Organizations Profiled

Seacoast Family Practice, Exeter, New Hampshire Core General Surgery, Exeter, New Hampshire

Jessica Boccelli, Director of Service Excellence, Core Physicians Caron Callahan, Practice Manager, Seacoast Family Practice

Beth Fletcher, Medical Office Coordinator II, Core General Surgery Marc Fournier, CMPE, Director of Human Resources, Core Physicians

Nicholas D. Garcia, M.D., Vascular Surgeon and Chief Physician Executive, Exeter Health Resources

Jason Howe, D.O., Primary Care Family Practitioner, Core Physicians Jana Jacobs, Senior Practice Administrator, Core General Surgery

Roderick S. McKee, M.D., FACS, General Surgeon, Core Physicians Diane P. Palladino, M.D., General Surgeon, Core Physicians

Jay W. Swett, M.D., FACS, Chief of Surgery and Interim CMO, Core Physicians

Core Physicians: Meeting Patient Needs with Empathy and Excellence By Elaine Zablocki, Staff Writer, Picker Institute

october 2015

pat i e n t- c e n t e r e d c a r e c a s e s t u d y A Picker Institute Series

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ii Core Physicians: Meeting Patient Needs with Empathy and Excellence Call Toll Free (800) 388-4264

Organization Profile

Seacoast Family Practice and Core General Surgery are divisions of Core Physicians, a community-based, multi-specialty group practice affiliated with Exeter Health Re- sources. Core Physicians includes over 160 providers in 28 locations, providing com- prehensive primary, specialty, and pediat- ric dental care throughout New Hampshire’s Seacoast Region. Core Physicians is an af- filiate of Exeter Hospital, a 100-bed, com- munity-based hospital serving the Seacoast Region. Exeter Hospital is a Magnet-recog- nized healthcare organization.

Seacoast Family Practice includes two family practice physicians, a part-time physician’s assistant, a registered nurse, a licensed practical nurse, and a medical assistant. Core General Surgery includes five general surgeons, a nurse practitio- ner and registered nurse, and three medi- cal assistants. Core Physicians and Exeter Hospital are both operating affiliates of Exeter Health Resources, which also in- cludes the Rockingham Visiting Nurse As- sociation.

Statement of Interest Medical groups today strive to meet patient needs on many levels. The Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey documents medical group performance in five areas of patient-centered care: • Patients’ rating of the provider (doctor,

nurse practitioner, and physician assis- tant)

• Getting timely appointments, care, and in- formation

• How well providers (doctors, nurse prac- titioners, and physician assistants) com- municate with patients

• Helpful, courteous, and respectful office staff

• Follow-up on test results

In each of these areas, certain medical groups are excellent performers, with con- sistent high scores on specific CG-CAHPS measures. Picker Institute case studies ex- plore the ways medical groups achieve these outstanding results, and share examples of best practices.

This case study profiles Seacoast Family Practice and Core General Surgery, which the Picker Institute has identified as high performers in delivering patient-centered care based on their exemplary performance in CG-CAHPS publicly reported data. Both organizations have top ratings for “How well providers communicate with patients.” In addition, Core General Surgery has top rat- ings for “Getting timely appointments, care, and information.”

Core Physicians: Meeting Patient Needs with Empathy and Excellence Core Physicians defines its mission in terms of “Triple Aim Plus One.” The Triple Aim is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system per- formance by pursuing three dimensions si- multaneously: • Improve the patient’s experience of care

(including quality and satisfaction) • Improve the health of populations • Reduce the per capita cost of healthcare

Core Physicians adds “Plus One,” an empha- sis on sustainability, because so many orga- nizations have found that it’s not enough to just make improvements; it is equally as im- portant to develop ways to sustain those im- provements, and to hardwire a system that sustains improvements.

Core Physicians relies on Lean methodol- ogy for process improvement and to sustain its improvements. “Lean is one of the tools we use constantly to re-examine our pro- cesses so we can be more efficient, improve workflow, and see more patients,” said Jes- sica Boccelli, Director of Service Excellence for the organization. “On every improvement project we conduct a Lean analysis and we use Lean tools. Key stakeholders at Exeter review our processes to determine which improvement projects should be our high- est priorities.”

Based on these aims and methods, it’s not surprising that Seacoast Family Prac- tice and Core General Surgery receive top ratings for “How well providers communi- cate with patients,” and that Core General Surgery has top ratings for “Getting timely

How Well Providers Communicate with Patients

The survey asks patients how often their providers explained things clearly and lis- tened carefully to them. The specific questions are: • Provider explained things in a way that was easy to understand • Provider listened carefully to patient • Provider gave easy-to-understand information about health questions or concerns • Provider knew important information about patient’s medical history • Provider showed respect for what patient had to say • Provider spent enough time with patient

Possible responses for these questions include “Never,” “Sometimes,” “Usually,” and “Always.”

Getting Timely Appointments, Care, and Information

The survey asks patients how often they got appointments for care as soon as needed and timely answers to questions when they called the office. The specific questions are: • Patient got appointment for urgent care as soon as needed • Patient got appointment for non-urgent care as soon as needed • Patient got answer to medical question the same day he/she phoned provider’s office

• Patient got answer to medical question as soon as he/she needed when phoned provider’s office after hours

• Patient saw provider within 15 minutes of appointment time

Possible responses for these questions include “Never,” “Sometimes,” “Usually,” and “Always.”

1Core Physicians: Meeting Patient Needs with Empathy and Excellence Call Toll Free (800) 388-4264

appointments, care, and information.” All of the staff at these clinics makes a special effort to listen to patients, tune in to their feelings, and treat them with care and re- spect. Core Physicians processes for hiring and evaluating physicians, nurses, and other staff emphasize qualities such as empathy, creativity, initiative, and optimism.

We asked some physicians at these orga- nizations exactly what they do that assures their patients that they are listening care- fully, showing them respect, and explaining things clearly. Not surprisingly, one of the most important things they do is take time to listen.

Patients can face anxiety when questions arise in addition to uncertainty about what to do after a surgical procedure. Taking a per- sonalized approach is standard practice for Jay W. Swett, M.D., FACS, Chief of Surgery and Interim Chief Medical Officer, who calls all of his patients. “If there are any issues that arise, I want to speak to them directly,” he said. “Patients like receiving a call from their surgeon and it saves the on-call physician from getting a call.” This best practice has created streamlined efficiencies in addition to increased patient satisfaction scores.

Jason Howe, D.O., Primary Care Family Physician at Seacoast Family Practice, be- lieves that when your patients talk with- out interruption, it can be extremely useful. “When you let them speak without interrup- tion, nine times out of 10 they’re going to tell you what’s wrong,” he said. “If you don’t lis- ten, they’re not able to tell you what is really happening with them.”

Dr. Howe likes to begin patient encoun- ters by making a personal connection with his patients. He might ask them about a re- cent trip, or how they’ve felt over the past few months; he doesn’t necessarily start with the current chief complaint. Once he has estab- lished a personal connection, he moves for- ward. “The biggest thing in being empathic is listening,” he said. “When you’re seeing 20 or 25 patients a day, sometimes that can be stressful, but I think in the end it saves time. I ask someone what they think is wrong, and many times that’s a great time-saver because you can allay their fears rather quickly. In the end, it’s not me driving the visit, it’s more the patient driving the visit.”

When a patient is coping with a complex issue, too much to cover in 15 minutes, Dr. Howe often encourages them to make an- other appointment. “You explain that to fully

address this problem we need to get you back in,” he said. “It’s a matter of time man- agement. If we’re not giving you enough time to really figure out this problem, it’s not fair to you or me or the next patient who is wait- ing for me—they understand that.”

“The biggest thing in being empathic is listening. I ask someone what they think is wrong, and many times that’s a great time-saver because you can allay their fears rather quickly. In the end, it’s not me driving the visit, it’s more the patient driving the visit.”

—Jason Howe, D.O., Primary Care Family Practitioner, Core Physicians

Diane Palladino, M.D., is primarily a general surgeon, but she felt her technical training hadn’t prepared her to help people cope with the mental, spiritual, and emotional effects of serious illness. Through a brief intensive course at Dartmouth-Hitchcock, plus in- formal training through the Exeter Hospi- tal hospice and palliative care service, she became board certified in hospice and pal- liative medicine. “I was always more inter- ested in the human side of healthcare,” she reflected. “I felt that the technical side was relatively easy to learn, but human touch was more difficult and equally as important.”

Through hospice and palliative care train- ing, she learned specific methods, such as always sitting down at the patient’s level, in- stead of standing up and looking down at them. It’s also important to make eye con- tact and ask questions, so the patient ends up doing most of the talking. “You say, ‘Tell me a bit more about that.’ You try to get is- sues that are in the closet out on the table,” Dr. Palladino said. “This helps you build a re- lationship of trust with the patient. It leads them to feel that you’re interested in them for who they are, not just for their diagnosis.”

Her hospice training also emphasized shared decision making, describing possi- ble options, and offering patients choices. “With every treatment option, we need to discuss the benefits and risks of those op- tions with the patient, always focusing on quality of life,” she said. “This means we need

to take the time to understand and listen to where the patient is coming from—what their most important goals and desires are.” At the end of each visit, she asks patients whether they have any questions. Sometimes she asks them to summarize their under- standing of the conversation, since this is a way to double check how much the patient has understood, and whether there are any gaps in their understanding.

All of the staff at these practices under- stands that listening carefully to patients is an important aspect of their role. Recently a medical office coordinator at Core General Surgery helped a patient who was extremely upset. She encouraged this patient to take her time, listened to her concerns, and helped her find solutions. A few days later the coordinator found a package on her desk. When she opened it, she saw a small vase made of shells, plus a handwritten note say- ing, “Your kindness and help is appreciated.”

In addition to emphasizing communica- tion with patients, physicians at Seacoast Family Practice and Core General Surgery also emphasize effective communications with other physicians. Their EMR makes it easy to send questions to specialists, or refer a patient for specialty care, and also be aware of what the specialist has done. “Having spe- cialist notes available has been very useful,” Dr. Howe said. “For example, when the spe- cialist changes medications, I’m aware of those changes, and this increases our pa- tients’ confidence in us.” The practice has two-way communications between primary care physicians and specialists. “Specialists often refer people back to me for issues re- lated to primary care, such as acid reflux,”

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Dr. Howe said. “In those situations, I forward the note to my nurse and ask her to bring the patient in for an appointment. We close the loop, and our patients appreciate it.”

At the end of each visit, the electronic health record generates an end-of-visit sum- mary, also called a patient plan, which sum- marizes the reasons for the visit, chronic conditions, medication list, the discussion during the visit, and next steps needed. Gen- erally this customized patient plan is com- pleted during the visit, so patients leave with a description of their entire visit, plus the next steps needed for the most effective care.

“With every treatment option, we need to discuss the benefits and risks of those options with the patient, always focusing on quality of life. This means we need to take the time to understand and listen to where the patient is coming from—what their most important goals and desires are.”

—Diane P. Palladino, M.D., General Surgeon, Core Physicians

Practitioners and Staff Listen to Each Other to Improve Patient Care For Seacoast Family Practice and Core Gen- eral Surgery to function effectively, it’s essen- tial to have open communications between physicians, nurses, and all the staff about ev- erything that affects the patients. “The phy- sicians are always open to ideas that lead to better patient care or improved workflow,” said Caron Callahan, Practice Manager at Seacoast Family Practice. “Recently the clin- ical staff at Seacoast Family Practice devel- oped new ideas for improved workflow for prescriptions to be picked up at the office. They presented a proposal, and the physi- cians accepted it.”

“In our healthcare environment, it is es- sential for staff members to be able to clar- ify what a physician says, to ensure there are no errors,” said Jana Jacobs, Senior Practice Administrator for Core General Surgery. She recalls one person who was obviously intim- idated when she first arrived at the prac- tice. “I walked with her to the provider and

encouraged her to ask her question. That broke down the initial barrier and set some communication parameters for them, and their mutual communication strengthened.”

Since 2014, Core Physicians has been using tiered huddles, which help to create a culture of communication throughout all levels of the organization. A huddle is a short face-to-face stand-up meeting, usually last- ing about five minutes. One definition calls the huddle “a planning session to re-estab- lish situation awareness, reinforce plans al- ready in place, and assess the need to adjust the plan.”

Core Physicians uses a brief template for topics to be covered at the huddle: Who is working today, providers and staff ? Who is available for backup, if needed? Are there open appointments? Are there any quality or safety concerns?

One of the basic principles at Core Physi- cians is that everyone is encouraged to step forward and facilitate communications. Boccelli recalls one day when both manag- ers were out, so the medical assistant imme- diately stepped forward and led the huddle. “Communication is everybody’s responsibil- ity,” she said. “The huddle is usually led by a manager, but the reality is that they could be anywhere, so everyone should be able to pick it up and lead the team.”

After each practice has its daily huddle, all the practice managers get together on the phone with the Core Physicians vice pres- idents and directors and the president for a tier-two huddle. This huddle reviews any- thing that came up at the tier-one huddle, plus some additional categories. Fifteen minutes later, the Core Physicians adminis- tration and hospital get on the phone for a tier-three huddle.

One of the basic principles of Lean meth- odology is that work should flow smoothly. About two months ago Core Physicians added workflow to the huddle list, and asked managers to notice anything that interrupts flow and makes life difficult, and bring those issues to the tier-two level. The tier-two level sets a deadline for fixing the issue or brings it to tier three if needed. The basic princi- ple here is that these issues will be fully re- searched and resolved within a very short timeframe.

It seems to be working. When Boccelli rounds, she makes a point of asking whether there are process issues or flow busters to

review. At one high-volume express care site, the front desk staff said that printing same- day medication reconciliation sheets in ad- vance for each patient added up to an hour of work each day, and took them “out of flow.” The clinical staff always reviews medications with each patient during the intake process. After looking closely at the issue, the tier- two office decided that this preliminary step, printing out the medication list, wasn’t re- ally necessary.

Callahan agrees that the new focus on flow busters is extremely valuable. “When it was my turn to present a flow buster, we talked about medication prior authoriza- tions, which are very time-consuming and take a substantial amount of time away from patient care. Deb Cresta, President of Core Physicians, happened to be on that call. She was the first one to say, ‘We’ve to do some- thing about this right away. Let’s get this centralized so one person can deal with the authorizations, while the practices continue focusing on patient care.’ When you see ac- tion being taken at that level, so quickly, you really feel validated.”

The Environment Supports a Culture of Care Many aspects of the physical and social en- vironment at Core Physicians support a culture of patient-centered care. This is espe- cially noticeable at Seacoast Family Practice, where the space is organized so each physi- cian sits right next to their principal assis- tant, with materials and files for the day filed nearby. The clinical support person juggles priorities and organizes workflow to make the best use of the physician’s time.

This close environment supports team- work between physicians and other pro- fessionals. “There is a great deal of trust between the provider and clinical staff, and they will take the time to stop and take care of essential functions in between patients,” Callahan said. “I’ve also noticed that in this situation many things are handled verbally, so it’s very quick and efficient.”

Dr. Howe relies on his nurse to interrupt him between patients when something needs to be addressed quickly. Clinical and administrative staff is trained to prioritize messages. “Low priorities can wait for the next 24 or 48 hours before I need to look at them,” Dr. Howe said. “We try to deal with high priorities within 10 to 15 minutes, and

3Core Physicians: Meeting Patient Needs with Empathy and Excellence Call Toll Free (800) 388-4264

then middle-of-the-road issues are dealt with by the end of the day.”

Core Physicians’ patient portal plays an important role in responding quickly and efficiently to patient requests. It was first set up four years ago, and at present about 38 percent (28,000) of patients have regis- tered to use it. It is a confidential, secure Web site that patients can use to commu- nicate directly with medical and adminis- trative staff, request appointments, send messages, request prescription refills, or re- view their health history. When a physician responds, patients receive an email saying there’s a message waiting on the portal, and they sign in using a password.

The portal is particularly effective for routine lab results and appointments. “It’s a great avenue to support communication between the doctor and the patient because it addresses so many mundane things that can be accomplished easily with this type of communication,” Dr. Howe said. “It’s a two- way street, so patients can contact me with questions about a recent appointment or a question about a medication, and we can ad- dress those questions rapidly without tying up resources.” His nurse reviews patient por- tal messages and prioritizes them before he sees them. “Often there are issues she can address directly, so she’s working at the high- est level of her licensing. She’s very good at

triaging messages so I see the most impor- tant issues in a timely way,” he said. Dr. Howe responds to portal messages throughout the day, and estimates this takes about 45 min- utes per day.

“The patient portal is a great avenue to support communication between the doctor and the patient because it addresses so many mundane things that can be accomplished easily with this type of communication. It’s a two-way street, so patients can contact me with questions about a recent appointment or a question about a medication, and we can address those questions rapidly without tying up resources.”

—Jason Howe, D.O., Primary Care Family Practitioner, Core Physicians

When someone learns they need surgery, they naturally want to see the surgeon as soon as possible. Core General Surgery makes a special point of adjusting sched- ules in order to get them into the office. Even when the schedule seems to be full, it is still possible to make adjustments. “We’ve made it very clear to staff that we do want to get patients in as soon as possible,” said Nich- olas D. Garcia, M.D., Vascular Surgeon and Chief Physician Executive, Exeter Health Re- sources. “We build in flexibility, and make special allowances for people who need to be seen, even when the schedule is already crowded.”

To support proactive responses to patient needs, Core Physicians has developed clear standards for phone calls, with model scripts for typical calls. For example, when calling a patient, staff always asks whether this is a good time for a call. When taking a message for a practitioner, staff assures patients they will get a call back by the end of the day. At the end of each call, they always say, “Thank you for calling.”

Core General Surgery has one receptionist who answers 90 percent of incoming calls, and then sends them on to the appropriate clinical or administrative person. Since pro- viders don’t have answering machines, all

their messages flow through the staff or the patient portal. This means physicians have more time available for actually seeing pa- tients.

At the same time, they all try to return calls promptly. Dr. Palladino responds to calls whenever she has time between pa- tients; she doesn’t wait until the end of the day. Her nurse calls patients who have be- nign results, but she personally calls each person who needs further testing or who has negative results.

Similarly, Dr. Garcia asks his assistant to bring him notes about needed phone calls throughout the day, and responds as soon as possible. This pattern of timely responses to incoming phone calls promotes an even workflow. It also supports patient-centered care, reducing patients’ anxiety since they don’t have to wait till the end of the day for a call back. “We’ve had positive results from this,” Dr. Garcia said. “The model is basically you’re always doing the work as it’s coming in. As we do more of this sort of work, we think we’ll get better and faster.”

Core General Surgery has developed pro- tocols for typical appointments, so now most staffers can schedule appointments based on their own knowledge of patient needs. “Be- fore we streamlined our processes, some ap- pointments had to be reviewed in advance by the provider,” said Beth Fletcher, Medical Office Coordinator II for Core General Sur- gery. “Often that was quite difficult, since the physician was in the OR or the cath lab—we ended up playing phone tag. Now we just put the patient on the schedule, and let the pro- vider know afterwards.

Hiring and Training Staff for Service Core Physicians has developed a patient- centered culture, and one factor that supports this culture is its emphasis on finding and hiring appropriate people. It seeks people with warm, caring personal- ities, people who want to offer excellent patient care. When Jacobs interviews po- tential employees, she sometimes asks them to describe a particularly difficult patient in the past, how they dealt with that situation, and its outcome. “As a man- ager you can hear a lot in that story,” she said. “ You’re looking for someone who can focus, because this is always a busy envi- ronment. We can teach people the prac- tical skills they need; we are looking for

4 Core Physicians: Meeting Patient Needs with Empathy and Excellence Call Toll Free (800) 388-4264

someone who can consistently, sincerely deliver excellent patient service.”

About four years ago, Core Physicians em- barked on a customer service training pro- gram for all employees, called “Taking the HEAT.” HEAT stands for four important prin- ciples: • Hear. Listen to the patient. • Empathize. Put yourself in the other per-

son’s place, tune in to their feelings, de- sires, and needs.

• Apologize. Simply say, “I’m so sorry that this happened.”

• Take responsibility for action. Take ap- propriate steps to meet the patient’s ex- pressed needs.

When this program was introduced, every employee went through several four-hour training modules, which combined an intro- ductory talk with educational videos. Each module included breakout sessions, with op- portunities for role-playing, so the training sessions were lively and interactive. People learned more effectively because they were involved in the process. In addition, each ses- sion used a variety of materials, to suit peo- ple who often learn in different ways.

All the physicians participated in a short- ened version of the HEAT training, lasting about two-and-a-half hours, so they were able to absorb similar concepts and de- velop similar skills. Nowadays, this sort of training is built into the orientation pro- gram for all new employees and providers. “Initially, this was a completely new view- point for most of the physicians,” Dr. Gar- cia said. “Most of us tend to assume that we are superior communicators.” He appreci- ated the specific examples of excellent and poor communication that were built into the training program. “As we listen to vivid stories about patients who have had good experiences or negative experiences, at some point a lightbulb goes off and people become increasingly receptive to these no- tions,” he said.

Today, new employees receive a full-day orientation program, plus additional two- hour modules that emphasize specific as- pects of customer service, including empathy and meeting patients’ needs. When Boccelli introduces new employees to these princi- ples, she emphasizes the importance of lis- tening and letting someone tell their story. “When you hear a patient or a customer re- peat a story over and over again, the reason

is that they don’t think you’ve heard them,” she said. “I encourage people to let someone finish telling their story, and then repeat a few key words back to them so they will un- derstand that they have been heard.”

The training program often uses the word “customers” rather than “patients,” because everyone is encouraged to use these meth- ods broadly. During the day, employees need to deal with all sorts of people: suppliers, their fellow employees, staffers at the local hospital, as well as patients. “We deal with each other all the time, so it’s particularly important to apply these principles of listen- ing and empathy in our daily interactions,” Boccelli said.

“When you hear a patient or a customer repeat a story over and over again, the reason is that they don’t think you’ve heard them. I encourage people to let someone finish telling their story, and then repeat a few key words back to them so they will understand that they have been heard.”

—Jessica Boccelli, Director of Service Excellence, Core Physicians

Hardwiring customer service has become organic within the office culture. When asked about processes that have resulted in increased scores for the clinic, Roderick S. McKee, M.D., FACS, General Surgeon, noted it was difficult to articulate because the methods of interaction through their train- ings have become a natural way to how they practice. This is often the case with high-per- forming organizations—a culture exists that facilitates interactions that are meaningful to patients using a patient-centric approach.

Core Physicians also emphasizes cross- training, flexible roles, and mutual support. Fletcher is trained to cope with special prob- lems that may arise, unique situations in- volving employees or patients that require special handling. Another Medical Office Co- ordinator II deals primarily with gastroen- terology, but they are each trained to step in and fill the other’s role as needed.

Medical office coordinators (MOC) have a primarily administrative role, while medi- cal assistants (MA) have a primarily clinical

role. A couple years ago, Core Physicians designed a position profile called MOC- MA for people who are certified as med- ical assistants and trained to function in both roles. While MOC-MAs receive a some- what higher pay scale, the organization benefits because they are able to function in either role, depending on each day’s spe- cific needs.

“The nice thing about the pod is it’s in the center of the workspace, and everybody’s cross-trained,” Dr. Palladino said. “When you have an immediate need, and your own MA is busy, you can ask someone else to help you and they jump right to it.” The clinic en- courages everyone to work to the top of their license. “Our medical assistants tend to be real self-starters,” Dr. Palladino said. “They’ll mention that they’ve never assisted at cer- tain complex procedures, and we’ll invite them to observe and learn.”

Setting Expectations and Supporting a Patient- Centered Culture Exeter Health Resources recently clarified its expectations for all employees through what it calls Ex3, “Expectations for Excellence at Exeter.” This emphasizes three concepts: • Care/customer service (putting patients’

needs first). • Communication and teamwork • Creating efficiencies

In practice, Ex3 means developing situa- tional awareness and anticipating the needs of others. It means following Lean concepts such as standard work, and helping to im- prove efficiency and outcomes. Everyone at Core Physicians is encouraged to function as part of a team and develop supportive rela- tionships with colleagues.

“We emphasize specific behaviors, such as relying on Lean concepts and using Team- STEPPS,” said Marc Fournier, CMPE, Director

5Core Physicians: Meeting Patient Needs with Empathy and Excellence Call Toll Free (800) 388-4264

of Human Resources at Core Physicians. “We emphasize attitudes such as optimism and respect. About 60 percent of the overall eval- uation for staff is tied to these behaviors and adhering to Ex3 principles.”

Compensation for physicians is deter- mined by a base salary plus incentives, in- cluding incentives for productivity, quality, and positive behaviors. Physicians are ex- pected to demonstrate compassion as a basis of positive human relations, display strong teamwork skills, and use service re- covery methods based on the HEAT model when they encounter a dissatisfied patient. They are expected to support creativity and optimism among their work team and dem- onstrate initiative and flexibility in address- ing issues. Annual evaluations for physicians include a discussion of progress on various quality metrics and patient satisfaction sur- vey results.

All of these steps contribute to a flexible culture, with focused improvement efforts that impact the quality of care for patients, and also increase workplace efficiency. Phy- sicians are involved in improvement efforts, and there is a remarkable degree of commu- nication throughout different levels of the organization.

Seacoast Family Practice functions ef- fectively in a space that’s designed for close communication between each physician and their principal assistants. Core General Surgery has a much more expansive space, but both practices are applying the same

principles of team coordination and per- sonal accountability.

“We’re trying to define certain expecta- tions about our work that will always be the same regardless of office or setting or specialty,” Dr. Garcia said. “The principle of standard work is very important, and you can follow these basic principles in differ- ent physical settings. Having said that, we are also trying to make our office settings increasingly the same, with standard equip- ment in multiple locations throughout our organization.”

Recently Core General Surgery used Lean methods to solve problems with its checkout process, and this story exemplifies some of the most important factors in the practice’s evolving culture. Initially, the checkout pro- cess was cumbersome and patients didn’t know exactly what they were supposed to do, and sometimes ended up milling around in the hallway. One reason is that after see- ing the physician, a patient could face sev- eral different “next steps.” One person might need diagnostic testing, another needed to schedule a second office appointment, and someone else needed to schedule surgery. Providers had to fill out a checkout form that was two pages long, and meanwhile patients weren’t sure where to go next.

The practice used Lean methods to focus on this issue, and it went through four “plan, do, study, act” cycles. Now there is a standard process: physicians ask patients to wait in the exam room for a moment until someone

comes to walk them through checkout. No- tice flags outside the exam room are pushed to the side, so staff knows the provider is fin- ished seeing the patient.

Meanwhile, the checkout form has been revised, and now it takes just one page. Since these changes were implemented, physicians do their notes quickly and con- sistently. The paperwork goes to a bin next to the medical assistant’s desk, so everyone knows where it is.

These changes were only possible thanks to excellent communication between office staff and physicians, Fletcher said. “Jana Ja- cobs and I went to several general surgeons’ meetings and presented our plans for pa- tient flow. We explained that we wanted to make things easier for them and for the pa- tients. It was definitely a team effort,” she said. “The providers had significant input. We went back and forth, explaining why we needed this information or that information at each point before we could move forward on the next steps for the patient.”

Perhaps the most interesting thing about this example is, as the saying goes, it’s not rocket science. Consolidating a two-page form into a one-page form that still includes all the essential information takes slow and careful work. It’s not a $500,000 machine. It’s not something you could put in an advertise- ment. But this sort of clear-eyed, patient, co- operative effort makes work flow smoothly. Patients, providers, and the practice team all reap the benefits.

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