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By Roger Coleman

The Principles of Redesign™ provide a nice framework for redesign models. Much like the frame of a house, they give the initial visit redesign model shape, structure, and solidity. But to make the house work well, you need to construct the interior: the walls, windows, ceilings, plumbing, and fixtures.

This is what The Advanced Model is all about. Teams recognize they need to Prepare for the Expected from the Principles of Redesign, but just what is it they are expecting? And just how do they prepare for it? We now are at the “rubber meets the road” level.

The whole focus of The Advanced Model is preparation, preparation, preparation, teamwork, teamwork, and tools. Pretty much in that proportion.

1. Preparation.

Preparing well for a clinic session is the most powerful way to decrease cycle time, increase productivity, and enhance quality and outcomes. Here are four elements that should be built into every patient visit redesign.

• Prepare medical records. Obviously we are talking about facilities without full electronic medical records, but that’s most of the public health sector. The statistic is that a paper chart is not where it is suppose to be 27% of the time. In short, one out of three charts is missing. This produces a negative impact on quality, staff morale, and patient satisfaction. Ouch! What to do?
• Request charts from medical records two days prior to the clinic day. On Wednesday, your clinic receives charts for Friday’s patients. On Friday, for Tuesday’s patients.
• When the charts arrive, someone on the Patient Care Team, often a medical assistant, quickly reconciles the stack of charts with the patient schedule. Immediately the unit identifies missing charts and requests them from medical records. Don’t wait until the next day to do this—always do it on the day (and time) of chart arrival.

• During the morning of the following day (the day before the clinic session), Patient Care Team (PCT) members use brief interludes of downtime to work through the stack to review each chart for completeness. Missing reports are requested. Missing forms are added. The PCT also follows up with medical records, if missing charts have not appeared yet on the unit. If you’ve ever worked in a diner, this routine is similar to the routine of filling the salt and pepper shakers, the ketchup squirter, and wiping down all surfaces during those brief interludes when there aren’t a lot of customers.
• Really sharp redesign teams also build in a chart checklist during the above chart review. This can be a form or a log (the latter covers all scheduled patients in a provider’s clinic session on one sheet of paper). It will note the patient’s gender and age, date of last visit, reason for coming in, expiring medication orders, and any other key info. It should be brief and easy to fill out but immensely helpful in the Patient Care Team morning huddle. (More on this later.)
• Confirm Patient Appointments. Initially, this is a pain in the neck. Your patient contact information is probably outdated or not recorded or just plain wrong, so reaching patients is a monumental headache.

  But if you stick with it, you learn to get much better at gathering good contact information, which you will want anyway in case of patient emergencies, abnormal test results, or visit recalls. We’ve been working with NYC hospitals around no-show rates, and we’re stunned to find that you can routinely get them down into the single digits. Here are a few pointers:

• Confirm every scheduled patient one to two days prior to the clinic session. Call until you reach the patient. If it takes one call, great. If it takes 10 calls, well that’s the luck of the draw. Vary the time of day you do the repeat calls to increase your chances of reaching the person.

• Pre-register new patients over the phone when you call to confirm. This not only expedites the registration process but it makes it far more likely the patient shows up for the appointment. New patient no-show rates are typically quite high.
• Pass on the intelligence by making notes that will be helpful to Patient Care Teams. In the course of the confirmation call, clinic staff may discover the patient now has two complaints she wants addressed, or have a medication order that’s expiring, or is bringing her other child “just in case you have a chance to look at his rash.”
• Disconnects are often “No-show-nnects”. We’ve worked with a number of NYC Patient Centered Scheduling teams that have measured the correlation between disconnected telephone numbers and no-shows, and it’s not unusual for 60-90% of all disconnects to not appear for their visits. This is valuable information for a Patient Care Team—these are prime slots for same-days. 
• Prepare Your Space. Organizing everything for the next clinic session so that all needed equipment and supplies are in stock and at hand is one of the single most dramatic ways of avoiding lost staff time due to running back and forth to get the obvious.

• Organize and stock every exam room during the late afternoon, NOT first thing in the morning. (We are saving that time for another purpose to be discussed shortly.)
• Check all equipment to make sure it’s in working order, that batteries are recharged (and get spare batteries to also recharge), and that you have all the equipment you need.
• Put a scale and blood pressure device in every exam room to avoid the back-and-forth patterns of the old way of doing things.

2. Teamwork.

• Patient Care Team (PCT) Huddles. This is when you get to discover the incredible resistance to teamwork that is endemic to healthcare. But here’s the good news: If you can successfully get a group of folks to work like a real, live team, they almost always love it!

  Well, love starts here—with the daily, first-thing-in-the-morning Patient Care Huddle. We call this The Golden Beginning. It takes 15 to 20 minutes if it is well organized—and often it is not.

  This huddle takes place during what would have been the first patient appointment of the day. Don’t let this concept send chills up your spine. If the huddle is well executed, you’ll make up this lost productivity within 60-90 minutes after the clinic session begins, and then you’ll reap additional productivity gains for the remainder of the session. 

• All PCT members are present for the huddle—for the entire huddle. No drifting in and out of the huddle room.
• A private, well-lit space is required so there will be no interruptions during the huddle. A hallway or front desk area is not an appropriate space.
• Provide everyone with a writing space even if it’s a clipboard.
• Bring the charts for the day’s scheduled patients.
• Select a facilitator to make sure the huddle is well executed. The best huddle captain I’ve ever seen is Patricia Barnes of NYC who was in the Air Force for a chunk of time. She could command people’s attention and keep them intensely focused for 15 minutes—and that’s what it takes.  

So what does a Patient Care Team do in such a huddle? The following is the minimum:


• The facilitator uses the patient schedule as a guide and talks about each patient in order of appointment time with a sort of “what do we have here and what are we going to do about it tone.” Often the chart is reviewed concurrently.
• The clinician and other team members identify the tests and procedures that can be done before the clinician sees the patient.
• The team devises strategies and tactics to deal with the inevitable “curve balls” and to exploit the “disconnect” slots and other opportunities to accommodate same-day patients.
• Team members confirm and test their walkie-talkie channel.
• Remember: This huddle is NOT a chart-review to see if the chart is on the unit (that was done two days ago) or that all forms and reports are in the chart (that was done yesterday). It’s to strategize about how to take care of patients.
• Patient Care Teams. Just a word about these. They can be small (a clinician and a medical assistant) but they are much more effective if they have about four to five folks on them—a clinician, one to two medical assistants, a front-desker, someone from medical records, etc. There are limitless possible configurations.

  The important point is that a PCT functions like a small self-contained practice. It is a medical home for a specific population of patients—a patient panel. The more highly developed a PCT is, the more likely you are delivering great quality care within tight cycle times and being productive to boot.

• A PCT is comprised of team members who work together every day. Consistency and relationship-building are key prerequisites to smooth running, high-powered teams.
• The team remains tactically fluid all day. The work day is a video game where you know bad guys lurk around every corner, but you’re ready for them!
• Tight teamwork is based more on “getting the work done” than on job descriptions.
• Each team member does all she/he can do for the patient during the visit.

3. Tools.

• Tools. We need em’. We often don’t have em’. We even more often don’t know how to use em’. But, gosh are they great time savers.

  It will be a great journey of discovery for you. Start with a Nextel phone/walkie, or voice recognition software (Naturally Speaking), or a PDA with all the bells and whistles. Or a laptop, flash drive, or digital camera. The more you experience the benefit of tools, the more you will insist that having have all the tools they need makes Patient Care Teams optimally effective.

• A new process—or way of doing things—can be a “tool”. These are the tools teams often invent in redesigning the patient visit process. One really profound tool is an utterly revamped patient schedule template. We call this Simplified Patient Scheduling (SPS) and it is a key tool in Patient Centered Scheduling and in getting control over a chaotic schedule system in Patient Visit Redesign. You can read about Simplified Patient Scheduling in the Techniques section of this website.

This article, along with the two previous articles on the Principles of Redesign™ are intended to stimulate your thinking and get you jazzed into making big changes in how you take care of patients in your facility. Got some good ideas? Ready to put them into action?