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Change InitiativesProduce Meaningful, Sustainable Change

Learning Objectives
1. Identify ways to determine if a proposed change in process or procedures will ease workloadsof those who deliver care
2. Describe how to implement change that will ease workloads for physicians and staff
3. List ways to measure improvement in the quality of patient care
4. Summarize methods to identify a revenue stream that will support the practice work involved in the change
0.5 Credit CME
How will this module help me?

  1. Provides a simple three-step framework to prioritize and choose the right change opportunity.

  2. Answers questions to commonly asked questions.

  3. Includes downloadable resources to guide your practice through the decision-making process.

Introduction

When physicians and their teams lead change initiatives to address important goals within their practice, it can result in both improved patient care and improved physician satisfaction. When the desire for change comes from within the practice, it can counter change fatigue and make the results energizing and unifying for team members. Identifying the right opportunities for change by following three simple steps can help the practice ensure the thoughtful selection of successful initiatives that will produce meaningful and sustainable change.

These steps are meant to provide a framework for selecting change “wins” for your practice and all of your stakeholders: your patients, the care team, and the practice as a whole.

Three STEPS to help choose and implement successful, sustainable change

  1. Determine the Benefits for the Care Team.

  2. Determine the Benefits for Patient Care.

  3. Determine the Resources Needed to Support the Change.

Step 1 Determine the Benefits for the Care Team.

A successful change should make it easier for everyone to do their work in the most efficient manner. The medical assistant, nurse, and physician each have to be able to see “what's in it for them.” This will help generate buy-in and commitment.

Quiz Ref IDWhen considering whether a proposed project will save time and make work easier, you might ask:

  • What aspects of the daily work frustrate the physicians and care team?

  • What do physicians and the care team do that seems counterproductive or unnecessary?

  • In what areas are the results of care delivery disappointing?

Creating a respectful team environment where everyone's voice is heard is important. Remember that everyone on the change team may not agree with everything that is said during the team's meetings. Start by setting ground rules, so everyone has the same expectations of how they can expect to be treated and how they should treat each other.

“I have a lot more fun with my practice because I am doing the things I love to do. To me, the journey was definitely worth it. It is worth it for me, personally. It is worth it for my staff and for my patients.”

—Richard Fossen, MD, Chair, Internal Medicine, Marshfield Clinic, Minocqua Center
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Q&A

  • What team members are important to consider when choosing practice change initiatives?

    Involve all members of the team. They may see opportunities that physicians or leaders do not, and their recommendations and insights will add an important dimension to the change process. Involving all members of your team from the very beginning of the change process—including determining which project to undertake—will ensure their buy-in and engagement throughout the process.

    For example, a practice team may decide to implement expanded rooming and discharge protocols. The nurses, medical assistants, and physicians will all need to be involved to redistribute the work and ensure a smooth implementation. Everyone will likely need training, and the physicians will be involved in educating them as they take on more responsibilities and document more in the medical record.

  • When we establish a change team, whom should we involve?

    The composition of an effective change team will reflect the resources available based on the size of the practice. Regardless, a high-level champion and multidisciplinary representatives should be involved. Examples include physicians, nurses, medical assistants, front desk personnel, administration, as well as representatives from information technology (IT), pharmacy, care management, and compliance.

    Additionally, make sure the change team consists of people who are positive, energetic, change-oriented, and future-looking; these characteristics are essential to creating a successful change team that will effectively lead the practice.1

  • What are some example opportunities for change to ease the work burden for our team?

    Here are some examples:

    • Time spent giving test results to patients and discussing changes in treatment outside of the appointment time. Start with your team giving normal test results to patients.

    • Changing certain chronic medication's refill duration from 6 months to 15 months (#90 x 4)

    • Patients with high blood pressure who are often not put on medication or educated about lifestyle changes to control their condition.

    • No-shows resulting in wasted time preparing for visits and unproductive time during the scheduled appointment.

    • Registration representatives having to reach for or walk to the printer several times per patient, wasting time.

    • Patients who are not taking their medications as prescribed or following treatment plans.

    • Having to sit on hold at a main scheduling number in order to schedule an appointment with radiology or the lab.

    • Manually scanning results that have been faxed to the office to include them in the patient's electronic medical record (EMR) after the physician's review.

    • Not charging for services provided to patients who come to the office for routine or follow-up therapy.

  • Sometimes when we brainstorm as a team, a couple of voices are heard above the rest. How do we make sure everyone's ideas are heard?

    Involving a larger team in the improvement project means that your practice's personalities will emerge; some people love to share ideas and other people are not terribly excited to speak out in a group. Especially when people are brainstorming, you will see that some may be inclined to diminish a problem that is brought forward or make a counterargument that the process “has always been done that way” or “we have to do it that way.” Setting ground rules will help the team set the tone for success. The work you do up front to ensure that your team collaborates successfully will lead to an effective project implementation.

Step 2 Determine the Benefits for Patient Care.

Quiz Ref IDMost initiatives identified by the team will likely benefit patients. For example, eliminating duplication or repetition in a process or increasing efficiency will translate to more time available to spend with patients, increased access to care, and other measurable benefits. For the project to gain and maintain traction, it is helpful to measure and demonstrate the benefits. First, measure the current state. Then, over time, continue to measure your results to show improvement after implementation.

Measurement gives the team a goal to work towards; showing improvement helps the team maintain enthusiasm and support for the project. If the team anticipates saving 20 minutes by implementing a certain process, they will likely remain motivated until they accomplish that goal. Even if the goal is exceeded, many teams will continue working to surpass their original goal. Seeing improvement is a positive energy builder.

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Q&A

  • What are some ways that we could improve quality for patients?

    It's important to always remember what the patient values. If you aren't sure, ask your patients! A simple survey, email, or patient advisory group could help your practice align on what patients value. Clinical quality is more challenging for a patient to perceive but is also important for the practice to prioritize. Here are some ideas:

    • Better quality of care, measured through:

      • Panel management (e.g., pre-diabetes and hypertension management and timely preventive screening).

      • Utilization outcomes (e.g., reducing hospital admissions and emergency room visits).

      • Patient adherence to treatment plans by shared decision-making (e.g., medication adherence or lifestyle changes).

    • Convenience, measured through:

      • Less time spent at the office.

      • Easier transitions to referred appointments and follow-up appointments scheduled before leaving the office.

      • Increased time spent with care team or physician.

    • Improved access, measured through:

      • Patient ability to schedule appointments when desired.

      • Patient ability to see the physician or team on short notice.

  • What are some examples of projects that we could do that would produce measurable improvement in quality for patients?

    Thinking of current problems that need to be addressed helps in imagining the practice's future state and what changes are needed to achieve that state:

    • Patients who are discharged from the hospital are readmitted at a higher rate than national benchmarks.

    • Patients who visit the emergency room often have to return there within a month.

    • Playing “phone tag” with patients to deliver test results delays changes in treatment.

    • Patients with hypertension are not receiving adequate education about medication options or lifestyle changes that can help control their condition.

    • Physicians have to leave the exam room if they do not have the information or supplies that they need for a patient visit.

    • Patients must come in for multiple appointments, when care could be consolidated into a single appointment or coordinated on the same day.

    You do not need to come up with your own metrics or guidelines. Examples include Choosing Wisely and clinical best practice guidelines (percent of patients with acute coronary syndrome prescribed appropriate medications, or percent of patients up to date on vaccinations)

  • How should we determine which metrics to track?

    Think about the patient benefits. Will successful implementation lead to an increase in convenience (e.g., time saved or fewer trips to the office), improved health, improved access or more time spent with the clinical team? The metrics should be directly related to the change; if the result is indirectly impacted by the initiative, people could say that the impact was achieved through another initiative. These indirect results will not demonstrate as powerfully the change management work of the practice. These may be process and/or outcome measures, depending on what is most important to the team. Keep the metrics simple enough to track in a reasonable manner, yet specific enough to focus on the change. Remember to start with the baseline measurement, so your team can quantifiably compare pre- and post-implementation results.

  • How do we measure our project's impact on patients?

    There are several ways to measure a project's impact:

    • Audit: Use an audit to spot-check the process. This can be done through direct observation of a patient visit to witness specific parts of a process, reviewing paperwork or forms for a field that should be completed or reviewing the patient record to confirm that a field has been completed by a specific person at a specific time.

    • Survey: Use a survey to understand the patient, team, or physician experience. To obtain 30 patient responses, your practice may need to survey patients for several days. If your practice does not have 30 people on the team, that is okay; you may choose to rely more on qualitative survey responses.

    • Electronic medical record (EMR) or registry data: Use EMR or registry data to evaluate your patients' health and visit documentation. Many EMRs and registries have modifiable reports that can be set up so that they are generated regularly. If your EMR or registry does not come with reporting capabilities that are easily modified, work with your vendor or IT liaison to obtain the data you need.

    • Registration software time stamps: Use registration software time stamps to evaluate efficiencies that are achieved in the practice. If your change initiative will result in increased efficiency, time saved or more streamlined operations, use your software's time stamps to quantify just how much more efficient your team has become.

    • Measuring cycle time as a proxy for office organization and flow is an easy way to monitor progress. Simply record when the patient registers at the front desk and when he or she checks out or leaves the office.

    Measurement cycles start with establishing a baseline (pre-implementation) with evaluation at regular intervals (e.g., monthly for 3 months) after implementation. After the project is considered “complete,” you can consider maintaining the metric as an indicator on your practice's quality scorecard, so the team can ensure that the results are maintained.

    Use run charts or some other visual display of results to track progress over time. Display them on a data wall or dashboard in an easily visible or accessible place in the practice, along with other key outcome measures. Consider posting in a central area near where the team has huddles.

  • What if the project we choose will make things better for most but not all patients?

    It is true that not all changes will significantly benefit all patients. In fact, especially with projects that impact payment (e.g., the practice may choose to start billing for visits that had previously been done pro bono), demonstrating a patient benefit may be a challenge. Keep in mind that patient benefits can be indirect. With a revenue cycle-related initiative, complete documentation and billing may increase patient safety and enhance the ability to provide continuity of care. Help your patients see the benefits of the new process and be honest about how the change will impact them. Establishing open communication with patients and giving them the opportunity to voice their concerns can help patients understand that you do care and that you are making decisions that are best for them.

Step 3 Determine the Resources Needed to Support the Change.

Dedicating resources (e.g., people, time, and energy) to embark on an improvement initiative needs to make financial sense. If the benefit will not outweigh the cost of preparing for the change and implementing it, the practice should not make the change. It is easier for a practice to commit to change when the costs of not changing—of maintaining inefficient operations or poor patient outcomes—are made clear.

Work with your financial manager or someone who can do some financial modeling for you to see the potential benefits of implementing your change project. Use indicators such as revenue from increased patient appointments or savings from increased patient health and reduced re-visits. To determine the financial benefits of implementing other STEPS Forward modules, see the calculators in the pre-visit lab, pre-visit planning, team documentation, prescription management and expanded rooming and discharge protocols modules.

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Q&A

  • What are some examples of revenue stream impacts that I might expect to see?

    • Increased efficiency can lead to increased revenue.

      • More available appointments lead to increased patient access.

    • Better quality of patient care can lead to better value-based payment positioning.

      • A healthier patient panel leads to lower downstream costs for the health care system.

      • Better preventive care means preventing or diagnosing dangerous conditions early.

      • Investing in health education can result in a lowered incidence of chronic conditions.

    • Consider incentives and penalties that you can opt into or out of depending on your practice priorities and payer mix.

  • What if I cannot determine what the cost of implementing the change will be?

    Practice transformation is challenging work. For practices that do not have extensive financial services, Lean experts, or internal consultants, developing accurate financial projections may be challenging. Using the resources you already have to implement processes or systems that are “known to work” is a good starting point. Your formal process will evolve in time; waiting to implement because of a lack of formal evaluation could dampen the team's enthusiasm and desire to change.

  • How can I tell what all of the downstream benefits will be?

    Thinking about both positive and negative downstream effects is a very powerful exercise. For example, if the practice's change initiative will lead to an increase in scheduled appointments at your radiology and laboratory departments and increased referrals to specialty physicians, and you have the resources, you might consider quantifying those changes. Tracking this type of secondary metric can be useful, especially in improving relationships among referring clinicians and departments.

  • What if, despite answering yes to all three questions and making a strong financial case, our leadership does not support our initiative?

    If your leadership must approve all hires and practice development, realize that the approval process for a change initiative may be slow. You may have to alter your proposal several times before it is approved. Think of ways you can effectively be heard by your leaders. Create an airtight proposal that shows the benefits for patients, the care team, and the financial implications of implementing your new project. If you need to increase staffing, the finances included in your proposal will need to be well defined. Remember to provide a report showing the work your team has done. Your leadership will be particularly interested in results and revenue impact, and they may be interested in using your team as a prototype for future innovations. Often this can mean having access to more resources to continue your innovative work.

    Whether you are trying to make a small or more significant change, it may help to frame the project as a “pilot.” A pilot project is one that is being tried out. Smaller changes may only require a few weeks or months to pilot, while larger changes may need a full year to implement and test the new processes. Either way, the pilot can be designed to last as long as necessary to show that the change has resulted in improvement.

    By framing your work as a pilot, you will get the opportunity to try out your new process or procedure, and when it is a success, you will have the ability to extend the project beyond the trial period. You and your team will need to be fully invested in the success of the project to see it through. Ultimately, you must be able to demonstrate favorable results: improved patient care and satisfaction, decreased work for the care team, and positive revenue impact.

Conclusion

Selecting a change initiative to improve your practice can be challenging, but when you choose the right project, assemble an enthusiastic change leader and team, and engage the entire practice in its implementation, it can have a profound effect on patient care, practice efficiency, and physician and team satisfaction. Keep in mind the three-pronged framework when selecting a change initiative—how will it benefit the care team? How will it improve patient care? What resources are needed to support the change? Identifying opportunities for practice improvement, implementing a focused change, and using the most appropriate metrics to track and evaluate the direct effect of change on the patients, practice, and team will allow you to achieve effective and sustainable change.

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AMA Pearls

AMA Pearls

Ask “why” to identify the root cause of the problem.

Most medical offices are living with well-known issues that have been pointed out by patients, team members, or physicians as opportunities for change. A simple conversation is often all that is needed to decide what to work on first—and a good place to start would be to discuss “why” the current process or problem exists. Be sure to keep asking why until you discover the root cause that may be very early in the process or part of a different one (sometimes called the “5 why” exercise).

Use the three-step framework to help leaders understand the sustainability of current practice.

Change becomes much easier to lead and facilitate when it addresses issues that arise from the perceived needs and experiences of the professionals involved. The fact that every project has the goals of benefiting patients, easing of the work burden, and achieving financial sustainability ensures that the potential impact of the selected project is recognized by leaders. The framework also encourages and empowers physicians and other team members who are used to the burden of extra work without regard to sustainability.

Start the improvement project.

When the team has determined that they are “ready” to start the change, determine what to measure by asking the essential quality improvement questions:

  • What are we trying to accomplish?

  • How will we know a change is an improvement?

  • What types of changes are most likely to result in improvements?

Measure the current state before beginning the quality improvement project, then improve and measure again. This is called a PDSA cycle (plan, do, study, act), and it is an important framework to follow when implementing any sort of quality improvement initiative in the practice. Essentially, it means that the team should plan for the change, implement the change, measure improvement to assess the effect of the change, and act based on what was identified during the assessment. The cycle can be repeated many times over the course of implementation and then continuously to sustain the improvement over time.

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Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.5 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

Successful completion of this CME activity, which includes participation in the activity and individual assessment of and feedback to the learner, enables the learner to earn up to 0.5 MOC points in the American Board of Pediatrics' (ABP) Maintenance of Certification (MOC) program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABP MOC credit.

Article Information

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of .50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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

ABMS MOC Statement: Through the American Board of Medical Specialties (“ABMS”) ongoing commitment to increase access to practice relevant Maintenance of Certification (“MOC”) Activities, this activity has met the requirements as an MOC Part II CME Activity. Please review the ABMS Continuing Certification Directory to see what ABMS Member Boards have accepted this activity.

Renewal Date: December 10, 2016; October 03, 2019

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