Snow Mesa Internal Medicine in Fort Collins, CO, implemented the Awesome Patient Experience (APEX) model to streamline appointments and decrease patient wait times.1,2 In the APEX model, one medical assistant (MA) remains with the patient for the duration of the visit, performing expanded rooming functions like agenda-setting and following disease-specific protocols to address care gaps.3 Knowing that supplemental training would help MAs successfully conduct these tasks, the Snow Mesa team developed a tailored professional development program that is now being extended to several other sites and specialties.
The preliminary program was largely a grass roots effort led by the registered nurse (RN) supervisor. Each element of the patient encounter was broken down into small pieces within one of four areas of focus: check in, exam room preparation before the provider enters, being in the exam room with the provider, and check out. The MAs chose to start their training with rooming. The MAs wanted to “own” this process and therefore added to their responsibilities by taking over some tasks that were previously done by other team members.
One of the first rooming tasks MAs took over from providers was medication reconciliation. The RN supervisor identified appropriate training materials with the help of a consulting pharmacist. The curriculum included self-study and Friday morning workshops with the RN supervisor and pharmacist. After completing the module, the MAs took a paper-based test to ensure competency. The MAs also underwent electronic health record (EHR) retraining to learn new tools, cross-trained with other team members to get a feel for how other members work, practiced motivational interviewing techniques to help them communicate more effectively with patients, and brushed up on medical terminology through an online learning management system.
The training program is evolving as staff turns over and established MAs continue to grow their skillsets. Now when a new MA comes on board, the new team member spends six to eight weeks learning from the rest of the team.
The new MA's training progress is overseen by an assigned mentor—often the physician they will be working with. After training in the EHR during their first week, the new MA spends their second week shadowing an experienced MA. The third and fourth weeks focus on rooming: starting with basic rooming skills like taking vitals, medicine reconciliation, and allergy checks, the MA is then trained in robust rooming procedures. like history-taking, agenda-setting and order entry per protocols, once the MA is comfortable with the basics.
During weeks five and six, the new MA learns techniques for writing a complete history of present illness (HPI) and in-basket management. By weeks seven and eight, most MAs are confident and performing many tasks with minimal oversight, and much the remaining training time is spent on partial scribing with “elbow support” by another MA and real-time feedback from the physicians regarding their documentation. Most MAs progress to full scribing and brushing up on areas of need by the end of the eight-week training period. In addition, all MAs spend at least two hours per month focusing on self-taught or item-specific growth areas to help keep them current with scribe technique, terminology, and EHR documentation. MAs at Snow Mesa have become so engaged in the learning process that they have independently started a monthly “scribe training,” where one MA teaches details of a body system to peers in a lecture or game-type format during a morning pre-clinic session.
The success of MA training was measured indirectly by how the APEX rollout was affecting practice efficiency. Daily huddles provided one forum to discuss barriers and successes. Initially, timelines and a Kamishibai board (a visual storyboard commonly used in Lean Management approaches) were posted in the clinic to document accomplishments, track metrics like time studies results, and recognize opportunities for improvement.
Without additional training for MAs, the innumerable successes Snow Mesa is now experiencing would not be possible. Care team members work more efficiently and providers spend less time performing clerical work after hours; team satisfaction has increased overall. Quality metrics have also improved—just one year after implementing its professional development program for MAs, patient satisfaction at Snow Mesa was excellent as demonstrated by a 96 percent top box score. “Productivity,” as measured by relative value units generated, has also increased. Snow Mesa continues to monitor a dashboard and are rolling APEX out to other primary care practices in the system.
As more clinics in the University of Colorado Health System transition to the APEX model, they are starting to emulate the training program created at Snow Mesa. MAs from the pilot clinic are now rotating through other primary care clinics to teach pieces of the APEX model in real time. Because expanded rooming is such an integral component of APEX, training on proper technique is now being standardized and taught to all incoming MAs in the northern region of Colorado served by the University Health System. Specialty clinics are also beginning to integrate pieces of this model, tailoring the model depending on the practice (surgical versus medical subspecialty). These efforts are still in the pilot phase, so it is unclear what aspects of the MA professional development program they will implement.