The team at Doctors Grand Plaza have had great success with their version of the patient held health summary – “the blue folder”

Melissa Cahill tells their story.

Our finest achievement conceived through the collaborative process is our “blue folder”. The blue folder is our version of the hand held record and the patients are encouraged to take it with them to specialist appointments, allied health appointments or to the ED if they need to present there.

In this is a copy of

• the patient’s medical history,
• current medication,
• allergies,
• immunisations,
• management plan,
• recent results (bloods, x-rays, echos etc) and
• current ECGs or ABIs.

The management plan also includes our invention – “the care calendar” (something I know that Tony’s practice has stolen shamelessly). The care calendar is a one paged three columned monthly calendar that sets out what needs to be done by the patient and the doctor for each month. The three columns include last year, this year and the next year. That way I can see what has been done when (i.e. the patients last yearly eye check was in Aug 2008 so it must be due again in Aug 09). and what is due to come before they are seen in 3 months time (i.e. we are seeing the patient in October and their ophthalmology appointment is due in November so a referral should be done at the October visit) and what is due in the future (i.e. their follow up colonoscopy or pap smear is not due til next year).

If updated correctly and regularly (I try to update the calendar even when I get a specialist letter telling me the patient is due to see them in 6 months), it is an easy way to know what is due when (without going through screens of old notes and blood results) and helps keep the patient organised as well (I derive great pleasure when the patient tells me when their blood tests are due rather than the other way around).

We continually get great feedback via the patients from the hospitals about our folder. One of my regular patients came in to see me today. We had tried very hard to sell him the idea of the blue folder but he finally took it in with him when he saw a physician at the PAH. He told me with great pride that the physician and the registrar poured over the folder with its depth of information like “piranhas” and that the comments they gave were “impressive” and “every doctor should look after their patients like this”.

Needless to say that made me quite proud and ensured that he would continue to take his blue folder to all his specialist appointments in future.

Melissa has been kind enough to share an example of their care caendar at this link.

Are you using a patient held record? Have you found it useful? What do you include? Have you any sample pages to share?

He was a hard headed man....

“Life in the Fast Lane,
Surely make you lose your mind“

The Collins Street Medical Centre has developed a strategy that has been effective in changing their capacity to match their demand. Fiona Broderick has generously presented on their ‘Swift Solutions Clinic’ at a number of APCC workshops.

Why block up a 15 minute slot if all that is needed is a brief appointment for a script, a certificate, a referral or a normal result? A number of practices have told us about variations on this idea that have worked for them.

Dr Boyapati’s practice restricted the clinic to prescriptions…

“We allocate 1 hour a week to “script only” time. Patients now know that if all they need is a repeat script they can book in at that time with next to no wait but it can ONLY be for a script. So far it has worked extremely well. Patients are happier that they don’t wait for “just a script”

At Campaspe Family Practice they deal with a wider range of problems but there are still strict guidelines…

“Our most successful innovation to date (shamelessly stolen from the Collins St Medical Centre at a collaborative workshop) is the introduction of the Swift Clinic set up daily for each doctor for approximately one and a half hours. Each appointment time is 5 minutes instead of 15. Patients are triaged at reception and educated about the clinic. A nurse sees the patient first and checks blood pressure etc…or arranges what is necessary for the patient..

The clinics are suitable for : repeat scripts, blood pressure checks, minor paper work (signature), sickness certificates (for a patient who has been treated by the practice already), results (if advised by the doctor to book swift) etc….We set them up after lunch or first thing in the morning to prevent a late start and consultations are usually bulk billed. Patients are very happy as are the doctors and reception staff.”

At Bribie Medical Centre they have specific clinics for individual problems…

“For one of our doctors, we have initiated script and referral clinics (for ongoing referrals and repeat scripts for patients seen within a 3 month period), BP clinics (previously patients were using the chemist for short BP checks but now we see them at the practice), and BSL Clinics.  We have put these clinics in place to help the waiting time for patients with appointments and to stop the interruptions for these types of visits.  .

The script clinics are 8.30 – 9.00 two days per week and 5.00 – 5.30 two days per week Tuesday through to Friday.  The BP and BSL clinics are also 2 days per week Tues and Thurs. The clinics usually see about 10 people per session.  The clinics have proven popular with the patients and other doctors have now started to follow.”

Quick clinics seem to be popular with patients and practices.   Your comments are welcome on this idea for improving practice efficiency

Have you ever worked out the steps involved in completing a GP Management Plan and Team Care Arrangement?

The Doctors of Ivanhoe have mapped this process, and produced a Tracking Sheet to assist in making sure each step is completed.

Mary Howe from the practice added this comment to our story on Chronic Care Coordinators.

I think these days a CCC is a must. Most of the work performed seems to be administrative and / or preparation for the doctor so I feel it is very hard to track the cost / benefits of this extra nurse.

At present the way we monitor the benefits is by checking to see if the CDM items billed have been increasing since hiring our CCC. The most important thing to us in maximising the benefits of these plans for the patient and medical staff / practice, is to ensure everyone is on board with the program and working together as a team.

When a member of the team doesn’t complete their part, the plan may not get completed (nurse time wasted), the item doesn’t get billed (nurse and GP time wasted) or both (everyones time wasted).

We have developed ‘tracking sheets’ for each patient having a ‘plan’ to ensure the whole process from identifying the patient through to billing is completed. These tracking sheets allow any member of the team to check on a patients ‘Plan’ progress and to act as a reminder of the many steps involved in completing the ‘Plan’ cycle.

Since then many have asked for a copy of the tracking sheets used in the practice.

Mary writes

Please find attached our tracking sheets for GPMP/TCA and DMMR items.

It would be easy for any Practice to create their own. We print these tracking sheets and keep them in a folder. The progress of the items on the tracking sheets are regularly checked by our co-ordinator to see if they have been completed and all the steps have been followed.

The sheets provide opportunity for continuous monitoring and once all the steps have been completed we just destroy them. If the co-ordinator is away then staff / doctors can access the sheets to see where the specific items are up to.

We do not specify who is responsible for each of the steps as we are all
aware of our roles, but a Practice could name the person / department
responsible for completion of each step to ensure staff understand the
role they play in the process.

I hope this small initiative helps others in the complex world of
Chronic Disease Management.

Thanks for sharing generously, Mary.

The Doctors of Ivanhoe tracking sheets are available from the links below:

• GPMP / TCA Tracking Sheet (pdf version)
• GPMP / TCA Tracking Sheet (spreadsheet xls version)
• DMMR Tracking Sheet (pdf)

‘Protected time’ is invaluable for improvement work – but in a busy practice it is often hard to find. The Sorell Family Practice came up with a novel way to protect this endangered species.

As you know, if you keep doing what you’re doing you’re keep getting what you get. The most successful collaborative practices have allocated time for their clinicians and staff to think about the systems in their practice, and to work on improving these systems.

This work is rewarded with success in the triple aim – improving patient outcomes, making work easier and more satisfying, and improving the practice bottom line.

How can you give staff ‘purple time‘ to undertake this work without having them called away to deal with more pressing and immediate problems.

The Sorell Family Practice have produced this fantastic uniform to indicate that the staff member wearing it is doing important work and is not to be interrupted.

Here is their purple smock, as modelled by their practice nurse Ruth Sproule at the Wave Four learning workshop in Sydney today.

And, if the person interrupting you doesn’t get the message – you can turn your back to them to give it to them in a more direct Tasmanian way.

Ruth says

“When people see you behind closed doors, and they don’t know what you are doing, they wonder why you aren’t out helping them”

“The Purple Smock has been successful in letting people understand that you are doing important and valuable work”

The practice shares the results of this work via a special collaborative noticeboard, where the results of their improvements and suggestions and ideas are posted. I don’t know if the noticeboard is also purple.
Do you allocate ‘purple time’ in your practice? And how do you protect it?

The people at Mt Barker/Balhannah Medical Clinic in South Australia were part of the second wave of the Collaborative back in 2005. They remind us that “care redesign” is one of the pillars of effective chronic care. That is you can’t keep doing the same thing and expect different results!

What did they do? Like many of the successful practices in the collaborative they created a new creature –the chronic disease coordinator.

“We have made quite a few changes but I believe the most significant change was brought about by employing a Registered Nurse to co-ordinate chronic disease management.

The first plan we tried was to have the nurse identify our patients with high HBA1C levels and invite them to a diabetic clinic which involved the clinical nurse, diabetic educator and doctor with an appointment at a later date with the podiatrist if indicated.

Now rather than running a dedicated diabetes clinic our nurse manages the recall of our diabetic patients in order to complete cycles of care (and achieve PIP recognition). She is adept at checking appointment schedules to achieve these outcomes.

Our doctors are now much more opportunistic and will identify patients who present with “risk” factors. These patients have the necessary tests ordered and see our chronic care coordinator, with the doctors signing off after consultation and planning. She also performs home health reviews and identifies those who may benefit from home medication reviews. Other functions include following up our outstanding pathology results – making sure all patients have been notified of abnormalities and irregularities and ensuring they have appointments to discuss their results with their doctor. From these patients she will make appointments if indicated by doctor and accepted by patient, for chronic disease management.

In our Practice of six – seven doctors, the demands of clinical nursing were increasing rapidly. By using our Chronic Disease Management Nurse we were able to rethink how we addressed our patients’ needs, we had more time to look at being much more pro-active in seeking out patients who were at risk.”

By making chronic disease care an explicit, resourced, “job-descriptioned”, core part of their way of working general practices like Mt Barker/Balhannah Medical Clinic are leading the way.

Have you redesigned your practice to include a chronic disease coordinator role? Make a comment and share your good idea below.

As Ai-Vee Chua writes
“In the spirit of PDSAs, I am submitting one ’small’ step in the multitude of changes we have made (and will make) at our practice as a result of being involved in the APCC program…”

“Our waiting room is relatively small, but its walls have always been filled with many posters and signs (akin to the advertising noticeboards seen at many local shops!). Following one of the APCC workshops, we returned home and decided to create an electronic noticeboard.”

Recipe for an Electronic Noticeboard

Ingredients

1. One old laptop
2. Version of Powerpoint downloaded free from the Internet
3. PDF converter software
4. TV screen with wall bracket and cabling
5. One practice principal with an interest in IT and in being a handyman!

Method

1. Strip waiting room walls of existing posters/signs.
2. Download posters from the Internet where possible and use PDF converter software to tun these into Powerpoint slides; create versions of remaining posters/signs as Powerpoint slides; add some slides of beautiful scenery (so patients can momentarily dream that they are in South America and not in a doctors waiting room in Dubbo)
3. Mount wall bracket, mount TV screen onto wall bracket
4. Run cable from TV screen up through ceiling, across ceiling space, and down to laptop hidden in cupboard
5. Run repeated Powerpoint presentation throughout the day
6. Delegate one receptionist task of maintaining electronic noticeboard slides
7. Stick back a few posters/signs on areas of walls that require a re-touch paint job!

Thanks for that, Ai-vee.

Have you got an electronic noticeboard in your practice? Any suggestions for what works well? Have you developed a different solution? Let us know in the comments below.

How much of our capacity is lost bit by bit – chipped away in little inefficiencies? This story from Romsey Medical Centre appealed to me because it underlines a lesson it took me years learn. Here is how they tell it…

“It’s hard to choose just one from the most worthwhile collaboratives journey, however, the one that most stands out in my mind is ‘Tracking doctor starting times’, the graphing of which named (and sometimes shamed) each doctor’s performance in this area.

It basically measured how long after the 1st booked appointment the doctor actually saw the first patient and drew direct correlations between this and session times blowing out.

It was painfully obvious that those doctors who regularly started their session late, finished even later, and those who started on time fared much better. As a result, we have seen a behavioural shift in ‘promptness’ which has benefitted everybody; the doctor (not feeling so stressed by the end of a session), reception (not copping so much abuse from patients), and patients (not having to wait as long to see the doctor).

If that’s not a win/win/win, I don’t know what is!!!”

It is a tribute to the healthy team Romsey has developed that they were willing to put themselves under the microscope to improve this area of their performance. As Tony Lembke says 15 minutes late is not on time (see “Becoming a Time Lord”).

In the ‘Carve Out’ model for appointments, some appointments each day are kept reserved as ‘book on the day appointments’, for patients with acute conditions. In our practice, these are coloured green.

If ‘Demand is Finite and Predictable’, we should be able to look at our appointment history to anticipate the future acute requirements, and thereby determine how many appointments need to be carved out.

(Indeed, a few years ago we analysed the appointments over a whole year and found that the number of both acute and planned appointments was very consistent for any particular day of the week.)

Successfully carving out the right number of appointments proves to be harder than anticipated. Even if we know that we will require 54 acute appointments on a Monday, and ‘reserve’ them some weeks ahead of time, many of these reserved slots are mysteriously taken up beforehand. By the time Monday starts, there are always far less than 54 still ‘carved out’.

So in our practice we are now playing ‘Appointments Golf’.

It is way of scoring the success of the appointment system. It is also a means of ascertaining how many acute appointments you need each day, without having to tally them up.

The scorecard we use can be downloaded here.
Part of the scorecard looks like this.

At the start of each day, before the phones are switched on, the ‘early’ receptionist counts how many free appointments are available. (A – Acute at Start of Day”

At the end of the day, the ‘closing’ receptionist counts how many extras needed to be fitted in, “B – Extras at End of Day”and how many gaps there are where noone was booked “C – Gaps”. (an unnusual event). You should also tally how many people (if any) were turned away (hopefully an even more unnusual event!) “D – Unmet”

Your score for the day is
Number of Extras(B) – Number of Gaps(C) + Number Turned Away(D).

The lower the score, the better.
An eagle is zero. Birdie is between one and three. Par is four to six. Bogie is seven to nine. Double Bogie starts from ten.

And here’s the tip to improve your score!

The number of appointments you need to carve out to get zero on the same day of the week in one week’s time will be
Number of Free Appts at start of day (A) + Your Score for the Day (E)
This is the demand for acute appointments (F).

We have found that this number is amazingly consistent from Monday to Monday, Tuesday to Tuesday, etc.

Could you play Appointment Golf in your clinic? Let me know how you score.

Can you think of ways of adapting or extending Appointment Golf?

Do you think the ideal score is zero? Perhaps a few extras each day is a good thing?

Perhaps we should include a doctor and staff ‘zen score’, to determine how much zen was lost in a frazzled high scoring day.

Your questions and comments for this ‘virtual tabletop’ are very welcome below.