Knowledge Expansion Integrated care teams: A Lean model to reduce burden and optimize throughput Insight Article Staffing Models Patient Access Practice Efficiency Sign in to save Terra Spann RN, BSN Physician burnout, staff turnover and disjointed throughput are common factors affecting care access and quality in today’s healthcare settings. The Medscape National Physician Burnout, Depression & Suicide Report 2019 quantifies the physician burnout crisis. A survey conducted with more than 15,000 physicians representing 29 specialties paints the grim picture that more than 40% of physicians report signs of burnout.1 This rate is even higher for female physicians and other providers within certain specialties.2 A primary cause attributed to burnout is increasing demands which require physicians to spend more hours at work, leaving less time for family interaction or other fulfilling activities. As a result, physicians have an annual turnover rate of 14% and reduced job satisfaction. Even more concerning, the physician suicide rate is more than double the general population average and the highest of all professions.3 Burnout’s effects on turnover A parallel concern for all clinical settings is the high rate of turnover and dwindling resource pools of support personnel. A report from 2017 demonstrated an average turnover rate of 18.2%, the highest rate in almost a decade and second only to the hospitality industry. Additionally, 23.8% of new hires leave within a year, and more than 50% of employees spent less than two years with their organization,4 the absence of workplace engagement contributing significantly to this continued churning. This phenomenon, along with increased numbers of retiring employees, creates challenges in maintaining appropriate staffing levels and also ensuring the skill and knowledge level of personnel. Over the next 10 years, turnover will become an even larger issue as the number of healthcare employees entering and continuing in the workforce is not sufficient to meet the expected increase in patient demand. The result of these factors is a reduction in patient access. Additionally, broken processes build waste and waiting into our systems, adding additional congestion to the patient care flow. Increasing demand of an aging population and further limitations imposed by regulatory requirements will compound these challenges in the future. Building a strategy to increase physician satisfaction Bon Secours Medical Group (BSMG) is not immune to these challenges. Over the past three years, BSMG experienced single-digit physician satisfaction, excessive documentation after hours, staff turnover rates at or above the national average, third-next-available access greater than three to six months in certain locations and specialties, and low patient satisfaction scores for ease of scheduling appointments and wait times in the clinic. As a countermeasure to these problems, the System Transformation Office (STO), along with consultants, partnered with providers and staff to develop an integrated care team model, also known as a flow cell, through the integration of Lean methodology. In late 2018, Palmetto Pulmonary and Critical Care (PP) hosted a five-day workshop to outline the current state of its patient flow, define improvements expected in the future, and redesign processes to decrease provider burden, increase staff satisfaction, decrease defects and improve patient throughput, thereby enhancing patient satisfaction. The outcome of the workshop was the creation of an integrated care team model. Travis Greer, MD, a pulmonary critical care physician at PP, summarized the purpose of the transformation work: With this model, the goal was to make the patient the center of each visit, with the various employees coming to them instead of making the patient move from station to station within our office. Through ongoing small tests of change via the Plan-Do-Check-Act (PDCA) cycle, the team developed a succinct workflow that decreased patients’ time spent in the office by 37% through the reduction of waste, primarily waiting and motion. Additionally, through level-loading responsibilities across the entire care team, time patients spent face to face with physicians remained unchanged at 20 minutes. “We combined this flow cell model with various work sharing strategies between the provider and the MAs [and front office personnel] to offload some of the charting and clerical work from our providers, which allowed us to get through our charting faster and on to our next patient, which meant less waiting for [our patients],” Greer said. This redistribution of work cut provider documentation time in half, allowed providers to complete all work at work (eliminating after-hours work), and enhanced personnel job satisfaction by increasing a sense of importance for all roles and developing employees through ongoing learning. Long-term benefits demonstrated a reduction in third-next availability from more than 20 days to less than three days and increased patient satisfaction in the area of ease of scheduling an appointment. After demonstrating success in our specialty setting, the next venture was to test the same model in our primary care practices. In March 2019, Family Practice Associates of Easley (FPA) embarked on developing an integrated care model. Although some aspects varied from PP’s design, many of the same aspects were replicated easily in the primary care setting. Through a similar process, FPA orchestrated a system in which the MAs drive the daily workflow serving as “flow managers” in each clinical area. Throughout the day, MAs assist physicians in addressing time sensitive requests and integrating out-of-cycle work, or work that does support patients seen that day in the clinic, into their routine. This allows all team members to address a few small items (e.g., FMLA paperwork, laboratory results, patient phone calls, etc.) between each patient instead of holding everything to complete in one large batch at the end of the day. According to workshop participant Cynthia Squires, MD, physicians are able to “address the patient’s labs and concerns in a more timely manner and … address the most urgent messages first on an hourly basis” as a byproduct of these changes. FPA also saw similar results to PP with a 21% reduction in patient wait times and time to chart closure decreased by 38%. Additionally, external setup by MAs allowed providers to address many health maintenance initiatives, such as mammography and colonoscopy screening, which enhanced individual and system-wide quality scores. Finally, physician work-life balance was significantly improved with one provider’s child even inquiring why they no longer brought home their computer. Despite the great successes noted at PP and FPA, not all attempts to spread the concepts resulted in favorable outcomes. Primary factors contributing to the inability to integrate these new concepts included: Limited understanding and adoption of Lean core principles by site leadership Failure to adequately prepare the team for the changes to expect in work patterns Inclusion of providers who were not open or ready to change. Countermeasures for these challenges included the development of a site pre-evaluation plan and tool to assess readiness for all parties, close collaboration with site leaders regarding communication plans and preparing the team, and mentor/observation opportunities between providers who successfully integrated the new model and those considering the effort. Although the process and changes are challenging, due diligence and commitment to the integrated care team approach is a viable solution for many of the problems plaguing healthcare today, including physician burnout, staff turnover and patient throughput. The success of these initiatives is dependent on the efforts and engagement of the team and the willingness to trial and adopt change. Julie Dangler, MD, a primary care physician at FPA, summarized the process well: “It’s about change. You think it won’t work, but it really does work. However, it requires providers [and staff] to be flexible. Small changes can make a big difference. It’s not changing how you practice but changing the things around you. If you do, then life will be so much easier!” Integrated care team model components Resources for replication will include: Pre-assessment tool to determine readiness Workshop preparation checklist Data collection board model to track daily process metrics Leadership rounding tool to maximize support and increase success Standard work for out-of-cycle work level-loading Standard work for shared documentation (Epic platform) Standard work for MA support of health maintenance requirements (Epic platform) Other documents as identified during presentation development. Notes Kane L. Medscape National Physician Burnout, Depression & Suicide Report 2019. Medscape, Jan. 16, 2019. Available from: wb.md/3axL1Wm. Ibid. Anderson P. “Physicians experience highest suicide rate of any profession.” Medscape. May 7, 2018. Available from: wb.md/3bt9YU6. Wells M. “Healthcare turnover rates in 2018.” DailyPay. Nov. 14, 2018. Available from: bit.ly/3cHLAyc.