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American Medical Group Association

Friday, 16 May 2008

Big Dots
The Everett Clinic
2007 Acclaim Award Recipient

The Everett Clinic’s team (front row from left to right): Richard Rafoth, M.D., Associate Medical Director, Quality and Utilization; Harold Dash, M.D., President; Rick Cooper, CEO. (back row): Al Fisk, M.D., M.M.M., Medical Director; Karen Nardinger, R.N.; Paige Nelson R.N., B.S.N., CPHQ, Director, Quality Improvement

The Everett Clinic (TEC) is a community-focused multispecialty medical group that provides a full range of medical services to a 3-county service area in Washington, with a population of over 800,000. With an active patient base of 225,000 patients, the group has 14 practice sites, 8 urgent care clinics, and 2 outpatient surgery centers. The organizational culture supports and reinforces a clinic that is adaptive to a changing environment and responsive to external factors, such as the IOM Aims. Patient service, accessible locations, and convenience are hallmarks of the organization.

TEC believes implementing the IOM Aims presents an opportunity to add value to the patient care process as they work to anticipate patient needs and proactively strive to improve their overall state of health and well being. The level of care defined by the IOM Aims encompasses the total care needs of the patient, as opposed to the individual’s immediate or acute-visit care needs.

In 2005, TEC set out to determine how it could truly accomplish adding value to the care provided. The focus was on two main issues: the challenge of keeping the visit focused on the patient’s needs (balancing their immediate needs with the long term) as well as effectively measuring whether TEC was achieving the desired results. To achieve the goals of further embedding a patient care philosophy oriented toward the whole patient and measurement of results, TEC began using a methodology known as “Big Dot.”

To drive change in that direction throughout TEC, the medical group adopted a set of metrics defined as Big Dots, which parallel the IOM Aims.

Goals

TEC is a physician-driven and -directed organization, which is exceedingly proud of its standards of excellence and track record that combines quality of care; cost-effectiveness; patient, physician, and staff satisfaction; and solid financial performance. The values of the organization are reflected in the following “guiding principles” adopted by the Board of Directors in 1998 and renewed subsequently.

CLINIC GUIDING PRINCIPLE(S)

We do what is right for each patient
We provide an enriching and supportive workplace
Our team focuses on value: service, quality, and cost

Within the construct of these principles, the Board of Directors’ goals and objectives for 2007 are:

CUSTOMER SATISFACTION
We will improve our American Medical Group Association (AMGA) patient survey response for “the visit overall” and rank in the 75th percentile by:

Implementing the “patient friendly/physician efficient” visit

Listening to the patient through increased patient involvement in process improvement and more frequent patient satisfaction surveys

Eliminating the perception that “The clinic is closed” by ensuring open practices are available at every clinic location

Improving specialty department access by aligning incentives

PATIENT SAFETY AND QUALITY
We will strength our “culture of safety” and quality improvement by:

Using Clinic Improvement Systems to double the percentage of patients who are optimally managed for their health registries

Promoting the use of “evidence-based” medicine to decrease variations in care

Increasing use of the Culture of Excellence reporting tool to minimize adverse clinical events

Implementing EpicCare successfully in the summer of 2007

BEST WORKPLACE
We will be a premier employer with employee satisfaction scores greater than the 75th percentile and physician satisfaction scores greater than the 90th percentile by:

Achieving greater staff participation in clinic Improvement events (>30 percent of staff and physicians)

Improving our systems for staff and physician training and development

Evaluating skills and performance-based compensation plans for staff

SECURE FUTURE
We will achieve greater than a five percent profitability margin by:

Using Clinical Improvement to provide value to patients

Reversing the trend of decreasing visits per physician

Managing the Epic project to budget goals and timelines

Opening physical therapy, podiatry, and pathology services

In the table below, The Everett Clinic demonstrates how their Big Dots goals and metrics are linked to their organizational goals, the six IOM Aims, and implementation at the staff level.

METRIC	IOM	THE CLINIC	METRIC	FRONT-LINE STAFF AND PHYSICIAN IMPACT/ACTIONS
Patient-Centered	Providing care that is respectful of an responsive to individual patient preferences, needs, and values and ensuring that patient values guide all decisions	The patients is satisfied with the care they received as The Everett Clinic	Percent of patients “satisfied with their visit overall”—answering excellent on the annual AMGA patient satisfaction survey	Standard work—One call does it all Standard Work—After visit planning Individual patient prompts—Up-to-date and in control data
Effective	Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse)	A patient’s health and disease are managed appropriately	Percent of unique active patients who are up-to-date and optimally managed in all registries in which they appear	Standard Work—Standard rooming process Individual practitioner reports—Up-to-date and in control data
Timely	Reducing waits (and sometimes harmful delays) for both those who receive and those who give care	The patient is able to access personal health care on a timely basis	Internal weighted average of third available appointment—primary care and specialty	Redesigned and removed barriers to scheduling
Safe	Avoiding injuries to patients from the care that is intended to help them	The clinic will minimize the frequency of adverse clinical care events which lead to or might least to an adverse outcome	The clinic “accident” rate, the monthly frequency of an event entered into the Risk Management database, and the clinic “near miss” rate of a clinical incident referred to Risk Management	Culture of Excellence—non-punitive reporting Ease of reporting Improved coordination with Risk Management
Equitable	Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status	The clinic provides its fair share of care for the underinsured in the community	Percent “active” patients who are Medicaid and Medicare	Monitor metric Ensure access Medicare Advantage CMS Demonstration Project
Efficient	Avoiding waste, in particular waste of equipment, supplies, ideas, and energy	The clinic is a good steward in using its clinical care resources to provide care	“Operating expenses” / total work RVUs	Monitoring cost/RVU Redefine efficiency education

Implementation

The process of implementation of Big Dots at TEC was multi-pronged. The Big Dot goals and metrics are now overarching for the clinic as a whole, complementing the prior processes to drive change at TEC. The historical perspective and the transition of goal setting for 2007 can be depicted as follows:

The impact of adopting Big Dot goals was to provide the Board, and in turn each management unit, a common perspective on their individual goals. For 2007, the Board not only set specific patient care, service, and business goals for TEC (now aligned with the Big Dot goals)—which then filter throughout the organization and are drivers in setting goals and accountability measures at the operating unit level—but also provided a set of six overarching organizational metrics aligned with the six IOM Aims. The results of working towards Clinic goals are then reflected in these Big Dot metrics—a measurement of results and accountability.

Results

The adoption of the six Big Dot goals and metrics has already accelerated change at TEC. Focusing on the Big Dots at the Board level, with regular review of those metrics, is driving change. The Big Dots have:

Facilitated communication of the Board’s aims throughout the organization

Captured the attention of the practitioners

Aligned organizational measures, strategies, and projects

Focused leadership’s attention on monitoring the progress of process and quality improvement efforts

The Effective Big Dot (IOM Rule 1—Care based upon continuous healing relationships) is the first example of their success. The results are beginning to show, as indicated below:

The Efficient Big Dot suggested that TEC could be missing the mark, becoming less efficient. While not happy with this result, the medical group is pleased that it now has a tool that forces it to ask the question “why” and consider corrective actions. The Efficient Big Dot is reported annually; TEC expects major, positive change when 2007 data is reported.

TEC has used the Safe Big Dot to assist with the culture change in the area of Patient Safety (IOM Rule 6—Safety as a system priority). It encouraged the organization to review how it gathers and analyzes information. As a result, TEC has expanded its infrastructure and taken advantage of technology to improve the collection of safety-related information; both potential incidents and actual accidents. The results indicate that they are making progress:

Moving the Big Dots in the right direction has required The Everett Clinic to reassess all of their activities. Projects, many of which were already in place, received renewed and increased emphasis if they might effect a favorable change in the Big Dots. And new projects are designed to focus on gaining positive results in Big Dot metrics.

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