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Ambulatory Management Program Increases Efficiency, Patient and Provider Satisfaction

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Ambulatory Management Program Increases Efficiency, Patient and Provider Satisfaction

Ambulatory Management Program Increases Efficiency, Patient and Provider Satisfaction

Kelly Thomas, Judy Lee, Allison Lange and Rebecca Felter-Wernsdorfer applied lessons from the Ambulatory Management Program to improve communication and increase efficiency in the Johns Hopkins Outpatient Center’s gynecology/obstetrics practice.

Date: 11/02/2015

The exercise was both lighthearted and serious. Knowing staff morale was low, Judy Lee, medical director of the Johns Hopkins Outpatient Center’s gynecology and obstetrics practice, asked everyone in her clinic to rate their pain levels coming to work that day using the “happy face/frowny face” pain scale.

The result: Too many frowns.

Two years later, much has changed, due in large part to the Ambulatory Management Program that Lee attended with administrator Allison Lange and nurse practitioner Erica Gifford. The program, sponsored by the Clinical Practice Association, trains physician-administrator-nurse triads in Lean, a quality improvement methodology. During the six-month program, participants take what they learn back to their clinics. Then, with their staff’s help, they identify quality improvement goals and work together to achieve them.

The goals for Lee’s clinic were to improve workflow, cut patient wait times, and increase staff and provider satisfaction.

A Fresh Look at the Familiar

“One strength of Lean is that it enables those trained in it to take a fresh look at familiar processes, see their problems and then find a better way,” says John Flynn, vice president of the Office of Johns Hopkins Physicians and the organizer of the program.

One problem was immediately apparent: Instruments and other supplies were stored inconsistently room to room, creating inefficiency as the certified medical assistants (CMAs) pulled together what was needed for a specific appointment type — a well-woman visit or a pregnancy checkup, for instance. The solution they implemented was to use color-coded shower caddies as an inexpensive way to organize the supplies needed for different types of appointments.

The team decided to improve provider and staff cohesion by pairing one CMA with one provider; before, the CMAs floated from provider to provider. This change had two benefits. Not only did the provider and the CMA get familiar with each other and work together more efficiently, but patients also saw the same CMA consistently, making their medical visits more personal.

The program brought to light that procedure appointments, such as IUD insertion or endometrial biopsy, tended to run late and crowd the schedule for the remainder of the day, meaning that patients waiting for other appointments had to wait longer. So Lee and colleagues started scheduling procedures for later in the day, affecting other appointments less. This made the workday more predictable for staff members and providers, increasing their satisfaction. The more efficient scheduling reduced overtime.

For Lee, an important aspect of the Ambulatory Management Program was that it encouraged learning from peers at other institutions. “We learned that our Bayview colleagues had similar problems, and we shared solutions.”

Another big takeaway from the program, she says, is the importance of morning huddles before clinic to identify what patients that day are likely to need. “AMP really emphasized communication. The morning huddles really improved how the providers and CMAs interacted, and increased staff and provider satisfaction.”

Although patient wait times did not drop significantly, the gyn/ob practice achieved greater efficiency, reflected in reduced overtime, and dramatically increased provider and staff cohesion, trust and communication, says Lee. For example, she points to the unit’s much improved Safety Attitude Questionnaire scores. Compared with the unit’s results from 18 months earlier, the unit’s score on “Perceptions of Local Management” nearly doubled, reflecting staff members’ enhanced trust in one another. The questionnaire asks respondents to rate the health of their unit’s “Safety Climate.” Lee’s practice saw its score for that question jump 150 percent.

Johns Hopkins Bayview Medical Center Oncology: Scheduling Problems

The triad attending the course from Johns Hopkins Bayview Medical Center’s hematology and oncology clinic — medical director Satish Shanbhag, administrator Maryana Townsend and nurse manager Judy Bekowitz — also had a scheduling problem. Common practice was to have patients come for labs, doctor appointments and chemotherapy on the same day. This meant a long day for patients, and it created a bottleneck, as appointments had to be scheduled for the morning to accommodate all that patients needed to have done. “The patient volume stressed all the clinic processes,” says Shanbhag. “We had overbooking and too much staff overtime.”

So Shanbhag and his colleagues decided to focus on reducing by 10 percent the number of patients who had labs, a provider visit and chemotherapy on the same day, with the aim of improving patient satisfaction scores, reducing overtime, and preventing provider and staff fatigue. So they started offering patients a two-part visit over two days.

Between October 2014 and January 2015, the clinic saw the percentage of patients who chose a three-part visit drop 19 percent, from 63 percent to 51 percent. Press Ganey patient satisfaction scores improved too, from the 69th percentile to the 73rd.

Shanbhag compared the solution to a highway during rush hour: “If you take 2 or 3 percent of cars off the road, you relieve the bottleneck and traffic flows 30 to 40 percent better,” he says. “The Ambulatory Management Program helped us acquire and analyze data around the issues we were having. That allowed us to gain buy-in for moving forward with a change in clinic operations.”

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