# Presentation: 057605

## Clinic Process Evaluation: Overview of Role and Utility

- David Reagan, MD PhD
- ACOS Ambulatory Care
- Mountain Home VAMC
- Johnson City, TN

## What Is Clinic Process Evaluation?

-   Evaluation of the processes integral to clinical care delivery, including analysis of system constraints with identification and prioritization of system improvements.

## Change: What, Where, When?

- “Every system is perfectly designed to achieve exactly the results it gets”
- System redesign is central, however...
- Understand the system first 		(measure twice, cut once)
- Must implement change to improve, but...
- Change can be constructive or destructive

## Systems Thinking

- Complexity
- Interdependence
- Subsystems
- Multiple efficiency bottlenecks
- One primary bottleneck at a time
-  (primary system constraint)
- People are essential to system function

## Idealized System

**Demand**

**Demand**

**Demand**

**System Resources**

**Satisfied**
**Demand**

**Satisfied**
**Demand**

**Satisfied**
**Demand**

## Simple Real System

**Demand**

**Demand**

**Demand**

**System Resources**

**Satisfied**
**Demand**

**Satisfied**
**Demand**

**Satisfied**
**Demand**

## Simple Clinic System

- Walk-in

- Scheduled

- Phone

- Satisfied
- Patient

- Satisfied
- Patient

- Satisfied
- Patient

- Patients

- Clinic Resources

- Results

## Simple Clinic System

- Walk-in

- Scheduled

- Phone

- Satisfied
- Patient

- Satisfied
- Patient

- Satisfied
- Patient

- Patients

- Clinic Resources

- Results

- Registration

- Nursing interview

- Provider encounter

- Check out

- Ancillary testing

## Optimized Clinic System

- Walk in

- Scheduled

- Phone

- Satisfied
- Patient

- Satisfied
- Patient

- Satisfied
- Patient

- Registration

- LPN

- Provider

- Ancillary testing

- Check out

## ACA 10 Key Changes

- Work down the backlog
- Reduce demand
- Understand supply and demand
- Reduce appointment types
- Plan for contingencies

## ACA 10 Key Changes

**Manage the constraint**
- For example, by figuring out where the “log jams” occur in your patient care process and designing actions to deal with them
- Optimize the care team
- Synchronize patient and provider information
- Predict and anticipate patient needs
- Optimize rooms and equipment

## Case Study: Emergency Dept

**Clerk**

**ED Nurse**

- Lab / Radiology

- Business Office

- ED Physician

- UC Provider

- Treatments &
-  Monitoring

- Treatments &
- Monitoring

- Admit

- D/C Home

- Means Test

- Consultation

**January 2001**

## ED Clinic System

- Emergent
- Patient

- Urgent
- Patient

- Clinic
- Referral

- Satisfied
- Patient

- Satisfied
- Patient

- Satisfied
- Patient

- Patients

- Clinic Resources

- Results

- Clerical

- Nursing

- Physician

- Laboratory

- Radiology

## Case Study: Emergency Dept

- Triage RN

- Clerk

- Lab / Radiology

- Business Office

**ED Physician**

**UC Provider**

- Treatments &
-  Monitoring

- Treatments &
- Monitoring

- Admit

- D/C Home

- Consultation

**March 2003**

- Class III or IV

- Class I or II

- Clerk

## ED After System Changes

- Emergent
- Patient

- Urgent
- Patient

- Clinic
- Referral

- Satisfied
- Patient

- Satisfied
- Patient

- Satisfied
- Patient

- Registration

- Nursing

- Physician

- Laboratory

- Radiology

## Viewing Improvement Through A Constraints Cycle

**Identify system**
**constraints**

**Remove primary constraint**

**Identify primary constraint**

**Study primary constraint**

## View From 1,000 Feet

## View From 10,000 Feet

## Multiple Levels of System Analysis

- Facility

-  PC Clinics

- 1,000 foot view

- 10,000 foot view

- Microsystem

## A Microsystem Is*

- A small group of people working together on a regular basis to provide care to discrete subpopulations of patients.
- This is different than a team, in that patients and IT are included

- * IHI, Idealized Design of Clinical Office Practices

## Microsystem Components

- Small group of clinicians and nurses
- Some administrative support
- Some information technology
- Small patient population
- Interdependent to achieve a common aim or purpose

- * IHI, Idealized Design of Clinical Office Practices
-    www.clinicalmicrosystem.org

## Microsystems: So What?

- Focus on the small functional unit
- Sees the system from the front lines, with patients as an integral part
- Aim for best function / maximal efficiency
- When small care delivery units are optimized, then focus on linkages

## Clinic Process EvaluationSo What?

- Demands thorough understanding of the whole system
- Allows prioritization of interventions
- Most value added for effort expended (improvement process itself is efficient)
- Informs continuous improvement cycles

## Apply ACA Key Changes(Now That Providers Are The Bottleneck)

- Work down the backlog
- Reduce demand
- Reduce appointment types
- Plan for contingencies
- Optimize the care team
- Predict and anticipate patient needs

## Key Areas For Efficiency

- Exam space
- Support staff
- Number, training, experience
- Optimize communication (listen)
- Staff ownership and alignment

## Determinants of Panel Size*

** ****Age/Gender**
** ****Co morbidity**
** ****Reliance**

**Visit Intensity**
**(RVU/Visit)**

**Visits/Year/Pt**

**Appt**
** ****Length**

**Visits**
**per Hr**

**Panel Size**

**Hours In Clinic**

**Support Staff**

**Exam Rooms**

- *After Kathy Lee Frisbee, March 2003

## With Improvement...

- Design is from Mars,
- Implementation is from Venus

- Modified from Peter Pronovost, MD PhD

## Implementing Change:Underlying Principles

- We must measure to improve, but...
- Measurement is to learn, not to judge
- Data do not improve processes, people do
- Data exposes and clarifies, but    	   the heart motivates

- Modified from Peter Pronovost, MD PhD

## Implementing Change:Personal Motivation

- “Ultimately, the secret of quality is love. You have to love your patients, you have to love your profession, you have to love your God. If you have love, you can work backward to monitor and improve the system

- Donabedian

## Implementing Change:Interpersonal Side of Management

- “A promotion to manager can give authority, but not power. It is the people you are to manage who will give you power... Management is a matter of being in relationship.”

- James Autry, _Love and Profit_

## Implementing Change:The Need For Servant Leadership

- “Every day another company wakes up and realizes that its most underutilized resources are the minds and hearts of its people. It is people – those closest to the customer and closest to the work – who have the answers, who own the solutions.”

- Doug Krug, _Enlightened Leadership_

## Implementing Change:The Role of Leadership

- “Good leaders do three things...
- they provide permission for their people to          try new things...
- they provide protection... from the corporate immune systems whose job it is to kill anything new, different...
- Finally, leaders provide their people with processes to help them tackle and solve problems.”

- Doug Krug, _Enlightened Leadership_

## Conclusions

- Clinic Process Management is part of ACA
- CPM facilitates efficient improvement
- Encourages the 10,000 ft view before making 1,000 ft recommendations
- Focuses efforts on key bottlenecks
- Encourages a long term view of improvement
- For lasting success, honor the interpersonal side of implementing change