Providers' experience with an organizational redesign initiative to promote patient-centered access: a qualitative study

Experiences of primary care physicians and staff following lean workflow redesign

BACKGROUND

In response to growing pressures on primary care, leaders have introduced a wide range of workforce and practice innovations, including team redesigns that delegate some physician tasks to nonphysicians. One important question is how such innovations affect care team members, particularly in view of growing dissatisfaction and burnout among healthcare professionals. We examine the work experiences of primary care physicians and staff after implementing Lean-based workflow redesigns. This included co-locating physician and medical assistant dyads, delegating significant responsibilities to nonphysician staff, and mandating greater coordination and communication among all care team members.

METHODS

The redesigns were implemented and scaled in three phases across 46 primary care departments in a large ambulatory care delivery system. We fielded 1164 baseline and 1333 follow-up surveys to physicians and other nonphysician staff (average 73% response rate) to assess workforce engagement (e.g., job satisfaction, motivation), perceptions of the work environment, and job-related burnout. We conducted multivariate regressions to detect changes in experiences after the redesign, adjusting for respondent characteristics and clustering of within-clinic responses.

RESULTS

We found that both physicians and nonphysician staff reported higher levels of engagement and teamwork after implementing redesigns. However, they also experienced higher levels of burnout and perceptions of the workplace as stressful. Trends were the same for both occupational groups, but the increased reports of stress were greater among physicians. Additionally, members of all clinics, except for the pilot site that developed the new workflows, reported higher burnout, while perceptions of workplace stress increased in all clinics after the redesign.

CONCLUSIONS

Our findings partially align with expectations of work redesign as a route to improving physician and staff experiences in delivering care. Although teamwork and engagement increased, the redesigns in our study were not enough to moderate long-standing challenges facing primary care. Yet higher levels of empowerment and engagement, as observed in the pilot clinic, may be particularly effective in facilitating improvements while combating fatigue. To help practices cope with increasing burdens, interventions must directly benefit healthcare professionals without overtaxing an already overstretched workforce.

Patients' Online Access to Their Primary Care Electronic Health Records and Linked Online Services: Implications for Research and Practice

Online access to medical records and linked services, including requesting repeat prescriptions and booking appointments, enables patients to personalize their access to care. However, online access creates opportunities and challenges for both health professionals and their patients, in practices and in research. The challenges for practice are the impact of online services on workload and the quality and safety of health care. Health professionals are concerned about the impact on workload, especially from email or other online enquiry systems, as well as risks to privacy. Patients report how online access provides a convenient means through which to access their health provider and may offer greater satisfaction if they get a timely response from a clinician. Online access and services may also result in unforeseen consequences and may change the nature of the patient-clinician interaction. Research challenges include: (1) Ensuring privacy, including how to control inappropriate carer and guardian access to medical records; (2) Whether online access to records improves patient safety and health outcomes; (3) Whether record access increases disparities across social classes and between genders; and (4) Improving efficiency. The challenges for practice are: (1) How to incorporate online access into clinical workflow; (2) The need for a business model to fund the additional time taken. Creating a sustainable business model for a safe, private, informative, more equitable online service is needed if online access to records is to be provided outside of pay-for-service systems.

Designing Asynchronous Communication Tools for Optimization of Patient-Clinician Coordination

Asynchronous communication outside the clinical setting has both enriched and complicated patient-clinician interactions. Many patients can now interact with a patient portal 24 hours a day, asking questions of their clinicians via secure message, checking lab results, ordering medication refills, or making appointments. However, the mode of communication (asynchronous) and the nature of the interaction (lacking tone or body language) strip valuable information from each side of patient-clinician asynchronous communication. Using interviews with 34 individuals who actively manage a chronic illness of their own, or for a child or partner, we elicited narratives about patients' experiences and expectations for using asynchronous communication to address medical issues with their clinicians. Based on these perspectives, we present opportunities for designing asynchronous communication tools to better facilitate understanding of and coordination around care activities between patients and clinicians.

Patients' online access to their electronic health records and linked online services: a systematic interpretative review

OBJECTIVES

To investigate the effect of providing patients online access to their electronic health record (EHR) and linked transactional services on the provision, quality and safety of healthcare. The objectives are also to identify and understand: barriers and facilitators for providing online access to their records and services for primary care workers; and their association with organisational/IT system issues.

SETTING

Primary care.

PARTICIPANTS

A total of 143 studies were included. 17 were experimental in design and subject to risk of bias assessment, which is reported in a separate paper. Detailed inclusion and exclusion criteria have also been published elsewhere in the protocol.

PRIMARY AND SECONDARY OUTCOME MEASURES

Our primary outcome measure was change in quality or safety as a result of implementation or utilisation of online records/transactional services.

RESULTS

No studies reported changes in health outcomes; though eight detected medication errors and seven reported improved uptake of preventative care. Professional concerns over privacy were reported in 14 studies. 18 studies reported concern over potential increased workload; with some showing an increase workload in email or online messaging; telephone contact remaining unchanged, and face-to face contact staying the same or falling. Owing to heterogeneity in reporting overall workload change was hard to predict. 10 studies reported how online access offered convenience, primarily for more advantaged patients, who were largely highly satisfied with the process when clinician responses were prompt.

CONCLUSIONS

Patient online access and services offer increased convenience and satisfaction. However, professionals were concerned about impact on workload and risk to privacy. Studies correcting medication errors may improve patient safety. There may need to be a redesign of the business process to engage health professionals in online access and of the EHR to make it friendlier and provide equity of access to a wider group of patients. A1 SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42012003091.

The patient centered medical home: mental models and practice culture driving the transformation process

BACKGROUND

The Patient-Centered Medical Home (PCMH) has become a dominant model of primary care re-design. The PCMH model is a departure from more traditional models of healthcare delivery and requires significant transformation to be realized.

OBJECTIVE

To describe factors shaping mental models and practice culture driving the PCMH transformation process in a large multi-payer PCMH demonstration project.

DESIGN

Individual interviews were conducted at 17 primary care practices in South Eastern Pennsylvania.

PARTICIPANTS

A total of 118 individual interviews were conducted with clinicians (N = 47), patient educators (N = 4), office administrators (N = 12), medical assistants (N = 26), front office staff (N = 7), nurses (N = 4), care managers (N = 11), social workers (N = 4), and other stakeholders (N = 3). A multi-disciplinary research team used a grounded theory approach to develop the key constructs describing factors shaping successful practice transformation.

KEY RESULTS

Three central themes emerged from the data related to changes in practice culture and mental models necessary for PCMH practice transformation: 1) shifting practice perspectives towards proactive, population-oriented care based in practice-patient partnerships; 2) creating a culture of self-examination; and 3) challenges to developing new roles within the practice through distribution of responsibilities and team-based care. The most tension in shifting the required mental models was displayed between clinician and medical assistant participants, revealing significant barriers towards moving away from clinician-centric care.

CONCLUSIONS

Key factors driving the PCMH transformation process require shifting mental models at the individual level and culture change at the practice level. Transformation is based upon structural and process changes that support orientation of practice mental models towards perceptions of population health, self-assessment, and the development of shared decision-making. Staff buy-in to the new roles and responsibilities driving PCMH transformation was described as central to making sustainable change at the practice level; however, key barriers related to clinician autonomy appeared to interfere with the formation of team-based care.

Doctors on status and respect: a qualitative study

While doctors generally enjoy considerable status, some believe that this is increasingly threatened by consumerism, managerialism, and competition from other health professions. Research into doctors' perceptions of the changes occurring in medicine has provided some insights into how they perceive and respond to these changes but has generally failed to distinguish clearly between concerns about "status," related to the entitlements associated with one's position in a social hierarchy, and concerns about "respect," related to being held in high regard for one's moral qualities. In this article we explore doctors' perceptions of the degree to which they are respected and their explanations for, and responses to, instances of perceived lack of respect. We conclude that doctors' concerns about loss of respect need to be clearly distinguished from concerns about loss of status and that medical students need to be prepared for a changing social field in which others' respect cannot be taken for granted.

Open access in the patient-centered medical home: lessons from the Veterans Health Administration

BACKGROUND

The Veterans Health Administration (VHA) has undertaken a 5-year initiative to transform to a patient-centered medical home model. An early focus of implementation was on creating open access, defined as continuity and capacity in primary care.

OBJECTIVE

We describe the impact of readiness for implementation on efforts of pilot teams to make changes to improve access and identify successful strategies used by early adopters to overcome barriers to change.

DESIGN

A qualitative, formative evaluation of the first 18 months of implementation in one Veterans Integrated Service Network (VISN) spread across six states.

PARTICIPANTS

Members of local implementation teams including administrators, primary care providers, and staff from primary care clinics located at 10 medical centers and 45 outpatient clinics.

APPROACH

We conducted site visits during the first 6 months of implementation, observations at Learning Collaboratives, semi-structured interviews, and review of internal organizational documents. All data collection took place between April 2010 and December 2011.

KEY RESULTS

Early adopters employed various strategies to enhance access, with a focus on decreasing demand for face-to-face care, increasing supply of different types of primary care encounters, and improving clinic efficiencies. Our interviews with key contacts revealed three important areas where readiness for implementation (or lack thereof) had an impact on interventions to improve access: leadership engagement, staffing resources, and access to information and knowledge.

CONCLUSIONS

Key factors related to readiness for implementation had an impact on which interventions pilot teams could put into place, as well as the viability and sustainability of access gains. Wide variations in interventions to improve access occurring across sites situated within one organization have important implications for efforts to measure the impact of enhanced access on patient outcomes, costs, and other systems-level indicators of the Medical Home.

The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers

As the patient-centered medical home model emerges as a key vehicle to improve the quality of health care and to control costs, the experience of Seattle-based Group Health Cooperative with its medical home pilot takes on added importance. This paper examines the effects of the medical home prototype on patients' experiences, quality, burnout of clinicians, and total costs at twenty-one to twenty-four months after implementation. The results show improvements in patients' experiences, quality, and clinician burnout through two years. Compared to other Group Health clinics, patients in the medical home experienced 29 percent fewer emergency visits and 6 percent fewer hospitalizations. We estimate total savings of $10.3 per patient per month twenty-one months into the pilot. We offer an operational blueprint and policy recommendations for adoption in other health care settings.

Patient experience in the pediatric otolaryngology clinic: does the teaching setting influence parent satisfaction?

OBJECTIVES

Patient experience scores are now recognized as a chief indicator of healthcare quality. This report compares outpatient pediatric otolaryngology patient satisfaction in the teaching and non-teaching settings.

STUDY DESIGN

Cross-sectional, multi-site, patient-level analysis of satisfaction surveys (Press Ganey™ Medical Practice©) completed by parents of pediatric otolaryngology patients in FY2010.

METHODS

Surveys were stratified by teaching/non-teaching affiliation. The survey has 29 Likert-scaled questions which comprise an overall score and subscores in 6 domains: access, visit, nursing, provider, personal issues, and assessment. The item likelihood-to-recommend was measured to indicate practice loyalty. Mean scores were compared by Kruskal-Wallis rank test. Multivariate logistic regression was performed to evaluate the association of teaching status with receipt of highest scores (HI-SCORES).

RESULTS

4704 pediatric surveys were analyzed, with 1984 (42%) from the teaching setting. For the teaching setting, mean scores were lower overall (88.1 vs. 89.0; p<0.001) and in domains of access (includes scheduling ease, promptness in returning calls; 86.7 vs. 89.4; p<0.001) and personal issues (includes office hour convenience, sensitivity to needs; 87.0 vs. 88.5; p<0.001). Differences in access scores were largest for young children (0-<6 years; 86.0 vs. 89.5; p<0.001). Children in the teaching setting were less likely to have HI-SCORES overall (OR 0.78; 95%CI 0.65-0.95; p=0.011) and for access (OR 0.8; 95%CI 0.67-0.95; p=0.012); probability of HI-SCORES was similar for the two settings for all other domains.

CONCLUSIONS

Parents of pediatric otolaryngology patients evaluated in the teaching setting report lower satisfaction related to access, but similar scores for care providers and practice loyalty. Academic otolaryngology practices might focus on access issues to improve the overall care experience for children and families.

Does a large-scale organizational transformation toward patient-centered access change the utilization and costs of care for patients with diabetes?

The authors examined whether Group Health's Access Initiative changed the utilization and costs of care among enrollees with diabetes. Using a single (one-group) interrupted time series design, repeated-measures generalized estimating equation models were used to estimate changes in utilization and costs during the Initiative rollout (2002-2003) and to compare the slopes (annual rates of change) for utilization and costs during the Pre-Initiative period (1998-2002) to the slopes during Full-Implementation (2003-2006) among 9,871 members continuously enrolled from 1997 to 2006 with type 1 or 2 diabetes. Total costs increased in Full-Implementation, but the annual change in total costs did not change. Primary care visits declined, but primary care contacts grew, largely from the Initiative's introduction of secure messaging. Specialty visits did not change; however, the Initiative may have increased emergency visits. To reduce emergency visits, future access initiatives should include proactive and comprehensive outpatient care for patients with diabetes.

[Internet, SMS or voice portals tools. New technologies for an old problem]

OBJECTIVE

To analyse the frequency of use, effectiveness and usability of automated systems for obtaining appointments in primary care from a user point of view.

METHODS

A cross-sectional study was conducted using a telephone survey of a random sample of 6193 patients (or parents or guardians of paediatric patients) treated in primary care in the Valencian Autonomous Community.

RESULTS

A total of 397 (13.4%) adult patients and 1000 (31%) of parents or guardians of the paediatric patients used the Internet. The Voice Portal (225, 3.6%) and SMS (57, 0.9%) was the least used. The Internet was mostly used by men (χ(2) 15.1, P<.004) and among adult patients aged between 51 and 70 years (χ(2) 40.5, P<.001). The traditional channels (telephone call or asking for an appointment personally) were used by chronic patients (χ(2) 28.7, P<.001) and those with who used the health sytem less (χ(2) 52, P<.001). The use of ICT is not responsible for delays in the date of appointment. Usability was very high (above 90%), except in the case of the system based on SMS (80.7%).

CONCLUSIONS

The Internet is the preferred channel among ICT to obtain an appointment. Its use is expected to increase. The effectiveness of ICT to get an appointment is somewhat higher than traditional channels. The usability of ICT to get an appointment is similar or superior to the traditional channels. The exception is the messages from a mobile.

Integrating an internet-mediated walking program into family medicine clinical practice: a pilot feasibility study

Background

Regular participation in physical activity can prevent many chronic health conditions. Computerized self-management programs are effective clinical tools to support patient participation in physical activity. This pilot study sought to develop and evaluate an online interface for primary care providers to refer patients to an Internet-mediated walking program called Stepping Up to Health (SUH) and to monitor participant progress in the program.

Methods

In Phase I of the study, we recruited six pairs of physicians and medical assistants from two family practice clinics to assist with the design of a clinical interface. During Phase II, providers used the developed interface to refer patients to a six-week pilot intervention. Provider perspectives were assessed regarding the feasibility of integrating the program into routine care. Assessment tools included quantitative and qualitative data gathered from semi-structured interviews, surveys, and online usage logs.

Results

In Phase I, 13 providers used SUH and participated in two interviews. Providers emphasized the need for alerts flagging patients who were not doing well and the ability to review participant progress. Additionally, providers asked for summary views of data across all enrolled clinic patients as well as advertising materials for intervention recruitment. In response to this input, an interface was developed containing three pages: 1) a recruitment page, 2) a summary page, and 3) a detailed patient page. In Phase II, providers used the interface to refer 139 patients to SUH and 37 (27%) enrolled in the intervention. Providers rarely used the interface to monitor enrolled patients. Barriers to regular use of the intervention included lack of integration with the medical record system, competing priorities, patient disinterest, and physician unease with exercise referrals. Intention-to-treat analyses showed that patients increased walking by an average of 1493 steps/day from pre- to post-intervention (t = (36) = 4.13, p < 0.01).

Conclusions

Providers successfully referred patients using the SUH provider interface, but were less willing to monitor patient compliance in the program. Patients who completed the program significantly increased their step counts. Future research is needed to test the effectiveness of integrating SUH with clinical information systems over a longer evaluation period.

Group health cooperative's transformation toward patient-centered access

The Institute of Medicine suggests redesigning health care to ensure safe, effective, timely, efficient, equitable, and patient-centered care. The concept of patient-centered access supports these goals. Group Health, a mixed-model health care system, attempted to improve patients' access to care through the following changes: (a) offering a patient Web site with patient access to patient-physician secure e-mail, electronic medical records, and health promotion information; (b) offering advanced access to primary physicians; (c) redesigning primary care services to enhance care efficiency; (d) offering direct access to physician specialists; and (e) aligning primary physician compensation through incentives for patient satisfaction, productivity, and secure messaging with patients. In the 2 years following the redesign, patients reported higher satisfaction with certain aspects of access to care, providers reported improvements in the quality of service given to patients, and enrollment in Group Health stayed aligned with statewide trends in health care coverage.