Health Serv Manage Res 2008;21:276-280
doi:10.1258/hsmr.2008.008009
© 2008 Royal Society of Medicine Press
Standardized care processes to improve quality and safety of patient care in a large academic practice: the Plummer Project of the Department of Medicine, Mayo Clinic
Douglas L Wood * 
,
Michael D Brennan ,
Rajeev Chaudhry ,
Anthony A Chihak 
,
Wayne L Feyereisn ,
Naomi L Woychick ,
Philip T Hagen ,
Jonathan W Curtright 
,
James M Naessens **,
Barbara R Spurrier and
Nicholas F LaRusso
* Division of Health Care Policy and Research;
Department of Internal Medicine;
Department of Facilities and Support Services;
Internal Medicine Administrative Services;
** Division of Biostatistics;
Department of Biochemistry and Molecular Biology;
Department of Research Administration, Mayo Clinic, Rochester, MN, USA
Correspondence to: Rajeev Chaudhry Email: chaudhry.rajeev{at}mayo.edu
There are opportunities to improve quality and safety of care provided to adult patients. The Plummer Project of the Department of Medicine at the Mayo Clinic (Rochester, MN, USA) is an initiative to redesign outpatient practice. We used multidisciplinary teams to standardize the tasks essential to improve patient care. With the initiative to standardize the rooming process, patient care and safety improved with greater accuracy of the medication list. The standardization also improved physician efficiency because trained clinical assistants helped address the needs of the patient. Physicians were satisfied by the new process and the technology enhancements. Clinical assistants were also highly satisfied by the training process. The quality and safety of patient care can be significantly improved by practice redesign. This practice redesign was satisfying for all, especially the patients, physicians and support team in our practice.
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Introduction
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Ever since the Institute of Medicine's groundbreaking publication
Crossing the Quality Chasm1 was released, health-care organizations
across the USA have accelerated their efforts to improve quality
and safety. The Joint Commission and other entities have developed
guidelines and metrics to enhance patient safety and reduce
medication errors.
2–6 The recently announced Medicare
pay-for-performance project lists performance metrics that must
be met for preventive services and treatment of chronic diseases.
7 The requirements for maintaining accurate medication lists and
administering preventive care are laudable but are also time-consuming
and can encroach on face-to-face time with patients. By applying
the principles of quality improvement, LEAN systems, and a team
approach for patient care, the Department of Medicine at Mayo
Clinic (Rochester, Minnesota) underwent a major transformation
of its multispecialty practice to improve the quality and safety
of patient care and to improve the efficiency and satisfaction
of all the team members, including physicians.
8–11 In
this report, we describe the outcomes of this practice redesign
initiative, which may be replicated by other large, ambulatory
practices.
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Department of Medicine Plummer Project
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The Department of Medicine at our institution comprises 690
staff physicians and provides care for more than 490,000 patient
visits annually. Our department launched a major practice redesign
initiative in early 2006 that was named after Dr Henry Plummer,
one of its founding members. The goals of the Plummer Project
were to increase physician efficiency and the quality of patient
care through process redesign and technology upgrades throughout
the Department's outpatient practice. Transformational changes
continue to occur and are guided by teams of clinical assistants,
nurses and physicians working collaboratively.
Standardized rooming initiative
This team developed and implemented a standardized process of patient care that included collaborative work between physicians and appropriately trained clinical assistants (‘rooming process’). The team was charged with streamlining the process of accurately obtaining and recording key clinical information for immediate review by the physicians during the clinical visit. This information included: (i) the name of referring physician; (ii) allergies; (iii) age- and sex-specific preventive services performed in the past and preventive services required by the patient (necessary services were determined by a standardized protocol that was developed and approved for clinical practice); (iv) accurate documentation of current medications and use of standardized notation in the medical record (i.e. medication name, dosage, route of administration and dosing schedule); and (v) documentation of advance directives.
All clinical assistants participated in a standardized training programme. Training consisted of (i) a medical terminology course (online, required seven weeks to complete); (ii) a pharmacology course (online, required seven weeks to complete); (iii) education and training to measure and record vital signs; (iv) development of patient-interaction skills (e.g. interpersonal skills, communication skills); and (v) instruction in shorthand tools for creating preliminary ‘stub notes’ in the electronic medical record (stub notes consisted of key clinical information for the physician to review).
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Results
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Standardization of the rooming process
Multiple surveys were conducted to assess the effectiveness
of the standardization of the rooming process. Specifically,
we looked for improvement in the quality and safety of patient
care, and improved efficiency and satisfaction of physicians
and allied health personnel.
Enhancements in quality and safety of care
We reviewed 1157 consecutive clinical notes before rooming process standardization and 257 clinical notes after the initial implementation. Identification of the referring physician increased from 57% to 88%, documentation of allergies increased from 52% to 70%, documentation of advance directives increased from 2% to 83% and medication list completeness for all the four required elements (medication name, dosage, route of administration and dosing schedule) increased from 32% to 91%. These differences were statistically significant (P < 0.001 for all).
Impact on efficiency of the outpatient practice
Before standardization, all the clinical notes were dictated (authored) by physicians. After completion of training in the standardized rooming process, clinical assistants obtained and documented key clinical information from patients to help physicians fulfil those tasks. Word counts of the clinical notes (n = 200) after standardization showed that 21% of the note was authored by clinical assistants and 79% by physicians (Table 1).
Satisfaction with the standardized rooming process
Satisfaction was assessed for the initial pilot participants
(137 physicians) who were part of the standardized process for
a minimum of three months. The results point to heightened physician
satisfaction (Table
2). We also surveyed 12 allied health
staff members who had participated in the process for at least
three months. Improved satisfaction was also noted in several
aspects of their work (Table
3).
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Discussion
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Our outpatient practice project showed that marked improvement
in the ambulatory practice can be achieved through process redesign
and technological improvements. Improved training of clinical
assistants and their acquisition of new skills resulted in reduced
work for clinicians and greater compliance with national quality
and safety standards, including medication accuracy, medication
reconciliation and completion of preventive services. Clinical
note creation was considerably more efficient and complete when
using this standardized approach. Physician transcription time
was also reduced. As clinical documentation of elements pertaining
to quality and safety increases, it will be increasingly important
for physicians and trained allied health staff to work as a
collaborative team.
We are encouraged by the results of the satisfaction surveys completed by patients, allied health staff and physicians. Physicians were assured that the tasks assigned to allied health staff were performed reliably. The allied health staff survey showed that the new training process helped them become comfortable and skilled in those patient services. Improved allied health staff satisfaction also reflected their increased participation in clinical interactions that approached the maximum level of their training and licensure.
Our experience was similar to that reported by others who showed that improving the systems and coordination of care improves overall health-care quality, safety and efficiency.12–16 We were also able to build on previous institutional quality and safety improvement initiatives for medication reconciliation.17,18 We believe these changes will result in enhanced compliance with national quality and safety guidelines.
As the health-care environment continues to evolve, and as the population of patients with chronic disease continues to rise, it is increasingly important for clinical practices to be redesigned to provide care that is safe, efficient and of high quality. Standardized processes, such as those described in this report, are needed to achieve these goals.
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Conclusion
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Health-care quality may be greatly enhanced by addressing the
processes of care in a coordinated manner with teams of allied
health professionals and physicians who work together to provide
patient care. Simple technologic enhancements may also improve
the efficiency of care processes and increase the satisfaction
of providers with their work environment.
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Disclosures
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None of the authors have any financial conflict to disclose.
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Acknowledgements
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We acknowledge Mary Pat Anderson and Kristen King for secretarial
support. Editing, proofreading and reference verification were
provided by the Section of Scientific Publications, Mayo Clinic.
This quality improvement initiative was supported by a small
grant from Mayo Foundation for Medical Education and Research.
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Footnotes
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Douglas L Wood MD, Division of Health Care Policy and Research, Department of Internal Medicine; Michael D Brennan MD, Department of Internal Medicine; Rajeev Chaudhry MBBS MPH, Department of Internal Medicine; Anthony A Chihak, Department of Facilities and Support Services; Wayne L Feyereisn MD, Department of Internal Medicine; Naomi L Woychick, Department of Facilities and Support Services; Philip T Hagen MD MPH, Department of Internal Medicine; Jonathan W Curtright MHA MBA, Internal Medicine Administrative Services; James M Naessens ScD, Division of Biostatistics; Barbara R Spurrier MHA Internal Medicine Administrative Services; Nicholas F LaRusso MD, Department of Internal Medicine; Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
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References
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- Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press, 2001
- National Committee for Quality Assurance. See www.ncqa.org (last accessed 2 January 2008)
- Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press, 2000
- The Leapfrog Group. The Leapfrog Group Fact Sheet. See www.leapfroggroup.org/about_us/leapfrog-factsheet, 2007 (last accessed 2 January 2008)
- Bedell SE, Jabbour S, Goldberg R, et al. Discrepancies in the use of medications: their extent and predictors in an outpatient practice. Arch Intern Med 2000;160:2129–34[Abstract/Free Full Text]
- Ernst ME, Brown GL, Klepser TB, Kelly MW. Medication discrepancies in an outpatient electronic medical record. Am J Health Syst Pharm 2001;58:2072–5[Free Full Text]
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- Shewhart WA. Economic Control of Quality of Manufactured Product. New York: Van Nostrand, 1931
- Rosenthal MB, Frank RG, Li Z, Epstein AM. Early experience with pay-for-performance: from concept to practice. JAMA 2005;294:1788–93[Abstract/Free Full Text]
- Deming EW. Out of the Crisis. Cambridge, MA: MIT Press, 1982
- Endsley S, Magill MK, Godfrey MM. Creating a lean practice. Fam Pract Manag 2006;13:34–8[Medline]
- Amalberti R, Auroy Y, Berwick D, Barach P. Five system barriers to achieving ultrasafe health care. Ann Intern Med 2005;142:756–64[Abstract/Free Full Text]
- Salas E, Burke CS, Stagl KC. Developing teams and team leaders: strategies and principles. In: Day DV, Zaccaro SJ, Halpin SM, eds. Leader Development for Transforming Organizations: Growing Leaders for Tomorrow. Mahwah, NJ: Lawrence Erlbaum Associates, 2004:325–58
- Amalberti R. Revisiting safety and human factor paradigms to meet the safety challenges of ultra complex and safe systems. In: Willpert B, Falhbruck B, eds. System Safety: Challenges and Pitfalls of Intervention. Amsterdam: Pergamon, 2002:265–76
- Baker DP, Gustafson S, Beaubien JM, Salas E, Barach P. Medical Teamwork and Patient Safety: The Evidence-Based Relation (Literature review). Rockville (MD): Agency for Healthcare Research and Quality (AHRQ Publication no. 05-0053), 2005
- Porter ME, Teisberg EO. How physicians can change the future of health care. JAMA 2007;297:1103–11[Abstract/Free Full Text]
- Nassaralla CL, Naessens JM, Chaudhry R, Hansen MA, Scheitel SM. Implementation of a medication reconciliation process in an ambulatory internal medicine clinic. Qual Saf Health Care 2007;16:90–4[Abstract/Free Full Text]
- Varkey P, Cunningham J, Bisping DS. Improving medication reconciliation in the outpatient setting. Jt Comm J Qual Patient Saf 2007;33:286–92[Medline]
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Introduction
Department of Medicine Plummer...
