Dr Brad Volk was uploading pictures just an hour after learning it was possible

We knew it was possible. We heard it was being done by wound care. When was it going to be “our” turn in family practice to try incorporating photos into our progress notes? About 2 weeks ago we borrowed the digital camera from our wound care department. Four providers and a couple MAs took the time to figure out to upload and embed the pictures, and now a week later we are ready to make this a regular practice.  We plan to have all of our cluster D providers and MAs trained.  About a dozen charts of patients seen in the past week now have bright detailed photos of wounds, abscess, and suspicious skin lesions. We have also found cc’ing the charts to a specialty pool (often derm or infectious disease) has been helpful.

While the “techies” in our group are excited to keep moving forward, this process did raise a few questions. Are there guidelines or advice on what types of conditions are best documented by photos in charts?  How to take a quality photo (too might light distorts the picture, is a measuring tape or patient label a must, should we avoid “private” areas?) 

Images can be great for patient care and followup, but we want to start good habits early so this remains a valuable use of our time.  I am curious who else is using photos in their notes and to learn some best practices. 

Sarah (physician) & Sherry (medical assistant): Stellar Servant Leaders of Cluster A, Facilitating the Creation of a Standard Approach to Patient Discharge

Cluster A, whose servant-leaders are Sarah Levy, MD, and Sherry Sardona, MA, is developing a standard discharge process for when patients are concluding their appointments.  Cluster A, one of the six clusters at Northgate Medical Center, has about 15 people working in it, including 7 providers.  The group has decided that developing such a discharge process will decrease the chance of errors, make it easier to crosscover, and improve the patient experience.  Cluster A began their work at a cluster workshop, a four hour block of time focused on team and process improvement available three times a year, and has been following up in huddles.  You can see the process map over and behind Sherry’s left shoulder.  This is great work, and after the cluster refines the procedure, we’ll see about its applicability across all of Northgate Medical Center. 

Way to go, Sarah, Sherry, and Cluster A!!!

Honore Daumier - The Burden, aka Washerwoman with Load, 1865

My two manager partners– Malathi Michael and Jacqui Davis — and I decided yesterday that we liked the term BURDEN more than WASTE when working on clinic improvement using Lean principles.  Though these terms can be used interchangeably, our staff are more likely to recognize that we want to help them if we focus on finding BURDENS, rather than WASTE.   So, to that end, here is the latest list of burdens to be addressed in future improvement efforts. 

BURDENS AT NORTHGATE MEDICAL CENTER

• External referrals
• Lack of good education materials for obstetrics and diabetes
• Durable medical equipment (DME) referrals
• Not getting hard copy prescriptions to pharmacy on time
• Upsetting patients when provider is running late
• Losing lab specimens due to labeling problems
• Unreliable use of masks to limit spread of infections
• Add on of procedures to treatment center
• Routing of normal labs by LPN to ordering providers
• Patients stuck at lab waiting for orders
• Paperwork delays related to routing of faxes
• Lack of clear process for triaging over lunch hour for pediatrics
• Patient visits starting late
• Papers making it to provider’s desk without being screened by MA
• Excessive overhead pages in the medical center

Something missing from the list?  Got something to say about BURDENS versus WASTE?  Add a comment!

What is diabetes?

How do I know if my diabetes is under control?

Do I need to check my blood sugar at home?

How often do I need to come in for tests and check ups?

How to use metformin

How to use insulin

The idea Marty had was to put all of these in one dot-phrase and then just delete from the AVS the parts that are not relevant to that patient.   I like it a lot.  Each short paragraph is written as the answer to a commonly asked question which is the same approach that I have taken in my book The Diabetes Answer Book and the blog that accompanies it:

www.morediabetesanswers.com

I had our Patient Health Education Resource (PHER) team look  over Marty’s dot-phrase to make sure it is at the appropriate reading level and written in plain language.  It is now in production in EPIC so feel free to check it out and see if you like it.  It is called:

.pidiabetesexplained

If other folk have developed dot phrases that they really like feel free to share them on the blog.

Problem: When patient is not in clinic, provider prescribes medication needing a hard copy when patient arrives at pharmacy window, the script is not there.

Process Mapping & Observations:  Design team mapped out the process from the time the prescription was ordered, through it’s printing, signing, and transport to pharmacy.  Design team viewed the carrying of the unsigned prescription from the printer to the ordering provider’s office inbox and then the leaving of the script in that inbox as problematic. This step seemed to add little value and seemed to lead to further delays.

Types of Wastes Identified in Observations: complexity, corrections, inventory, waiting time, searching time, transportation.

Proposed Solution: Medical assistants ensure the hardcopy is signed without leaving it in the provider’s office inbox.

Results:  Proposed solution tested for one week, during which time the number of occasions in which a patient was stuck at the pharmacy window waiting for a signed hardcopy dropped off noticeably.  Because this experiment resulted in a greater than 50% improvement over the prior procedure, the solution was adopted as a new standard procedure. 

Lesson Learned:  It was important not to mandate how the medical assistant got the signature (eg, at printer, posted on exam door, etc.)  as variation at this level seemed valuable.

Kristi, a smart, hardworking, and committed medical assistant in cluster D

Kristi said to me last week, “Hey, Marty, can we see the list of improvement ideas that the frontline improvement design team is using?”  I told Kristi I’d post it on the blog so the whole clinic could see it.  The team meets tomorrow and will likely pick a new problem to tackle. 

• External referrals
• Patient educational materials for obstetrics and diabetes
• Durable medical equipment (DME) referrals
• Call management coverage during lunch time
• Hard copies of controlled substance medications making it to pharmacy on the same day patient is seen in clinic
• Notifying patient when provider is running late
• Labeling of lab specimens
• Safe use of phenol
• Use of masks by patients with suspected infections
• Add on of procedures to treatment center
• Routing of normal labs by LPN to ordering providers
• Difficulty reaching provider for lab orders when patient presents to lab and there are no orders on file
• Pediatric faxes and paperwork delayed when they arrive downstairs
• Triaging of pediatric patients if they walk in during lunchtime in pediatrics cluster
• Patients not being ready to be seen on time
• Papers making it to provider’s desk without being screened by MA

If you want something added to the list, post a comment!  This is your clinic and we need your input to make it better!

Denise, ARNP, Typing Up an After Visit Summary

Background

Our electronic medical record allows providers to type after visit summaries (AVS) for patients that are printed off and given to patients when they leave.  I see tremendous variation in the quality of these after visit summaries.  Because we do not have established standards for the construction of the AVS, it is not surprising to find such variation.  In preparation for next week’s Primary Care Forum (a quarterly front line primary care manager meeting), medical center chiefs and clinical operations managers have been asked to review the AVS’s of several providers to see if there might not be a link between AVS quality and access.  In doing this homework, I decided to draft some quick definitions of AVS quality. 

Seven Measures of AVS Quality

• Summary begins by addressing patient by name (ie, first name or Mr./Ms., as appropriate)
• The diagnosis (or health status, if it is a physical) is stated
• The reason the diagnosis matters is stated
• The actions necessary for the patient to take are stated
• There is some demonstration of empathy in the AVS
• Summary is reasonably well organized
• Summary ends with a typed signature (eg, Martin Levine, MD, Northgate Medical Center)

What do you think about this list?  How could it be better?

For work to be fun and engaging for staff, staff need to be able to improve their work processes regularly.  The Frontline Improvement Campaign at Northgate Medical Center supports this kind of culture.  In Frontline Improvement, a small design team with representatives from disciplines across the clinic (eg, doctors, medical assistants, business office, pharmacy) meets weekly to create a testable solution to a vexing problem.  This design team’s solution is then announced to the rest of the clinic the following day, and then the full medical center tests the proposed solution for a week, giving the design team feedback along the way.  A week later, the design team reconvenes, reviews the feedback, and revises the solution, and, if necessary, has the full clinic test the procedure for another week.  This cycle is repeated until we feel we have a procedure that is 50% better than what we had before we started.  It does haven’t to be perfect, just 50% better.

Who is the Frontline Improvement Design Team?

Marty, medical center chief; Pattie, LPN; Carol, pharmacist; Ceci, business office; Jessy, MA; Karla, MA; Kim, physician; Malathi, clinic manager

Share Your Comments!!

If you have an idea for an improvement, or want to share your thoughts, upload a comment.  Our design team is going to be checking this blog regularly and posting our updates.  We want to learn from each other.

Problem: Patient stuck at pharmacy window because pharmacy staff has a question for provider and cannot dispense medication until question answered.

Process Mapping & Observations: No standard procedure existed for the pharmacy staff member to follow to solve this problem.  Each time the problem occurred, the pharmacy staff member would try whatever made sense at the time: eg, call the medical assistant, call the provider on office phone, use the overhead announcement system to page the provider, leave the pharmacy window and walk around the clinic looking for the provider.

Types of Wastes Identified in Observations: complexity, corrections, inventory, waiting time, searching time, transportation.

Proposed Solution: Pharmacy staff member pages the provider on her or his personal cell phone or pager through the Group Health paging system.

Results: Proposed solution tested for one week, during which time the consensus opinion in the clinic was that the new procedure was at least a 50% improvement on the previous procedure and became formally adopted by clinic.

Lessons Learned: 1) many providers not carrying pagers or cell phones; 2) many providers did not have the appropriate pager or cell phone registered with the Group Health paging operator; 3) if the provider did not respond to the page in 8-10 minutes, the pharmacy staff member would have to use judgment as to next best step.

Before the meeting the team all read through some helpful materials from our HR department regarding the path that people may go through as they transition through change. Alicia Eng, Administrative Director, and Steve Hockheiser, Medical Center Chief, led the team through a discussion and exercise to better understand the four phases on the transition path; Denial, Resistance, Exploration and Commitment. They discussed what it means to be in the various phases and what a person might need to help move them through the transition path from denial to commitment.

They talked about their own role versus that of management and were honest with each other about their personal experience of transition that has resulted from being part of the FLI team.

On the floor of their meeting room was a large cross made of blue painter’s tape representing the four quadrants on the transition path. They each got up from their chairs and stood in the quadrant they felt represented their current experience related to the FLI process. Although you cannot tell from the photo which square corresponds to which phase each team member was in one of these three places: Commitment (as seen in the left of the photo), on the line between Commitment and Exploration, or in Exploration (the right side of the photo).

Congratulations to our teams at both Northshore and Redmond who have braved the world of front line improvement and all the change it represents for themselves and their clinics. And thanks to the rest of the clinic staff who have been willing to run the experiments designed by the FLI team and give them honest feedback to help ensure that their experiments result in improvement, not just change. To quote a famous British pop icon they have been willing to “turn and face the strain” on the path toward continuous improvement at Group Health.

Feet In Transition