Introduction
In the
early 1990s, the Kaiser Permanente (KP) Orange County Medical Service
Area (MSA) sought to become a leader in delivery of accessible, high-quality
health care. Facing major cost challenges and shrinking market share,
the Orange County MSA implemented two major changes: 1) decentralizing
both primary and specialty care into a dozen different medical office
buildings scattered over a large geographical area; and 2) shifting
the support staff personnel from registered nurses and licensed vocational
nurses to medical assistants. As these two changes coincided with
rapid growth of the Health Plan membership, physicians struggled daily
to meet the needs of members. In response to the need to improve support
and efficiency in the medical offices, the KP leadership in Orange
County, California commissioned the Optimal Office Practice Support
(OOPS) project. The design phase of the project extended from August
1996 through October 1997; implementation began in March 1998 and
is ongoing.
Goals of the OOPS Project
The
goals of the OOPS project were simple yet comprehensive:
- Physicians
would receive consistent clinical support from competent staff;
- Each
team would be supervised by a Team Leader trained to support the
medical assistants and to manage the flow of patients and physician
messages;
- Examination
rooms and special procedure rooms would be consistently stocked
with equipment and supplies needed by physicians in daily practice;
-
Physicians
and other providers of care (such as nurse practitioners and physician
assistants) would be grouped into care teams visible to members
and matched to those members' needs (eg, Vietnamese-speaking clinicians
would be grouped at locations visited by Vietnamese-speaking members);
-
Agreements
and other tools would be developed to help clinicians to share
the work (eg, answering messages from patients, reporting test
results, and prescribing medication refills); and
-
Receptionists
would be recognized as vital members of the care team who begin
the patient's care experience--ie, at initial contact at the office
visit.
Figure
1. Structure of the Optimal Office Practice Support (OOPS) project
designed and implemented in the KP Southern California Region. MA
= medical assistant; TL = team leader; NP = nurse practitioner; PA
= physician assistant; SLL = service line leader.
Process Used by the
OOPS Project
A change
effort of this magnitude required--and received--guidance from a multidisciplinary
committee, the steering committee, chaired by a physician recognized
as a leader by other physicians; by an administrative co-chair at
the assistant medical group administrator level; and by an organizational
effectiveness consultant whose function was to assist the group in
managing change (Figure 1).
Because
of the magnitude of the change effort and the natural divisions in
the work to be carried out, four multidisciplinary teams were created
to address specific aspects of the project: the Clinical Assistant/Team
Leader Team, the Physical Layout Team, the Nurse Practitioner/Physician
Assistant Team, and the Reception Team (Figure 1). Each team included
a representative from each stakeholder group that would be involved
in the change effort. Following the partnership model of the steering
committee, each team was led jointly by a physician and an administrator
at the assistant medical group administrator level.
The
Clinical Assistant/Team Leader Team addressed issues of nursing consistency
and skills competency and supported team agreements and relationships.
The
Physical Layout Team devised guidelines for creating a professional
appearance for all parts of office buildings visited by members (eg,
waiting rooms, check-in stations, examination rooms, and procedure
rooms). This team also developed strategies that would help physicians
to decide what supplies would be stocked in examination and procedure
rooms and that would enable the staff to stock these supplies easily.
The
Nurse Practitioner/Physician Assistant Team created tools to help
Health Plan members to better understand the team care concept and
to identify their care team. The team also devised both a set of templates
and a process for creating work agreements for the teams. The process
was designed to clarify the answers to such questions as who prescribes
medication refills or handles patient messages when a clinician is
away from the office.
The
Reception Team worked to standardize appearance of the reception area
and the forms used there and developed strategies to meet variable
demand at check-in while avoiding long waits in lines.
The
project was conducted in two phases: a design phase and an implementation
phase. Although the membership of the design teams was different than
membership of the implementation teams, some key members served during
both phases, mainly to help ensure continuity. During the implementation
phase, each team visited each medical office building sequentially
to work with a building-based implementation team. Depending on the
team product being implemented, the OOPS team conducting the implementation
remained involved from start to finish at each building. The mean
duration of this process was three months.
Early
in the implementation process, teams discovered that the extensive
amount of work required for implementing change at each location could
not be done without using an explicit "roadmap" of tasks
to be accomplished. Each team therefore developed "toolkits"
containing templates and timelines for all tasks to be accomplished.
This degree of detailed instruction as well as periodic follow-up
were necessary to ensure completion of the work.
Products Created by
the Teams
Medical
Assistant/Team Leader Team
This
team compiled a list of all skills necessary for each staff member
of every clinical department. The team also established a process
for training and monitoring staff competency in those skills. The
team also established guidelines for ensuring that for every clinician,
a primary medical assistant would be designated and that this support
would be provided with an established level of consistency (ie, at
least 80% of the time). The team created the "Provider Preference
Guide," a tool for physicians, nurse practitioners, and physician
assistants to clearly state their preferences for work-related items
and procedures (eg, glove size, preparing patients presenting with
certain problems, or whether the clinicians' mail would be opened
for them.) Templates for agreements between medical assistants and
their team leader were devised, and the role of each team leader was
clarified. Suggested target ratios were established for the number
of clinicians supported by each team leader, although we have found
that these target ratios must be adjusted as processes of delivering
care become progressively complex.
Physical
Layout Team
This team created templates for planning specialty-based examination
and procedure rooms. Each template consisted of a map taped inside
the cabinet to list supplies located in the examination or procedure
room. Supplies were organized in a series of blue plastic bins labeled
with the item contained. Each bin was also labeled with a "par"
value, a designation intended to assist the restocking process: Items
used in high volume would be assigned a high par value, indicated
that the items should be stocked in greater quantities.
The
team also developed guidelines for ensuring a more professional appearance
of examination rooms and nursing stations. For example, items taped
to examination room walls were not permitted; instead, items were
to be attached to bulletin boards or framed. The appearance of patient
check-in stations also was addressed: All personal items were to be
kept from members' view by being located under a mat on the desktop.
Items remaining in view were to have an uncluttered appearance.
Nurse
Practitioner/Physician Assistant Team
This team facilitated development of care teams consisting of physicians,
nurse practitioners, and physician assistants. The team also developed
visibility tools (eg, photographs) to be posted in examination rooms
of all care team members supporting a given physician. This practice
allowed the nurse practitioner or physician assistant assigned to
work with a physician to be introduced to the patient at the time
of a visit. In addition, agreements were made between physicians and
their "practice partners" (nurse practitioner or physician
assistant) about how to share the care of patients with chronic conditions
(eg, diabetes). For example, the physician and his or her practice
partner could each see the patient separately at alternate visits.
Another
product created by the team was a template for formulating agreements
about "who will cover for whom" with regard to obtaining
and conveying test results, handling messages to and from patients,
and prescribing medication refills when team members are away from
the office. In addition, tools were created for clearly communicating
these agreements.
Reception
Team
This team examined the forms available and functions being performed
in reception areas. The team streamlined the number of forms that
receptionists were required to handle and identified communication
strategies for use with the "back office" team. The "lead
receptionist" position was created so that the group would have
a point person for communication about new tasks and systems as well
as issues of importance to the team. This team also originated the
concept of a "morning report" for each building: For this
daily morning event, the staff "huddle" for a few minutes
to communicate and plan the day's work.
Assessment of OOPS Project
Progress
Throughout
the project period, the Steering Committee continually reevaluated
whether or not the issues being discussed were indeed the right issues
and whether the changes being attempted were actually happening. Understanding
that many things are required to support medical practices and that
efforts at change may sometimes become secondary to the struggles
of day-to-day operations, the Steering Committee used an audit process
to maintain focus. Instead of merely asking, "Do you have agreements
between providers about coverage?" each team audited certain
key elements of their products. For example, an audit might instruct,
"Show me the agreements that your team has made" or "Show
me your exam room templates for the pediatricians in your building."
This audit was conducted at the conclusion of the implementation team's
efforts for a building. These audits were necessary to ensure consistent
implementation across the medical service area. For the same reason,
a semiannual audit process was developed to help teams to maintain
focus on an ongoing basis.
A survey
also was developed for each group of care team members (physicians,
nurse practitioners and physician assistants, team leader, medical
assistants, receptionists, and department administrators) in each
building. This survey was designed to examine all aspects of the team's
products and to locate opportunities for further improvement.
Figure 2. Graph shows results of question 11 on 2001 Physician Assessment
of Support Service survey distributed to KP physicians in Orange County,
California.
Figure 3. Graph shows results of question 13 on 2001 Physician Assessment
of Support Service survey distributed to KP physicians in Orange County,
California.
Figure 4. Graph of results of Ambulatory Satisfaction Questionnaire
(ASQ) shows percentage of patient-respondents reporting "very
high satisfaction" with their medical visit.
Results of Project Assessment
The
results of this effort were measured in many ways. An OOPS audit and
survey were done annually; the data from these instruments were used
primarily to determine whether the planned work was actually done;
whether the constituents of each building perceived these results
as helpful; and whether need for improvement remained. Physicians'
perceptions were measured by using relevant questions from the Physician
Assessment of Support Services (PASS) study done semiannually by KP
in Orange County (Figures 2,3).
The
overall staff satisfaction was measured by the People Pulse study,
which examines more than OOPS-related issues. In this employee survey,
Orange County ranked first in Southern California for 20 of 28 indicators.
Health Plan members' perceptions were inferred from the Meteor study
and from the Ambulatory Satisfaction Questionnaire) study (ASQ) (Figure
4), two tools used in Orange County to measure satisfaction.
Learning From the Project
A project
of this size, scope, and length of time produced some key learnings:
-
Visible support from senior leaders is essential. This support was
embodied by the OOPS project being part of the strategic plan, by
carefully allocating key people's time, and by intervening with
regard to key issues to help project teams move forward.
-
Physician leadership and involvement is critical. Physicians selected
to lead teams were highly regarded by their peers In addition, physicians
served as team co-chairs and were involved in every aspect of implementing
the project.
-
Allow enough time to successfully anchor the changes. Resist attempts
to set overly optimistic or unrealistic timelines.
-
Make work easier for target groups. Create processed checklists
and toolkits.
-
Adapt, adjust, and revise as needed. Ask questions as they arise;
listen to complaints and feedback; and change, adapt and revise
operations as needed. Use learnings gleaned from each site to implement
and adapt products according to the unique needs of each department
and location.
-
Communicate, communicate, communicate! Keep changes on everyone's
"radar screen." Share design data and reasons for each
change. Focus positively on the need for change and on the ways
this change will improve the workplace for everyone.
-
Actively manage all aspects of the process. Regularly update the
leadership and obtain help from all available sources.
-
Observe and integrate the success of others. Showcase and use best
practices and novel ideas regardless of their origin.
-
Create accountability within operations. Ensure that accountability
is part of everyone's role and is clearly stated to be a performance
expectation.
-
Celebrate success. Reward progress and celebrate small milestones.
Because the process is long, maintaining the team's enthusiasm is
essential. Create an overall award to be given annually for the
highest-achieving locations.
Conclusions
The
magnitude of change contemplated by the OOPS project required enormous
planning, resources, and commitment on the part of everyone who worked
at KP in Orange County. As often occurs when staff implement efforts
to change daily operations, projects begun with much energy are later
found to require tools for maintaining processes of change as well
as for refocusing efforts. These mechanisms are needed to ensure that
all change takes root in the organization and accommodate the continuous,
rapid evolution of health care delivery systems--in particular, the
electronic medical record. Thus, the need to reassess continuously
the basic assumptions and workflow analyses used to design office
support systems forms the basis for the OOPS project, whose work is
continuing.
Acknowledgments
We
would like to acknowledge the following individuals for their contributions
to this project: Edward Ellison, MD, Orange County Area Associate
Medical Director (2002 through present) Kenneth Bell, MD, Orange
County Area Associate Medical Director through 2001; Judy White,
MBA, Medical Group Administrator, Orange County Medical Center;
Gerald McCall, Senior Vice President and Service Area Manager, Kaiser
Foundation Hospital, Anaheim (January 1988 through November 1998);
Janice L Head, RN, FACHE, Senior Vice President and Service Area
Manager, Kaiser Foundation Hospital, Anaheim (November 1998 through
May 2002); Julie Miller-Phipps, MSHA, Senior Vice President and
Service Area Manager, Kaiser Foundation Hospital, Anaheim; Diem
H Do, MBA, Optimal Office Practice Systems (OOPS) Project Manager
(2000 through present); Sharon Hobson, RN, OOPS Project Manager
(inception through 2000); Monica Mehren, MD, OOPS Physician Chair
(inception through 1998); Peggy Grau, MD, and Judith Malouf, RN,
MSA, Medical Assistants/Team Leaders; Sam Constantini, MD, and Priscilla
Daniel, RN, Nurse Practitioner/Physician Assistant Team Leaders;
David Cordes, MD, and Jeff Hunter, Physical Layout Team Leaders;
Brenda Steffensen, MD, and Arlene Lundy, Reception Team Leaders;
Debra Freedman, MA, Organizational Research; Maggie H Pierce, RN,
and Tam Minh Chung, MD, Leaders Educare Team. Virginia Fitz provided
administrative and graphics support; and Juan Domingo, Department
of Medical Editing, provided graphics assistance
