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Stories of Change :
"TransforMED Helps Free Up Time to Actually Practice Medicine"

Oregon Docs Prove Cutting Hours
Can Improve Patient Satisfaction Without Losing Income

Cramped quarters, long hours, grouchy patients and unhappy staff are all too familiar in the daily life of a family physician. When Bruce McElroy, MD, joined Steven W. Cross, MD at Central Oregon Family Medicine ten years ago, he was the second physician and office space was tight, but serviceable. But when two more physicians came on board to share the growing workload, the situation became tense. Four overbooked exam rooms were merely one symptom of a practice that wasn't working.

As Drs. McElroy and Cross began preparing to overhaul their practice, they learned of and applied to participate in the TransforMED National Demonstration Project. TransforMED's practical applications for its Medical Home Model and its crucial practice metrics provided tools this team used to achieve a remarkable level of success. After just a few short years implementing practice improvements, Central Oregon Family Medicine is meeting quality performance benchmarks with high patient satisfaction and low wait/cycle times, while overall income levels stabilize and job satisfaction increases.

Addressing Structural Changes Tops the To-Do List

With their office space bursting at the seams, the Central Oregon Family Medicine group first made requests to their hospital landlord to expand into neighboring suites, but nothing came of their proposal. Eventually, they learned that the hospital was being closed and torn down. Rather than rent again, they opted for their own building. Planning a new office meant that Dr. McElroy and the practice team could create a new environment that would support their improvement goals — goals that included integrating the Electronic Health Record (EHR), meeting HIPAA requirements, improving patient flow and creating a more equal, pod-like office layout.

Plans got underway in 2003. But Dr. McElroy credits TransforMED's Medical Home Model and the National Demonstration Project (NDP) as critical to their success. "When TransforMED came along in 2006, the Model helped us to break things down into specific tasks and pieces to address. The Personal Medical Home is cute as a concept, but it alone doesn't necessarily tell you what to do. The TransforMED Model breaks it down into ways you can choose to improve, even including quality of life and job satisfaction."

Building an Office — and a Team

The practice overhaul went well beyond the office building itself. Improving teamwork, as well as the bottom line, meant looking closely at the impact of hiring and training staff. Retaining office staff is usually much less expensive than training new people. Central Oregon Family Medicine adopted three principles to enhance Team-based Care and improve retention and job satisfaction for staff: education, empowerment and recognition. Cross-training and regular meetings with the full staff keeps team members learning and adapting to move forward. Everyone is expected to give input by either speaking up or writing down reactions or ideas so that the office manager can say it. Dr. McElroy stresses, "It's important to have a strong office manager who is not afraid of the doctors and will speak up. You can't just have one voice." This collaborative approach empowers the staff to keep physicians accountable to the overall goals.

The TransforMED Model's call for same-day appointments was another crucial component in making the practice improvements successful. Central Oregon Family Medicine prepared for the first wave of scheduling changes with announcements to patients one month in advance. After some trial and error, the new process became much easier when the practice committed to pre-scheduling only the first 60 to 90 minutes each morning and afternoon, as well as the last appointment of the day. All other periods were left open for same-day scheduling in 15- to 30-minute slots (unless specifically requested otherwise by the physician in anticipation of special needs).

Patient Cycle and Touch Time Metrics Tell a Surprising Story

As part of the continuous quality improvement process, TransforMED is conducting a series of practice metrics to help practice's improve their performance and outcomes. The first study focused on the relationship of patient cycle time, "touch time" with the provider and an evaluation of the patient's satisfaction/experience with the visit. The results for the study indicated that the average "touch time" for the providers in the NDP's facilitated practices was 20 minutes. The benchmark for Patient Cycle Time for this metric study was calculated using IHI's recommendation that patient cycle time should be equal to or less than 1.5 times the "touch time," or in this case, 30 minutes.

Central Oregon Family Medicine is only one of two practices participating in the TransforMED National Demonstration Project to have reached this benchmark so far.

Central Oregon Family Medicine logged an average "touch time" of 17 minutes per patient and scored the second highest overall rating in the study.

TransforMED's Practice Metrics Manager Elaine M. Skoch, RN, MN, points out this curious anomaly in the data: "In general, this study demonstrated a strong correlation between the patient's overall satisfaction and the amount of time spent with the provider. But Drs. McElroy and Cross actually averaged the least amount of time with their patients and yet they had the second highest satisfaction score overall! Comments from their patients on the Satisfaction Survey indicated that the physicians were focused and listened to the problems of their patients. These qualities of ‘patient centeredness' are the core of TransforMED's Medical Home Model."

Dr. McElroy attributes striving for a paperless office and implementing the Preventive Care Flow Sheet as two important ways they improved the quality of encounter time with an individual patient. "The most surprising thing patients have said to me is ‘I haven't been touched by a doctor in years.' The physical exams are the most important thing we do and these changes have given us more time to actually examine our patients," said Dr. McElroy. "You don't find yourself going over charts at the end of the day and realizing you should have checked for something."

By the Numbers: Staying Fiscally Viable

Dr. McElroy found the financial component in the Model particularly useful. In addition to their mission to "do what is right for the patient," they recognized that it is appropriate to include the value and profitability components for the practice, too. He stresses, "The focus of TransforMED with its eye toward real-world financial management and technology — to keep headaches relatively low without micromanaging — helps free up time to actually practice medicine."

Using the TransforMED Model made them take a hard look at whether or not to eliminate certain services. For example, their office used to have a dedicated space for treadmill stress tests which the team liked to administer. But the tests took too long (two or three patients could have been seen in the same amount of time), insurers reimbursed the tests poorly, and it was not typical for family practices in Central Oregon to perform. (The region features an abundance of cardiologists who often do stress tests in their offices). Eliminating this test — as well as certain surgical procedures — improved the bottom line and freed up lots of time in the schedule.

Streamlining the practice required integrating many administrative processes, with EHR technology as the key factor. The mostly paperless office has a "no fax" rule; incoming faxes are routed into patient charts. Staff uses the EHR to track recalls and all follow-ups, including who, when, why and if any tests are needed. "The EHR reduced duplication and got us to concentrate on how to develop a patient-centric office," Dr. McElroy explains.

The most surprising thing Dr. McElroy discovered in this process was his ability to reduce the number of hours he works per week (by 30-40%) without seeing an equivalent reduction in income. At first his income level fell (by less than 10%), but after a short time it rose to its previous level. Dr. McElroy is delighted with the results: "It's remarkable to actually cut hours, have a life and still feel that job satisfaction."

Dr. McElroy presented their refreshing practice improvements at TransforMED's September Learning Collaborative for participants in the National Demonstration Project. Elaine Skoch saw attendees find real hope in his story: "Attendees seemed to move from thinking that these concepts were good only in theory to understanding how the concepts can work in reality. The real-life experience of Central Oregon Family Medicine effectively demonstrates that the TransforMED Medical Home Model is a theory that works."

Web site:Central Oregon Family Medicine, PC - Redmond, Oregon