By Virginia Smyth
Look what's happened behind the scenes to improve patient health and the care experience at Group Health Medical Centers.
At Group Health, we want to improve our patients' health. To do that, we're working hard behind the scenes to keep improving our care and services.
How can we reduce the time patients wait for their prescriptions at Group Health pharmacies? When a patient leaves the hospital, what can we do to make sure they know how to get well and get the follow-up care they need? How can we accommodate patients who drop in to the clinic without an appointment?
These are just a sampling of the patient concerns that have stretched the creative thinking and problem solving skills of Group Health staff over the last few years. Each one became an actual behind-the-scenes project whose goal was to improve the health care experience.
Many improvements are the result of a management philosophy we adopted several years ago that focuses on continuous improvement and creating standard work that can be consistently applied. As these projects demonstrate — whether they're implemented systemwide or used in a single clinic or department — our patients and members are reaping the rewards.
Project: Better, Faster Service in Pharmacy
The goal: Reduce wait time for prescriptions at Group Health Medical Centers' high-volume pharmacies.
Then: You arrived at one of these pharmacies to fill a prescription or pick up a refill, and you had to wait a long time, perhaps up to 30 minutes.
Now: At most of our pharmacies, almost all patients — between 85 percent and 90 percent of them — wait only 10 minutes or so to get their prescription. When a patient is prescribed a new medication at an office visit, it's not unusual for that patient to leave an exam room, walk up to the pharmacy, and find the prescription already waiting.
Behind the scenes: Group Health has more than two dozen pharmacies — each a little bit different — which made this a challenging project. The ultimate goal is to serve 90 percent of customers in any Group Health pharmacy waiting room within 10 minutes. That goal is close to being realized at Group Health's Bellevue, Northgate, and Everett pharmacies where staff have rolled up their sleeves, analyzed data, and pulled apart the old way of doing things. They've completely revamped their work and created standard systems that deliver prescriptions more quickly, while maintaining high standards for safety. The new process at each pharmacy includes a way for staff to suggest more changes for further improvements.
Aha discovery: In the past, improvements to Group Health pharmacies followed a cookie-cutter approach despite wide differences in size and volume. "This time, we did not want to create one size fits all," says Tom Colleran, director of Pharmacy Systems and Operations for Group Health. "We wanted to allow for individuality and creativity because each pharmacy is different. In doing that, we're accomplishing our goal, and our managers and staff continue to work on how to improve service." Transformation continues and by year's end Capitol Hill Campus, Riverfront, Tacoma, Silverdale, and Olympia locations, and the mail order pharmacy, will all have shorter wait times.
Project: Think Pink Mammography Screening Program
Goal: Increase the number of women who get recommended mammograms.
Then: All members received yearly letters near their birthday, reminding them about recommended preventive care they should schedule.
Now: Members still receive this yearly letter, but women for whom mammograms are recommended also receive a phone call reminding them that it's time for their mammogram, and encouraging them to make an appointment. The hours for mammogram appointments have also been extended at some Group Health locations. And all breast centers offer Saturday appointments.
Behind the scenes: Before the reminder call program began, about 60 percent of women for whom mammograms were recommended followed through with appointments, says Amy Montgomery, a radiology services manager. An analysis revealed a number of reasons why the number was so low. Forgetting to make an appointment was at the top of the list, followed by inconvenient scheduling. With reminder phone calls and extended mammography hours, more than 70 percent of the women due for mammograms are following through.
Aha discovery: "When I make calls to women on my list, if I am able to speak with them (rather than leave a message), 90 percent schedule an appointment right away. Women are really appreciative of receiving a reminder," says Catherine Hardwig, a patient care representative who heads a team of Group Health employees who make these outreach calls.
Project: Shorter Waits for Colonoscopy Appointments
The goal: Reduce the backlog of patients waiting to have a colonoscopy at the Capitol Hill Campus Gastroenterology Department, and do it without increasing costs.
Then: You and your doctor decided that a colonoscopy was your best colon cancer screening option (other options are a sigmoidoscopy and a stool test). You called for an appointment and were put on a waiting list that was several months long.
Now: After you and your doctor decide on a colonoscopy, you are given an appointment for the procedure that's just three weeks away. The appointment itself — start to finish — takes less time than before since all work has been standardized. Every staff member knows exactly what should happen every step of the way, and each patient moves through the admitting, procedure, and recovery process with greater efficiency.
Behind the scenes: "We wanted to find ways to decrease the time it takes for the procedure without compromising patient safety and the quality of the screening procedure," says Sally Jacob, RN, MSN, clinical operations manager for Gastroenterology at Capitol Hill. The staff made some easy changes first, like identifying ways to decrease patient cancellations. Then they did the hard work: a time/motion study to figure out where there was duplication, and where time could be saved. Then standard work procedures were written for every step.
Aha discovery: "By making the process more efficient and organized, we've decreased stress for the staff and increased patient and staff satisfaction," says Jacob. Our multispecialty center's Bellevue Gastroenterology Department completed a similar process to reduce wait times for appointments that has also yielded impressive results. One unexpected outcome: Now that patients know they can get an appointment quickly, the department is experiencing more cancellations. Jacob tells patients: "If you have to cancel, do so at least 72 hours in advance so someone else can use the appointment and we can ensure that everyone gets access to this important procedure in a timely manner."
Project: Lidgerwood Patient Drop-In Pilot Program
Goal: In Spokane, offer Lidgerwood clinic patients with acute care needs the option to drop in at the clinic.
Then: Patients with an urgent health issue — perhaps a sore throat, bad cut, or severe stomachache — often went to the emergency room instead of calling their doctor. Some who called were offered appointments at a time inconvenient to them. If they dropped in, there wasn't any provider with time to see them.
Now: Clinic patients with urgent concerns are encouraged to call their doctor before going to an emergency room or an urgent care center. When they come to the clinic — whether they have called ahead or just dropped in — a provider is available to see them, usually in a half hour or less.
Behind the scenes: "Before making any changes, we gathered information about why our patients were going to the emergency room or Urgent Care," says Paul Skrei, MD, medical center chief at Lidgerwood. "Many of those visits were between 8 a.m. and 5 p.m. We also learned what the health issues were. About 70 percent of them were problems we could have resolved in the clinic. Then we asked ourselves what we could do to make sure that if a patient called us, we would have someone available to see them." There is now one member of the clinical staff — either a physician's assistant or a physician — who starts the day with an empty appointment schedule to accommodate drop-in patients.
Aha discovery: "Most people think that a clinic has to be exclusively appointment-based, or exclusively for walk-ins. We wanted to accommodate both," says Dr. Skrei. "The patients love this, and our staff really appreciate the ability to say, 'Yes, I think you should be seen. If you come in, we'll take care of you.' That's very powerful."
Project: Emergency Department/Hospital Inpatient Initiative (EDHI)
Goal: Reduce the number of hospital patients who are readmitted to the hospital after just a few days, and make sure patients who come to the hospital emergency room are in the right care setting.
Then: Some patients came to a hospital emergency room who might have been better served at an urgent care center, or who should have been put under observation rather than admitted to the hospital. There was no mechanism in place to route those patients elsewhere.
For those patients admitted to the hospital, Group Health doctors and nurses focused on their clinical needs. The majority of patients who were hospitalized would spend a short time there, go home, get well, and return to their life. But some patients — usually those who had significant surgeries or multiple health conditions — left the hospital and returned home or to another care setting, such as a nursing home, without understanding what they needed to do to get well. Or they didn't have a clear plan in place for getting the post-hospitalization care they needed. A significant number wound up back in the hospital within seven days.
Now: In many partner hospitals, Group Health hospitalists — doctors who specialize in hospital care — evaluate Group Health patients when they arrive in the ER, and are able to send them to the most appropriate care setting, whether that's the hospital, an urgent care center, or their regular clinic. These doctors and Group Health care management nurses also identify patients with complex needs as soon as they are admitted to the hospital. They immediately begin to develop a care plan for what will happen when the patient leaves the hospital, working with both the patient and the family. They follow a carefully developed system that is designed to make sure that the transition from hospital to the next care setting goes smoothly.
Behind the scenes: This new approach allows doctors and nurses to spend some time making sure patients move well from one care setting to another. An important part of this transition is the post-hospital care plan. As part of that plan, nurses make sure that the patient and family understand the patient's health condition, what medications the patient is taking and what the medications are for, what follow-up care is needed, and what the signs are that a condition may be worsening and what steps to take. Tools are provided to help patients manage their medications and keep a personal health record to use in communicating with health providers.
Patients also get a phone call from a nurse within 48 hours of when they leave the hospital. And within a week, a Group Health pharmacist gets involved, reviewing all medications the patient is taking and updating their medical record as appropriate.
At some partner hospitals, Group Health has nurses on site, but not doctors. These nurses do the transition planning from one care setting to another. Hospitals that have very few Group Health patients also assign nurses to do this planning, but it usually happens via the telephone rather than in person.
As a result of this work and the new systems in place, patients are not admitted to the hospital if another care setting would better meet their needs. Those who are hospitalized understand what they need to do when they arrive at home or their next care setting, their overall care has improved, they are returning less frequently to the hospital, and they're happier with their care.
Aha discovery: "We weren't doing a good job at handoffs from hospital to the next care setting. Some people fell through the cracks. We saw an opportunity to improve things," says Emily Homer, executive director of Care Management for Group Health. "Our nurses love to do this work now. And the patients really appreciate it and feel more supported. They are so grateful that someone is paying attention." Others in health care are paying attention too, coming to Group Health for information on how to implement this in other care systems.
Project: Flu Vaccinations During Regular Clinic Hours
Goal: Make it easier for Group Health patients to get their yearly flu vaccine.
Then: Each year, patients were asked to make a special trip to a Group Health Medical Centers flu clinic for their annual vaccine. At each location, the flu vaccine was available only on a few dates during the fall.
Now: Flu shots are available throughout the flu season at all Group Health Medical Centers clinics, Monday through Friday, 8:30 a.m. to 5 p.m. You can get your flu shot any time you find yourself at the facility — whether for a medical appointment, lab test, to pick up a prescription, or just because you're in the neighborhood. And if you haven't yet gotten it? A member of the medical staff is likely to invite you to get it taken care of on the spot during an office visit.
Behind the scenes: The expanded hours began in time for the 2010-2011 flu season, and it's been a resounding success. "Prevention is the key," says Laurie Sarver, operations manager in charge of the program. "We don't want patients to miss an easy opportunity to get their flu shot."
Aha discovery: "Patients like that Group Health is watching out for their health, and encouraging them to get this preventive care benefit," says Sarver. "And they like not having to make a special visit for a flu shot."
Project: Riverfront Urgent Care Improvements
Goal: Change the Riverfront urgent care clinic from appointment based, to drop in.
Then: When a patient at Group Health Medical Centers Riverfront clinic in Spokane needed to be seen after hours or on weekends, they had to call the Urgent Care Center for an appointment (which differs from the urgent care approach in our Western Washington facilities). As a result, many just went to a hospital emergency room where no appointment was needed, even if they faced long wait times.
Now: Unless they have a life-threatening emergency, all patients are encouraged to call their primary care doctor, or go to Urgent Care. Urgent Care Center hours at Riverfront have been extended, and patients can drop in, no appointment needed. Patients are typically seen in 15 minutes to a half hour from when they walk in.
Behind the scenes: "The urgent care staff worried that changing from appointments to a drop-in schedule would lead to long waits for patients," says Tom Schaaf, MD, assistant medical director for Spokane. An urgent care team spent about six months analyzing the issue, and studying other places with this model. "We wanted to learn best practices and avoid pitfalls," says Dr. Schaaf. "Then we redesigned the system without appointments, and without significant wait times for patients." When it went live in early January, the hard work was evident. Long wait times haven't materialized, patients are getting excellent care, and both patients and staff are happy.
Aha discovery: "The biggest thing we figured out was that for a number of our patients — because of transportation or other life issues — having an appointment actually made it more difficult for them to be seen in urgent care," says Dr. Schaaf. "There have been little glitches now and then, but our staff continues to work on developing tools to make it easier for Urgent Care doctors to see patients quickly and effectively."