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National Academy of Engineering (US) and Institute of Medicine (US) Committee on Engineering and the Health Care System; Reid PP, Compton WD, Grossman JH, et al., editors. Building a Better Delivery System: A New Engineering/Health Care Partnership. Washington (DC): National Academies Press (US); 2005.

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Building a Better Delivery System: A New Engineering/Health Care Partnership.

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Deploying Resources for an Idealized Office Practice: Access, Interactions, Reliability, and Vitality

Thomas W. Nolan

Associates in Process Improvement and Institute for Healthcare Improvement

The goal of our initiative is to create an idealized design of clinical office practices (IDCOP) that offers the best possible solutions to the health care practice needs of our customers. When implemented, these solutions should lead a visiting patient to say, “They give me exactly the help I want (and need) exactly when I want (and need) it.” To accomplish this goal, we have to improve measures associated with: clinical outcomes; patient satisfaction; finance; and staff satisfaction. To simplify and further systematize the systems that emerge from IDCOP, we have developed a framework of four “themes” to guide the redesign processes as a whole: access, interactions, reliability, and vitality.

Access. Timing is an essential component of health care. When things happen is almost as important as what happens. Of all forms of timing, patients almost certainly value most the timing of entry into the system—getting to care when the care is needed. Care in this context does not mean only encounters or visits. It means all appropriate forms of interaction, including access to information, support, dialogue, reassurance, treatment, and supplies, as well as all possible routes of delivery—not just face-to-face meetings, but also electronic, print, and other media of exchange.

Interactions. Health care is fundamentally interaction. Interaction is not the price of or vehicle for care; it is the care. Those who regard health care as a list of resources—people, medications, machines, technologies, and so forth—are merely listing the “inert” ingredients that become care only when they are combined in interactions between patients and the system. The quality of care is the quality of interaction among resources, not the quality of the resources per se.

Reliability. Reliability involves ensuring an exact match between knowledge and activity in the IDCOP practice. Ideally, “all and only” effective and helpful care is given. The IDCOP practice, therefore, aims always to give care that can help a patient and never to give care that harms or cannot help a patient. Reliability is the conscious attempt to avoid the defects in health care that the Institute of Medicine Roundtable on Quality summarizes as “overuse, underuse, and misuse” of care. (The Roundtable defines misuse as errors in care and threats to patient safety.)

Vitality. IDCOP aims for a sustainable design. The new system would be financially viable and would provide a great workplace. In other words, the demanding performance standard is not realized at the expense of those who work in the practice and depend upon it for their livelihood. Vitality also implies renewal—continual innovation and improvement. The IDCOP practice is not a fixed, solved system; it is a learning organization with the capability, agility, resilience, and will to change over time as desires, environments, and knowledge change.

Each of these themes or aspects of IDCOP requires certain activities, some familiar and some new. One of the initial steps to redesigning the system as a whole is the systematic examination of the current premises and beliefs concerning the activities performed and the people who perform them. Meeting each of the goals requires some resource deployment and scheduling. To achieve excellent access, the demand for visits and other interactions must be estimated beforehand, and capacity, for example for appointments, must be available to meet the demand. Conceiving of care as interactions between the patient and the system via multiple media means that resources must be deployed to enable these interactions. Reliability requires an exact match between knowledge and activity in the practice, knowing the activities that will meet the needs of patients and ensuring that these activities are performed in an orderly manner and at the proper time. The activities that contribute to the vitality of a practice, such as training and process redesign, might easily be put off in the face of pressing daily demands, but these activities are essential. Hence, time must be scheduled for them.

Besides helping with the daily deployment of resources, the development of a master schedule for the practice will facilitate the fundamental rethinking of the design of the practice. The following three tasks serve as a guide to the deployment of resources consistent with the IDCOP themes:

  1. Understand and define the work involved in caring for persons who depend on the practice.
  2. Assemble a team of people and resources to match the work.
  3. Develop a repetitive master schedule to optimize the use of resources relative to the needs of the population.

Defining the work involves describing activities in the practice and then assessing them in terms of the four themes. The activities can then be adjusted to ensure that the practice has all four characteristics and the appropriate clinician matched with the work. Once the work and appropriate team have been identified, the practice can match the work to the members of the team on specific days of the week using a repetitive master schedule.

REPETITIVE MASTER SCHEDULE

The work of a clinical practice is varied and complex—no two patients are alike, insurance companies have different requirements, and the external environment is changing rapidly. Designing an IDCOP practice is impossible unless some sense of order is established in the midst of increasing demands and varying conditions. Developing and using a repetitive master schedule is one method of establishing order.

Although the work varies, every practice has a natural rhythm—the length of time after which the work begins to repeat. Staff in a primary care practice often cite one week as the repetitive period. Up to a point, the work done in one week is similar to the work done the next week. Of course, the rhythm in a practice is also influenced by shorter periods, such as days, and longer seasonal periods that must also be taken into account.

The practice must first establish the period for which a master schedule will be designed. For purposes of discussion, let's assume the period is one week. That means that a master schedule for a “typical” week can be used with minor adjustments for any week. The definition of the repetitive period simplifies the task of deploying the resources of the practice because the schedule is built only for a short period of time.

Once the period has been chosen, a master schedule can answer the questions of what work will be done, who will do it, when they will do it, and where they will do it. An IDCOP practice calls for forms of interaction in addition to one-on-one visits with the doctor. Who will be using e-mail? Who will provide chronic disease management and review registries? When will training and staff development take place? The master schedule should provide answers to these questions.

The slogan for a master schedule with a period of one week is “do today's work today.” Although there is some overlap in each day's work, Tuesday's work will not be exactly the same as Thursday's. The practice may hold a group visit on Tuesday, for example, and review the chronic disease registries on Thursday. Daily work should be completed on the day it is scheduled.

“Open access” requires that patients be scheduled within the master schedule cycle. Hence, practice-patient interactions are a very large component of the master schedule. Backlogs are defined as work that is not scheduled or completed within the master scheduling period. Consider a patient's initial appointment in a behavioral health practice. Because the initial appointment requires that multiple providers see the patient during the visit, a practice may designate one morning a week for initial appointments. The “open access” philosophy requires that new patients be seen within a week. Backlogs of two or more weeks for new patients are inconsistent with the repetitive master scheduling approach.

Open access and repetitive master scheduling are based on the general concept of “continuous flow,” which requires that the amount of work be predicted and resources deployed to complete the work in a specified period of time without backlogs. Continuous flow principles apply to weekly scheduling and even daily scheduling. The physician who sees a patient and completes the chart before moving on to the next patient within the specified activity cycle time is using continuous flow.

Many practices already use some aspects of master scheduling. Practices with open access to visits and phone calls are well along in the development of a repetitive master schedule. For practices that wish to develop a master schedule the following steps should be considered:

  1. Implement an open access system for visiting patients.
  2. Define the care process for each of the top diagnoses to use as input to the master schedule. Include in the definition the desired time between when a patient first presents with the problem and when an effective plan of treatment is begun.
  3. List the services required to accomplish the themes and the internal processes required to support these services.
  4. Devise a master schedule of one to two weeks that addresses who, what, where, and when for the services and processes enumerated above.
  5. Use the following metrics to assess success in executing the master schedule:
    1. the degree of completion of the schedule and the reasons for not achieving it
    2. the percentage of time physicians are doing work that only they can do or that only they are legally allowed to do
    3. the time from patient presentation to treatment for the top 10 diagnoses
Copyright © 2005, National Academy of Sciences.
Bookshelf ID: NBK22839
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