Intermountain Medical Group Appointment Standardization Mark Briesacher, MD Senior Administrative Medical Director Chris Thornock Chief Administrative Officer
Conflict of Interest Disclosure The presenters have no real or apparent conflicts of interest to report.
Intermountain Medical Group Part of integrated delivery system, in the state of Utah 875 physicians; 200 APCs 146 service locations primary and secondary care Other services include urgent care, pharmacy, industrial medicine clinics, onsite clinics
How we got here Standard practice management system throughout group Rapid growth in the Medical Group meant schedules were left largely to the discretion of the individual physician Attempts to limit number of appointment types in a consistent way have been unsuccessful
Drivers For Change Desire to implement online patient scheduling and other remote scheduling options Implementation of patient centered medical home (requirement for same day access) Belief that there can/should be a best practice in this area Desire to improve access for patients Variation leads to higher cost Culture of quality improvement increased emphasis on operations
Variation in Satisfaction Scores Family Medicine Patient Satisfaction Getting an Appt When You Wanted to be Seen Springville Bear River Syracuse Gorang Medical Tower Cottonwood Fp Hurricane Taylorsville Layton North Canyon Cedar City Logan Salt Lake Clinic Ephraim Bountiful West Jordan Herefordshire Central Orem North Ogden Memorial 0 10 20 30 40 50 60 70 80 90 Percentage Excellent 6
Quality Improvement History of clinical quality improvement at Intermountain Pockets of operational quality improvement Desire to get managers and front-line staff involved in improvement efforts Looked inward and implemented 100% Participation
100% Participation Incorporates many principles of accepted QI programs Directs program to front-line employee, manager, physician Places accountability on coach (managers) to lead front-line teams Requires everyone to spend 5 percent of their time improving the way they work Uses rapid-cycle improvement to refine processes
Appointment Standardization Workgroup Intent to use QI principles to improve standardization Membership included: Facilitator Patient schedulers Clinic managers IT staff who support appointments Patient access manager Medical Home leaders Physician champion Senior leadership sponsorship and attendance
Workgroup Process Met five times in four-hour blocks over three-month period Defined scope of problem Clarified what we want the future to be (online scheduling, better access, etc.) Reviewed current state Types by specialty How are they used Frequency of use Decision to focus on primary care to start
Primary Care Accounts for more than 55% of all of the Group Visits No. Appts No. Types Comments Family Medicine 621,000 45 Pediatrics 267,370 21 Internal Medicine 232,000 30 Ob/Gyn 191,024 38 4 types accounted for 80% of all visits 4 types accounted for 94% of all visits 5 types accounted for 92% of all visits 4 types accounted for 71% of all visits 11
Routine Office Visit Work In Visit Extended Office Visit Recheck Office Visit Physical Exam Routine Non Md Visit Physical Exam Extended Brief Office Visit New Patient Office Visit Work In Extended Well Child Check Ob Office Visit Comprehensive Adult Exam New Patient Extended Comprehensive Office Visit Surgical Procedure Moderate Child-Youth Sport Physical Consultation Depression Office Visit Physical Exam Brief Return To Clinic Work In Brief Worker'S Compensation Visit Surgical Procedure Extended VISITS 300,000 Workgroup Process (cont d) Family Medicine - Visit Type Usage 100% 250,000 90% 80% 200,000 150,000 100,000 50,000 70% 60% 50% 40% 30% 20% 10% cumulative percentage 0 0%
Work In Visit Well Child Check Non Md Visit Routine Office Visit Extended Office Visit New Born Check Physical Exam Extended Well Child Extended Attention Deficit Disorder Comprehensive Office Visit Consultation Two Month Check Recheck Office Visit New Patient Office Visit Surgical Procedure Moderate Post Operative Visit Child-Youth Sport Physical Surgical Procedure Comprehensive Gyn Office Visit Surgical Procedure Extended Physical Exam Routine VISITS 140,000 Workgroup Process (cont d) Pediatric - Visit Type Usage 100% 120,000 100,000 90% 80% 70% 80,000 60,000 40,000 20,000 60% 50% 40% 30% 20% 10% cumulative percentage 0 0%
Routine Office Visit Work In Visit Physical Exam Routine New Patient Office Visit Extended Office Visit Physical Exam Extended Non Md Visit Brief Office Visit Procedure 1 Consultation Medicare Office Extended Work In Extended New Patient Extended Counseling Consultation Work In Brief Surgical Procedure Moderate Comprehensive Adult Exam Physical Exam Brief Treadmill Stress Echo Treadmill Recheck Office Visit Physical Exam Comprehensive Gyn Office Visit Consultation Extended Heart Scan Extended Surgery-Off Site Flexible Sigmoidoscopy Comprehensive Office Visit Stress Test Ear Check VISITS 160,000 Workgroup Process (cont d) Internal Medicine - Visit Type Usage 100% 140,000 120,000 100,000 80,000 60,000 40,000 20,000 90% 80% 70% 60% 50% 40% 30% 20% 10% cumulative percentage 0 0%
Ob Office Visit Gyn Office Visit New Ob Visit Routine Office Visit Extended Office Visit Physical Exam Routine Post Partum Office Visit Post Operative Visit Procedure 2 New Patient Gyn Visit Ob Office W/Ultrasound Gyn Office Brief Recheck Office Visit Non Md Visit Brief Office Visit Work In Visit Comprehensive Office Visit Procedure 1 Gyn Office Extended Physical Exam Extended New Patient Office Visit Non Stress Test Visit Consultation Pre Operative Visit Colposcopy Classroom Instruction 1 Surgery-Off Site VISITS 100,000 Workgroup Process (cont d) Ob/Gyn - Visit Type Usage 100% 90,000 90% 80,000 80% 70,000 70% 60,000 50,000 40,000 30,000 20,000 60% 50% 40% 30% 20% cumulative percentage 10,000 10% 0 0%
Specialty Specific Groups Met off-line and focused on detailed solutions Used other clinic staff and physicians for input and ideas Brought recommendations back to the Workgroup Workgroup approved standards for pilot within each specialty
Specialty Specific Guidelines Family Medicine (ROV) Routine Office Visit (EOV) Extended Office Visit (WIV) Work in Visit (Same Day) (PHR) Physical Exam Routine (WCC) Well Child Check (NPV) New Patient Visit (NOB) New OB Visit (Only if provider does OB)
Specialty Specific Guidelines Pediatrics (ROV) Routine Office Visit (EOV) Extended Office Visit (WIV) Work in Visit (Same Day) (WCC) Well Child Check (NPV) New Patient Visit
Specialty Specific Guidelines Internal Medicine (ROV) Routine Office Visit (EOV) Extended Office Visit (WIV) Work in Visit (Same Day) (PHR) Physical Exam Routine (NPV) New Patient Visit
Specialty Specific Guidelines Ob/Gyn (OBV) OB Visit (ROV) Routine Office Visit (WIV) Work in Visit (Same Day) (PHR) Physical Exam Routine (NPV) New Patient Visit (NOB) New OB Visit (Only add if provider does OB)
Pilots Started with one family medicine clinic Eventually piloted at one clinic of each specialty Funneled feedback to Patient Access Manager and improvements made as needed Evaluated any request to increase number of appointment types to date no new appointment types have been added in response Dispelled many myths
Clinic Feedback Easier to schedule an appointment Schedulers have to keep the same amount or less information in their heads Easier to train new employees using the new standards
Clinic Feedback (cont d) I think it is much better than the old way. It is much easier and faster Clinic Manager New standardized appointment types have made scheduling appointments easier not only for training purposes, but for a better understanding of daily schedules for our physicians. Appointment Scheduler Initially the physicians were reluctant to standardize. Now that the standardization has taken place, all our physicians are satisfied with the change. I think the greatest benefit to them is ease and efficiency of scheduling. Clinic Manager I did not find the process difficult in anyway. It was pretty transparent to the physicians, which helped with the ease. Clinic Manager
Where Are We Today? Focused initially on patient centered medical home locations (so far this has moved quickly enough) Implemented 21 clinics consisting of 31 departments to date Family Medicine 11 Pediatrics 11 Internal Medicine 7 Ob/Gyn 2 Additional clinics scheduled for implementation as they implement medical home
Where Are We Today? Health plan directly schedules in three clinics Planning to implement online scheduling in 2012 Evaluating data from initial sites to assess impact Taking feedback and updating appointment type definitions
Next Steps Continued roll-out (moving ahead of Medical Home) Assessing resource needs for implementation and ongoing support Need to revisit sites and ensure adherence Need a process for reviewing/updating standards Other specialties?
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