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Optimal Practice Support (OPS) at the Kaiser Permanente Los Angeles Medical Center | pdf >>

By Nancy A Cohen, MD

Abstract
Control over the practice environment is one determinant of the quality of professional life for physicians. As part of its Quality of Professional Life Initiative, senior leadership at the Kaiser Permanente (KP) Los Angeles Medical Center implemented Optimal Practice Support (OPS) to increase the quality of physicians' professional lives. In primary as well as specialty ambulatory care departments, OPS is a clinician-focused way to address standards for relaying messages between patients and their physicians; for ensuring consistent availability of support staff; and for preparing examination rooms (ie, setting up for each patient visit and ensuring that the examination room is well stocked with necessary medical supplies). Departments that had been implementing OPS were audited three times during 2002. Compared with results of a 2001 survey, a 2002 survey of quality of physicians' professional lives showed that 12% more physicians reported believing that the KP Los Angeles Medical Center had been successful in its efforts to improve the quality of physicians' professional lives.

One determinant of the quality of a physician's professional life is control over the practice environment. Indeed, perceived control over the practice environment is one of 10 evidence-based practices for successful organizational retention of physicians.¹

The Southern California Permanente Medical Group (SCPMG) has made an organizational commitment to improve physicians' control over the practice environment. At the Kaiser Permanente (KP) Los Angeles Medical Center--the tertiary medical center for KP in Southern California, the Optimal Practice Support (OPS) Project was launched to support physician practice in the ambulatory setting. OPS was sponsored by senior leadership and was introduced in April 2001 as part of the Quality of Professional Life Initiative, an effort to increase the quality of physicians' professional lives.

The philosophy of OPS is to be physician-focused in addressing several areas: relaying messages between patients and their physicians; ensuring consistent availability of support staff; and preparing examination rooms (ie, setting up for each patient visit and maintaining sufficient inventory of supplies). The goal of OPS is to create an environment in which all physicians at the Los Angeles Medical Center achieve a sense of professionalism by using practice methods that support optimal patient care delivery.

OPS was originally intended to support primary care physicians in an ambulatory care setting. Because the KP Los Angeles Medical Center is a tertiary care facility, however, expansion of OPS was needed beyond primary care departments.

OPS was implemented by a steering committee in conjunction with three specific workgroups, each of which respectively set standards for auditing message handling, consistent availability of staff, and preparation of examination rooms (ie, setting up for each patient visit and ensuring that examination rooms remained well stocked with appropriate supplies). Needs and standards of the workgroups--named Exam Room Stocking and Setup; Message Handling; and Staffing Consistency--were determined by office personnel, whose expertise in these areas was thus relied upon.

The OPS Steering Committee consisted of Assistant Medical Group Administrators from the surgical and primary care services in addition to a Department Administrator from Care Management. Physician representatives included the Assistant Area Medical Director, who was also Chair of the Quality of Professional Life Steering Committee; the Chief of the dermatology service; primary care physicians from the Departments of Internal Medicine and Family Practice; and a surgeon from the Department of Head and Neck Surgery. Members of the steering committee served on the workgroups as liaison to the steering committee.

The workgroups had the following membership:

• The Exam Room Stocking and Setup workgroup consisted of a registered nurse from the pediatrics department; clinic assistants from the family practice and obstetrics and gynecology departments; department administrators from the dermatology and internal medicine departments; and physicians from the orthopedics and family practice departments.
• The Message Handling workgroup consisted of the advice nurse from the family practice department; department administrators from the family practice and surgery departments; clinic assistants from the neurology and pediatrics departments; the Call Center assistant medical group administrator; a Call Center supervisor; and physicians representing the family practice, head and neck surgery, and dermatology departments.
• The Staffing Consistency workgroup consisted of an assistant medical group administrator; a registered nurse from the internal medicine department; department administrators from the internal medicine and family practice departments; licensed vocational nurses from the medical office buildings; a representative from the central staffing department; and physicians representing the family practice and obstetrics and gynecology departments.

The main focus of the OPS Steering Committee was development of an audit tool for departments implementing OPS. Using a 0- or 1-point scale, members of the OPS Steering Committee audited the ambulatory care departments in the KP Los Angeles Medical Center to determine compliance with OPS implementation. The audit consisted of inspections, review of documents, and interviews with physicians and staff. Special attention was given to methods for evaluating clinician satisfaction with OPS at the departmental level.

OPS Challenges and Learnings

Use of the audit tool presented various challenges and led us to reach several conclusions:

• When OPS was expanded beyond primary care, the audit tool was applied inconsistently.
• OPS implementation reflected different resources for primary and specialty departments.
• Relocation of departments made OPS implementation difficult.
• Space constraints affected OPS implementation of standards for handling messages.
• At most physician office visits, personnel shortages adversely affected OPS implementation standards for triage and advice nurse staffing as well as for consistent clinical support staffing (ie, consistent staff available at least
  80% of the time).

A target of 85% was established for acceptable implementation of OPS. Twenty-five departments, including outlying medical office buildings and several specific modules, were audited. Audits were conducted in February, July, and November of 2002. At the end of 2002, 17 departments had achieved a mean score of 85% or better. Four departments scored 100% on the November 2002 audit.

Several departments demonstrated successful practices in the OPS audit areas: The Department of Pediatrics developed and implemented a message record/progress note system (Figure 1).


Figure 1. Message Record form developed by the Pediatrics Department

• The Department of Nephrology developed and implemented a tracking process that used a medical office checklist for cross-training, orientation, and competency.
• The Exam Room Stocking and Setup workgroup developed a Provider Preference Guide and posted lists of examination room supplies as well as par levels and location of supplies.

Other successful practices included use of a message log, advance preparation of medical charts before appointments, and attaching to these charts copies of relevant laboratory and radiology reports as well as recent consultation notes.

OPS was identified as a process useful for increasing the quality of professional life for physicians. Developed to evaluate overall quality of professional life among physicians, a Quality of Professional Life Survey was distributed to 433 physicians at the KP Los Angeles Medical Center in 2002 and yielded a 50% return rate (215 surveys returned). Compared with results of a similar survey conducted in 2001, results of the 2002 survey showed a 12% increase in the category, "I believe that the efforts of LAMC to improve the quality of professional life have been effective."

The senior leadership of the KP Los Angeles Medical Center continues to recognize the importance and accountability of OPS as an ongoing effort. Departments that achieved OPS goals were recognized by the medical center at a meeting of chiefs of service and department administrators.

Continuous implementation of OPS and focus on OPS are in progress. For 2003, the OPS process was revised to be more inclusive of nonoffice and hospital-based departments. All departments were asked to address an aspect of Quality of Professional Life that would lead to increased physician satisfaction. In addition, departments that fell below the previous OPS threshold underwent another full OPS audit and identified a new Quality of Professional Life initiative.

Departments were required to submit an OPS proposal, an implementation plan with status update, and a report of final outcomes. The OPS Steering Committee evaluated the OPS/Quality of Professional Life projects by using an outcome scoring system based on the following criteria:

• Was the initiative identified and its goals and objectives presented to the OPS Steering Committee for agreement? (15 points)
• Was the initiative defined? (2 points)
• Did the project show consensus? (2 points)
• Was the project's methodology shown? (2 points)
• Was the project's implementation plan completed? (2 points)
• Was the project's measure of success defined? Were the project's baseline data obtained? (3 points)
• Were timelines met? (2 points)
• Was agreement shown? (2 points)
• Were status updates given, including demonstrated progress toward goals? (5 points)

For each department, the committee evaluates final outcomes scoring responses to three core survey items:

• The Optimal Practice Support Project is positively impacting my professional life. (15 points)
• The 2003 initiative addresses an important issue impacting my professional life in this department. (15 points)
• I am satisfied with my ability to influence decisions affecting my professional life in this department. (15 points).

All departments submitted a proposal, and only three departments were deficient in submitting an implementation plan with status update. Data regarding final outcomes from individual department projects are pending, and further revisions to the OPS process for 2004 are underway. These developments demonstrate an ongoing commitment to optimal office practice as well as to continued improvement in the quality of physicians' professional lives.

Acknowledgments

Liz M Manvelyan assisted with manuscript preparation.
Scott Rasgon, MD, gave valuable advice and encouragement in writing the article.

Reference

1. King H, Speckart C. Ten evidence-based practices for successful physician retention. Perm J 2002 Summer;6(3):52-4.

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