video tape can be helpful.</p>
<p>6. Debrief your staff on what you did and what you learned.</p></td>
</tr>
<tr class="even">
<td><blockquote>
<p>Date:</p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="3">Staff Members:</td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4">Walk Through Begins When:</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td>Ends When:</td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"><strong>Positives</strong></td>
<td colspan="3"><strong>Negatives</strong></td>
<td colspan="4"><strong>Surprises</strong></td>
<td colspan="2"><strong>Frustrating/Confusing</strong></td>
<td colspan="2"><strong>Gratifying</strong></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="2"></td>
</tr>
</tbody>
</table>

+---------------------------+--------+-------+-------+-------+-------+
| # **Patients**            |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| Staying healthy can be    |        |       |       |       |       |
| difficult when you have a |        |       |       |       |       |
| chronic condition. We     |        |       |       |       |       |
| would like to learn about |        |       |       |       |       |
| the type of help you get  |        |       |       |       |       |
| from your health care     |        |       |       |       |       |
| team regarding your       |        |       |       |       |       |
| condition. This might     |        |       |       |       |       |
| include your regular      |        |       |       |       |       |
| doctor, the nurse, or the |        |       |       |       |       |
| physician's assistant who |        |       |       |       |       |
| treats your illness.      |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| **Assessment of Care for  |        |       |       |       |       |
| Chronic Conditions ©**    |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| **Copyright 2004 MacColl  |        |       |       |       |       |
| Institute for Healthcare  |        |       |       |       |       |
| Innovation, Group Health  |        |       |       |       |       |
| Cooperative. Used with    |        |       |       |       |       |
| permission, Judith        |        |       |       |       |       |
| Schaefer, MPH. Version    |        |       |       |       |       |
| 8/13/03**                 |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| **[Over the past 6        |        |       |       |       |       |
| months]{.underline}, when |        |       |       |       |       |
| I received care for my    |        |       |       |       |       |
| chronic conditions, I     |        |       |       |       |       |
| was:**                    |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
|                           | [None  | [A    | [Some | [Most | [Alwa |
|                           | of the | L     | of    | of    | ys]{. |
|                           | Time]  | ittle | the   | the   | under |
|                           | {.unde | of    | Ti    | Ti    | line} |
|                           | rline} | the   | me]{. | me]{. |       |
|                           |        | Ti    | under | under |       |
|                           |        | me]{. | line} | line} |       |
|                           |        | under |       |       |       |
|                           |        | line} |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
|                           |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| 1.  Asked for my ideas    | ~1~   | ~2~  | ~3~  | ~4~  | ~5~  |
|     when we made a        |        |       |       |       |       |
|     treatment plan.       |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| 2.  Given choices about   | ~1~   | ~2~  | ~3~  | ~4~  | ~5~  |
|     treatment to think    |        |       |       |       |       |
|     about.                |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| 3.  Asked to talk about   | ~1~   | ~2~  | ~3~  | ~4~  | ~5~  |
|     any problems with my  |        |       |       |       |       |
|     medicines or their    |        |       |       |       |       |
|     effects.              |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| 4.  Given a written list  | ~1~   | ~2~  | ~3~  | ~4~  | ~5~  |
|     of things I should do |        |       |       |       |       |
|     to improve my health. |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| 5.  Satisfied that my     | ~1~   | ~2~  | ~3~  | ~4~  | ~5~  |
|     care was well         |        |       |       |       |       |
|     organized.            |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| 6.  Shown how what I did  | ~1~   | ~2~  | ~3~  | ~4~  | ~5~  |
|     to take care of       |        |       |       |       |       |
|     myself influenced my  |        |       |       |       |       |
|     condition.            |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| 7.  Asked to talk about   | ~1~   | ~2~  | ~3~  | ~4~  | ~5~  |
|     my goals in caring    |        |       |       |       |       |
|     for my condition.     |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| 8.  Helped to set         | ~1~   | ~2~  | ~3~  | ~4~  | ~5~  |
|     specific goals to     |        |       |       |       |       |
|     improve my eating or  |        |       |       |       |       |
|     exercise.             |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| 9.  Given a copy of my    | ~1~   | ~2~  | ~3~  | ~4~  | ~5~  |
|     treatment plan.       |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| 10. Encouraged to go to a | ~1~   | ~2~  | ~3~  | ~4~  | ~5~  |
|     specific group or     |        |       |       |       |       |
|     class to help me cope |        |       |       |       |       |
|     with my chronic       |        |       |       |       |       |
|     condition.            |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| 11. Asked questions,      | ~1~   | ~2~  | ~3~  | ~4~  | ~5~  |
|     either directly or on |        |       |       |       |       |
|     a survey, about my    |        |       |       |       |       |
|     health habits.        |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| 12. Sure that my doctor   | ~1~   | ~2~  | ~3~  | ~4~  | ~5~  |
|     or nurse thought      |        |       |       |       |       |
|     about my values,      |        |       |       |       |       |
|     beliefs, and          |        |       |       |       |       |
|     traditions when they  |        |       |       |       |       |
|     recommended           |        |       |       |       |       |
|     treatments to me.     |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| 13. Helped to make a      | ~1~   | ~2~  | ~3~  | ~4~  | ~5~  |
|     treatment plan that I |        |       |       |       |       |
|     could carry out in my |        |       |       |       |       |
|     daily life.           |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| 14. Helped to plan ahead  | ~1~   | ~2~  | ~3~  | ~4~  | ~5~  |
|     so I could take care  |        |       |       |       |       |
|     of my condition even  |        |       |       |       |       |
|     in hard times. Cont'd |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+

+---------------------------+--------+-------+-------+-------+-------+
| **Patients**              |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| **[Over the past 6        |        |       |       |       |       |
| months]{.underline}, when |        |       |       |       |       |
| I received care for my    |        |       |       |       |       |
| chronic conditions, I     |        |       |       |       |       |
| was:**                    |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
|                           | [None  | [A    | [Some | [Most | [Alwa |
|                           | of the | L     | of    | of    | ys]{. |
|                           | Time]  | ittle | the   | the   | under |
|                           | {.unde | of    | Ti    | Ti    | line} |
|                           | rline} | the   | me]{. | me]{. |       |
|                           |        | Ti    | under | under |       |
|                           |        | me]{. | line} | line} |       |
|                           |        | under |       |       |       |
|                           |        | line} |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
|                           |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| 15. Asked how my chronic  | ~1~   | ~2~  | ~3~  | ~4~  | ~5~  |
|     condition affects my  |        |       |       |       |       |
|     life.                 |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| 16. Contacted after a     | ~1~   | ~2~  | ~3~  | ~4~  | ~5~  |
|     visit to see how      |        |       |       |       |       |
|     things were going.    |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| 17. Encouraged to attend  | ~1~   | ~2~  | ~3~  | ~4~  | ~5~  |
|     programs in the       |        |       |       |       |       |
|     community that could  |        |       |       |       |       |
|     help me.              |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| 18. Referred to a         | ~1~   | ~2~  | ~3~  | ~4~  | ~5~  |
|     dietitian, health     |        |       |       |       |       |
|     educator, or          |        |       |       |       |       |
|     counselor.            |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| 19. Told how my visits    | ~1~   | ~2~  | ~3~  | ~4~  | ~5~  |
|     with other types of   |        |       |       |       |       |
|     doctors, like an eye  |        |       |       |       |       |
|     doctor or surgeon,    |        |       |       |       |       |
|     helped my treatment.  |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+
| 20. Asked how my visits   | ~1~   | ~2~  | ~3~  | ~4~  | ~5~  |
|     with other doctors    |        |       |       |       |       |
|     were going.           |        |       |       |       |       |
+---------------------------+--------+-------+-------+-------+-------+

+---+------------------+------------------------------+------------------+---+
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+---+------------------+------------------------------+------------------+---+
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| . |                  |                              |                  |   |
+---+------------------+------------------------------+------------------+---+
| * |                  | **Our Proven WEB SITE will   | **...May Seem    |   |
| * |                  | help you!**                  | Confusing**      |   |
| G |                  |                              |                  |   |
| e |                  | [***ww                       |                  |   |
| t |                  | w.howsyourhealth.org***](htt |                  |   |
| t |                  | p://www.howsyourhealth.org/) |                  |   |
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| * |                  |                              |                  |   |
| * |                  |                              |                  |   |
+---+------------------+------------------------------+------------------+---+
| ! |                  | 1.  **What matters to you:   | ![               |   |
| [ |                  |     fun, easy, brief, for    | ](media/image8.w |   |
| ] |                  |     ages 9-99**              | mf){width="0.601 |   |
| ( |                  |                              | 3888888888889in" |   |
| m |                  | 2.  **Instant, personalized  | h                |   |
| e |                  |     information**            | eight="1.625in"} |   |
| d |                  |                              |                  |   |
| i |                  | 3.  **Completely             |                  |   |
| a |                  |     confidential with no     |                  |   |
| / |                  |     advertising**            |                  |   |
| i |                  |                              |                  |   |
| m |                  | 4.  **Gets patient and       |                  |   |
| a |                  |     doctor on the same       |                  |   |
| g |                  |     page**                   |                  |   |
| e |                  |                              |                  |   |
| 7 |                  | 5.  **And much more**        |                  |   |
| . |                  |                              |                  |   |
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| } |                  |                              |                  |   |
+---+------------------+------------------------------+------------------+---+
| ! |                  |                              |                  |   |
| [ |                  |                              |                  |   |
| ] |                  |                              |                  |   |
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| 1 |                  |                              |                  |   |
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| 4 |                  |                              |                  |   |
| 0 |                  |                              |                  |   |
| 9 |                  |                              |                  |   |
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| 2 |                  |                              |                  |   |
| 7 |                  |                              |                  |   |
| 7 |                  |                              |                  |   |
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| } |                  |                              |                  |   |
+---+------------------+------------------------------+------------------+---+
|   | *                |                              |                  |   |
|   | *Professionals** |                              |                  |   |
+---+------------------+------------------------------+------------------+---+
|   | -   Creating a   |                              |                  |   |
|   |     joyful work  |                              |                  |   |
|   |     environment  |                              |                  |   |
|   |     starts with  |                              |                  |   |
|   |     a basic      |                              |                  |   |
|   |                  |                              |                  |   |
|   |    understanding |                              |                  |   |
|   |     of staff     |                              |                  |   |
|   |     perceptions  |                              |                  |   |
|   |     of the       |                              |                  |   |
|   |     practice.    |                              |                  |   |
|   |     All staff    |                              |                  |   |
|   |     members      |                              |                  |   |
|   |     should       |                              |                  |   |
|   |     complete     |                              |                  |   |
|   |     this survey. |                              |                  |   |
|   |     Use a tally  |                              |                  |   |
|   |     sheet to     |                              |                  |   |
|   |     summarize    |                              |                  |   |
|   |     results.     |                              |                  |   |
|   |                  |                              |                  |   |
|   | -   Ask all      |                              |                  |   |
|   |     practice     |                              |                  |   |
|   |     staff to     |                              |                  |   |
|   |     complete the |                              |                  |   |
|   |     Staff        |                              |                  |   |
|   |     Survey.      |                              |                  |   |
|   |     Often you    |                              |                  |   |
|   |     can          |                              |                  |   |
|   |     distribute   |                              |                  |   |
|   |     this survey  |                              |                  |   |
|   |     to any       |                              |                  |   |
|   |     professional |                              |                  |   |
|   |     who spends   |                              |                  |   |
|   |     time in your |                              |                  |   |
|   |     practice.    |                              |                  |   |
|   |     Set a        |                              |                  |   |
|   |     deadline of  |                              |                  |   |
|   |     one week and |                              |                  |   |
|   |     designate a  |                              |                  |   |
|   |     place for    |                              |                  |   |
|   |     the survey   |                              |                  |   |
|   |     to be        |                              |                  |   |
|   |     dropped off. |                              |                  |   |
|   |     You may have |                              |                  |   |
|   |     an           |                              |                  |   |
|   |     o            |                              |                  |   |
|   | rganization-wide |                              |                  |   |
|   |     survey in    |                              |                  |   |
|   |     place that   |                              |                  |   |
|   |     you can use  |                              |                  |   |
|   |     to replace   |                              |                  |   |
|   |     this survey, |                              |                  |   |
|   |     but be sure  |                              |                  |   |
|   |     it is        |                              |                  |   |
|   |     CURRENT      |                              |                  |   |
|   |     data, not    |                              |                  |   |
|   |     months old,  |                              |                  |   |
|   |     and that you |                              |                  |   |
|   |     are able to  |                              |                  |   |
|   |     capture the  |                              |                  |   |
|   |     data from    |                              |                  |   |
|   |     all          |                              |                  |   |
|   |                  |                              |                  |   |
|   |    professionals |                              |                  |   |
|   |     specific to  |                              |                  |   |
|   |     the Primary  |                              |                  |   |
|   |     Care         |                              |                  |   |
|   |     Practice     |                              |                  |   |
|   |     workplace.   |                              |                  |   |
+---+------------------+------------------------------+------------------+---+
|   | **Primary Care   |                              |                  |   |
|   | Staff            |                              |                  |   |
|   | Satisfaction     |                              |                  |   |
|   | Survey**         |                              |                  |   |
+---+------------------+------------------------------+------------------+---+
|   | > **1. I am      |                              |                  |   |
|   | > treated with   |                              |                  |   |
|   | > respect every  |                              |                  |   |
|   | > day by         |                              |                  |   |
|   | > everyone that  |                              |                  |   |
|   | > works in this  |                              |                  |   |
|   | > practice.**    |                              |                  |   |
|   | >                |                              |                  |   |
|   | > ** Strongly   |                              |                  |   |
|   | > Agree  Agree  |                              |                  |   |
|   | >  Disagree    |                              |                  |   |
|   | > Strongly       |                              |                  |   |
|   | > Disagree**     |                              |                  |   |
|   | >                |                              |                  |   |
|   | > **2. I am      |                              |                  |   |
|   | > given          |                              |                  |   |
|   | > everything I   |                              |                  |   |
|   | > need---tools,  |                              |                  |   |
|   | > equipment, and |                              |                  |   |
|   | > en             |                              |                  |   |
|   | couragement---to |                              |                  |   |
|   | > make my work   |                              |                  |   |
|   | > meaningful to  |                              |                  |   |
|   | > my life.**     |                              |                  |   |
|   | >                |                              |                  |   |
|   | > ** Strongly   |                              |                  |   |
|   | > Agree  Agree  |                              |                  |   |
|   | >  Disagree    |                              |                  |   |
|   | > Strongly       |                              |                  |   |
|   | > Disagree**     |                              |                  |   |
|   | >                |                              |                  |   |
|   | > **3. When I do |                              |                  |   |
|   | > good work,     |                              |                  |   |
|   | > someone in     |                              |                  |   |
|   | > this practice  |                              |                  |   |
|   | > notices that I |                              |                  |   |
|   | > did it.**      |                              |                  |   |
|   | >                |                              |                  |   |
|   | > ** Strongly   |                              |                  |   |
|   | > Agree  Agree  |                              |                  |   |
|   | >  Disagree    |                              |                  |   |
|   | > Strongly       |                              |                  |   |
|   | > Disagree**     |                              |                  |   |
|   | >                |                              |                  |   |
|   | > **4. How       |                              |                  |   |
|   | > stressful      |                              |                  |   |
|   | > would you say  |                              |                  |   |
|   | > it is to work  |                              |                  |   |
|   | > in this        |                              |                  |   |
|   | > practice?**    |                              |                  |   |
|   | >                |                              |                  |   |
|   | > ** Very       |                              |                  |   |
|   | > stressful     |                              |                  |   |
|   | > Somewhat       |                              |                  |   |
|   | > stressful  A  |                              |                  |   |
|   | > little         |                              |                  |   |
|   | > stressful     |                              |                  |   |
|   | > Not            |                              |                  |   |
|   | > stressful**    |                              |                  |   |
|   | >                |                              |                  |   |
|   | > **5. How easy  |                              |                  |   |
|   | > is it to ask   |                              |                  |   |
|   | > anyone a       |                              |                  |   |
|   | > question about |                              |                  |   |
|   | > the way we     |                              |                  |   |
|   | > care for       |                              |                  |   |
|   | > patients?**    |                              |                  |   |
|   | >                |                              |                  |   |
|   | > ** Very easy  |                              |                  |   |
|   | >  Easy        |                              |                  |   |
|   | > Difficult     |                              |                  |   |
|   | > Very           |                              |                  |   |
|   | > difficult**    |                              |                  |   |
|   | >                |                              |                  |   |
|   | > **6. How would |                              |                  |   |
|   | > you rate other |                              |                  |   |
|   | > people's       |                              |                  |   |
|   | > morale and     |                              |                  |   |
|   | > their          |                              |                  |   |
|   | > attitudes      |                              |                  |   |
|   | > about working  |                              |                  |   |
|   | > here?**        |                              |                  |   |
|   | >                |                              |                  |   |
|   | > ** Excellent  |                              |                  |   |
|   | >  Very Good   |                              |                  |   |
|   | > Good  Fair   |                              |                  |   |
|   | > Poor**         |                              |                  |   |
|   | >                |                              |                  |   |
|   | > **7. This      |                              |                  |   |
|   | > practice is a  |                              |                  |   |
|   | > better place   |                              |                  |   |
|   | > to work than   |                              |                  |   |
|   | > it was 12      |                              |                  |   |
|   | > months ago.**  |                              |                  |   |
|   | >                |                              |                  |   |
|   | > ** Strongly   |                              |                  |   |
|   | > Agree  Agree  |                              |                  |   |
|   | >  Disagree    |                              |                  |   |
|   | > Strongly       |                              |                  |   |
|   | > Disagree**     |                              |                  |   |
|   | >                |                              |                  |   |
|   | > **8. I would   |                              |                  |   |
|   | > recommend this |                              |                  |   |
|   | > practice as a  |                              |                  |   |
|   | > great place to |                              |                  |   |
|   | > work.**        |                              |                  |   |
|   | >                |                              |                  |   |
|   | > ** Strongly   |                              |                  |   |
|   | > Agree  Agree  |                              |                  |   |
|   | >  Disagree    |                              |                  |   |
|   | > Strongly       |                              |                  |   |
|   | > Disagree**     |                              |                  |   |
|   | >                |                              |                  |   |
|   | > **9. What      |                              |                  |   |
|   | > would make     |                              |                  |   |
|   | > this practice  |                              |                  |   |
|   | > better for     |                              |                  |   |
|   | > patients?**    |                              |                  |   |
|   | >                |                              |                  |   |
|   | > **10. What     |                              |                  |   |
|   | > would make     |                              |                  |   |
|   | > this practice  |                              |                  |   |
|   | > better for     |                              |                  |   |
|   | > those who work |                              |                  |   |
|   | > here?**        |                              |                  |   |
+---+------------------+------------------------------+------------------+---+
|   | ©2003, Trustees  |                              |                  |   |
|   | of Dartmouth     |                              |                  |   |
|   | College, Nelson  |                              |                  |   |
+---+------------------+------------------------------+------------------+---+

+---+-----------------+------+----+---+------+-----------+-------+---+
| * |                 |      |    |   |      |           |       |   |
| * |                 |      |    |   |      |           |       |   |
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| c |                 |      |    |   |      |           |       |   |
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+---+-----------------+------+----+---+------+-----------+-------+---+
| P |                 |      |   | 1 |      | 4 5 6 7   | 8 9   |   |
| a |                 |      |    | 2 |      |           | 10    |   |
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| D |                 |      |    |   |      |           |       |   |
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+---+-----------------+------+----+---+------+-----------+-------+---+
| L |                 |      |   | 1 |      | 4 5 6 7   | 8 9   |   |
| a |                 |      |    | 2 |      |           | 10    |   |
| b |                 |      |    | 3 |      |           |       |   |
| R |                 |      |    |   |      |           |       |   |
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+---+-----------------+------+----+---+------+-----------+-------+---+
| P |                 |      |   | 1 |      | 4 5 6 7   | 8 9   |   |
| a |                 |      |    | 2 |      |           | 10    |   |
| t |                 |      |    | 3 |      |           |       |   |
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+---+-----------------+------+----+---+------+-----------+-------+---+
| P |                 |      |   | 1 |      | 4 5 6 7   | 8 9   |   |
| r |                 |      |    | 2 |      |           | 10    |   |
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+---+-----------------+------+----+---+------+-----------+-------+---+
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+---+-----------------+------+----+---+------+-----------+-------+---+
| R |                 |      |   | 1 |      | 4 5 6 7   | 8 9   |   |
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+---+-----------------+------+----+---+------+-----------+-------+---+
| D |                 |      |   | 1 |      | 4 5 6 7   | 8 9   |   |
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+---+-----------------+------+----+---+------+-----------+-------+---+
| D |                 |      |   | 1 |      | 4 5 6 7   | 8 9   |   |
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+---+-----------------+------+----+---+------+-----------+-------+---+
| N |                 |      |   | 1 |      | 4 5 6 7   | 8 9   |   |
| o |                 |      |    | 2 |      |           | 10    |   |
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+---+-----------------+------+----+---+------+-----------+-------+---+
| M |                 |      |   | 1 |      | 4 5 6 7   | 8 9   |   |
| e |                 |      |    | 2 |      |           | 10    |   |
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+---+-----------------+------+----+---+------+-----------+-------+---+
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+---+-----------------+------+----+---+------+-----------+-------+---+
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+---+-----------------+------+----+---+------+-----------+-------+---+
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+---+-----------------+------+----+---+------+-----------+-------+---+
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+---+-----------------+------+----+---+------+-----------+-------+---+
| R |                 |      |   | 1 |      | 4 5 6 7   | 8 9   |   |
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+---+-----------------+------+----+---+------+-----------+-------+---+
| O |                 |      |   | 1 |      | 4 5 6 7   | 8 9   |   |
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+---+-----------------+------+----+---+------+-----------+-------+---+
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<table>
<colgroup>
<col style="width: 6%" />
<col style="width: 26%" />
<col style="width: 10%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 7%" />
<col style="width: 5%" />
<col style="width: 11%" />
<col style="width: 16%" />
<col style="width: 12%" />
<col style="width: 4%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="11"><strong>Primary Care Practice Resources—Personal Skills
Assessment page 2</strong></td>
</tr>
<tr class="even">
<td>Name:</td>
<td colspan="5"></td>
<td>Unit:</td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="11"><strong>Technical Skills cont’d:</strong></td>
</tr>
<tr class="odd">
<td colspan="5"><em>Please rate the following on how often you use
them.</em></td>
<td><p><strong>Want to</strong></p>
<p><strong>Learn</strong></p></td>
<td colspan="2"><strong>Never Use</strong></td>
<td><strong>Occasionally</strong></td>
<td colspan="2"><strong>Frequently</strong></td>
</tr>
<tr class="even">
<td colspan="5">Central Dictation</td>
<td></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="odd">
<td colspan="5">Word Processing (e.g. Word)</td>
<td></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="even">
<td colspan="5">Spreadsheet (e.g. Excel)</td>
<td></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="odd">
<td colspan="5">Presentation (e.g. Power Point)</td>
<td></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="even">
<td colspan="5">Database (e.g. Access or File Maker Pro)</td>
<td></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="odd">
<td colspan="5">Patient Database/Statistics</td>
<td></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="even">
<td colspan="5">Internet/Intranet</td>
<td></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="odd">
<td colspan="5">Printer Access</td>
<td></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="even">
<td colspan="5">Fax</td>
<td></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="odd">
<td colspan="5">Copier</td>
<td></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="even">
<td colspan="5">Telephone System</td>
<td></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="odd">
<td colspan="5">Voice Mail</td>
<td></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="even">
<td colspan="5">Pagers</td>
<td></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="odd">
<td colspan="5">Tube System</td>
<td></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="even">
<td colspan="5"></td>
<td></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="4"><strong>Meeting &amp; Interpersonal
Skills:</strong></td>
<td colspan="2"><p><strong>Want to</strong></p>
<p><strong>Learn</strong></p></td>
<td colspan="2"><strong>Never Use</strong></td>
<td><strong>Occasionally</strong></td>
<td colspan="2"><strong>Frequently</strong></td>
</tr>
<tr class="odd">
<td colspan="4"><em>What skills do you currently use?</em></td>
<td colspan="2"></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="even">
<td colspan="4">Effective Meeting Skills (brainstorm/multi-vote)</td>
<td colspan="2"></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="odd">
<td colspan="4">Timed Agendas</td>
<td colspan="2"></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="even">
<td colspan="4">Role Assignments During Meetings</td>
<td colspan="2"></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="odd">
<td colspan="4">Delegation</td>
<td colspan="2"></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="even">
<td colspan="4">Problem Solving</td>
<td colspan="2"></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="odd">
<td colspan="4">Patient Advocacy Process</td>
<td colspan="2"></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="even">
<td colspan="4">Open and Effective Communication</td>
<td colspan="2"></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="odd">
<td colspan="4">Feedback – provide and receive</td>
<td colspan="2"></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="even">
<td colspan="3">Managing Conflict/Negotiation</td>
<td colspan="3"></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="odd">
<td colspan="4">Emotional/Spiritual Support</td>
<td colspan="2"></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="4"><strong>Improvement Skills and Knowledge:</strong></td>
<td colspan="2"><p><strong>Want to</strong></p>
<p><strong>Learn</strong></p></td>
<td colspan="2"><strong>Never Use</strong></td>
<td><strong>Occasionally</strong></td>
<td colspan="2"><strong>Frequently</strong></td>
</tr>
<tr class="odd">
<td colspan="4"><em>What improvement tools do you currently
use?</em></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="4">Flowcharts/Process Mapping</td>
<td colspan="2"></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="odd">
<td colspan="4">Trend Charts</td>
<td colspan="2"></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="even">
<td colspan="4">Control Charts</td>
<td colspan="2"></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="odd">
<td colspan="4">Plan/Do/Study/Act (PDSA) Improvement Model</td>
<td colspan="2"></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="even">
<td colspan="4">Aim Statements</td>
<td colspan="2"></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="odd">
<td colspan="4">Fishbones</td>
<td colspan="2"></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="even">
<td colspan="4">Measurement and Monitoring</td>
<td colspan="2"></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="odd">
<td colspan="4">Surveys-Patient and Staff</td>
<td colspan="2"></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="even">
<td colspan="4">StAR Relationship Mapping</td>
<td colspan="2"></td>
<td colspan="2">1 2 3</td>
<td>4 5 6 7</td>
<td colspan="2">8 9 10</td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
</tr>
</tbody>
</table>

+-------------------------+-------+---+-------------------------+------+
| **Professionals**       |       |   |                         |      |
+-------------------------+-------+---+-------------------------+------+
| -   What do you spend   |       |   |                         |      |
|     YOUR time doing?    |       |   |                         |      |
|     What is your best   |       |   |                         |      |
|     estimation of how   |       |   |                         |      |
|     much time you spend |       |   |                         |      |
|     doing it? The goal  |       |   |                         |      |
|     is to have the      |       |   |                         |      |
|     right person doing  |       |   |                         |      |
|     the right thing at  |       |   |                         |      |
|     the right time. The |       |   |                         |      |
|     group can discuss   |       |   |                         |      |
|     which activities    |       |   |                         |      |
|     are or are not      |       |   |                         |      |
|     appropriate for the |       |   |                         |      |
|     individual's level  |       |   |                         |      |
|     of education,       |       |   |                         |      |
|     training, and       |       |   |                         |      |
|     licensure.          |       |   |                         |      |
|                         |       |   |                         |      |
| -   You can start with  |       |   |                         |      |
|     one group of        |       |   |                         |      |
|     professionals such  |       |   |                         |      |
|     as MDs, NPs, RNs or |       |   |                         |      |
|     clerical staff,     |       |   |                         |      |
|     assessing their     |       |   |                         |      |
|     activities using    |       |   |                         |      |
|     the Activity        |       |   |                         |      |
|     Survey. This        |       |   |                         |      |
|     estimate of who     |       |   |                         |      |
|     does what is        |       |   |                         |      |
|     intended to reveal, |       |   |                         |      |
|     at a high level,    |       |   |                         |      |
|     where there might   |       |   |                         |      |
|     be mismatches       |       |   |                         |      |
|     between education,  |       |   |                         |      |
|     training, licensure |       |   |                         |      |
|     and actual          |       |   |                         |      |
|     activities. It is   |       |   |                         |      |
|     good to eventually  |       |   |                         |      |
|     have all roles and  |       |   |                         |      |
|     functions complete  |       |   |                         |      |
|     this survey for     |       |   |                         |      |
|     review and          |       |   |                         |      |
|     consideration. Be   |       |   |                         |      |
|     sure to create the  |       |   |                         |      |
|     same categories for |       |   |                         |      |
|     each functional     |       |   |                         |      |
|     role. Some groups   |       |   |                         |      |
|     may hesitate to     |       |   |                         |      |
|     make time           |       |   |                         |      |
|     estimates; if this  |       |   |                         |      |
|     happens, just ask   |       |   |                         |      |
|     them to list their  |       |   |                         |      |
|     activities for the  |       |   |                         |      |
|     first review.       |       |   |                         |      |
|                         |       |   |                         |      |
| # []{.mark}             |       |   |                         |      |
+-------------------------+-------+---+-------------------------+------+
| **Primary Care Practice |       |   |                         |      |
| Activity Survey Sheet** |       |   |                         |      |
+-------------------------+-------+---+-------------------------+------+
| **Position: MD**        | **%   |   | **Position: RN**        | **%  |
|                         | of    |   |                         | of   |
|                         | T     |   |                         | Ti   |
|                         | ime** |   |                         | me** |
+-------------------------+-------+---+-------------------------+------+
| Activity: [See Patients | 30%   |   | Activity: [Triage       | 15%  |
| in Clinic]{.underline}  |       |   | Patient                 |      |
|                         |       |   | Issue                   |      |
|                         |       |   | s/Concerns]{.underline} |      |
+-------------------------+-------+---+-------------------------+------+
| Specific Items          |       |   | -   Phone               |      |
| Involved:               |       |   |                         |      |
+-------------------------+-------+---+-------------------------+------+
| -   Review chart        |       |   | -   Face to face        |      |
|     history             |       |   |                         |      |
+-------------------------+-------+---+-------------------------+------+
| -   Assess/diagnose     |       |   | -                       |      |
|     patient             |       |   |                         |      |
+-------------------------+-------+---+-------------------------+------+
| -   Determine treatment |       |   | Activity:               | 3%   |
|     plan                |       |   | [Patient/Family         |      |
|                         |       |   | Education]{.underline}  |      |
+-------------------------+-------+---+-------------------------+------+
| Activity: [Minor        | 9%    |   | Specific Items          |      |
| Procedures]{.underline} |       |   | Involved:               |      |
+-------------------------+-------+---+-------------------------+------+
| Activity: [See Patients | 2%    |   | -                       |      |
| in                      |       |   |                         |      |
| Hospital]{.underline}   |       |   |                         |      |
+-------------------------+-------+---+-------------------------+------+
| Activity: [Follow up    | 10%   |   | Activity: [Direct       | 30%  |
| Phone                   |       |   | Patient                 |      |
| Calls]{.underline}      |       |   | Care]{.underline}       |      |
+-------------------------+-------+---+-------------------------+------+
| Specific Items          |       |   | -   See patients in     |      |
| Involved:               |       |   |     clinic              |      |
+-------------------------+-------+---+-------------------------+------+
| -   Answer patient      |       |   | -   Injections          |      |
|     messages and        |       |   |                         |      |
|     requests            |       |   |                         |      |
+-------------------------+-------+---+-------------------------+------+
| Activity:               | 25%   |   | -   Assist provider     |      |
| [Dictate/Document       |       |   |     with patients       |      |
| Patient                 |       |   |                         |      |
| Encounter]{.underline}  |       |   |                         |      |
+-------------------------+-------+---+-------------------------+------+
| Specific Items          |       |   | -                       |      |
| Involved:               |       |   |                         |      |
+-------------------------+-------+---+-------------------------+------+
| -   Dictate encounter   |       |   | Activity: [Follow-up    | 22%  |
|                         |       |   | Phone                   |      |
|                         |       |   | Calls]{.underline}      |      |
+-------------------------+-------+---+-------------------------+------+
| -   Review              |       |   | Specific Items          |      |
|     transcriptions and  |       |   | Involved:               |      |
|     sign off            |       |   |                         |      |
+-------------------------+-------+---+-------------------------+------+
| Activity: [Complete     | 5%    |   | -                       |      |
| Forms]{.underline}      |       |   |                         |      |
+-------------------------+-------+---+-------------------------+------+
| Specific Items          |       |   | Activity: [Review and   | 5%   |
| Involved:               |       |   | Notify Patients of Lab  |      |
|                         |       |   | Results]{.underline}    |      |
+-------------------------+-------+---+-------------------------+------+
| -   Referrals           |       |   | Specific Items          |      |
|                         |       |   | Involved:               |      |
+-------------------------+-------+---+-------------------------+------+
| -   Camp/school         |       |   | -   Normal with         |      |
|     physicals           |       |   |     follow-up           |      |
+-------------------------+-------+---+-------------------------+------+
| Activity: [Write        | 5%    |   | -   Drug adjustments    |      |
| Pre                     |       |   |                         |      |
| scriptions]{.underline} |       |   |                         |      |
+-------------------------+-------+---+-------------------------+------+
| Specific Items          |       |   | Activity: [Complete     | 18%  |
| Involved:               |       |   | Forms]{.underline}      |      |
+-------------------------+-------+---+-------------------------+------+
| -                       |       |   | Specific Items          |      |
|                         |       |   | Involved:               |      |
+-------------------------+-------+---+-------------------------+------+
| Activity: [Manage       | 5%    |   | -   Referrals           |      |
| Charts]{.underline}     |       |   |                         |      |
+-------------------------+-------+---+-------------------------+------+
| Activity: [Evaluate     | 5%    |   | -   Camp/school         |      |
| Test                    |       |   |     physicals           |      |
| Results]{.underline}    |       |   |                         |      |
+-------------------------+-------+---+-------------------------+------+
| Specific Items          |       |   | Activity: [Call in      | 5%   |
| Involved:               |       |   | Pre                     |      |
|                         |       |   | scriptions]{.underline} |      |
+-------------------------+-------+---+-------------------------+------+
| -   Review results and  |       |   | Specific Items          |      |
|     determine next      |       |   | Involved:               |      |
|     actions             |       |   |                         |      |
+-------------------------+-------+---+-------------------------+------+
| Activity: [See Patients | 2%    |   | -                       |      |
| in Nursing              |       |   |                         |      |
| Home]{.underline}       |       |   |                         |      |
+-------------------------+-------+---+-------------------------+------+
| Activity:               | 2%    |   | Activity:               | 2%   |
| [Mis                    |       |   | [Mis                    |      |
| cellaneous]{.underline} |       |   | cellaneous]{.underline} |      |
+-------------------------+-------+---+-------------------------+------+
| Specific Items          |       |   | Specific Items          |      |
| Involved:               |       |   | Involved:               |      |
+-------------------------+-------+---+-------------------------+------+
| -   CME; attend         |       |   | -   CME; attend         |      |
|     seminars; attend    |       |   |     seminars; attend    |      |
|     meetings            |       |   |     meetings            |      |
+-------------------------+-------+---+-------------------------+------+
| **Total**               | 100%  |   | **Total**               | 100% |
+-------------------------+-------+---+-------------------------+------+

+-----------------------+-------------------+-------------------+------+
| **Activity Occurrence |                   |                   |      |
| Example:**            |                   |                   |      |
+-----------------------+-------------------+-------------------+------+
| *What's the next      |                   |                   |      |
| step? Insert the      |                   |                   |      |
| activities from the   |                   |                   |      |
| Activity Survey       |                   |                   |      |
| Here.*                |                   |                   |      |
|                       |                   |                   |      |
| Activities are        |                   |                   |      |
| combined by role from |                   |                   |      |
| the data collected    |                   |                   |      |
| above. This creates a |                   |                   |      |
| master list of        |                   |                   |      |
| activities by role.   |                   |                   |      |
| Fill-in THE NUMBER OF |                   |                   |      |
| TIMES PER SESSION (AM |                   |                   |      |
| and PM) THAT YOU      |                   |                   |      |
| PERFORM THE ACTIVITY. |                   |                   |      |
| Make a mark by the    |                   |                   |      |
| activity each time it |                   |                   |      |
| happens, per session. |                   |                   |      |
| Use one sheet for     |                   |                   |      |
| each day of the week. |                   |                   |      |
| Once the frequency of |                   |                   |      |
| activities is         |                   |                   |      |
| collected, the        |                   |                   |      |
| practice should       |                   |                   |      |
| review the volumes    |                   |                   |      |
| and variations by     |                   |                   |      |
| session, day of week, |                   |                   |      |
| and month of year.    |                   |                   |      |
| This evaluation       |                   |                   |      |
| increases knowledge   |                   |                   |      |
| of predictable        |                   |                   |      |
| variation and         |                   |                   |      |
| supports improved     |                   |                   |      |
| matching of resources |                   |                   |      |
| based on demand.      |                   |                   |      |
+-----------------------+-------------------+-------------------+------+
| Role: RN              | Date:             | Day of Week:      |      |
+-----------------------+-------------------+-------------------+------+
| Visit Activities      | AM                | PM                | T    |
|                       |                   |                   | otal |
+-----------------------+-------------------+-------------------+------+
| Triage Patient        |                   |                   | 14   |
| Concerns              |                   |                   |      |
+-----------------------+-------------------+-------------------+------+
| Family/Patient        |                   |                   | 11   |
| Education             |                   |                   |      |
+-----------------------+-------------------+-------------------+------+
| Direct Patient Care   |                   |                   | 42   |
+-----------------------+-------------------+-------------------+------+
| Non-Visit Activities  |                   |                   |      |
+-----------------------+-------------------+-------------------+------+
| Follow-up Phone Calls |                   |                   | 26   |
+-----------------------+-------------------+-------------------+------+
| Complete Forms        |                   |                   | 19   |
+-----------------------+-------------------+-------------------+------+
| Call in Prescriptions |                   |                   | 16   |
+-----------------------+-------------------+-------------------+------+
| Miscellaneous         |                   |                   | 15   |
+-----------------------+-------------------+-------------------+------+
|                       |                   |                   |      |
+-----------------------+-------------------+-------------------+------+
| **Total**             | 63                | 65                | 128  |
+-----------------------+-------------------+-------------------+------+

<table>
<colgroup>
<col style="width: 2%" />
<col style="width: 12%" />
<col style="width: 7%" />
<col style="width: 2%" />
<col style="width: 9%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 16%" />
<col style="width: 6%" />
<col style="width: 8%" />
<col style="width: 2%" />
<col style="width: 11%" />
<col style="width: 0%" />
<col style="width: 2%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="15"><strong>Processes</strong></td>
</tr>
<tr class="even">
<td colspan="15"><ul>
<li><p>Beginning to have all staff understand the processes of care and
services in the practice is a key to developing a common understanding
and focus for improvement. Start with the high level process of a
patient entering your practice by using the Patient Cycle Time tool. You
can assign someone to track all visits for a week to get a sample, or
the cycle time tool can be initiated for all visits in a one week period
with many people contributing to the collection and completion of this
worksheet.</p></li>
<li><p>Typically, other processes will be uncovered to measure and you
can create time tracking worksheets like this template to measure other
cycle times.</p></li>
</ul></td>
</tr>
<tr class="odd">
<td colspan="15"><strong>Primary Care Practice Patient Cycle
Time</strong></td>
</tr>
<tr class="even">
<td></td>
<td></td>
<td colspan="4"></td>
<td><strong>Day:</strong></td>
<td colspan="2"></td>
<td><strong>Date:</strong></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="8"></td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="4"><strong>Scheduled Appointment Time</strong></td>
<td colspan="3"></td>
<td colspan="3"><strong>Provider you are Seeing Today</strong></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="8"></td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"><strong>Time</strong></td>
<td></td>
<td colspan="8"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="8"><strong>1. Time you checked in.</strong></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="8"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="8"><strong>2. Time you sat in the waiting
room.</strong></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="8"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="8"><strong>3. Time staff came to get you.</strong></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="15"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="8"><strong>4. Time staff member left you in exam
room.</strong></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="15"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="8"><strong>5. Time provider came in room.</strong></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="15"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="8"><strong>6. Time provider left the room.</strong></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="15"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="8"><strong>7. Time you left the exam room.</strong></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="15"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="8"><strong>8. Time you arrived at check out.</strong></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="15"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="8"><strong>9. Time you left practice.</strong></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="15"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="8"></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="15"></td>
</tr>
<tr class="odd">
<td colspan="15"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="14"><strong>Comments:</strong></td>
</tr>
</tbody>
</table>

<table style="width:100%;">
<colgroup>
<col style="width: 2%" />
<col style="width: 12%" />
<col style="width: 7%" />
<col style="width: 2%" />
<col style="width: 9%" />
<col style="width: 8%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 16%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 6%" />
<col style="width: 2%" />
<col style="width: 11%" />
<col style="width: 0%" />
<col style="width: 2%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="19"><strong>Processes</strong></td>
</tr>
<tr class="even">
<td colspan="19"><ul>
<li><p>Beginning to have all staff understand the processes of care and
services in the practice is a key to developing a common understanding
and focus for improvement. Start with the high level process of a
patient entering your practice by using the Patient Cycle Time tool. You
can assign someone to track all visits for a week to get a sample, or
the cycle time tool can be initiated for all visits in a one week period
with many people contributing to the collection and completion of this
worksheet.</p></li>
<li><p>Typically, other processes will be uncovered to measure and you
can create time tracking worksheets like this template to measure other
cycle times.</p></li>
</ul></td>
</tr>
<tr class="odd">
<td colspan="19"><strong>Primary Care Practice Patient Cycle
Time—Academic Example</strong></td>
</tr>
<tr class="even">
<td></td>
<td><strong>Type of Visit:</strong></td>
<td colspan="4"></td>
<td colspan="2"><strong>Day:</strong></td>
<td colspan="3"></td>
<td colspan="2"><strong>Date:</strong></td>
<td colspan="4"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="10"></td>
<td colspan="8"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="4"><strong>Scheduled Appointment Time</strong></td>
<td colspan="4"></td>
<td colspan="6"><strong>Provider you are Seeing Today</strong></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="10"></td>
<td colspan="8"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"><strong>Time</strong></td>
<td></td>
<td colspan="12"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="12"><strong>1. Time you checked in.</strong></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="12"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="12"><strong>2. Time you sat in the waiting
room.</strong></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="12"></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="12"><strong>3. Time staff came to get you.</strong></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="19"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="12"><strong>4. Time staff member left you in exam
room.</strong></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="19"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="12"><strong>5. Time provider came in room. If the provider
left the</strong></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="12"><strong>room more than once, please note the
times.</strong></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="3"><strong>1</strong></td>
<td colspan="3"></td>
<td colspan="2"><strong>2</strong></td>
<td colspan="2"></td>
<td colspan="3"><strong>3</strong></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="4"><strong>Time Left</strong></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="4"><strong>Time Returned</strong></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="19"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="12"><strong>6. Time provider left the room.</strong></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="19"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="12"><strong>7. Time you left the exam room.</strong></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="19"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="12"><strong>8. Time you arrived at check out.</strong></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="19"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td></td>
<td colspan="12"><strong>9. Time you left practice.</strong></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="19"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="18"><strong>Comments:</strong></td>
</tr>
</tbody>
</table>

+------------------+------+------+------+------+------+------+------+
| **Processes**    |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+
| -   Review,      |      |      |      |      |      |      |      |
|     adapt and    |      |      |      |      |      |      |      |
|     distribute   |      |      |      |      |      |      |      |
|     the Core and |      |      |      |      |      |      |      |
|     Supporting   |      |      |      |      |      |      |      |
|     Processes    |      |      |      |      |      |      |      |
|     evaluation   |      |      |      |      |      |      |      |
|     form to ALL  |      |      |      |      |      |      |      |
|     practice     |      |      |      |      |      |      |      |
|     staff. Be    |      |      |      |      |      |      |      |
|     sure the     |      |      |      |      |      |      |      |
|     list is      |      |      |      |      |      |      |      |
|     accurate for |      |      |      |      |      |      |      |
|     your         |      |      |      |      |      |      |      |
|     practice and |      |      |      |      |      |      |      |
|     then ask     |      |      |      |      |      |      |      |
|     staff to     |      |      |      |      |      |      |      |
|     evaluate the |      |      |      |      |      |      |      |
|     CURRENT      |      |      |      |      |      |      |      |
|     state of     |      |      |      |      |      |      |      |
|     these        |      |      |      |      |      |      |      |
|     processes.   |      |      |      |      |      |      |      |
|     Rate each    |      |      |      |      |      |      |      |
|     process by   |      |      |      |      |      |      |      |
|     putting a    |      |      |      |      |      |      |      |
|     tally mark   |      |      |      |      |      |      |      |
|     under the    |      |      |      |      |      |      |      |
|     heading      |      |      |      |      |      |      |      |
|     which most   |      |      |      |      |      |      |      |
|     closely      |      |      |      |      |      |      |      |
|     matches your |      |      |      |      |      |      |      |
|                  |      |      |      |      |      |      |      |
|    understanding |      |      |      |      |      |      |      |
|     of the       |      |      |      |      |      |      |      |
|     process.     |      |      |      |      |      |      |      |
|     Also mark if |      |      |      |      |      |      |      |
|     the process  |      |      |      |      |      |      |      |
|     is a source  |      |      |      |      |      |      |      |
|     of patient   |      |      |      |      |      |      |      |
|     complaints.  |      |      |      |      |      |      |      |
|                  |      |      |      |      |      |      |      |
| > Tally the      |      |      |      |      |      |      |      |
| > results to     |      |      |      |      |      |      |      |
| > give the Lead  |      |      |      |      |      |      |      |
| > Team an idea   |      |      |      |      |      |      |      |
| > as to where to |      |      |      |      |      |      |      |
| > begin to focus |      |      |      |      |      |      |      |
| > improvement    |      |      |      |      |      |      |      |
| > from the staff |      |      |      |      |      |      |      |
| > perspective.   |      |      |      |      |      |      |      |
|                  |      |      |      |      |      |      |      |
| -   **Steps for  |      |      |      |      |      |      |      |
|                  |      |      |      |      |      |      |      |
|   Improvement:** |      |      |      |      |      |      |      |
|     Explore      |      |      |      |      |      |      |      |
|     improvements |      |      |      |      |      |      |      |
|     for each     |      |      |      |      |      |      |      |
|     process      |      |      |      |      |      |      |      |
|     based on the |      |      |      |      |      |      |      |
|     outcomes of  |      |      |      |      |      |      |      |
|     this         |      |      |      |      |      |      |      |
|     assessment   |      |      |      |      |      |      |      |
|     tool. Each   |      |      |      |      |      |      |      |
|     of the       |      |      |      |      |      |      |      |
|     processes    |      |      |      |      |      |      |      |
|     below should |      |      |      |      |      |      |      |
|     be           |      |      |      |      |      |      |      |
|     [flowchar    |      |      |      |      |      |      |      |
| ted]{.underline} |      |      |      |      |      |      |      |
|     in its'      |      |      |      |      |      |      |      |
|     current      |      |      |      |      |      |      |      |
|     state. Once  |      |      |      |      |      |      |      |
|     you have     |      |      |      |      |      |      |      |
|     flowcharted  |      |      |      |      |      |      |      |
|     the current  |      |      |      |      |      |      |      |
|     state of     |      |      |      |      |      |      |      |
|     your         |      |      |      |      |      |      |      |
|     processes    |      |      |      |      |      |      |      |
|     and          |      |      |      |      |      |      |      |
|     determined   |      |      |      |      |      |      |      |
|     your Change  |      |      |      |      |      |      |      |
|     Ideas, use   |      |      |      |      |      |      |      |
|     the PDSA     |      |      |      |      |      |      |      |
|     Cycle        |      |      |      |      |      |      |      |
|     Worksheet to |      |      |      |      |      |      |      |
|     run tests of |      |      |      |      |      |      |      |
|     change and   |      |      |      |      |      |      |      |
|     to measure.  |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+
| **Primary Care   |      |      |      |      |      |      |      |
| Practice Know    |      |      |      |      |      |      |      |
| Your Processes** |      |      |      |      |      |      |      |
|                  |      |      |      |      |      |      |      |
| **Core and       |      |      |      |      |      |      |      |
| Supporting       |      |      |      |      |      |      |      |
| Processes**      |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+
| **Processes**    | **W  | **S  | **   | *    | **Ca | **W  | **So |
|                  | orks | mall | Real | *Tot | nnot | e're | urce |
|                  | We   | P    | P    | ally | Ra   | Wor  | of   |
|                  | ll** | robl | robl | Brok | te** | king | Pat  |
|                  |      | em** | em** | en** |      | On   | ient |
|                  |      |      |      |      |      | It** | Com  |
|                  |      |      |      |      |      |      | plai |
|                  |      |      |      |      |      |      | nt** |
+------------------+------+------+------+------+------+------+------+
| Answering Phones |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+
| Appointment      |      |      |      |      |      |      |      |
| System           |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+
| Messaging        |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+
| Scheduling       |      |      |      |      |      |      |      |
| Procedures       |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+
| Order Diagnostic |      |      |      |      |      |      |      |
| Testing          |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+
| Reporting        |      |      |      |      |      |      |      |
| Diagnostic Test  |      |      |      |      |      |      |      |
| Results          |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+
| Prescription     |      |      |      |      |      |      |      |
| Renewal          |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+
| Making Referrals |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+
| P                |      |      |      |      |      |      |      |
| re-authorization |      |      |      |      |      |      |      |
| for Services     |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+
| Billing/Coding   |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+
| Phone Advice     |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+
| Assignment of    |      |      |      |      |      |      |      |
| Patients to Your |      |      |      |      |      |      |      |
| Practice         |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+
| Orientation of   |      |      |      |      |      |      |      |
| Patients to Your |      |      |      |      |      |      |      |
| Practice         |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+
| New Patient      |      |      |      |      |      |      |      |
| Work-ups         |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+
| Minor Procedures |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+
| Education for    |      |      |      |      |      |      |      |
| P                |      |      |      |      |      |      |      |
| atients/Families |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+
| Prevention       |      |      |      |      |      |      |      |
| Asses            |      |      |      |      |      |      |      |
| sment/Activities |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+
| Chronic Disease  |      |      |      |      |      |      |      |
| Management       |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+
| Palliative Care  |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+
|                  |      |      |      |      |      |      |      |
+------------------+------+------+------+------+------+------+------+

+-----------------------------------------------------------------------+
| **Processes**                                                         |
+-----------------------------------------------------------------------+
| -   Deming has said, "If you can't draw a picture of your process you |
|     can't improve anything." He is referring to the improvement tool  |
|     of process mapping. With your interdisciplinary team, create a    |
|     high level flow chart of the appointment process or the entire    |
|     treatment experience. Start with just ONE flow chart. Eventually  |
|     you will wish to create flowcharts for many different processes   |
|     in-and-between your practice. Keep the symbols simple!            |
|                                                                       |
| -   Review the flowchart to identify unnecessary rework, delays and   |
|     opportunities to streamline and improve.                          |
+-----------------------------------------------------------------------+
| **Primary Care Practice High Level Flowchart**                        |
+-----------------------------------------------------------------------+

![](media/image10.wmf){width="7.372222222222222in"
height="0.5576388888888889in"}

<table style="width:100%;">
<colgroup>
<col style="width: 7%" />
<col style="width: 5%" />
<col style="width: 9%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 7%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 6%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 7%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 2%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="26"><blockquote>
<p><strong>Patterns</strong></p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="26"><ul>
<li><p>Patterns are present in our daily work and we may or may not be
aware of them. Patterns can offer hints and clues to our work that
inform us of possible improvement ideas. The Unplanned Activity Tracking
Card is a tool you can ask staff to carry to track patterns of
interruptions, waits and delays in the process of providing smooth and
uninterrupted patient care. Start with any group in the staff. Give each
staff member a card to carry during a shift, to mark each time an
interruption occurs when direct patient care is delayed or interrupted.
The tracking cards should then be tallied by each person and within each
group to review possible process and system redesign opportunities.
Noticing patterns of unplanned activities can alert staff to possible
improvements.</p></li>
<li><p>This collection tool can be adapted for any role in the Primary
Care Practice to discover interruptions in work flow. Circles in the
example indicate processes to further evaluate for possible
improvements.</p></li>
</ul></td>
</tr>
<tr class="odd">
<td colspan="26"><blockquote>
<p><strong>Primary Care Practice Unplanned Activity Tracking
Card</strong></p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="26"></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>Unplanned Activity Tracking</strong></td>
<td></td>
<td colspan="14"><strong>Unplanned Activity Tracking</strong></td>
</tr>
<tr class="even">
<td>Name:</td>
<td colspan="9">  </td>
<td></td>
<td></td>
<td colspan="2">Name:</td>
<td colspan="11"> </td>
<td> </td>
</tr>
<tr class="odd">
<td>  Date:</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td>Time:</td>
<td colspan="4"> </td>
<td></td>
<td></td>
<td colspan="2">Date:</td>
<td colspan="6"> </td>
<td>Time:</td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="11"></td>
<td></td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="8"><strong>Place a tally mark for each occurrence of an
unplanned activity</strong></td>
<td colspan="3"><strong>Total</strong></td>
<td></td>
<td colspan="11"><strong>Place a tally mark for each occurrence<br />
of an unplanned activity</strong></td>
<td colspan="3"><strong>Total</strong></td>
</tr>
<tr class="even">
<td colspan="8"> </td>
<td colspan="3"> </td>
<td></td>
<td colspan="11"> </td>
<td colspan="3"> </td>
</tr>
<tr class="odd">
<td colspan="4">Interruptions</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"> </td>
<td></td>
<td colspan="8">Interruptions </td>
<td colspan="3"></td>
<td colspan="3"> </td>
</tr>
<tr class="even">
<td colspan="6"><ul>
<li><p>Phone</p></li>
</ul></td>
<td colspan="2"> </td>
<td colspan="3"> </td>
<td></td>
<td colspan="4"><ul>
<li><p>Phone</p></li>
</ul></td>
<td colspan="7"><del>llll</del> <del>llll</del> <del>llll</del></td>
<td colspan="3">15</td>
</tr>
<tr class="odd">
<td colspan="4"><ul>
<li><p>Secretary</p></li>
</ul></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"> </td>
<td></td>
<td colspan="8"><ul>
<li><p>Secretary</p></li>
</ul></td>
<td colspan="3"></td>
<td colspan="3"> </td>
</tr>
<tr class="even">
<td colspan="4"><ul>
<li><p>RN</p></li>
</ul></td>
<td colspan="2"> </td>
<td colspan="2"> </td>
<td colspan="3"> </td>
<td></td>
<td colspan="3"><ul>
<li><p>RN</p></li>
</ul></td>
<td colspan="8"><del>llll</del> <del>llll</del></td>
<td colspan="3">10</td>
</tr>
<tr class="odd">
<td colspan="4"><ul>
<li><p>Provider</p></li>
</ul></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"> </td>
<td></td>
<td colspan="6"><ul>
<li><p>Provider</p></li>
</ul></td>
<td colspan="5"></td>
<td colspan="3"> </td>
</tr>
<tr class="even">
<td colspan="4">Hospital Admissions</td>
<td colspan="2"> </td>
<td colspan="2"> </td>
<td colspan="3"> </td>
<td></td>
<td colspan="6">Hospital Admissions</td>
<td colspan="5"><del>llll</del> <del>llll</del> ll</td>
<td colspan="3">12</td>
</tr>
<tr class="odd">
<td colspan="4">Patient Phone Calls</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"> </td>
<td></td>
<td colspan="6">Patient Phone Calls</td>
<td colspan="5"></td>
<td colspan="3"> </td>
</tr>
<tr class="even">
<td colspan="4">Pages</td>
<td colspan="2"> </td>
<td colspan="2"> </td>
<td colspan="3"> </td>
<td></td>
<td>Pages</td>
<td colspan="10"><del>llll</del> <del>llll</del> <del>llll</del>
<del>llll</del></td>
<td colspan="3">20</td>
</tr>
<tr class="odd">
<td colspan="6">Missing Equipment</td>
<td colspan="2"></td>
<td colspan="3"> </td>
<td></td>
<td colspan="11">Missing Equipment</td>
<td colspan="3"> </td>
</tr>
<tr class="even">
<td colspan="4">Missing Supplies</td>
<td colspan="2"> </td>
<td colspan="2"> </td>
<td colspan="3"> </td>
<td></td>
<td colspan="5">Missing Supplies</td>
<td colspan="6"><del>llll</del></td>
<td colspan="3">5</td>
</tr>
<tr class="odd">
<td colspan="8">Missing Chart: Same Day Patient</td>
<td colspan="3"> </td>
<td></td>
<td colspan="11">Missing Chart: Same Day Patient</td>
<td colspan="3"> </td>
</tr>
<tr class="even">
<td colspan="6">Missing Chart: Patient</td>
<td colspan="2"> </td>
<td colspan="3"> </td>
<td></td>
<td colspan="7">Missing Chart: Patient</td>
<td colspan="4"><del>llll</del> <del>llll</del></td>
<td colspan="3">10</td>
</tr>
<tr class="odd">
<td colspan="4">Missing Test Results</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"> </td>
<td></td>
<td colspan="10">Missing Test Results</td>
<td></td>
<td colspan="3"> </td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="2"> </td>
<td colspan="2"> </td>
<td colspan="3"> </td>
<td></td>
<td colspan="10"></td>
<td> </td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
<td colspan="10"></td>
<td></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="4">Other</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
<td colspan="10">Other</td>
<td></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
<td colspan="10"></td>
<td></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
<td colspan="10"></td>
<td></td>
<td colspan="3"></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
<td colspan="10"></td>
<td></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
<td colspan="10"></td>
<td></td>
<td colspan="3"></td>
</tr>
</tbody>
</table>

<table style="width:100%;">
<colgroup>
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 6%" />
<col style="width: 4%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 7%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="19"><strong>Patterns</strong></td>
</tr>
<tr class="even">
<td colspan="19"><ul>
<li><p>Patterns can be found through tracking the volumes and types of
telephone calls. Review the categories on the telephone tracking list to
ensure they reflect the general categories of calls your practice
receives. Ask clerical staff to track the telephone calls over the
course of a week to find the patterns of each type of call and the
volume peaks and valleys.</p></li>
<li><p>Put a tally mark each time one of the phone calls is for one of
the listed categories. Total the calls for each day and then total the
calls in each category for the week. Note the changes in volume by the
day of the week and am/pm.</p></li>
</ul></td>
</tr>
<tr class="odd">
<td colspan="19"><strong>Primary Care Practice Telephone Tracking
Log</strong></td>
</tr>
<tr class="even">
<td colspan="4"><strong>Week of</strong></td>
<td colspan="2" rowspan="2"><strong>Monday</strong></td>
<td colspan="2" rowspan="2"><strong>Tuesday</strong></td>
<td colspan="2" rowspan="2"><strong>Wednesday</strong></td>
<td colspan="2" rowspan="2"><strong>Thursday</strong></td>
<td colspan="2" rowspan="2"><strong>Friday</strong></td>
<td colspan="2" rowspan="2"><strong>Saturday</strong></td>
<td colspan="2" rowspan="2"><strong>Sunday</strong></td>
<td rowspan="2"><strong>Week Total</strong></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td></td>
<td>AM</td>
<td>PM</td>
<td>AM</td>
<td>PM</td>
<td>AM</td>
<td>PM</td>
<td>AM</td>
<td>PM</td>
<td>AM</td>
<td>PM</td>
<td>AM</td>
<td>PM</td>
<td>AM</td>
<td>PM</td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>Appointment for Today</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"><strong>Total</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>Appointment for Tomorrow</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"><strong>Total</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>Appointment<br />
for Future</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"><strong>Total</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>Test Results</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"><strong>Total</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>Nurse Care</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"><strong>Total</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>Prescription Refill</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"><strong>Total</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>Referral Information</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"><strong>Total</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>Need Information</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"><strong>Total</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>Message for Provider</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"><strong>Total</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>Talk with Provider</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"><strong>Total</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td colspan="4"><strong>DAY TOTAL</strong></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

+-----------------------------------------------------------------------+
| **Metrics That Matter**                                               |
+-----------------------------------------------------------------------+
| -   Measures are essential for microsystems to make and sustain       |
|     improvements and to attain high performance. All clinical         |
|     microsystems are awash with data but relatively few have rich     |
|     information environments that feature daily, weekly and monthly   |
|     use of Metrics That Matter (MTM). The key to doing this is to get |
|     started in a practical, doable way; and to build out your Metrics |
|     That Matter and their vital use over time. Some guidelines for    |
|     your consideration are listed below. Remember these are just      |
|     guidelines and your microsystem should do what makes sense in the |
|     way of collecting, displaying and using Metrics That Matter.      |
+-----------------------------------------------------------------------+
| **Primary Care Practice Metrics That Matter**                         |
+-----------------------------------------------------------------------+
| 1.  **W**hat? Every microsystem has vital performance                 |
|     characteristics, things that must happen for successful           |
|     operations. Metrics That Matter (MTMs) should reflect your        |
|     microsystem's vital performance characteristics.                  |
+-----------------------------------------------------------------------+
| 2.  **W**hy? The reason to identify, measure and track MTMs is to     |
|     ensure that you are not "flying blind."\                          |
|     Safe, high quality and efficient performance will give you        |
|     specific, balanced and timely metrics that show:                  |
|                                                                       |
|     a.  When improvements are needed                                  |
|                                                                       |
|     b.  If improvements are successful                                |
|                                                                       |
|     c.  If improvements are sustained over time, and                  |
|                                                                       |
|     d.  The amount of variation in results over time                  |
+-----------------------------------------------------------------------+
| 3.  **H**ow? Here are steps you can make to take advantage of MTMs.   |
|                                                                       |
| > [Lead]{.underline} [Team]{.underline} to establish the              |
| > [need]{.underline} for metrics and their [routine]{.underline} use. |
| >                                                                     |
| > Quality begins with the intention to achieve measured excellence.   |
+-----------------------------------------------------------------------+
| > [balanced]{.underline} set of [metrics]{.underline} to provide      |
| > insight into what's working and what's not working. Some categories |
| > to consider are: process flow, clinical, safety, patient            |
| > perceptions, staff perceptions, operations, and finance/costs.      |
| > Avoid starting with too many measures.                              |
| >                                                                     |
| > Every metric should have an operational definition, data owner,     |
| > target value and action plan.                                       |
| >                                                                     |
| > Strongly consider using the \"national\" JCAHO\* and CMS\* metrics  |
| > whenever they are relevant to your microsystem. Consider other      |
| > \"vital\" metrics based on your own experience, strategic           |
| > initiatives and other \"gold standard\" sets such as measures from  |
| > NQF\* and professional organizations like ASTS\*.                   |
+-----------------------------------------------------------------------+
| > Identify a [data]{.underline} [owner(s)]{.underline} for each       |
| > metric. The owner will be responsible for getting this measure and  |
| > reporting it to the Lead Team. Seek sources of data from            |
| > organization wide systems.\                                         |
| > If the needed data is not available, use manual methods to measure. |
| > Strive to build data collection in the flow of daily work.          |
+-----------------------------------------------------------------------+
| > Build a data wall and use it daily, weekly, monthly, and            |
| > annuallyGather data for each metric and [display]{.underline} it on |
| > the "data wall" reporting:                                          |
|                                                                       |
| -   Current value                                                     |
|                                                                       |
| -   Target Value                                                      |
|                                                                       |
| -   Action Plan to improve or sustain level                           |
|                                                                       |
| > Display metrics as soon as possible--daily, weekly, monthly metrics |
| > are most useful--using visual displays such as time trend charts    |
| > and bar charts.                                                     |
+-----------------------------------------------------------------------+
| > your set of metrics on a regular basis---daily, weekly, monthly,    |
| > quarterly, annually.\                                               |
| > [Use]{.underline} metrics to make needed improvements whenever      |
| > possible.                                                           |
| >                                                                     |
| > Make metrics fun, useful and a lively part of your microsystem      |
| > development process. Discuss Metrics That Matter frequently and     |
| > take action on them as needed.                                      |
+-----------------------------------------------------------------------+
| \* JCAHO, Joint Commission on Accreditation of Healthcare             |
| Organizations                                                         |
|                                                                       |
| CMS, Centers for Medicare and Medicaid Services                       |
|                                                                       |
| NQF, National Quality Foundation                                      |
|                                                                       |
| ASTS, American Society of Thoracic Surgeons                           |
+-----------------------------------------------------------------------+

+------------------------+--------------+--------------+--------------+
| **Metrics That         |              |              |              |
| Matter**               |              |              |              |
+------------------------+--------------+--------------+--------------+
| -   Review the         |              |              |              |
|     currently          |              |              |              |
|     determined "best   |              |              |              |
|     metrics" your      |              |              |              |
|     practice should be |              |              |              |
|     monitoring.        |              |              |              |
|                        |              |              |              |
| -   List your current  |              |              |              |
|     performance in     |              |              |              |
|     these metrics and  |              |              |              |
|     what the targets   |              |              |              |
|     are.               |              |              |              |
+------------------------+--------------+--------------+--------------+
| **Primary Care         |              |              |              |
| Practice Metrics That  |              |              |              |
| Matter**               |              |              |              |
+------------------------+--------------+--------------+--------------+
| **Name of Measure**    | **Definition | **Current    | **Action     |
|                        | &**          | &**          | Plan &**     |
|                        |              |              |              |
|                        | **Data       | **Target     | **Process    |
|                        | Owner**      | Values**     | Owner**      |
+------------------------+--------------+--------------+--------------+
| ***General Metrics***  |              |              |              |
+------------------------+--------------+--------------+--------------+
| **                     |              |              |              |
| [Access]{.underline}** |              |              |              |
+------------------------+--------------+--------------+--------------+
| 3^rd^ Available        |              |              |              |
| Appointment ^\##^      |              |              |              |
+------------------------+--------------+--------------+--------------+
|                        |              |              |              |
+------------------------+--------------+--------------+--------------+
|                        |              |              |              |
+------------------------+--------------+--------------+--------------+
| **[Staff               |              |              |              |
| Morale]{.underline}**  |              |              |              |
+------------------------+--------------+--------------+--------------+
| Staff Satisfaction     |              |              |              |
| ^\##^                  |              |              |              |
+------------------------+--------------+--------------+--------------+
| Voluntary Turn Over    |              |              |              |
| ^\##^                  |              |              |              |
+------------------------+--------------+--------------+--------------+
| Work days lost per     |              |              |              |
| employee per year ^\#^ |              |              |              |
+------------------------+--------------+--------------+--------------+
|                        |              |              |              |
+------------------------+--------------+--------------+--------------+
| **[Safety &            |              |              |              |
| Reli                   |              |              |              |
| ability]{.underline}** |              |              |              |
+------------------------+--------------+--------------+--------------+
| Identification of high |              |              |              |
| risk patient diagnosis |              |              |              |
| & associated           |              |              |              |
| medications that put   |              |              |              |
| patient at risk, (e.g. |              |              |              |
| Coumadin, Insulin) &   |              |              |              |
| related tests you must |              |              |              |
| track.                 |              |              |              |
+------------------------+--------------+--------------+--------------+
|                        |              |              |              |
+------------------------+--------------+--------------+--------------+
|                        |              |              |              |
+------------------------+--------------+--------------+--------------+
|                        |              |              |              |
+------------------------+--------------+--------------+--------------+
|                        |              |              |              |
+------------------------+--------------+--------------+--------------+
| **[Patient             |              |              |              |
| Satis                  |              |              |              |
| faction]{.underline}** |              |              |              |
+------------------------+--------------+--------------+--------------+
| Overall ^\##^          |              |              |              |
+------------------------+--------------+--------------+--------------+
| Access ^\##^           |              |              |              |
+------------------------+--------------+--------------+--------------+
|                        |              |              |              |
+------------------------+--------------+--------------+--------------+
|                        |              |              |              |
+------------------------+--------------+--------------+--------------+
|                        |              |              |              |
+------------------------+--------------+--------------+--------------+
|                        |              |              |              |
+------------------------+--------------+--------------+--------------+
| **[                    |              |              |              |
| Finance]{.underline}** |              |              |              |
+------------------------+--------------+--------------+--------------+
|                        |              |              |              |
+------------------------+--------------+--------------+--------------+
|                        |              |              |              |
+------------------------+--------------+--------------+--------------+
|                        |              |              |              |
+------------------------+--------------+--------------+--------------+
|                        |              |              |              |
+------------------------+--------------+--------------+--------------+
| ***Patient-Centered    |              |              |              |
| Outcome Measures \**** |              |              |              |
+------------------------+--------------+--------------+--------------+
| Assessment of Care for |              |              |              |
| Chronic Conditions     |              |              |              |
| ^\##^                  |              |              |              |
+------------------------+--------------+--------------+--------------+
|                        |              |              |              |
+------------------------+--------------+--------------+--------------+
| Visit                  |              |              |              |
| [www.doqit.org](       |              |              |              |
| http://www.doqit.org/) |              |              |              |
| for Data Submission    |              |              |              |
| Process information    |              |              |              |
+------------------------+--------------+--------------+--------------+
|                        |              |              |              |
+------------------------+--------------+--------------+--------------+
|                        |              |              |              |
+------------------------+--------------+--------------+--------------+
|                        |              |              |              |
+------------------------+--------------+--------------+--------------+
|                        |              |              |              |
+------------------------+--------------+--------------+--------------+
|                        |              |              |              |
+------------------------+--------------+--------------+--------------+
|                        |              |              |              |
+------------------------+--------------+--------------+--------------+
| \# Denotes OSHA Safety |              |              |              |
| Log measure            |              |              |              |
|                        |              |              |              |
| \## Denotes IHI Whole  |              |              |              |
| System Measures (2004) |              |              |              |
+------------------------+--------------+--------------+--------------+

+------------------------+--------------+--------------+--------------+
| **Metrics That         |              |              |              |
| Matter**               |              |              |              |
+------------------------+--------------+--------------+--------------+
| **Primary Care         |              |              |              |
| Practice Metrics That  |              |              |              |
| Matter**               |              |              |              |
+------------------------+--------------+--------------+--------------+
| **Name of Measure**    | **Definition | **Current    | **Action     |
|                        | &**          | &**          | Plan &**     |
|                        |              |              |              |
|                        | **Data       | **Target     | **Process    |
|                        | Owner**      | Values**     | Owner**      |
+------------------------+--------------+--------------+--------------+
| ***Patient-Centered    |              |              |              |
| Outcome Measures \**** |              |              |              |
+------------------------+--------------+--------------+--------------+
| **[Coronary Artery     |              |              |              |
| Disease                |              |              |              |
| (CAD]{.underline}**)   |              |              |              |
+------------------------+--------------+--------------+--------------+
| Antiplatelet Therapy   |              |              |              |
+------------------------+--------------+--------------+--------------+
| Lipid Profile          |              |              |              |
+------------------------+--------------+--------------+--------------+
| Drug Therapy for       |              |              |              |
| Lowering LDL Chol.     |              |              |              |
+------------------------+--------------+--------------+--------------+
| LDL Cholesterol Level  |              |              |              |
+------------------------+--------------+--------------+--------------+
| Beta-Blocker           |              |              |              |
| Therapy-Prior MI       |              |              |              |
+------------------------+--------------+--------------+--------------+
| ACE Inhibitor Therapy  |              |              |              |
+------------------------+--------------+--------------+--------------+
| Blood Pressure         |              |              |              |
+------------------------+--------------+--------------+--------------+
| **[Heart Failure       |              |              |              |
| (HF)]{.underline}**    |              |              |              |
+------------------------+--------------+--------------+--------------+
| Left Ventricular       |              |              |              |
| Function (LVF) Assess. |              |              |              |
+------------------------+--------------+--------------+--------------+
| Left Ventricular       |              |              |              |
| Function (LVF) Testing |              |              |              |
+------------------------+--------------+--------------+--------------+
| Patient Education      |              |              |              |
+------------------------+--------------+--------------+--------------+
| Beta-Blocker Therapy   |              |              |              |
+------------------------+--------------+--------------+--------------+
| ACE Inhibitor Therapy  |              |              |              |
+------------------------+--------------+--------------+--------------+
| Weight Measurement     |              |              |              |
+------------------------+--------------+--------------+--------------+
| Blood Pressure         |              |              |              |
| Screening              |              |              |              |
+------------------------+--------------+--------------+--------------+
| Warfarin Therapy for   |              |              |              |
| Pts with Atrial Fib    |              |              |              |
+------------------------+--------------+--------------+--------------+
| **[Diabetes Mellitus   |              |              |              |
| (DM)]{.underline}**    |              |              |              |
+------------------------+--------------+--------------+--------------+
| HbA1c Management       |              |              |              |
+------------------------+--------------+--------------+--------------+
| Lipid Measurement      |              |              |              |
+------------------------+--------------+--------------+--------------+
| HbA1c Management       |              |              |              |
| Control                |              |              |              |
+------------------------+--------------+--------------+--------------+
| LDL Cholesterol Level  |              |              |              |
+------------------------+--------------+--------------+--------------+
| Blood Pressure         |              |              |              |
| Management             |              |              |              |
+------------------------+--------------+--------------+--------------+
| Urine Protein Testing  |              |              |              |
+------------------------+--------------+--------------+--------------+
| Eye Exam Foot Exam     |              |              |              |
+------------------------+--------------+--------------+--------------+
| **[Preventive Care     |              |              |              |
| (PC)]{.underline}**    |              |              |              |
+------------------------+--------------+--------------+--------------+
| Influenza Vaccination  |              |              |              |
+------------------------+--------------+--------------+--------------+
| Pneumonia Vaccination  |              |              |              |
+------------------------+--------------+--------------+--------------+
| Blood Pressure         |              |              |              |
| Measurement            |              |              |              |
+------------------------+--------------+--------------+--------------+
| Lipid Measurement      |              |              |              |
+------------------------+--------------+--------------+--------------+
| LDL Cholesterol level  |              |              |              |
+------------------------+--------------+--------------+--------------+
| Colorectal Cancer      |              |              |              |
| Screening              |              |              |              |
+------------------------+--------------+--------------+--------------+
| Breast Cancer          |              |              |              |
| Screening              |              |              |              |
+------------------------+--------------+--------------+--------------+
| Tobacco Use            |              |              |              |
+------------------------+--------------+--------------+--------------+
| Tobacco Cessation      |              |              |              |
+------------------------+--------------+--------------+--------------+
| **[Hypertension        |              |              |              |
| (HTN)]{.underline}**   |              |              |              |
+------------------------+--------------+--------------+--------------+
| Blood Pressure         |              |              |              |
| Screening              |              |              |              |
+------------------------+--------------+--------------+--------------+
| Blood Pressure Control |              |              |              |
+------------------------+--------------+--------------+--------------+
| Plan of Care           |              |              |              |
+------------------------+--------------+--------------+--------------+
| \* CMS (Center for     |              |              |              |
| Medicare and Medicaid  |              |              |              |
| Services)              |              |              |              |
|                        |              |              |              |
| > American Medical     |              |              |              |
| > Association (AMA)    |              |              |              |
| > Physician Consortium |              |              |              |
| > for Performance      |              |              |              |
| > Improvement          |              |              |              |
| >                      |              |              |              |
| > National Diabetes    |              |              |              |
| > Quality Improvement  |              |              |              |
| > Alliance (Alliance)  |              |              |              |
| >                      |              |              |              |
| > National Committee   |              |              |              |
| > for Quality          |              |              |              |
| > Assurance (NCQA)     |              |              |              |
+------------------------+--------------+--------------+--------------+

<table>
<colgroup>
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 13%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 11%" />
<col style="width: 3%" />
<col style="width: 57%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="12"><strong>Step 3 Diagnose</strong></td>
</tr>
<tr class="even">
<td colspan="12"><p>With the Interdisciplinary Lead Team review the 5Ps
assessment, Metrics That Matter, and with consideration of your
organizational strategic plan, select a first “theme,” (e.g., access,
safety, flow, reliability, patient satisfaction, staff morale,
prevention, supply and demand) for improvement.</p>
<ul>
<li><p>The purpose of assessing is to make an informed and correct
overall diagnosis of you microsystem.</p></li>
<li><p>First, identify and celebrate the strengths of your
system.</p></li>
<li><p>Second, identify and consider opportunities to improve your
system.</p>
<ul>
<li><p>The opportunities to improve may come from your own
microsystem—based on assessment, staff suggestions and/or patient and
family needs and complaints.</p></li>
<li><p>The opportunities to improve may come from outside your
microsystem—based on a strategic project or external performance/quality
measures.</p></li>
<li><p>Look not only at the detail of each of the assessment tools, but
also synthesize all of the assessments and Metrics That Matter to “get
the big picture” of the microsystem. Identify linkages within the data
and information. Consider:</p>
<ul>
<li><p>Waste and delays in the process steps. Look for processes that
might be redesigned to result in better functions for roles and better
outcomes for patients.</p></li>
<li><p>Patterns of variation in the microsystem. Be mindful of smoothing
the variations or matching resources with the variation in
demand.</p></li>
<li><p>Patterns of outcomes you wish to improve.</p></li>
</ul></li>
</ul></li>
<li><p>It is usually smart to pick or focus on one important “theme” to
improve at a time, and work with all the “players” in your system to
make a big improvement in the area selected.</p></li>
<li><p>Suggestions on how to make your diagnosis and select a theme
follow next.</p></li>
</ul></td>
</tr>
<tr class="odd">
<td colspan="12"><strong>Diagnose Your Primary Care
Practice</strong></td>
</tr>
<tr class="even">
<td colspan="12"><strong>Write your Theme for Improvement</strong></td>
</tr>
<tr class="odd">
<td colspan="12"><strong>Overall Theme “Global” Aim
Statement</strong></td>
</tr>
<tr class="even">
<td colspan="12">Create an aim statement that will help keep your focus
clear and your work productive:</td>
</tr>
<tr class="odd">
<td colspan="6"></td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="5"><em>We aim to improve:</em></td>
<td colspan="6"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="6"></td>
<td colspan="5">(Name the process)</td>
<td></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"><em>In:</em></td>
<td colspan="3"></td>
<td colspan="5"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="4"></td>
<td colspan="2"></td>
<td colspan="5">(Clinical location in which process is embedded)</td>
<td></td>
</tr>
<tr class="even">
<td colspan="8"><em>The process begins with:</em></td>
<td colspan="3"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="6"></td>
<td colspan="5">(Name where the process begins)</td>
<td></td>
</tr>
<tr class="even">
<td colspan="7"><em>The process ends with:</em></td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="6"></td>
<td colspan="5">(Name the ending point of the process)</td>
<td></td>
</tr>
<tr class="even">
<td colspan="9"><em>By working on the process, we expect:</em></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="6"></td>
<td colspan="5">(List benefits)</td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="9"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="9"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="10"><em>It is important to work on this now
because:</em></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="6"></td>
<td colspan="5">(List imperatives)</td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="9"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="9"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="9"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="9"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="9"></td>
<td></td>
</tr>
</tbody>
</table>

+---+---------+--------------------------------------------------------+---+
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+---+---------+--------------------------------------------------------+---+
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|   |         |                                                        |   |
+---+---------+--------------------------------------------------------+---+
|   |         |                                                        |   |
+---+---------+--------------------------------------------------------+---+
| * |         |                                                        |   |
| M |         |                                                        |   |
| e |         |                                                        |   |
| a |         |                                                        |   |
| s |         |                                                        |   |
| u |         |                                                        |   |
| r |         |                                                        |   |
| e |         |                                                        |   |
| s |         |                                                        |   |
| : |         |                                                        |   |
| * |         |                                                        |   |
+---+---------+--------------------------------------------------------+---+
|   |         |                                                        |   |
+---+---------+--------------------------------------------------------+---+
|   |         |                                                        |   |
+---+---------+--------------------------------------------------------+---+
|   |         |                                                        |   |
+---+---------+--------------------------------------------------------+---+
|   |         |                                                        |   |
+---+---------+--------------------------------------------------------+---+
|   |         |                                                        |   |
+---+---------+--------------------------------------------------------+---+
|   |         |                                                        |   |
+---+---------+--------------------------------------------------------+---+
|   |         |                                                        |   |
+---+---------+--------------------------------------------------------+---+
|   |         |                                                        |   |
+---+---------+--------------------------------------------------------+---+
|   |         |                                                        |   |
+---+---------+--------------------------------------------------------+---+

+-----------------------------------------------------------------------+
| **Treat Your Primary Care Practice**                                  |
+-----------------------------------------------------------------------+
| -   Once you have completed the assessment and diagnosis of your      |
|     practice and have a clear theme to focus on, review current best  |
|     practice and Change Ideas to consider.                            |
|                                                                       |
| -   The Change Ideas will continue to develop as more field testing   |
|     is done and more colleagues design improvements.                  |
+-----------------------------------------------------------------------+
| **Primary Care Practice Change Ideas to Consider:**                   |
+-----------------------------------------------------------------------+
| > You will find additional support and tools at the websites listed   |
| > below                                                               |
| >                                                                     |
| > Change Ideas to Improve Access to Care                              |
| > http://www.clinicalmicrosystem.org/access.htm                       |
|                                                                       |
| 1.  Shape Demand                                                      |
|                                                                       |
| 2.  Match Supply and Demand                                           |
|                                                                       |
| 3.  Redesign the System                                               |
|                                                                       |
| > Change Ideas to Improve Interaction                                 |
|                                                                       |
| 4.  Design group visits or Shared Medical Appointments                |
|     http://www.clinicalmicrosystem.org/sma.htm                        |
|                                                                       |
| 5.  Utilize email care                                                |
|                                                                       |
| 6.  Create a practice website                                         |
|                                                                       |
| 7.  Optimize professional roles to subpopulation care management      |
|                                                                       |
| > Change Ideas to Improve Reliability                                 |
|                                                                       |
| 8.  Adapt the Chronic Care Model: "Improving Chronic Illness Care"    |
|     (ICIC) http://www.improvingchroniccare.org                        |
|                                                                       |
| Change Ideas to Improve Vitality                                      |
|                                                                       |
| 9.  Engage all staff in continuous improvement and research           |
|                                                                       |
| 10. Develop strategies to actively develop individual staff           |
|                                                                       |
| 11. Create a favorable financial status which supports investments in |
|     the practice                                                      |
|                                                                       |
| 12. Utilize "daily huddle" process with MDs, RNs and clerical staff   |
|     to review yesterday, plan for today, tomorrow and the coming week |
|     (pg28)                                                            |
|                                                                       |
| > \*visit [www.ihi.org](http://www.ihi.org/) and                      |
| > [www.clinicalmicrosystem.org](http://www.clinicalmicrosystem.org/)  |
| > for the latest ideas                                                |
+-----------------------------------------------------------------------+
| > **Consider the Change Concepts on page 295 of [The Improvement      |
| > Guide]{.underline} by Langley, Nolan, Nolan, Norman and Provost     |
| > (1996). The main change categories are listed below.**              |
+-----------------------------------------------------------------------+
| A.  Eliminate Waste                                                   |
|                                                                       |
| B.  Improve Workflow                                                  |
|                                                                       |
| C.  Optimize Inventory                                                |
|                                                                       |
| D.  Change the Work Environment                                       |
|                                                                       |
| E.  Enhance the Producer/Customer Relationship                        |
|                                                                       |
| F.  Manage Time                                                       |
|                                                                       |
| G.  Manage Variation                                                  |
|                                                                       |
| H.  Design Systems to Avoid Mistakes                                  |
|                                                                       |
| I.  Focus on the Product or Service                                   |
+-----------------------------------------------------------------------+
| > Langley G, Nolan K, Nolan T, Norman T, Provost L. *The Improvement  |
| > Guide: A Practical Approach to Enhancing Organizational             |
| > Performance*. 1^st^ ed. The Jossey-Bass Business & Management       |
| > Series. San Francisco, CA: Jossey-Bass Publishers; 1996: xxix, 370. |
+-----------------------------------------------------------------------+

+------+---------------------------+----------+----+------------------+
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|  the |                           |          |    |                  |
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+------+---------------------------+----------+----+------------------+
| **Hu |                           |          |    |                  |
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+------+---------------------------+----------+----+------------------+
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+------+---------------------------+----------+----+------------------+
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+------+---------------------------+----------+----+------------------+
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+------+---------------------------+----------+----+------------------+
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+------+---------------------------+----------+----+------------------+
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+------+---------------------------+----------+----+------------------+
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+------+---------------------------+----------+----+------------------+

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+---+--------------------------+--------+--------+----------+----------+---+

  ---------------------------- --------------------------- --------- --------- ---------- ---------- --
  **Standardizing Current Best                                                                       
  Process and Holding the                                                                            
  Gains**                                                                                            

  **Standardize-Do-Study-Act                                                                         
  SDSA**                                                                                             

  **Standardize** the process                                                                        
  (specify what roles do what                                                                        
  activities in what sequence                                                                        
  with what information flow).                                                                       
  A good way to track and                                                                            
  standardize process is                                                                             
  through the creation of a                                                                          
  Primary Care Practice                                                                              
  Playbook. The Playbook is                                                                          
  the collection of process                                                                          
  maps to provide care and                                                                           
  services that all staff are                                                                        
  aware of and accountable                                                                           
  for. The Playbook can be                                                                           
  used to orient new staff,                                                                          
  document current processes                                                                         
  and contribute to                                                                                  
  performance appraisals.                                                                            

  **Do** the work to integrate                                                                       
  the standard process into                                                                          
  daily work routines to                                                                             
  ensure reliability and                                                                             
  repeatability.                                                                                     

  **Study** at regular                                                                               
  intervals. Consider if the                                                                         
  process is being "adhered"                                                                         
  to and what "adjustments"                                                                          
  are being made. Review the                                                                         
  process when new                                                                                   
  innovations, technology or                                                                         
  roles are being considered.                                                                        
  Review what the measures of                                                                        
  the process are showing.                                                                           

  **Act** based on the above,                                                                        
  maintain or "tweak" the                                                                            
  standard process and                                                                               
  continue doing this until                                                                          
  the next "wave" of                                                                                 
  improvements/innovations                                                                           
  takes place with a new                                                                             
  series of PDSA cycles.                                                                             

  ***S**tandardize* How shall                                                                        
  we **STANDARDIZE** the                                                                             
  process and embed it into                                                                          
  daily practice? Who? Does                                                                          
  what? When? With what tools?                                                                       
  What needs to be                                                                                   
  \"unlearned\" to allow this                                                                        
  new habit? What data will                                                                          
  inform us if this is being                                                                         
  standardized daily?                                                                                

                               Tasks to be completed to    Who       When      Tools      Measures   
                               run test of change                              Needed                

                                                                                                     

                                                                                                     

                                                                                                     

                                                                                                     

                                                                                                     

                                                                                                     

                                                                                                     

                                                                                                     

                                                                                                     

                               \*Playbook-Create standard                                            
                               process map to be inserted                                            
                               in your Playbook.                                                     

                                                                                                     

  **D**o What are we learning                                                                        
  as we ***DO*** the                                                                                 
  standardization? Any                                                                               
  problems encountered? Any                                                                          
  surprises? Any new insights                                                                        
  to lead to another PDSA                                                                            
  cycle?                                                                                             

  **S**tudy As we ***STUDY***                                                                        
  the standardization, what                                                                          
  have we learned? What do the                                                                       
  measures show? Are there                                                                           
  identified needs for change                                                                        
  or new information or                                                                              
  "tested" best practice to                                                                          
  adapt?                                                                                             

  **A**ct As we ***ACT*** to                                                                         
  hold the gains or modify the                                                                       
  standardization efforts,                                                                           
  what needs to be done? Will                                                                        
  we modify the                                                                                      
  standardization? What is the                                                                       
  Change Idea? Who will                                                                              
  oversee the new PDSA? Design                                                                       
  a new PDSA cycle. Make a                                                                           
  PLAN for the next cycle of                                                                         
  change. Go to PDSA                                                                                 
  Worksheet.                                                                                         
  ---------------------------- --------------------------- --------- --------- ---------- ---------- --

+-----------------------------------------------------------------------+
| **Step 5 Follow-Up**                                                  |
+-----------------------------------------------------------------------+
| -   Monitor the new patterns of results and select new themes for     |
|     improvement.                                                      |
|                                                                       |
| -   Embed new habits into daily work: daily huddles, weekly Lead Team |
|     meetings, monthly "town hall" meetings, datawalls, and            |
|     storyboards.                                                      |
+-----------------------------------------------------------------------+
| **Follow-Up**                                                         |
+-----------------------------------------------------------------------+
| Improvement in health care is a continuous journey.                   |
|                                                                       |
| The new patterns need to be monitored to ensure the improvements are  |
| sustained. Embedding new habits into daily work with the use of       |
| "huddles" to review and remind staff, as well as weekly Lead Team     |
| meetings keeps everyone focused on improvements and results that can  |
| lead to sustained and continuous improvements.                        |
|                                                                       |
| Datawalls, storyboards and monthly all-staff meetings are methods to  |
| embed new habits and thinking for improvement.                        |
|                                                                       |
| The Lead Team should repeat the process for newly recognized themes   |
| and improvements that are identified in the assessment and Metrics    |
| That Matter.                                                          |
+-----------------------------------------------------------------------+

  ----------------- ------------------------------- --------------------------
  **Assessing Your                                  
  Practice                                          
  Discoveries and                                   
  Actions**                                         

  **Know Your\      **Discoveries**                 **Actions Taken**
  Patients**                                        

  1\. Age           1\. 30% of our patients \> 65   1\. Designated special
  Distribution      years old                       group visits to review
                                                    specific needs of this age
                                                    group including physical
                                                    limitations, dietary
                                                    considerations.

  2\. Disease       2\. We do not know what percent 2\. Staff reviewed coding/
  Identification    our patients have diabetes.     billing data to determine
                                                    approximate numbers of
                                                    patients with diabetes.

  3\. Health        3\. We do not know what the     3\. Staff conducted a
  Outcomes          range of HgA1C is for out       chart audit with 50 charts
                    patients with diabetes of if    during a lunch hour. Using
                    they are receiving appropriate  a toll designed to track
                    ADA recommended care in a       outcomes; each member of
                    timely fashion.                 the staff reviewed 5
                                                    charts and noted their
                                                    findings on the audit
                                                    tool.

  4\. Most Frequent 4\. We learned we had a large   4\. Designed and tested a
  Diagnosis         number of patients with stable  new model of care delivery
                    hypertension and diabetes,      for stable hypertension
                    seeing the physician            and diabetes optimizing
                    frequently. We also learned     the RN role in the
                    that during certain season we   practice using agreed upon
                    had huge volumes of acute       guidelines, protocols and
                    diseases such as URI,           tools.
                    Pharyngitis and poison ivy.     

  5\. Patient       5\. We don't know what patients 5\. Implemented the "point
  Satisfaction      think unless they complain to   of service" patient survey
                    us.                             that patients completed
                                                    and left in a box before
                                                    leaving the practice.

  **Know Your\      **Discoveries**                 **Actions Taken**
  Professionals**                                   

  1\. Provider FTE  1\. We were making assumptions  1\. Changed our scheduling
                    about provider time in the      processes, utilized RNs to
                    clinic without really           provide care for certain
                    understanding how much time     subpopulations.
                    providers are OUT of the Clinic 
                    with hospital rounds, nursing   
                    home rounds, etc.               

  2\. Schedules     2\. Several providers are gone  2\. Evaluated the
                    at the same time every week, so scheduling template to
                    one provider is often left and  even out each provider's
                    the entire staff works overtime time to provide consistent
                    that day.                       coverage of the clinic.

  3\. Regular       3\. The doctors meet together   3\. Entire practice
  Meetings          every other week. The           meeting every other week
                    secretaries meet once a month.  on Wednesdays.

  4\. Hours of      4\. The beginning and the end   4\. Opened one hour
  Operation         of the day are always chaotic.  earlier and stayed open
                    We realized we are on the route one house later each day.
                    for patients between home and   The heavy demand was
                    work and want to be seen when   managed better and
                    we are not open.                overtime dropped.

  5\. Activity      5\. All roles are not being     5\. Roles have been
  Surveys           used to their maximum. RNs only redesigned and matched to
                    room patients and take vital    individual education,
                    signs, medical assistants doing training and licensure.
                    a great deal of secretarial     
                    paperwork and some secretaries  
                    are giving out medical advice.  

  **Know Your\      **Discoveries**                 **Actions Taken**
  Processes**                                       

  1\. Cycle Time    1\. Patient lengths of visits   1\. The staff identified
                    vary a great deal. There are    actions to eliminate,
                    many delays.                    steps to combine, and
                                                    learned to prepare the
                                                    charts for the patient
                                                    visit before the patient
                                                    arrives. The staff also
                                                    holds daily "huddles" to
                                                    inform everyone on the
                                                    plan of the day and any
                                                    issues to consider
                                                    throughout the day.

  2\. Key           2\. None of us could agree on   2\. Detailed flow charting
  Supporting        how things get done in out      of our practice to
  Processes         practice.                       determine how to
                                                    streamline and do in a
                                                    consistent manner.

  3\. Indirect      3\. The providers are           3\. The staff agreed on
  Patient Pulls     interrupted in their patient    standardization of exam
                    care process frequently. The    rooms and minimum
                    number one reason is to         inventory lists that were
                    retrieve missing equipment and  posted inside the cabinet
                    supplies from the exam room.    doors. A process was also
                                                    determined on WHO and HOW
                                                    the exam rooms would be
                                                    stocked regularly and
                                                    through the use of an
                                                    assignment sheet, a person
                                                    was identified and held
                                                    accountable.

  **Know Your\      **Discoveries**                 **Actions Taken**
  Patterns**                                        

  1\. Demand on the 1\. There are peaks and lows of 1\. Resources and role are
  Practice          the practice depending on day   matched to demand volumes.
                    of the week, session of the day Schedules are created
                    or season of the year.          which match resources to
                                                    variation.

  2\. Communication 2\. We do not communicate in a  2\. Every other week
                    timely way, nor do we have a    practice meeting to help
                    standard form to communicate.   communication and e-mail
                                                    use of all staff to
                                                    promote timely
                                                    communication.

  3\. Cultural      3\. The doctors don't really    3\. The staff meetings
                    spend time with non-doctors.    heightened awareness of
                                                    behaviors has helped
                                                    improve this.

  4\. Outcomes      4\. We really have not paid     4\. Began tracking and
                    attention to our practice       posting on a data wall to
                    outcomes.                       keep us alter to outcomes.

  5\. Finances      5\. Only the doctors and the    5\. Finances are discussed
                    practice managers know about    at the staff meetings and
                    the practice money.             everyone is learning how
                                                    we make a difference in
                                                    our financial performance.
  ----------------- ------------------------------- --------------------------

+-------------+---------------------------------+---------------------+
| **Assessing |                                 |                     |
| Your        |                                 |                     |
| Practice    |                                 |                     |
| Discoveries |                                 |                     |
| and         |                                 |                     |
| Actions**   |                                 |                     |
+-------------+---------------------------------+---------------------+
| **Common    | **Recommended Method to Reduce  | **Traps to Avoid**  |
| High Yield  | Waste**                         |                     |
| Wastes**    |                                 |                     |
+-------------+---------------------------------+---------------------+
| 1\. Exam    | \- Create Standard Inventory    | \- Don't assume     |
| rooms not   | supplies for all exam rooms.    | rooms are being     |
| stocked or  |                                 | stocked regularly   |
| s           | \- Design process for regular   | -- track and        |
| tandardized | stocking of exam rooms with     | measure.            |
| -- missing  | accountable person              |                     |
| supplies or |                                 | \- Providers will   |
| equipment   | \- Standardize and utilize all  | only use "their     |
|             | exam rooms                      | own" rooms          |
|             |                                 |                     |
|             |                                 | \- Providers cannot |
|             |                                 | agree on standard   |
|             |                                 | supplies; suggest   |
|             |                                 | "testing"           |
+-------------+---------------------------------+---------------------+
| 2\. Too     | \- Reduce appointment types to  | \- Frozen schedules |
| many        | 2-4                             | of certain types    |
| appointment |                                 |                     |
| types which | \- Utilize standard building    | \- Use one time     |
| create      | block to create flexibility in  | (e.g. 10-15 minute  |
| chaos in    | schedule.                       | "building blocks")  |
| scheduling  |                                 |                     |
+-------------+---------------------------------+---------------------+
| 3\. Poor    | \- Conduct daily morning        | \- People not       |
| co          | "huddles" to provide a forum to | showing up for      |
| mmunication | review the schedule, anticipate | scheduled huddles.  |
| amongst the | needs of patients, plan         | Gain support of     |
| providers   | supplies/ information needed    | providers who are   |
| and support | for a highly productive         | interested, test    |
| staff about | interaction between patient and | ideas and measure   |
| clinical    | provider.                       | results             |
| sessions    |                                 |                     |
| and patient |                                 | \- Huddles last     |
| needs.      |                                 | longer than 15      |
|             |                                 | minutes, use a work |
|             |                                 | sheet to guide      |
|             |                                 | huddle              |
|             |                                 |                     |
|             |                                 | \- Don't sit down   |
+-------------+---------------------------------+---------------------+
| 4\. Missing | \- Review patient charts BEFORE | \- Avoid doing      |
| information | the patient arrives --          | chart review when   |
| or chart    | recommended the day before to   | patient is present  |
| for patient | ensure information and test     |                     |
| visit.      | results are available to        | \- If you have      |
|             | support the patient.            | computerized test   |
|             |                                 | results, don't      |
|             |                                 | print the results   |
+-------------+---------------------------------+---------------------+
| 5\.         | \- Standardize messaging        | \- Providers want   |
| Confusing   | processes for all providers     | their "own" way --  |
| messaging   |                                 | adding to confusion |
| system      | \- Educate/ train messaging     | to support staff    |
|             | content                         | and decreases       |
|             |                                 | ability for cross   |
|             | \- Utilize a process with       | coverage            |
|             | prioritizing methods such as a  |                     |
|             | "bin" system in each provider   | \- Content of       |
|             | office.                         | message can't be    |
|             |                                 | agreed upon -- test |
|             |                                 | something           |
+-------------+---------------------------------+---------------------+
| 6\. High    | \- Anticipate patient needs     | \- Doesn't need to  |
| p           |                                 | be the RN --        |
| rescription | \- Create "reminder" systems in | Medical assistants  |
| renewal     | office, e.g. posters,           | can obtain this     |
| request via | screensavers                    | information         |
| phone.      |                                 |                     |
|             | \- Standardize information that |                     |
+-------------+---------------------------------+---------------------+
| 7\. Staff   | \- Review current roles and     | \- Be sure to focus |
| frustrated  | functions using activity survey | on talent, training |
| in roles    | sheets                          | and scope of        |
| and unable  |                                 | practice not        |
| to see new  | \- Match talent, education,     | individual people.  |
| ways to     | training, licensure to function |                     |
| function.   |                                 |                     |
|             | \- Optimize every role          |                     |
|             |                                 |                     |
|             | \- Eliminate functions          |                     |
+-------------+---------------------------------+---------------------+
| 8\.         | \- Evaluate follow-up           | \- Don't set a      |
| Appointment | appointments and return visit   | certain number of   |
| schedules   | necessity.                      | same day            |
| have        |                                 | appointments        |
| limited     | \- Extend intervals of standard | without matching    |
| same day    | follow-up visits                | variations          |
| appointment |                                 | throughout the      |
| slots.      | \- Consider RN visits           | year.               |
|             |                                 |                     |
|             | \- Evaluate the use of          |                     |
|             | protocols and guidelines to     |                     |
|             | provide advice for homecare-    |                     |
|             | [www.                           |                     |
|             | icsi.org](http://www.icsi.org/) |                     |
|             |                                 |                     |
|             | \- Consider phone care          |                     |
+-------------+---------------------------------+---------------------+
| 9\. Missed  | \- Utilize the flow sheets to   | \- Be alert to      |
| diseas      | track preventative activities   | creating a system   |
| e-specific/ | and disease-specific            | for multiple        |
| preventive  | interventions.                  | diseases and not    |
| in          |                                 | have many stickers  |
| terventions | \- Utilize "stickers" on charts | and many            |
| and         | to alert staff to preventative/ | registries.         |
| tracking.   | disease specific needs          |                     |
|             |                                 |                     |
|             | \- Review charts before patient |                     |
|             | visits                          |                     |
|             |                                 |                     |
|             | \- Create registries to track   |                     |
|             | subpopulation needs.            |                     |
+-------------+---------------------------------+---------------------+
| 10\. Poor   | \- Hold weekly staff meetings   | \- Hold weekly      |
| co          | to review practice outcomes,    | meetings on a       |
| mmunication | staff concerns, improvement     | regular day, time   |
| and         | opportunities.                  | and place           |
| i           |                                 |                     |
| nteractions | \- Education and Development    | \- Do not cancel -- |
| between     |                                 | make the meeting a  |
| members.    |                                 | new habit           |
+-------------+---------------------------------+---------------------+
| 11\. High   | \- Consider improving same day  | \- Automated        |
| no-show     | access                          | reminder telephone  |
| rate        |                                 | calls are not       |
|             | \- Reminder systems             | always well         |
|             |                                 | received by         |
|             |                                 | patients            |
+-------------+---------------------------------+---------------------+
| 12\.        | \- CARE vital sign sheet-       | \- Use reminders to |
| Patient     | [www.howsyourhealth.org](       | question patient    |
| e           | http://www.howsyourhealth.org/) | about needs being   |
| xpectations |                                 | met                 |
| of visit    | \- Evaluating patient at time   |                     |
| not met,    | of visit if their needs were    | \- New habits not   |
| resulting   | met                             | easily made.        |
| in phone    |                                 |                     |
| calls and   |                                 |                     |
| repeat      |                                 |                     |
| visits.     |                                 |                     |
+-------------+---------------------------------+---------------------+
| © 2003,     |                                 |                     |
| Trustees of |                                 |                     |
| Dartmouth   |                                 |                     |
| College,    |                                 |                     |
| Godfrey,    |                                 |                     |
| Nelson,     |                                 |                     |
| Batalden,   |                                 |                     |
| Institute   |                                 |                     |
| for         |                                 |                     |
| Healthcare  |                                 |                     |
| Improvement |                                 |                     |
+-------------+---------------------------------+---------------------+

  -----------------------------------------------------------------------

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