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How does one incorporate new partners in a practice to avoid variation? Is there an acceptable percentage of incorporating their practice pattern into the group practice time pattern or should they have to adopt to the overwhelming majority of the group practice pattern? Incorporating too much from the new partner will certainly add to variation and to inefficiencies.
Ray, you will have the answer to this at the end of the next course where we will talk about mentoring. I use an example from my local hospital when a new breast surgeon was having difficulty acclimating to the culture of the OR. She went to her department chief who referred her to the CMO who informed her that the hospital employs seasoned physicians and is not in the business of teaching. In short, no mentoring here. First, it is very important that members of a group reduce variation in their practice. This is associated with improve outcomes and increased safety. It is also demonstrated that the best way to achieve this is with a formal mentoring program. An example is described at the end of the Negotiation course.
Your question of how to incorporate a new physician into the practice is all about mentoring. A good mentoring program employs a two way exchange. The mentor guides the newie in practice culture and technique, and the newbie guides the mentor about new knowledge both culture and clinical that may be integrated into the group practice. Periodic meetings with all practice members should consider changes that will improve practice and reduce variation. As time goes on you march toward a best practice model as a group taking advantage of present, new and newly learned knowledge.
New physicians want to be mentored. They need to be mentored. When hospitals employ formal mentoring programs, physician turnover decreases. As opposed to our local CMO, teaching does not stop when you finish your residency. It is probably more important than ever as our practice careers advances.
For dialysis clinic phosphorus problem, I agree with Rubeen’s process. For step 3, we always blame noncompliance as a first cause. It would be interesting to see from the patient side what they think and how they think we can help. Perhaps they don’t know what we are talking about, don’t think it’s a problem, no money to afford food, lack of education, insurance problems, etc. If the idea comes from them, they might be willing to follow through the process than being told what to do.
Volume of patients in my private practice is a “keep me up at night” problem. The usual ebb and flow from month to month is expected but to have consistency is the key. We have weekly provider meetings to discuss work flow, marketing, etc. We have utilized patient surveys in our practice recently (both for my MOC and a payor quality incentive). These are most always 97-98% positive. I guess I’m not exactly certain how I’d apply other measures learned from this course to the problem…any suggestions on other approaches.
From your post I am figuring that you are talking about discovering the cause of low volumes? Or are your volumes too high, or not consistent? Each has a different business approach. The first is not a process improvement issue. There are no process problems causing low volumes. This is really a strategy/marketing issue. We do not discuss marketing in this program, although it certainly is a part of leadership, we had to draw a line somewhere. Developing a marketing plan is very similar to strategy planning. Begin with a SWOT and then TOWS asking the specific question of how to we increase volume? Go through each of the strategy planning steps and you should come up with a good plan. I would be happy to guide you or review any work you do in that direction. Convening a meeting to discuss marketing without using a specific framework is very inefficient.
Inconsistent volume is a process issue and can be solved with CPI. High volume is a strategy issue and would be best served with strategy planning technique.
This came in from Rubeen
In our dialysis clinics, there is the perennial problem of poorly controlled phosphorous. We have two ways of manipulating the phosphorous- diet and using phosphorous binders. I would like to see if we can improve our process in treating this problem. Step 1: understand scope of problem- percent of pts with uncontrolled phos (we have good data on this)
Step 2: Flow chart to figure out the current standard process and work arounds-
Step 3: list of possible causes – I was wondering if it would be better to go to the patients first or to the staff (nurses, technicians, dietician, social worker, NP/PA) to brainstorm the causes behind the poorly controlled phosphorous?
We usually blame the lack of phosphorous control on patient non-compliance but I hope to find out if there are other issues and how to change the process to improve compliance if that is the major issue.Example: One of the issues we face in our division is empowering our patients. We see patients 4 days a week and much of clinic time is spent with pharmacist going over medications and checking pillboxes to see if they were filled correctly. Incorrectly filled pillboxes can take as much as 1 hour to correct. Think of the hours wasted if each month’s visit requires refilling the pillboxes. Simple answer: find the cause, help them do it the right way, empower the patient.
might not seem a big issue: but one pharmacist to entire clinic- bottlenecks clinic= patient dissatisfaction
This problem closely parallels the pain control project in the CPI presentation of “Leading Improvement”. Rather than jump to the first obvious solution, which would have been wrong, our cause and effect work brought us to a rather obscure solution that really produced significant improvement. It is funny sometimes how our own bias will lead us down a path of less effectiveness. That is why doing improvment in a team setting is key.
We recently got to hear about data on floors that have patient centered rounds. Inspite of PCR rounds being implemented metrics such LOS, time of discharge, patient satisfaction did not improve. The data also showed discordance for plan of care was similar between the patient – doctor, nurse-patient and doctor-nurse on floors that had PCR rounds and floors that did not have PCR rounds. (I was one of the investigators in the study and there were a few points that I made that were not given any attention. I asked that in addition to interviewing the nurse/doc/patient that they also interview the PCF – patient care facilitator. I also asked that they atleast collect data on the pulmonary stepdown floor that I was the assoc medical director. This floor had shown improvements in LOS, patient satisfaction, decreased RRTs. My point to the person presenting the data was needles were move on the stepdown floor and we have no way of proving or disproving if discordance existed between doc/family/nurses. My point being that discordance might not be only issue with current PCR issues at the moment)
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