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Learn how standing orders and protocols can equip other team members to handle some of the physician's in-basket tasks.

What Was the Problem?

Not long ago, in-basket management was very disorganized at Bellin Health Ashwaubenon (Bellin), a family medicine practice in Green Bay, WI.

“We practice standardized rooming, but each medical assistant had 7 or 8 in-baskets they were checking throughout the day. No one knew what was going on or where they were supposed to be. We needed a process to keep on top of the in-basket and to make sure that the right team members were handling the right messages,” said Jami Burroughs, CMA.

Developing the Intervention

To understand the extent of the disorganization, Bellin performed an audit of in-basket communication and then used this information to guide improvements.

Physicians, nurses, and medical assistants (MAs) worked together to look at all in-basket subfolders and categorize the types of messages that came to each folder. Commonly-received messages included:

  • Symptoms-based calls

  • Requests for refills, appointments, or medical records

  • Laboratory orders and results

  • Questions about immunizations, medication, or a recent office visit

Once the messages were categorized, the cross-functional group determined if the messages coming into each folder were useful or redundant. They filtered out information that the recipient was not directly responsible for managing, and evaluated which team member would be most appropriate for handling each type of message or in-basket item. The group made sure to include representation from each specific role in the practice when determining where certain messages could be routed.

Once the audit was complete, the group started work on improving the in-basket. First, they created team pools, with specific MAs, licensed practical nurses (LPNs), and registered nurses (RNs) assigned to a particular physician. Next, they selected a naming convention for the team pools. The standard name might consist of the clinic location and/or physician name. For example, James Jerzak, MD's team pool is named “Jerzak Team.” This naming convention made it easier for individuals from an outside clinic to know the pool names.

All messages flow into the renamed team pool in-basket. Typically, the MA/LPN for that physician's team logs into the team pool in-basket and manages only that in-basket. The team pool arrangement encourages members to work together to complete the in-basket work in a timely manner. When time allows, the RN checks into team pools to help with the work.

In bigger clinics, each team consists of a larger team referred to as a pod. If a specific team within the pod is out on a particular day, the other MAs and LPNs within that pod can check the in-basket for the absent team pool. The only exception is the triage in-basket, which allows separation of the RNs' work and the MA/LPNs' work. Instead of having a triage nurse dedicated to each physician, the triage in-basket contains messages from all the physicians within the larger “triage team” or pod.

“I was at a conference recently and checked my in-basket—it was amazing to see things getting done by my team with our standing orders and protocols. Setting up processes to handle these tasks and then empowering the team to do it really works!” — James Jerzak, MD

The biggest challenge was determining what work should go to the team pool in-baskets and what work should go to the triage in-basket. In the past, the majority of messages, no matter what they were, ended up in the triage in-basket. This made it difficult for the RN to see patients and complete the in-basket work. The new team pool approach to in-basket work reduces the size of the triage in-basket and frees the RN to be more involved in direct patient care, such as diabetes education, blood pressure checks, and Medicare annual wellness visits.

As with any process change, training individuals on the new process can be challenging. In the past, the RNs working triage received all symptom-based calls, handled the majority of lab results, and were the default contact for almost any issue that arose in the office. One of the first things discovered at Bellin was that it made more sense to have MAs or LPNs start handling some of those messages, especially those related to a recent office visit. Patients seemed to prefer to receive a call back from the MA/LPN who was in the room with the physician during their visit, since they had developed a relationship with that team member. This approach was quite different, but physicians caught on quickly to routing some results to the MA/LPN instead of always sending them to the RN. Being co-located helped make this process easier.

For receptionists, Bellin developed standard messaging templates so that if a patient calls with a question, the receptionist is prompted to ask the patient if he or she was seen in the last 2 weeks. If the patient's message does not require triage, the receptionist sends the message to the MA/LPN through the team pool in-basket instead of to the RN and the triage in-basket. In addition to being more efficient, this process increases patient satisfaction, as the patient knows the person who is communicating with them.

Many times, team members will flag messages as reminders or to let anyone working the in-basket know that it requires action, such as that a message was left with the patient to call the office or for the office to call once results are available. The receptionist also uses a red arrow in Epic (a type of priority indicator) that highlights high priority messages that need to be addressed promptly by either the RN or MA/LPN. If a message in the in-basket does not need to be addressed until the following week, a reminder can be placed on the message so that it comes off the workload, and then automatically reappears as new on the specified date. These techniques help the team with time management and prioritizing tasks in the in-basket.

There are still some paper forms that come into the office, such as nursing home orders. For these forms, the receptionist drops them off in the RN paper in-basket, then the RN enters it into the electronic health record system (EHR) and routes it to the appropriate physician. For paperwork such as disability, Family and Medical Leave Act (FMLA), or wellness statements that require the physician to complete and sign, each team member completes as much information on the form as they can to the level of their licensure before passing it on to the next team member for completion. The receptionist fills in demographics and last office visit date before passing the form on to the MA/LPN. If the MA/LPN is unable to complete the form, it is passed to the RN to complete. The goal is for the physician to sign the complete or near-complete form, since the appropriate team members complete as much of the form as possible before the physician receives it.

“In-basket work also improves as your office visits improve because you're addressing refills, referrals, scheduling follow-up appointments and documenting so your team can communicate effectively with patients if issues later arise. You are getting tomorrow's work done today. It's just way more efficient.” — Jami Burroughs, CMA

Results

Bellin is satisfied with the new process and continues to build on it. The team is currently piloting a centralized refill team to handle all refill requests. They have also developed an anticoagulation clinic where either the pharmacist or trained RN handles International Normalized Ratio (INR) results based on a protocol, eliminating the need to send those results to the physician's in-basket. They are also using EHR smartphrases, such as “results reviewed at recent office visit,” to help streamline work.

About the Organization

Bellin Health System is an integrated health care delivery system comprised of Bellin Hospital (an acute care, 167-bed, multi-specialty hospital), Bellin Psychiatric Center (Hospital and Counseling Services), Bellin Medical Group, and other health care services. Bellin Medical Group consists of several Family Medical Centers, located throughout Northeast Wisconsin and Michigan's Upper Peninsula, providing physicians, nurse practitioners, and physician assistants to advance the health and wellness of area residents.

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Article Information

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

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