Group Medical Visits For Specialists

1. Group Medical Visits For Specialists

2. Group Medical Visits Aim • Improve patient access to and increase efficiency of care and follow-up through shared medical appointments, a time-efficient method of treatment

3. Focus on • Identify suitable patient populations and best suited practice approach • Plan, implement and evaluate shared medical appointments

4. SMA Aims • Improve access (decrease waiting time) • Improve efficiency • Integrate health services – ‘wrap the services around the patient’ • Improve patient and provider satisfaction • Improve health outcomes

5. What are the best patient populations for SMAs? • Baseline data • Endoscopy: Approximately 300 scopes per year • Individual consult appointments • Average wait time for consult – 8 weeks • Average wait time for scope 6-8 weeks • Procedure appointments booked by hospital staff via phone calls

6. Scenario – Defining the Measures • TIME 1 – referral letter to group visit • TIME 2 – group visit to scope procedure • Number of patients seen • Physician and staff work hours

7. Scenario – The Plan • Establish the team – including hospital staff • Determine objectives • Formulate a process • Set a date, time and location • Initiated group consults June 25 2008

8. Scenario – Summary of Measures • ↓ TIME 1 to 4 weeks (50% reduction) • ↓ TIME 2 to 4 - 6 weeks (30% reduction) • ↓ consult time by 52% • ↑ number of patients seen by 29% • ↓ hospital staff booking time by 64%

9. How do we know we have achievedpositive sustainable change? • Met objectives and measures • Group visits held twice a month • Process embedded in the clinic • Cross-training of clinic staff • Hospital staff continue to be involved • Lead physician promoting group visits with other physicians • Patient satisfaction • Provider and staff satisfaction

10. Group Medical Visit Benefits • Decreased wait time • Improved health maintenance • Enhanced services and quality of care • Improved patient and physician relationships • Improved patient and provider satisfaction • Cost savings

11. Group Medical Visits Roles • Specialist • MOA • PSP Coordinator • RNs/other health care providers

12. Specialist Role • 1 to 1 Specialist/patient appointment done in a Group • Share patient clinical data (flip chart, overhead) • Charting during the group meeting • Order lab/diagnostics • Prescriptions • Chart notes • Patients that need to be seen privately can do so at the end • Arrive on time • Leave on time • Participates in short debriefing at the end of GMV

13. MOA or office staff • Organize the group space • Working with the Specialist to ID good time and how often GMVs will be held • Overbook by 25% (stats show 81% of pre-registered actually show up) • Telephone bookings and patient invite and/or send out invitation letter • Make a patient information package • Confidentiality form • Evaluation form • Flow sheets • Handouts doctor wants • Track data/narrative reports/measures i.e. module measurements, completion and target rates • As patients arrive assist with BP, weight, etc. and document • Participates in short debriefing at the end of GMV

14. Coordinator role • Facilitates learnings for GMV for each team member • Encourages role maximizing, and role expansion training • Assists with finding a suitable behaviourist • Attends GMVs until independent • Facilitates team debrief after each GMV • Continues to keep in touch for support • Facilitates model for improvement testing and evaluating • Writes PDSA

15. Physicals Shared Medical Appointments • Shared physicals appointment • They reduce repetitive information • 8-12 patients • 90 minutes long • First half of the session is a private physical exam by doctor - while other group members are sharing & learning with behaviourist • Second half is doctor patient interactions in a group

16. Aim Statement: Increased access, capacity and efficiency in specialty practice • The care of patients requiring specialty services will be redesigned to increase access, capacity and efficiency in specialty practices. • Advanced Access, Efficiency change packages, including Group Medical Visits will be used to decrease the wait time of patients for and at appointments in specialty practices. • Change will be evidenced by improved 3rd next available appointment, or improved cycle time, or the implementation of a minimum of two Group Medical Visits.

17. The Model for Improvement • What are we trying to accomplish? • Aim • How do we know a change is an improvement? • Measures • What changes can we make that will result in an improvement? • Are the small test of changes showing improvement? Source: The Improvement Guide (Langley, Nolan, Nolan, Norman, and Provost, Jossey-Bass, 1996).

18. The PDSA cycle Act Plan • Objective • Questions and • predictions (why) • Plan to carry out • the cycle (who, • what, where, when) • What changes • are to be made? • Next cycle? Study Do • Complete the • analysis of the data • Compare data to • predictions • Summarize what • was learned • Carry out the plan • Document problems • and unexpected • observations • Begin analysis • of the data

19. A P S D D S P A A P S D A P S D Repeated use of the PDSA cycle Changes that result in improvement DATA Implementation of change Wide-scale tests of change Hunches theories ideas Follow-up tests Very small scale test

20. D S P A A P S D D S P A A P S D A P S D Specialty: Improving access Improved access = better patient outcomes DATA Cycle3: Group Medical Visit 2 X per month to work down backlog Cycle 2: Work 1 hour later each day to work down backlog Cycle 1: Measure 3rd Next Available Reduce backlog: Goal is 5 days

21. D S P A A P S D D S P A A P S D A P S D Kelowna’s Aim: Reduce use of Foley catheters following joint arthroplasty surgery Standing orders do not include catheters Idea: Don’t insert at all or else remove catheters Day 1 DATA Cycle3: Second surgeon trials no Foley and in and out PRN Cycle 2: Dr. O’C trials no Foley insertion on pt. with no hx of urinary problems. In and out catheter if unable to void Cycle 1: On male pt. of Dr. O’C’s, with no hx of urinary problems, Foley is d/c’d POD1 with order to perform in and out catheter if unable to void

22. Characteristics of the Model for Improvement • Action-oriented – “What are you going to test next Tuesday?” • Rapid-cycle testing of changes • Evaluation and revision of all changes before implementation • Testing and implementing the changes in small populations, then spreading to the larger population • Impact evaluated using annotated run charts • Monthly reporting of tests and outcomes

23. Planning for Action Period “Fail to plan, plan to fail.”Carl W. Buechner

24. For more information Practice Support Program 115 - 1665 West Broadway Vancouver, BC V6J 5A4 Tel: 604 736-5551 www.pspbc.ca