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    By Jason Foltz, DO, chief medical officer, ECU Physicians/Brody School of Medicine, East Carolina University; Pamela D. Hopkins, PhD, teaching associate professor, director, Speech Communication Center, East Carolina University; and Robert J. LaGesse, MSM, CMPE, FACHE, chief operations executive, ECU Physicians/Brody School of Medicine, East Carolina University.

    Our quest for the Quadruple Aim — enhancing patient experience, improving population health, reducing costs and improving the work life of healthcare providers, including clinicians and staff1 — can be analogous to the search for the Holy Grail. It’s a never-ending pursuit with a clear purpose toward achieving a systematic cure to our healthcare system. At East Carolina University’s ECU Physicians, we have further defined QUEST to reflect our act of pursuit through improved quality, utilization, efficiency, satisfaction and teamwork.

    During a four-year period, the physician practice strategically created a framework for infrastructure investments, change management strategy and organization structure changes.

    Setting the strategic framework

    Achieving the tenets of the Quadruple Aim requires a strong strategic foundation that serves as a basis for all quality/process improvement work within the organization. Creating a shared vision, using data to drive improvement and harnessing the power of the EHR can serve as a framework to drive improvement within each arm of the Quadruple Aim.

    Leading change

    ECU Physicians relied on John Kotter’s eight-step process for leading change2 in the QUEST project:

    1. Create a sense of urgency
    2. Build a guiding coalition
    3. Form a strategic vision and initiatives
    4. Enlist a volunteer army
    5. Enable action by removing barriers
    6. Generate short-term wins
    7. Sustain acceleration
    8. Institute change.


    In July 2015, our physician practice, made up of 11 clinical departments, created three key positions to help our practice focus on a group mindset. Prior to creating these positions, key operational decisions were primarily handled within each department. We chose to hire a chief operations executive, a director of clinical financial services and an associate medical director. Together with an on-staff chief nurse, they formed the clinical management team. This team was empowered to set strategic goals and drive system-level improvement efforts around the Quadruple Aim.


    A sense of urgency came after a significant financial downturn. We could continue to cut costs and potentially go out of business or make key investments that would enable the organization to focus on a group mindset with improved operational efficiencies leading to improved revenue opportunities.

    Working collaboratively within all operational aspects of our organization (clinical, nursing, administrative and revenue cycle), we were able to make organizational changes, set standard policies, change a culture that enabled bottom-up decision-making and set a strategic vision.

    As we developed a strategic vision, we based all decisions on our core purpose, core values and envisioned future (see Figure 1), which helped advance us in our QUEST toward achieving the Quadruple Aim. Annually, we participated in a strategic planning session that helped prioritize tactics to achieve strategic outcomes through a four-quadrant analysis. We brainstormed tactics we felt we needed to take that year, grouped them into buckets of high value/high resource, high value/low resource, low value/high resource and low value/low resource. From that exercise, we set SMART (specific, measurable, attainable, relevant, timely) goals and listed them under each area of the Quadruple Aim we were focused on. From there, we achieved organization buy-in with our support teams, practice plan board of directors, outpatient medical directors and nursing leaders. 

    Examples include:

    • Exceptional experience: Developed a “secret shopper” program, employee customer service training and staff incentive plan to help drive improvement in patient experience. Established a formal set of practice-wide ambulatory access standards and a set of appointment access/utilization dashboards developed to target opportunities for improved template management to facilitate better patient access.
    • Better health: Developed standard “top of license” nursing protocols, created a quality dashboard, hired quality nurse specialists and developed team quality competitions to drive improved clinical quality outcomes.
    • Better value: Implemented eConsults in 13 specialties (and growing) to help PCPs manage common conditions and prevent patients from expensive unnecessary specialty appointments.
    • Resilient teams: Implemented quarterly leadership development “boot camps” and devised multi-tiered internal communication platforms.


    Our patient experience strategy was divided into three phases. Figure 2 shows a 6.82% to 20.84% improvement in the key outcome questions we were targeting.

    We’ve shown steady growth in all our “quality spotlight” measures we identified as the most impactful to track and improve. Figure 3 shows our improvement over the past three years.

    Maximizing template utilization to improve patient access/volumes

    To drive improvement in access to care, we created a series of dashboards to help our practices identify opportunities to improve templates, referral processing protocols and minimize gaps in the schedule caused by no-shows. These dashboards are run monthly. 

    One of the primary reports used to drive this initiative was the Slot Utilization Report (Figure 4). This report provides a detail of the overall practice template appointment slot utilization. The key performance indicators (KPIs) include percent of slots booked and no-show rates, which is calculated by taking the total number of regular slots available on the template and dividing this number by total slots booked. This statistic provides a critical picture of how the practice is scheduling available appointment slots prior to accounting for patient no-shows. If a practice is not maximizing available slots, this may point to scheduling issues, problems with template control or possibly lack of volume. Each of these can then be studied further to identify opportunities to maximize available resources.

    The data also provide a picture of the number of no-shows. Each month, this allows us to trend the average no-show rates down to the provider level. This information allows us to adjust templates to account for no-shows. This in turn maximizes template utilization rate (the last column on the example report), which can be done by adjusting templates to account for the average percentage of no-shows by provider. 

    Along with referral, third-next-available appointment and provider productivity dashboards, this information provides us with a means to maximize patient access and improve revenue. 


    We made steady improvement in all our focus areas. The key to success is a central management team focused on clinic operations to integrate our 11 clinical departments around a common goal: “to provide the highest quality and most compassionate healthcare to the people of eastern North Carolina while educating the next generation of health professionals to do the same.”


    A dedicated leadership team, focused on a core purpose with a foundation based on the Quadruple Aim, can begin to change the culture of your organization to one with a group mindset passionate about serving the needs of its patients by providing high-value care. 

    Editor’s note:

    The authors wish to acknowledge Martha Dartt, Dagmar Herrmann Estes, Drillious Gay and Jennifer Thompson for their contributions to the article.


    1. Bodenheimer T, Sinsky, C. “From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider.” Annals of Family Medicine. Nov/Dec 2014. Vol 12. No 6. 573-576.
    2. Kotter JP. “Leading Change: Why Transformation Efforts Fail.” Harvard Business Review, May-June 1995 Issue. Available from:

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