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. While change fatigue is common, when the desire for change comes from within the practice, the results can be 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 care team, your patients and the practice as a whole.
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.
Three steps to help choose and implement successful, sustainable change
- Determine if it will ease the work burden for those who deliver care
- Confirm that it will improve patient care
- Confirm that a revenue stream will support the change
Determine if it will ease the work burden for those who deliver care
A successful change should make it easier for front-line workers to do their work well. The medical assistant (MA), nurse and physician have to be able to individually see “what’s in it for them.” This will help generate buy-in and commitment.
When considering whether a proposed project will save time and make work easier, you might ask:
- What aspects of the daily work frustrate the doctors and staff?
- What do doctors and staff do that seems counterproductive or unnecessary?
- In what areas are the results of care delivery disappointing?
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 involvement, buy-in and engagement throughout the process. For example, a practice team may decide to implement expanded rooming and discharge protocols. The nurses, MAs and physicians will all need to be involved to redistribute the work and ensure a smooth implementation. The staff 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?
An effective change team should have a high-level champion and multi-disciplinary representatives from the administrative staff; nurses; medical assistants; staff working in information technology (IT), compliance, pharmacy and care management; and physicians.
Additionally, make sure the change team consists of people who are positive, energetic, change-oriented and future-looking. According to change expert John Kotter, these are essential to creating a successful change team that will effectively lead the practice.1
What is the most effective way to lead change in the practice setting?
John Kotter has outlined eight steps for effectively leading change. The leader and team that will be involved in implementing the change should get to know these eight steps, as they provide a framework to follow throughout the improvement effort.
What are some examples of problem areas that we could 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
- 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 adhering to their medications or 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 record after the physician's review
- Not charging for services provided to patients who come to the office for routine or follow-up therapy
What if someone has an idea that other people on the team don't agree with?
Creating a respectful team environment where everyone's voice is heard is important. However, that doesn’t mean that everyone on the change team will 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.
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 and helping the team set the tone for successful meetings will pay dividends over time. A warm-up game like the “yes and” activity can help warm up the team and ignite a collaborative spirit. The work you do up front to ensure that your team works together successfully will lead to successful project implementation. See the culture module for more information about effective brainstorming tactics and see the team meetings module for more ideas about setting ground rules and involving the whole team in the discussion.
Confirm that it will improve patient care
Most 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 spent with patients 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. This enables the team 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 see by how much the original goal can be surpassed. Seeing improvement is a positive energy builder.
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:
- 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/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 measureable 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 seems reasonable
- Your patients who visit the emergency room often have to return to the emergency room within a month after their visit
- 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 sit on hold when they call the office or navigate through a complicated phone tree
- Patients are not adhering to their medications or treatment plans
- Patients must come in for multiple appointments, when care could be consolidated into a single appointment or coordinated on the same day
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, staff 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 physicians and staff, that is okay; you may choose to rely more on qualitative survey responses. (Thirty is commonly chosen as the minimum number of cases used to establish statistical significance.)
- Electronic health record (EHR)/registry data: Use EHR or registry data to evaluate your patients’ health and visit documentation. Many EHRs and registries have modifiable reports that can be set up so that they are generated regularly. If your EHR 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., three months, six months, nine months and one year) after implementation. After the project is considered “complete,” you can consider maintaining the metric as an indicator of 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.
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.
Confirm that a revenue stream will 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.
Change is only effective if it’s sustainable. 3 steps can bring meaningful change to your practice #STEPSforward
What are some examples of revenue stream impacts that I might expect to see?
- Increased efficiency can lead to increased revenue
- More available appointments (e.g., more billable patient encounters and a “closed” provider can open appointments to new patients)
- Increased patient access (e.g., patients can get into the office sooner, likelihood of losing patients to another practice decreases and likelihood of patients arriving to an emergency room or unaffiliated urgent care center decreases)
- Better patient quality of care can lead to better value-based payment positioning
- A healthier patient panel leads to less downstream costs for the health care system (e.g., fewer emergency room visits and hospitalizations)
- Better preventive care means preventing or catching dangerous, expensive conditions early (e.g., breast and colon cancer and pneumonia)
- Investing in education can result in a lowered incidence of expensive chronic conditions (e.g., diabetes and hypertension)
- Consider incentives and penalties that you can opt into or out of depending on your practice priorities and payer mix
- Increased efficiency can lead to increased revenue
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, and 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 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 providers 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 and business plan that shows the financial benefits of implementing your new project. If you need to hire more staff, the finances included in your proposal are going to hold more weight. 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.
For more significant changes, it may help to frame the project as a “pilot.” A pilot project is one that is being tried out; ideally, a full year is needed to test most new processes. 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: decreased work burden, increased patient quality and satisfaction and revenue stream impact. Of course, smaller changes may only require a few weeks or months to pilot. The pilot can be designed to last as long as necessary to show that the change has resulted in improvement.
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, staff 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 easing of the work burden, benefiting patients 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.
Getting the improvement project underway
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.
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 practice efficiency, patient care and physician and staff satisfaction. Keep in mind the three-pronged framework when selecting a change initiative—will it ease the work burden? Will it improve patient care? Is there a revenue stream to support it? 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 practice, patients and staff will allow you to achieve effective and sustainable change.
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- Kotter J. Leading Change. Boston, MA: Harvard Business School Press; 1996.
- Lynch DA. Three questions to guide any change effort. Fam Pract Manag. 2014;21(6):40.
- Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12(6):573-576.
- Big ideas to help your practice thrive. Fam Pract Manag. 2004;11(8):27-34.
- Bush J. Reducing risks for patients receiving warfarin. Fam Pract Manag. 2002;9(7):35-38.
- Newbell B, Schafer D, Pfenninger JL, et al. 10 big ideas that could make your practice better. Fam Pract Manag. 2008;15(8):33-41
- Anderson RJ. Optimizing the role of nursing staff to enhance physician productivity: one physician's journey. Fam Pract Manag. 2013;20(4):18-22.
- Kotter International. The 8-Step Process for Leading Change. http://www.kotterinternational.com/the-8-step-process-for-leading-change/. Accessed August 17, 2015.
STEPS in practice
How’s it working in Bellingham, WA?
Family Care Network in Bellingham, Washington is a physician-owned practice located in multiple community office sites throughout northwest Washington State. Over the last several years, they have used the three-question framework to select various change efforts, including telephone care treatment protocols, an online patient portal and web messaging system, numerous ancillary programs and value-based contracts with payers to help support innovation efforts with new payment mechanisms. Every project has deliberately sought to achieve three goals—easing the physicians’ work burden, measurably improving patient quality or convenience and attaching revenue to support the service.
A physician leader found that he was frequently interrupted with phone calls from patients on anticoagulation therapy who needed the lab results from their INR testing, so they could decide whether or not their anticoagulation therapy needed to be adjusted. His time with patients in the office was disrupted by these calls, and if he tried to review the information and call patients back later, he often failed to connect with the patient in a timely manner, which delayed proper management of the patients’ condition. It did not seem right to ask each patient to come back for another visit to discuss INR results and medication adjustment, and patients also did not want to make two visits to adjust their therapy.
The team wanted to design a better way to monitor patients on anticoagulation therapy that did not inconvenience the patient and would make the practice team’s lives better. The team thought that the physician might not be needed at all if he had previously specified the treatment level and duration for the patient’s diagnosis. The team also wanted to create a single visit in which the INR test could be performed as a point-of-care test in the office, where the clinical record would be available to both the clinician and patient at the same time. This would allow the results to be reviewed jointly, and if necessary, a change of therapy to meet the physician-prescribed goals could be discussed and agreed to, with all questions answered. This vision led to the selection of an in-office warfarin testing system and establishment of an in-office testing procedure with regular unknown sample quality testing, as well as the development by the practice physicians of a common protocol to adjust warfarin therapy. A nurse clinician was paid to undergo training so she could see patients and conduct the warfarin testing, counsel patients and follow the physician-created dose adjustment protocols in coordination with the patient’s physician. The results were dramatic. Phone call interruptions disappeared. Patients were pleased with the added convenience and the doctors and staff no longer worried about the patients they could not reach by phone who needed their medication adjusted. In addition, because consistent patient education was being provided by the same nurse clinician, the percent of patients at their therapeutic anticoagulation goal was improved.
Success leads to culture change
After the initial success with the anticoagulation project, the attitude of the practice physicians towards practice improvement projects started to change, and new projects were suggested. Unhappiness with the after-hours on-call experience led to the establishment of a shared office open in the evenings, on weekends and on holidays. This dedicated “after-hours” office enabled physicians to see patients with unanticipated and unscheduled needs. Several doctors in the group stepped up to provide this service, and extra physicians and mid-level practitioners were hired. The shared medical record made it easy to ensure that the patient’s personal physician was made aware of any after-hours office visit so follow-up could be arranged. Patients greatly appreciated the extra access to care, and revenue for these extra visits was a positive for the practice.
A learning experience: EHR implementation leads to team-based care
Not all of the practice’s change management initiatives have been successful. The team studied and selected an EHR that was supposed to improve record keeping, quality management and ability to serve patients with information where and when it was needed. They also believed it would pay for itself by eliminating expenses for transcription and the servicing of paper charts. However, the practice did not adequately appreciate the profound effect of using the computer on the physician–patient relationship and the extra burden it would place on the team and patients.
The team tried many approaches to easing the burden of capturing the patient’s information during patient visits, including dictation, using templates for common visit types and “smart phrases” that would add blocks of text by using verbal or keyboard cues. Despite these interventions, the practice realized that they had made more work for the clinicians during the patient visit, moving their attention from the patient to the computer.
Consequently, the practice chose another project to address the problem that had evolved from what had previously been viewed as a solution. The practice now uses two nurse assistants who work with patients and remain with them for the entire visit. (See the team documentation module.) The nurse assistant takes care of traditional rooming duties and acts as a scribe during the physician portion of the visit. She stays in the room after the physician portion of the visit is complete to arrange any needed tests, answer questions and print out a summary of the visit for the patient. The physician reviews the note, makes any needed alterations or additions and signs the note. This second intervention achieved the goal of easing the work burden, and the increased office efficiency allowed two extra visits per day that pay for the increase in nursing staff.
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Select sustainable change initiatives module
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