At a time when service counts more than ever, the Atlanta VAMC
established a formal customer service program to better meet the
needs of our veterans, their families, and employees. This program
focuses on providing prompt, informative, and courteous service
to all of our customers. Two specific aspects focus on ambulatory
care patients: our Customer Welcoming Station and the Service
Representative Program. Both significantly improve patient and
employee satisfaction.
In the past, patients had few ways to obtain assistance during
their visits to our outpatient area. Although the Patient Representative
was available to provide this assistance, having only one individual
serving as an advocate was not sufficient and did not meet our
standards of exceptional customer service. Our goal is to have
all 2,000 medical center employees serve as advocates each day.
To accomplish this, we developed the Service Representative Program
to involve large numbers of our employees in customer service
functions.
This program was designed to have each service provide at least
one individual to work with our Customer Service Office in assisting
patients and providing five-star service. Individuals selected
as Service Representatives serve a one-year term and provide special
assistance to customers in areas related to their expertise. Employees
participate voluntarily and receive special customer service training
throughout the year from outside educators, as well as guidance
from the Patient Representative. Their functions include addressing
patient complaints, family concerns, employee requests, and working
on customer service programs for the medical center. For example,
if a patient comes to the hospital with a concern related to his
medications, we now have an experienced, well trained, and identifiable
employee in the Pharmacy dedicated to completely delighting the
customer.
As our Customer Service Program evolved further, we developed
a Customer Welcoming Center located in the main waiting area of
Ambulatory Care. This center is staffed by two GS-6 Patient Representative
Associates and one volunteer from 7:30 a.m. to 5:00 p.m., Monday
through Friday. Immediately upon entering the outpatient area,
patients are now greeted by staff who ask them, "How may
we help you?" Here, patients may receive directional assistance;
schedule appointments; ask questions about eligibility, travel,
and other benefits; or be personally escorted to their destination.
The staff work closely with the Patient Representative and the
Service Representatives to ensure prompt and professional attention
to questions and concerns presented by customers. Outpatients
have grown so accustomed to finding immediate, friendly assistance
at the Welcoming Station that it is almost always their first
stop when they come for their visit.
Benefits
Since implementing these programs, the number of patient complaints
has decreased by more than 33% from the previous year. Also, the
amount of positive mail we have received about the medical center
has doubled. Therefore, we spend less time answering congressional
inquiries and more time with our customers.
We have also enhanced our ability to manage front-line workers
and have been able to institute a new work philosophy for these
individuals. Our employees are now expected to delight the customer,
and they understand why it is so important to do this. As these
customer service initiatives continue to grow, we also have begun
to receive more requests by employees to become participants.
Thus, we continue to expand the base of individuals who want to
extend themselves for our customers.
Contact Person: Chuck Bedo, MHA
Service: Office of the Director
Facility: Atlanta, GA VAMC
Number: (404) 728-7724 or FTS (700) 248-7483
Staff members identified the need to have a person in the Triage
waiting area who could provide information to family members of
patients being seen in Triage. It was felt that this position
would coordinate efforts to get information to family members,
reduce complaints of excessive waiting, reduce visitors in the
Emergency Room, and generally provide better customer service.
In light of a recent FTEE reduction, we decided to use a light
duty employee to provide this service.
The duties assigned are:
Benefits
This service has been met with tremendous support and gratitude
from patients and staff. It has reduced complaints from family
members in this area and has provided better coordination of information
for waiting family members.
Contact Person: Vivieca Wright
Service: Ambulatory Care Service
Facility: Nashville, TN VAMC
Number: (615) 321-6361 or FTS (700) 850-4751
F or the past three years, Big Spring VAMC has operated Haven
House, a resi- dence that provides lodging and food for wives
and female relatives and friends of hospitalized veterans. Billed
as "a place of honor for wives of hospital veterans,"
the residence opened 3-1/2 blocks from the medical center in November
1991. It is open to women friends and family members over the
age of 16 for as long as they need to stay. They may contribute
a suggested $3.00 or $4.00 per night if they wish or may stay
with no charge; free food is always available in a well stocked
pantry. The typical stay is for two or three days; two women stayed
for more than 60 days. Usually three to six women are there on
a given night, but there has been as many as 13 women guests on
the same night.
Haven House was originally donated by a VA employee, Lona Hood,
who saw the need for such a facility while she worked at the VA.
It is not officially owned by the VA, but by a non-profit corporation.
Social Work serves as the Inn Master, dispensing keys and registering
guests; the Social Work Service secretary serves as Chief Inn-keeper.
The home is supported by private donations from various service organizations; considerable rivalry has developed among groups wishing to be associated as donors. Unsolicited donations easily surpass the average monthly operating expenses of less than $300 per month. Donations have come from as far away as Alaska, and veterans groups in Tyler and Amarillo, Texas, some 200 and 400 miles away, have been regular donors.
Benefits
Haven House is a gesture by VA staff to honor veterans' families
and let everyone know, whether or not they use the home, that
VA cares in a special way for veterans. The women who stay there
write frequent letters of praise; many talk of the friendships,
fellowship, and therapy they derive from other women staying at
the home. It has been a positive experience for veterans, families,
service organizations, and VA staff, and it has brought much praise
for the medical center.
Contact Person: John Webb, LMSW
Service: Social Work Service
Facility: Big Spring, TX VAMC
Number: (915) 264-4850 or FTS (700) 728-7040
T he Iowa City VAMC is undergoing reorganization and moving toward
patient- centered care. In May 1994, Surgical Service made a registered
nurse responsible for managing and implementing a patient focused
environment in the Orthopedic Section. A few of the resulting
innovations are:
Benefits
The pre-operative screening telephone calls have decreased the
percentage of Operating Room cases that are canceled. By having
a specific registered nurse responsible for managing the Orthopedic
Section, patients know who to contact when they have questions
or problems. The change has enhanced patient satisfaction, improved
communications and efficiency, and provided Orthopedics with a
more patient-centered focus.
Contact Person: Dr. Kimberly S. Ephgrave
Service: Surgical Service
Facility: Iowa City, IA VAMC
Number: (319) 338-0581 or FTS (700) 863-6011
In an attempt to ensure patients receive the care they need and
reduce no-show rates, we introduced an Automated Patient Reminder
System (MUMPS Audio Fax) in February 1995. This system, which
interacts with DHCP, calls veterans with a recorded reminder of
their pending clinic appointments. An additional feature allows
veterans with a touch tone phone to cancel appointments when called.
The system improves the efficiency of clinic scheduling by increasing
the number of patients who keep their appointments and making
canceled appointment slots available for other veterans. If a
veteran does not wish to be reminded of his or her appointment,
the number can easily be "flagged" so that the computer
bypasses it. The scripted message also reminds patients to present
any insurance information to the clinic clerk. This has helped
in updating our computer data base and should increase our future
MCCR revenues.
The overall system cost was approximately $80,000 including supporting
PCs, hardware and 12 phone lines. Implementation requires IRM
assistance. However, the system is written in MUMPS and is fully
compatible with DHCP, making the installation no more difficult
than any other DHCP upgrade or change.
Benefits
Many veterans have commented to Ambulatory Care personnel that
the reminder call they received was helpful and much appreciated.
No-show rates have dropped significantly.
Contact Person: Larry P. Meschkat
Service: Medical Administration Service
Facility: San Antonio, TX VAMC
Number: (210) 617-5137 or FTS (700) 779-5137
At the Oklahoma City VAMC, we instituted a pilot program to loan
beepers to family members of patients in both ambulatory and inpatient
surgery. Our goal was to provide emotional support for our customers.
The 14 beepers we used had been turned in by staff as newer models
became available. A clinical staff member decided whether loan
of a beeper was appropriate and together with the family member
determined the loan period. The beeper was provided by Police
and Security personnel, who instructed the family member in its
use. During the nine month pilot, the beepers were loaned about
200 times with an average loan period of about a week. None were
lost or stolen.
Based on the success of the pilot, we extended the program into
the MICU, CCU, and Telemetry, using funds from service organizations
to purchase five new beepers. Our long-range plan is to continue
to expand the program until beepers are available for family members
in all areas of our facility.
Benefits
A survey of staff involved in the pilot program indicated that
all of them believed our goal of providing emotional support had
been reached. In a survey of family members, 100% of the respondents
described themselves as "satisfied" to "highly
satisfied" with the program. Family members wrote narratives
describing how much safer they felt having a beeper because they
knew staff could reach them if they left the waiting area. Other
benefits are decreased noise due to a reduced need for overhead
paging, increased staff awareness of their obligation to notify
family members of changes in the patient's condition or location,
and less crowded waiting areas.
Contact Persons: Kristi Morehead, M.Ed. and Dorothea Hunt, RN
Service: Psychology Service
Facility: Oklahoma City, OK VAMC
Number: (405) 270-5168 or FTS (700) 742-3140
Results from the Customer Feedback Survey in 1994 indicated that
a significant number of veterans at the Atlanta VAMC felt that
they and their families had not had adequate communication with
staff about their illness and treatment. Since the survey had
focused on veterans who had been discharged from inpatient status,
the discharge process was evaluated by medical center QI task
forces. They decided that we needed an immediate follow-up contact
with each of our discharged patients, and Social Work Service
seemed the logical service to "bridge" the discharge
process.
In May 1995, social workers began making phone calls to every
patient who had been discharged from the medical center on the
preceding day or over the week-end. The only exceptions are patients
who were transferred to another facility and those discharged
from substance abuse treatment. There are an average of 22 discharged
patients called each day by two social workers, each of whom devotes
a half-day to this task.
The objectives of the telephone calls are:
During the phone conversation, the social worker inquires about
specific aspects of the discharge experience, such as the receipt
of discharge instructions, medications, and appointments, and
invites the veteran or his caretaker to talk about his overall
treatment experience and his initial adjustment to home. Then,
the veteran is asked to rate the hospitalization and to make suggestions
for improving the care we provide. Arrangements are made to supply
any missing discharge items and to answer any treatment questions
by linking him to the appropriate resource at the medical center,
such as our Telephone Advice Program. Results of the conversation
are recorded and sent to the QA office and to the Chief of Staff
for forwarding to the appropriate service.
Benefits
The response of both patients and social workers has been positive.
Veterans express gratitude for being contacted, candidly talk
about their experiences, and are pleased to offer suggestions.
The phone calls seem to have a neutralizing effect on those who
were not satisfied with their care and provide an opportunity
for veterans who had a good experience to express pride in the
VA. Addressing problems immediately upon discharge decreases the
anxiety and frustration of patients and their families, freeing
them to concentrate on recuperation. Also, patients are more likely
to use hospital telephone services, if they have already experienced
a therapeutic phone call and are sure who to contact. Social worker
morale has improved because they feel their efforts benefit both
the individual patients and the overall operation of the medical
center.
Contact Person: Sherry Murphy, LCSW
Service: Social Work Service
Facility: Atlanta, GA VAMC
Number: (404) 321-6111 Ext. 6350 or FTS (700) 248-6350
Our substance abuse detoxification program was converted from
inpatient to outpatient during fiscal year 1995. The inpatient
detoxification program had averaged over 2,000 admissions per
year for many years, with the average length of stay ranging from
four to seven days. After careful analysis, it was determined
that only a small percentage of these patients required acute
medical detoxification. We also observed that many patients who
were being admitted to our 28 day inpatient rehabilitation programs
could appropriately receive outpatient rehabilitation treatment.
The inpatient detoxification program in Psychiatry Service was
closed. The staff from that program were used to establish an
outpatient detoxification program, reassigned to support a smaller
inpatient detoxification unit on Medical Service, or used to provide
additional support to our outpatient substance abuse clinic. Due
to the decreased staffing needs of the outpatient programs, the
medical center was able to recoup approximately eight FTEE.
Approximately 50 patients per month complete the outpatient detoxification
program, while about 20 require inpatient detoxification. Outpatients
who are homeless or lack a supportive environment are provided
shelter through a VA contract with a local, state licensed substance
abuse facility. This arrangement provides them with a safe, structured,
and supportive environment while going through outpatient detoxification.
With the additional outpatient staffing, we are able to offer
a larger number and a wider variety of outpatient rehabilitation
groups. The patient to staff ratio in these groups has been cut
from a 25-30 to 1 ratio to a more therapeutic 10-15 to 1 ratio.
Benefits
Cost savings for the first year of care are projected to be $600,000
with no negative impact on patient care. Patients have received
dispositions that are more appropriate for their needs, while
ambulatory substance abuse services have been enhanced. Staff
morale has also improved because patients are screened more carefully;
the result is a more motivated patient who is sincerely interested
in his or her rehabilitation.
Contact Person: John Rader, HSO
Service: Psychiatry Service
Facility: Little Rock, AR VAMC
Number: (501) 370-6629 or FTS (700) 740-1340
U ntil recently, substance abuse rehabilitation was done in a
traditional 21 day inpatient rehabilitation program at the West
Los Angeles VAMC. Because of the large number of veterans with
substance abuse disorders seeking treatment, waiting lists for
treatment extended beyond four weeks. We also felt that many of
our patients were becoming institutionalized by frequent and lengthy
hospitalizations, and we wanted to break this cycle.
In April 1995, our inpatient services were redesigned to focus
on acute detoxification, stabilization, and engagement in substance
abuse rehabilitation. The number of beds was decreased, and staff
were redeployed to an Intensive Outpatient Treatment of Addictions
(IOTA) Day Hospital. This program provides rehabilitation services
for alcoholism and addictions five days per week, serving as an
alternative to and a step down from acute hospitalization for
patients who are able to commute. Admission criteria are consistent
with the patient placement criteria of the American Society of
Addiction Medicine.
Day hospital care typically lasts four weeks but can be extended
up to eight weeks, and is followed by maintenance treatment in
our Substance Abuse Outpatient Clinic or in community programs.
Patients attend the day hospital for six hours per day. Services
include evaluation and treatment planning; dual diagnosis treatment;
psychoeducation; group, individual, and family psychotherapy;
training in relapse prevention; urine and breath toxicological
monitoring; vocational rehabilitation; social skills training;
and required community 12-step meetings. Homeless patients are
assisted in locating housing in community sober living homes.
Community shelters are used for temporary housing, and the medical
center domiciliary is used for stays up to three weeks to address
concurrent medical problems. To facilitate attendance, patients
are given bus tokens.
Benefits
IOTA's intensive outpatient treatment allows the least restrictive, most cost-effective treatment of addictive disorders. The lower costs associated with ambulatory treatment permit a longer duration of intensive rehabilitation. In addition, the waiting period for substance abuse treatment has been reduced from one month to within 24 hours.
IOTA's intensive treatment promotes patient bonding, while access
to the world outside allows practice of learned behavior and assists
with mastering skills to prevent relapse. The program provides
gradual integration into community self-help programs and other
resources and is able to operate in conjunction with non-institutional
housing. Most importantly, by providing an alternative to inpatient
hospitalization and emphasizing community re-integration, transition
through IOTA avoids institutionalization of patients in the VA
treatment system.
Contact Person: Mace Beckson, MD
Service: Psychiatry Service
Facility: West Los Angeles, CA VAMC
Number: (310) 268-3904 or FTS (700) 748-3904
I n response to excessive inpatient lengths of stay for patients
with suspected lung cancer, in 1993 the Philadelphia VAMC initiated
a program to perform lung cancer workups entirely on an outpatient
basis. One room in the pulmonary suite was converted to a patient
exam area for use as a "Nodule Clinic," and the Pre-Bed
Care Unit was engaged to provide nursing care for patients undergoing
outpatient bronchoscopy or needle biopsy. The pulmonary fellow
and attending "on service" for a given month were assigned
to staff the new clinic. An RN was designated to assist patients
with scheduling of multiple outpatient appointments for pulmonary
function tests, exercise tests, CT scans, and nuclear medicine
scans. Multidisciplinary conferences with radiologists, radiation
therapists, medical oncologists and thoracic surgeons are extensively
used for review of individual cases. The pulmonary clerk-typist
assists with scheduling and record retrieval. In short, a complete
program for outpatient care was established to move lengthy inpatient
workups entirely to the ambulatory setting. When the work-up (including
diagnosis and clinical staging) is complete, the patient is expeditiously
referred to thoracic surgery, radiation therapy, or medical oncology
for treatment and follow-up.
Benefits
Patients are able to live at home and complete complex testing
with less disruption of their lives, and pulmonary fellows and
attendings develop expertise in providing outpatient care. The
VA has benefited greatly in terms of diminished costs and less
need for inpatient care. For example, in April 1995, six of 15
new cases of suspected lung cancer were handled as outpatients.
Given an average length of stay for lung cancer of 10.5 days,
we saved 63 inpatient days in a single month.
Contact Person: Mitchell Margolis, MD
Service: Pulmonary (Medical Service)
Facility: Philadelphia, PA VAMC
Number: (215) 823-6428 or FTS (700) 481-6428
T wo perceived needs at the Denver VAMC were to improve continuity
of patient care around the time of a patient's hospitalization
and to broaden the training of Internal Medicine (IM) residents
in the ambulatory care setting. We initiated an Office Based Medical
Team (OBMT) service that replaces one month of inpatient ward
experience for IM residents and focuses on patients with subacute
on medical conditions who may require hospitalization. Patients
seen by the OBMT are referred from the ER or other clinics, or
are recently discharged inpatients. Their acuity of illness is
nearly severe enough to require inpatient care, but close outpatient
follow-up may prevent hospitalization.
Three to four house staff are supervised by an attending physician,
usually from the Ambulatory Care/General Medicine Division. The
day begins with a one-hour Ambulatory Morning Report focusing
on recent cases and related literature. The remainder of the day
is spent seeing patients scheduled into the OBMT clinic, consulting
on ER patients, and following short-stay admissions to the OBMT
inpatient service. Residents contribute to decisions regarding
whether a patient should be closely followed in the outpatient
setting or admitted to the short stay unit with likely OBMT outpatient
follow-up.
Benefits
The primary benefit of the OBMT service is improved continuity
of care for patients with subacute illnesses. During the first
six months, a mean of 226 scheduled clinic visits per month were
made, and an average of 30 additional patients per month were
seen from the ER. Approximately five to nine hospital admissions
were prevented each month due to the close follow-up that was
available in the outpatient setting. Patients with a wide variety
of diagnoses, including atypical chest pain, congestive heart
failure, and constipation, were cared for on the short-stay inpatient
unit, avoiding potentially more protracted admissions to the traditional
medical service.
The rotation was also very popular with house staff receiving
a mean score of 5.6 on a 1-7 scale (7=best rotation ever, 11/18
residents responding). Sixty-four percent of the residents noted
that this rotation reinforced their desire to work in General
IM/Primary Care or stimulated interest in primary care not previously
noted.
Contact Persons: Daniel G. Richie, MD and Thomas J. Meyer, MD
Service: Ambulatory Care Service
Facility: Denver, CO VAMC
Number: (303) 393-2839 or FTS (700) 322-2839
T o reduce health care costs, our hospital has attempted to identify
diagnostic procedures that could safely be performed in an outpatient
environment. The most recent initiative (January 1995) is the
Cardiac Observation Unit (COU) in which outpatients safely undergo
invasive cardiac procedures, including diagnostic catheterizations
and electrophysiology studies.
COU staff prepare patients for the procedure, perform the test,
and recover the patient afterwards. They also educate patients
and their families about the test, the findings, and the plan
of action. Patients arrive at the hospital the day prior to the
procedure for laboratory tests, an EKG, and a physical exam. They
stay at a local hotel overnight at the VA's expense if they live
more than 50 miles from the medical center, at home if less than
50 miles. The next day they arrive at the hospital at 8 a.m. and
have the procedure. The COU nurses monitor them during recovery
and provide discharge teaching. The patients and their families
then may either return to the hotel or home.
Fifty to 60% of diagnostic catheterizations are performed on an
outpatient basis. The appropriateness of an outpatient procedure
is determined collaboratively by nursing and cardiology staff,
using the following criteria:
Benefits
From January 1995 through October 1995, 202 outpatient catheterizations
were performed and 555 inpatient days saved. Patient satisfaction
has been monitored since the program's inception; the data have
been very positive. Patient and family comments indicate appreciation
of the additional education provided by the COU, the relaxed atmosphere
allowing for family involvement and discussion with staff, and
the freedom from hospital admission.
Contact Person: Kendra Szymanski, RN, BSN and Mark Starling, M.D.
Service: Nursing and Cardiology Services
Facility: Ann Arbor, MI VAMC
Number: FTS (700) 374-7978 or (700) 374-7976
I n September 1992, our medical center realized that it would
soon become necessary to restrict acute care beds to those patients
who needed them. A survey was initiated by the Chief of Surgery
to determine the placement of surgical patients who required minimal
care and observation for less than three days. The results showed
that 30% of patients meeting these criteria were occupying acute
care beds. A task force was created to make recommendations regarding
the treatment of these patients; it identified over 40 diagnoses
whose pre- and post-procedure treatment required minimal nursing
care and observation if the patient's baseline functioning involved
self-care.
The Nurse Administered Outpatient Unit (NAOU), an outpatient unit
to keep patients overnight without admitting them as inpatients,
was established on a vacant ward located on the ground floor of
the hospital. The ACOS/Ambulatory Care has overall program responsibility,
and Nursing Service administers the unit. As many as 17 self-care
patients may be on the NAOU at any time. Nursing FTEE is 6.0 RNs;
one RN covers the night shift. A CNA from the Mobile Resource
Team assists with vital signs during the busiest shifts which
are Monday through Thursday.
Patients are scheduled for beds beforehand, with nursing staff
screening each patient's appropriateness for the NAOU. Same-day
patients are given beds when they are available. A self-medication
program has been instituted, and arrangements with Nutrition and
Food Service enable patients to ambulate to the dining room or
receive a meal at the bedside when necessary. Patients ambulate
to their diagnostic appointments or are taken in wheelchairs by
Escort Service. The NAOU staff is authorized to make a referral
to or request a consultation from any hospital service.
Physicians utilize the unit for over 95% of appropriate patients.
They appreciate the greatly reduced paperwork requirements: no
discharge summaries are required and only brief H & Ps related
to the patient's procedure. There is also a reduction in the documentation
requirements for nursing staff.
Benefits
The unit costs less than $250 per patient day in comparison to
over $600 on a medical or surgical ward. Between 150-210 patients
are cared for on the NAOU each month, with an average length of
stay of less than 48 hours. Because acute care beds are now at
a premium, as predicted three years ago, Tucson VAMC is in a much
better position to care for the increasing numbers of veterans
migrating to the Southwest.
Surgery cancellations related to patient non-compliance or transportation
problems have decreased, and patients are more knowledgeable about
their procedures and after-care. The NAOU has become a "point
of reference" for those who have been treated there: They
regularly return to greet the staff or to have new questions answered.
Contact Person: C. Kay Morris, RN
Service: Nursing Service
Facility: Tucson, AZ VAMC
Number: (520) 629-1898 or FTS (700) 765-6011
U pon review of Joint Commission standards, it became apparent
that variation in the care provided to patients recovering from
conscious sedation existed within our facility. In the Medical
Endoscopy Clinic, patients were provided privacy, appropriate
monitoring of vital signs, and pulse oximetry by professional
staff during the acute recovery phase. In other areas, such as
Surgical Endoscopy and Pulmonary Bronchoscopy, patients recovered
on an inpatient nursing unit. These patients were being hospitalized
for procedures which could have been performed in an ambulatory
care setting if pre-procedure and post-procedure care was available.
Recognizing the need for change, several key staff proposed a
conversion of an under-utilized area of the facility at a cost
of approximately $14,000.00. Located near Pulmonary Medicine and
the Bronchoscopy Suite, the area provided ample space for a self-contained
unit which included Surgical Endoscopy and a Conscious Sedation
Recovery Unit (CSRU) complete with a negative flow isolation room,
a family waiting area, and a patient changing room. The CSRU is
manned by ACLS certified, fee base RNs, who have successfully
completed a Post-Procedure Recovery competency review in our Post-Anesthesia
Care Unit. Guidelines for care, discharge criteria, and documentation
forms are currently being standardized throughout the facility.
Benefits
From the outset, the care provided in the Conscious Sedation Recovery
Unit met or exceeded accepted clinical practice guidelines and
Joint Commission standards. Within two months of becoming fully
operational, the shift from inpatient to outpatient care was dramatic.
Approximately 25% of both endoscopies and bronchoscopies were
performed on an outpatient basis, reducing the cost to the facility
by approximately $600-$1,200 per procedure. Since the workload
fluctuates daily, staffing the CSRU with fee base nurses has proved
to be efficient and economical. Patient satisfaction and patient
safety have significantly improved, although it is too soon for
data to be reported.
Contact Person: Beverley A. Freeman, CNS
Service: Nursing Service
Facility: San Antonio, TX VAMC
Number: (210) 617-5196 or FTS (700) 617-5196
A need for better coordination of outpatient diagnostic work-ups
for both Medical Service and Surgical Service patients was identified.
In our affiliated medical center, many resource utilization decisions
are made by resident physicians who rotate in and out of the medical
center each month. These residents are often frustrated by the
administrative processes required to care for their patients.
As a result, patients who need complex pre-procedure workups are
often admitted to the hospital, because the resident views admission
as more efficient than facing the challenge of coordinating outpatient
work-ups.
The goal of the Coordinated Outpatient Testing Center (COTC) is
to reduce procedure length of stay by shifting as many diagnostic
workups as possible from inpatient to outpatient care. Two nurses
(one coordinator and one patient-educator) were transferred to
Surgical Service; with one MAS support staff, they began a pilot
program coordinating work-ups for General Surgery and Cardiology
patients. Once the pilot is complete, clinical sections will be
added progressively until all appropriate patients are coordinated
by the COTC.
Working closely with physicians staff and residents, the coordinator
is responsible for the administrative duties involved in the work-up.
A "COTC Day" is determined once a procedure date is
set, and the COTC coordinator schedules all diagnostic tests for
this day, including complex tests such as stress tests and pulmonary
work-ups, as well as standard EKGs, laboratory tests, and chest
x-rays. The diagnostic results are collected by the coordinator,
and abnormal results are brought to the attention of the treating
physician. Pre-procedure patient education and an anesthesia consultation
are also performed on the patient's "COTC Day."
Benefits
Because the COTC is still being piloted, it is too early to report
on the benefits. Data on the following indices are being collected
and will be compared to historical data: number of patients served,
proportion who are same-day admissions, proportion who are ambulatory
surgery patients, number of patients whose surgery procedure date
lags beyond the thirty day laboratory expiration, reasons for
ambulatory surgery cancellations or postponements, surgical cancellation
rate, and pre-operative length of stay.
Contact Person: Bruce Wyllie, AO
Service: Surgical Service
Facility: Clement J. Zablocki VAMC, Milwaukee, WI
Number: (414) 384-2000 or FTS (700) 383-1740
T he lack of coordination among services to provide timely pre-operative
medical evaluation for patients resulted in an average pre-operative
length of stay of 5.1 days and a surgery cancellation rate of
21% in 1992. The underlying causes of this problem were studied
by UCLA Health Services graduate students, directed by Quality
Management staff and assisted by Anesthesia, Surgery, and Nursing
Services. Data came from interviews of patients and hospital staff,
DHCP files, operating room records, and medical records.
Based on the initial findings, we initiated a pilot project which
involved:
Benefits
The pilot of the new ambulatory pre-operative system began in
July 1994 and was completed in November 1994. At the end of the
pilot period, the pre-operative length of stay for Pre-op Clinic
patients decreased from 5.1 days to 1.1 days, the surgery cancellation
rate dropped from 21% to 12%, and the ambulatory surgery workload
increased 12-fold, from 30 cases per year to 30 cases per month.
The annual savings generated by reducing pre-operative and post-operative
lengths of stay may be substantial.
Contact Person: Dean Norman, MD
Service: Chief of Staff
Facility: West Los Angeles, CA VAMC
Number: (310) 824-3136 or FTS (700) 748-3136
Until recently, ambulatory surgery patients at our facility were
admitted, pre- pared, and discharged by nursing staff on a busy
inpatient surgical unit. Since this assignment was rotated among
staff on a daily basis, several problems emerged:
At a brainstorming session, it was decided that the Nurse Manager
of the OR would oversee the operation of the Ambulatory Surgical
Care Unit and that one RN position would be transferred to the
OR for ambulatory surgery. The new RN position has the following
responsibilities:
Benefits
The surgical schedule is completed in a more timely manner since the ownership of delays is simple to establish, and the overtime budget is used only for emergency procedures as it is no longer needed for delayed procedures. On the follow-up calls,
100% of the patients have indicated they would return to this
facility for another surgical procedure. The reorganization has
also resulted in improved communication between surgeons and nursing
staff. Problems are now discussed at the monthly surgical staff
meeting and resolutions are made by the multidisciplinary team.
Contact Person: Lois Ann Atkins, RN
Service: Nursing Service
Facility: Erie, PA VAMC
Number: (814) 868-6212 or FTS (700) 726-6180
An overnight lodging program was instituted to decrease hospital
admissions. This program allows patients to stay overnight in
a local hotel at VA expense before a scheduled procedure or appointment
and thus stay out of the hospital until it is time for their appointment
or procedure. Family members often stay with them at the hotel.
Certain criteria apply: veterans awaiting therapeutic or diagnostic
procedures must live more than 50 miles from Ann Arbor, and veterans
awaiting outpatient appointments in a clinic not available at
a closer VA facility must reside more than 200 miles away. Once
eligibility is determined, admitting staff set up reservations,
transportation, and, if necessary, meals.
During FY 94, ambulatory surgery accounted for 50% of the patients
who were lodged by the program. Patients with outpatient appointments
were another 29%, radiation therapy patients 16%, chemotherapy
patients 3%, and cochlear implant patients were 2%.
Benefits
The financial benefits of the program are significant. On average,
hospitalization costs approximately $550 daily, while the current
nightly hotel rate is about $32. After the program officially
got under way in early FY 94, 1,401 inpatient days were avoided
during that year through the hotel lodging program. The lodging
program costs the medical center $43,030, whereas the hospitalization
of these patients would have cost $770,550. Thus, the program
saved the medical center $727,520.
Contact Person: Connie Standiford, MD
Service: Ambulatory Care Service
Facility: Ann Arbor, MI VAMC
Number: (313) 761-7975 or FTS (700) 374-5100 Ext 7975
Medical and surgical care of non-healing ulcers at the Dallas
VA had been fragmented between the emergency room, surgical clinics,
spinal cord injury nurses, medical evaluation clinic, and Rehabilitation
Medicine Service. There was virtually no continuity of care, and
patients often went months between episodes of wound care. The
result was often an infected wound that was beyond salvage.
In July 1992, an intensive effort was begun to improve the overall
clinical management of patients with non-healing ulcers. A comprehensive
multi-disciplinary wound care team was established, consisting
of a general surgeon, a vascular surgeon, a podiatrist, a nutritionist,
two nurses skilled in wound care, and an Orthotic Shoe Technician
from Prosthetics Service. The team members see patients one day
a week and address all issues relating to the healing of ulcers.
Due to the limited number of patients needing this intensive approach,
a patient may be seen each week if indicated.
Benefits
The rapid healing of ulcers, which in many cases had been present
for years, was immediately apparent. However, our the primary
measure of success was the number of below the knee amputations
(BKAs), an important and easily measured outcome parameter.
The number of below the knee amputations performed at the Dallas
VA from 1990 to 1995 is shown below. If the rate for January through
December 7 continues, 79 amputations will be performed by the
end of calendar year 1995. This would represent a reduction of
69 amputations from the 145 performed in 1990. Since our average
length of stay for a BKA is 43 days per patient, this equates
to avoiding 2,838 days of hospitalization in 1995 as compared
to 1990.
Contact Person: Mark S. Nelson, MD
Service: Ambulatory Care Service
Facility: Dallas, TX VAMC
Number: (214) 372-7010 or FTS (700) 749-5135
Health care workers are often challenged to provide care for patients
who obstruct treatment, behave in violent or abusive ways, or
seek multiple prescriptions and unnecessary drugs, often for resale
on the streets. In the past, frustrated providers, at their wits
end, have either done the minimal amount to "get rid"
of difficult, dangerous, and drug-seeking (3-D) patients or simply
refused to provide care.
The Portland VAMC's 3-D program was designed to deliver safe and
appropriate health care, while reducing the frequency of incidents
involving these patients. The 3-D program tracks incidents of
threatening, assaultive, uncooperative, and drug-seeking behavior
in the medical center, provides multidisciplinary clinical review,
advises and trains providers to manage 3-D problems, clarifies
to patients the behavior consistent with safe care, and informs
potential providers of a patient's special needs and the plan
to provide consistent care without tolerating disruptive behavior.
Rather than telling 3-D patients to "go away," we tell
them, "Come here, within these behavioral limits, for safe
and appropriate care."
Benefits
The program has empowered our front-line health care providers
to offer safe and appropriate care to 3-D patients, while reducing
the number of untoward incidents. We have dramatically reduced
violence in our medical center, reduced the number of inappropriate
narcotic prescriptions in our emergency room, and arranged less
fractionated, more coherent care for patients. A study of 36 violence
prone patients showed that the number of violent incidents decreased
from 47 the year before to four the year after 3-D care plans
were instituted. Narcotic prescriptions in the Emergency Room
went from 16 to 0 per year for a sample of 21 drug-seeking patients.
The average number of different physicians involved in the care
of difficult patients decreased by 26% and the average number
of days in the hospital decreased by 51%. Our medical center realizes
an average savings of $7,400 per year per patient managed through
this process.
Staff morale has improved as a result of this program. Providers
are more willing to report problems, rather than assume violence
and abuse are part of their job. They are also more willing to
work with challenging patients, knowing that they are part of
a team that is trying to solve a problem. Most important, our
patients are getting good medical care in a setting of safety
and consistency. As one veterans service officer, a tenacious
advocate for patient's rights, said when a patient hesitated to
sign a 3-D health care plan, "David, sign it. It's a good
deal. Heck, if you won't sign it, I'll sign up for myself."
Contact Person: Laurence H. Baker, Ph.D.
Service: Psychology Service
Facility: Portland, OR VAMC
Number: (503) 721-1039 or FTS (700) 424-1039
P reviously, clinicians had to flip through the entire medical
record to obtain data on an outpatient; in particular, it was
often difficult to find information regarding vaccinations, the
last physical examination, and procedures that had been performed.
Working with IRM, a health summary was developed for each clinic
that includes the specific data needed for that clinic. The first
page of the print-out includes monitoring information such as
the date of the last physical examination and vaccine history.
All medications are listed along with laboratory values and procedures
that are significant to that clinic. If the patient is on a medication
such as warfarin, the date and value of the last prothrombin time
and information about the last dosage adjustment is also printed.
Prior to the clinic, a medical clerk prints health summaries for
each patient scheduled for the clinic that day by entering the
name of the clinic and the date. The clerk then puts the summary
on the front of the medical record prior to the clinician seeing
the patient.
Benefits
Clinicians have much of the information needed to see the patient
readily available, cutting down the time spent leafing through
medical records. The monitoring information quickly indicates
patients who need a physical examination, an update or booster
on their vaccines, or a particular laboratory test to monitor
one of their medications.
Contact Person: R. Bowen
Service: Medical Service
Facility: Danville, IL, VAMC
Number: (217) 442-8000 Ext. 5283 or FTS (700) 951-5283
As a tertiary care referral site, Ann Arbor VAMC provides specialty
care to patients from Battle Creek and Saginaw VAMCs and the Grand
Rapids and Gaylord Outpatient Clinics. In the past, these facilities
sent consult requests via driver or mail to Ann Arbor for scheduling.
In an effort to improve processing time, the faxing of requests
was tried. While it reduced the delivery time, faxing required
staff time on both ends to transmit the requests and assure that
they were legible. More important, the process still involved
a substantial delay for return of the consult with the appointment
date, notification of the patient, and transfer of the record.
An additional problem was the incomplete data on patients who
were not already in Ann Arbor's database.
We proposed that access to Ann Arbor's DHCP database be given
to referral clerks and other designated staff at each referral
site so that they could schedule patients directly into Ann Arbor
clinics. At the same time they could make sure that the data were
complete for each patient scheduled. The referral sites agreed,
and their staff were trained by Ann Arbor personnel. Beginning
in March 1995, all patients who would previously have been scheduled
by Ann Arbor MAS staff were scheduled directly by the referral
sites.
Benefits
Contact Person: Jeanette Ventura
Service: Medical Administration Service
Facility: Ann Arbor, MI VAMC
Number (313) 769-7100 Ext. 5261 or FTS (700) 374-5261
T he present organization of the medical center aligns employees
hierarchically within services. Ambulatory care nurses and clerks
look upward within the service hierarchy for guidance on how to
function within their clinics. While this organization fosters
uniformity across clinics, it impedes the coordination between
services required to adapt to the unique needs of differing clinics.
We piloted Clinic Based Management Teams (CBMTs) to empower clinic
staff to collaborate in managing each clinic to meet its special
requirements. Each clinic's CBMT includes clinic clerks, clinic
nurses, the clinic Chief or designee, a representative from the
Ambulatory Care Management Team, and representatives from other
disciplines involved in the clinic (pharmacists, respiratory therapists,
social workers, etc). The team's mission is to improve the quality
of care and the quality of the patient's experience in the clinic.
The team has ownership of the following issues: clinic space,
work hours, patient flow, stocking and equipping of exam rooms,
and managing clinic delays. The CBMTs are encouraged to resolve
all problems that are within their scope. They report to the Ambulatory
Care Management Team consisting of the ACNS/Nursing, Chief AC&P,
and HSS/Ambulatory Care. Problems outside the team's scope are
communicated to the Ambulatory Care Management Team for action.
In early 1996, the medical center plans to take an additional
step toward integration of outpatient services into a comprehensive
ambulatory care program organized along product lines. Each clinic
will function as its own organizational unit, with the Office
of the ACOS/Ambulatory Care providing centralized leadership and
coordination for the program. Clinic clerks will be transferred
to the Ambulatory Care Service. Nurses will remain in Nursing
Service, but will have a more formalized matrix relationship to
Ambulatory Care.
Benefits
The CBMTs were piloted in the Orthopedics, Walk-In, General Medicine,
Infectious Disease, and Pulmonary clinics. While data are not
available to measure improvement, clinic staffs have responded
positively and a number of process improvements have been recommended
and implemented by the teams. Several other clinics have requested
inclusion in the next stage of implementation.
Contact Person: Jennifer Leeman, HSS/AC
Service: Ambulatory Care Service
Facility: Durham, NC VAMC
Number: (919) 286-6963 or FTS (700) 671-6963
Quality improvement monitors revealed that patients presenting
with chronic vascular ulcers but admitted for other medical problems,
were occasionally discharged without follow-up appointments for
management of their ulcers. While addressing this issue, we noted
that many patients followed in the Vascular and Surgery Clinics
for chronic vascular ulcers and non-healing wounds could appropriately
be managed by advanced practice nurses who had wound care expertise,
were operating within defined protocols, and had access to attending
physician consultation.
In April 1994, a Wound Management Clinic (WMC) was established
for the outpatient management of patients with chronic vascular
ulcers and non-healing wounds. Patients are referred from other
outpatient clinics and from inpatient settings at discharge. WMC
staff also provide consultation for patients managed by the Home
Based Health Care program and Community Nursing Home Care coordinators.
The clinic is staffed by two Clinical Nurse Specialists who are
also responsible for inpatient wound care programs, a Registered
Vascular Technologist, an LPN from the Ambulatory Care staff,
and two attending physicians from Gerontology and Surgery Services
who serve as consultants. Wound management protocols developed
with physician concurrence are used to direct clinic operations.
The clinic is held one afternoon a week at the same time as the
Surgery and Vascular Clinics in an adjacent space; this arrangement
facilitates patient referrals between clinics. Patients returning
to Vascular or Surgery Clinic appointments are also routinely
scheduled for the WMC, allowing staff from both services to examine
the patient's progress and develop an integrated interdisciplinary
plan of care. Patients are provided with telephone numbers to
contact WMC staff regarding changes in wound status or other patient
concerns. To decrease the number of appointments for patients
scheduled in another clinic, WMC staff arrange to see patients
outside regular clinic hours.
Benefits
The WMC has demonstrated improved efficiency and positive clinical
outcomes, with 77% of chronic patients achieving a healed wound
status. The waiting time for a WMC appointment is one week, compared
to prior waits of several weeks for a Vascular or Surgery Clinic
visit. Patients have expressed great satisfaction with the clinic's
accessibility and continuity of care. Using advanced practice
nurses to manage stable patients with chronic wounds has also
allowed Vascular and Surgery Clinic physicians to see more patients,
resulting in decreased waiting times for these clinics as well.
Finally, the Clinical Nurse Specialists are able to follow patients
for whom they managed wound care on an inpatient basis.
Contact Persons: Pamela Leugers, MS, RN, CS; Susan Thomason, MN, RN, CS;
Lynn Payne, RN, BS, RVT; Mary Cochran, LPN; Claudia Beghe, MD; and
Ariel Rodriguez, MD
Service: Nursing Service
Facility: Tampa, FL VAMC
Number: (813) 822-7541 or FTS (700) 822-7541
The Pharmacy and Therapeutics Committee established a subcommittee
to review all long-term users of narcotic analgesics. Patients
who have been prescribed narcotic analgesics for three or more
consecutive months are identified through a computer generated
drug search. Each patient's physician is notified and asked to
provide justification for the continued use of these medications.
The justification is reviewed by the subcommittee, and a determination
regarding the appropriateness of continued use of the narcotic
analgesic is made.
Those patients for whom continued use of narcotics is determined
not to be appropriate or who have not had a therapeutic trial
of alternative pain management are offered two options: admission
for inpatient detoxification or outpatient detoxification. Patients
choosing outpatient care are referred to a Pain Management Clinic
staffed by a clinical pharmacy specialist. They are detoxified
from narcotic analgesics and treated with various combinations
of NSAIDs, non-narcotic analgesics, skeletal muscle relaxants,
antidepressants, and antiepileptics. The clinical pharmacy specialist
provides close follow-up, and medication adjustments are made
as needed.
Benefits
As of October 1995, 129 long-term narcotic users had been identified.
Fifty had a diagnosis of terminal cancer or another severe end-stage
diagnosis and were continued on their narcotic analgesics. The
other 79 patients were successfully detoxified. The majority experienced
adequate pain relief with alternative pain therapy; 22 did not
and had their narcotics reinstated.
Contact Person: Sam Fox, Pharm. D.
Service: Pharmacy Service
Facility: Salisbury, NC VAMC
Number: (704) 638-2921 or FTS (700) 699-2921
Chronic pain patients seeking narcotic renewals through the Walk-In
Clinic were a major issue for our Ambulatory Care staff. The staff's
concerns were poor continuity of patient care, lack of unambiguous
plans relating to a patient's long-term pain management, possible
drug-seeking behavior and addictions, and the gate-keeping role
of staff. In addition, patients would sometimes become verbally
abusive and threatening to the staff when denied narcotics. It
was clear that patients needed a systematic method of obtaining
pain medication renewals, and staff needed guidelines for managing
patients with chronic pain.
A Chronic Pain Medication Program was established which requires
patients to enter into a written contractual agreement with their
clinician regarding when and how they will receive medications
and how changes in their prescriptions will be made. The objectives
of the program are to minimize drug use, maximize the effectiveness
of pain medications, and reduce patient frustration and waiting
time for renewing medications.
The majority of patients are placed on a pain cocktail which is
individually tailored to maximize pain relief. The cocktail vehicle
is used to mask its contents as patients are not told which medications
they are receiving. This approach enables the clinician to alter
the contents of the cocktail without undue stress for the patient
and to use placebo effects to assist in pain relief.
Patients agree to call the Ambulatory Care Nurse Coordinator seven
days before the renewal date to request their pain medication.
The prescription is then filled and available for pick-up at the
Pharmacy when the patient arrives. Those patients who are disabled
or reside a significant distance from the hospital may receive
their medication by certified mail with a signed receipt returned
to the Pharmacy. Initially, there was a great deal of manipulative
behavior by patients to receive their renewals early. However,
this has diminished as program staff have been firm about keeping
patients to the prescribed schedules.
Benefits
Currently, there are 147 patients enrolled in the Chronic Pain Clinic Program. More than 95 of the 295 patients who entered the program have been titrated off pain medications. Patients receive their refills as scheduled and are satisfied with the
program. Walk-In Clinic staff are no longer gate-keepers for requests
for pain medication renewal and are able to focus on medical issues.
Contact Persons: Dee Daugherty, MSN; Tesfai Gabre-Kidan, MD; and
Charles S. Paxson, MD
Service: Ambulatory Care Service
Facility: American Lake Division/Seattle, WA VAMC
Number: (206) 582-8440 Ext 6228 or FTS (700) 396-6228
We learned that the monitoring of laboratory values for patients
receiving warfarin needed improvement through a drug usage evaluation.
We decided to use DHCP to automatically screen for appropriate
laboratory monitoring prior to dispensing prescriptions for warfarin.
Upon entry of a new or refill warfarin prescription, the locally
developed software checks the laboratory package to see if an
INR has been done in the past 45 days. If so, the software will
allow dispensing of the prescription. If not, the package will
take the following actions:
Benefits
The software program is being implemented at this time. Anticipated
results are better anticoagulation management with fewer adverse
drug events and fewer hospitalizations.
Contact Person: Eva Fowler, R.Ph.
Service: Pharmacy Service
Facility: Carl T. Hayden VAMC, Phoenix, AZ
Number: (602) 222-6427 or FTS (700) 761-6427
C OPD was the most common diagnosis for medicine patients in the
Emergency Room/Urgent Care Center (ER/UCC) during 1993 and 1994.
In reviewing the care provided to COPD patients, several concerns
emerged. First, ER/UCC staff felt that COPD patients were not
triaged quickly enough, causing some patients to deteriorate while
waiting to be seen. Second, patients frequently came to the ER
with advanced bronchospasm because they were not identifying and
appropriately managing their COPD. Finally, only 12% of patients
receiving treatment for COPD in the ER/UCC were given a bronchodilator
by metered dose inhaler (MDI) as their first intervention, despite
literature showing that metered dose inhalations are less costly
than nebulizer treatment and equally effective.
The following actions were taken to address these three concerns:
Benefits
Data were collected for 12 months from January 1994 to December
1994. Analysis showed that patients are now triaged uniformly
and that there were no incidents of COPD patients deteriorating
in the waiting room. Initial treatment is also more uniform now,
and staff members are consistently educating patients in the use
of peak flow meters and MDIs with an aerochamber. However, only
46% of patients achieved a therapeutic response and were discharged
home in two hours, which is the standard we established. This
finding raises questions about the appropriateness and effectiveness
of the MDI protocol for our patient population, an issue which
is currently being assessed.
Contact Person: Sunita Baxi, MD
Service: Medical Service
Facility: San Diego, CA
Number: (619) 552-8585 or FTS (700) 552-8585
T he clinical guidelines recently published by the Agency for
Health Care Policy and Research (AHCPR) estimated that as many
as 50% of surgical patients and 80% of cancer patients experience
inadequate pain management. A survey of subspecialty clinics within
our VAMC revealed that more than 3,000 visits a year were for
chronic pain management, not acute subspecialty care. We addressed
these critical issues through the expansion of both our outpatient
clinic and inpatient pain services. The Chronic Pain Management
Clinic (CPMC) opened in January 1995 and was followed in April
by the establishment of the Acute Pain Service (APS).
The CPMC joins with the Anesthesiology Pain Clinic (APC) and Physical
Medicine and Rehabilitation to provide pain relief services to
veterans five days a week. The CPMC is staffed by a nurse practitioner
who maintains a very close collaborative relationship with the
physicians in the APC. The nurse practitioner provides treatment
services for the relatively stable patient who has a physician
completed work-up for the nociceptive complaint. Treatment includes
medication management, transcutaneous nerve stimulation, hypnosis,
biofeedback, and stress management. A comprehensive multidisciplinary
approach includes Physical and Occupational Therapy, Psychology,
Psychiatry, and Social Services. The total number of yearly visits
in the CPMC is anticipated to be 2,100 by 1996.
The APS provides a full range of analgesic options for inpatients.
While this service was initially intended for post-operative pain
management, patients with acute pain from other etiologies and
hospice patients are also eligible. This service provides a wide
range of treatment modalities, including neuraxial (epidural and
intrathecal) opioids, patient controlled analgesia, and various
nerve blocks.
Benefits
From January 1995 to May 1995, 300 patients were transferred from other clinics to the Chronic Pain Management Clinic, resulting in decreased waiting time for the Orthopedic, Neurosurgery and other specialty clinics, significant improvement in operating efficiency, and a significant reduction in health care costs. The more personalized approach made possible by use of a nurse practitioner in the CPMC has enhanced the continuity and efficiency of health care delivery and improved patient and family satisfaction.
The Acute Pain Service specifically addresses the issues raised
by the AHCPR guidelines with a targeted health care delivery mechanism.
Multiple studies have demonstrated that cost effectiveness, improved
outcomes, and increased patient satisfaction result from the use
of the nociceptive management modalities employed by the APS.
Contact Persons: W.T. Schmeling, Ph.D., MD; S. Burchman, MD; S.E. Abram, MD; A. Maitra, MD; M. Larcheid, FNP and D. Miller, RN
Service: Anesthesia Service
Facility: Clement J. Zablocki VAMC, Milwaukee, WI
Number: (414) 384-2000 Ext 2417 or FTS (700) 383-2417
T he Columbia VAMC participated in a national research project
in 1994 examining patient education related to advance directives.
The investigator interviewed 150 patients at the hospital: 75
inpatients and 75 outpatients. One of the findings was that outpatients
were far more comfortable and prepared to discuss advance directives
than were inpatients.
A clinic was developed which provided outpatients an opportunity
to meet with a social worker to discuss advance directives. Veterans
can schedule an appointment to meet with the social worker in
between their other appointments or may call the social worker
for more information. Signs and posters have been placed around
the hospital and brochures distributed to publicize the clinic.
Benefits
Approximately 150 outpatients were seen in the Advance Directives
Clinic between its inception in February 1995 and October 1995.
These patients and their care providers benefit when the patient
is subsequently admitted: the patient does not have to face these
difficult issues at a time of emotional vulnerability, and valuable
staff time is saved that can be used to provide needed inpatient
services such as discharge planning. The hospital is also effectively
fulfilling its obligations under the Self-Determination Act.
Contact Person: Laura Krejci, MSW
Service: Social Work Service
Facility: Columbia, SC VAMC
Number: (803) 776-4000 Ext. 7696 or FTS (700) 776-4000 Ext. 7696
At the Grand Junction VAMC, Orthopedics, ENT, and Urology clinic
services are provided by consultants. Appointment availability
is two to three months. To gain maximum use of the consultants'
time and to enable them to initiate a plan of care at the patient's
first visit, for each of these clinics we developed an algorithm
that prioritizes patients based on their condition and indicates
the work-up needed for each diagnosis. All requests for a consult
to a subspecialty clinic are reviewed by the RN assigned to that
clinic. Using the clinic's algorithm, he or she determines an
appropriate time for the appointment and schedules additional
tests needed for the work-up so that the results are available
for the appointment.
The nurse also reviews each patient's chart two to three days
prior to the clinic and takes the following actions:
The physician consultant works out of two to three exam rooms
with the facilitating nurse directing work flow. The nurse escorts
the patient to the room, places the x-rays on the view box, opens
the chart to the last visit, and prepares the patient for the
exam. When the visit is completed, the physician presents the
chart to the facilitating nurse for any pre-operative teaching,
patient education, referrals, etc. and continues to the room marked
"NEXT."
Because of the success of the program, we have recently begun
to use a modified version for our in-house clinics.
Benefits
*Reflects the removal of all patients referred to the ENT Clinic
for "hearing loss," unless referred by the audiologist.
Contact Person: Gayle Saunders, RN, BSN, CNOR
Service: Nursing Service
Facility: Grand Junction, CO VAMC
Number: (303) 242-0731 Ext. 2180 or FTS (700) 322-0183
While DHCP is an excellent reservoir of clinical information,
it has some disadvantages: much of the data is in separate categories
or menus, retrieving data requires multiple keystrokes, trends
are not often evident, and abnormalities are not highlighted.
A few years ago, Boise VAMC submitted a successful proposal to
the Western Region to develop a personal computer (PC) local area
network (LAN) that would interact with DHCP. This proposal led
to the Education Utility and Clinical Information Database (EUCLID),
which is essentially an electronic medical record with interactive
on-line information, designed to improve quality, lower costs,
and enhance productivity.
Data from DHCP are extracted by serial exchange into a Windows
based graphic user interface. Similar data are grouped together.
The last four values are displayed to identify trends and are
highlighted in red if abnormal, or magenta when trending. Sections
exist for demographics, laboratory results, outstanding orders,
medications, cultures, imaging studies, diagnoses, and electronic
documentation of care, e.g., discharge summaries, histories and
physicals, and electronic progress notes.
Double clicking on a laboratory value or medication opens a hypertext
help window to access a wealth of reference data. Further help
is available by exiting to a second level that allows access to
24 CD-ROMs with several standard textbooks of medicine, management
manuals, AHCPR clinical practice guidelines, Medline literature
search capabilities, full journal text of several recent journals,
and the Iliad expert diagnostic system. Further patient data are
available by accessing DHCP itself. Application software (Microsoft
Office and Harvard Graphics) are also on line. Scanning in ECGs
and other medical images has been successfully pilot tested. All
of the information can all be accessed as an SQL database, allowing
correlation of variables of interest.
Action profiles have been enhanced to include additional information,
e.g., for digoxin prescriptions, potassium and creatinine values
and the digoxin level are displayed. A column is used to display
less costly alternative medications; selecting the alternative
is just as easy as checking off the refill, but the clinician
still has the choice. Medications are also bar-coded.
Benefits
Providers enthusiastically use the system. Access to information
that highlights abnormal laboratory values is helpful in rapid
establishment of some diagnoses. Ready availability of information
appears to improve diagnosis and treatment. In addition, patients
are aggregated in ways that save clinicians from keeping several
lists. For example, one's own clinic patients are available by
appointment date or alphabetically, and ICU patients can be displayed
at the touch of a button.
Bar coding medications saves 5 to 10% of outpatient staff pharmacist
time. The alternative medication suggestions save at least 10%
of the outpatient pharmacy budget. Clinician acceptance of the
suggested alternatives is high because of the non-coercive way
in which they are presented and the on-line educational material
which can be easily referenced.
Contact Person: David Lee, MD
Service: Chief of Staff
Facility: Boise, ID VAMC
Number: (208) 338-7201 or FTS (700) 554-7201
We noticed that some ambulatory care patients were not compliant
with prescribed medical regimens and often had repeated visits
back to clinics before their next scheduled appointment due to
destabilization of health status. Of particular concern were patients
with diabetes, hypertension, those undergoing anticoagulation
treatment, and those being treated for tuberculosis.
Four nurse-operated outpatient clinics (one for each diagnosis)
were established in 1992, using RNs to manage the care of these
patients. All patients have had prior assessments and treatment
plans completed by their primary physician and orders written
for their treatment regimens. Referrals are made by the primary
physicians or Medical Clinic RNs for follow-up management in these
clinics. Using protocols, regular follow-up practices have been
established for each diagnostic category. Since none of the RNs
in these clinics are advanced practice nurses, a physician signature
is obtained for each patient activity that requires a physician's
order, e.g., x-rays, laboratory work, medication adjustment, etc.
The clinics are conducted by RNs who previously worked in the
Medical Outpatient Clinic. They are held in the same physical
space and at the same times as the Medical Clinics so physicians
are readily available for consultation and orders. No additional
FTEE or space was required. Patient and family education and repetitive
reinforcement of patient treatment activities are a large and
important part of the clinic. The nurses are available by telephone
for patient consultation during administrative work hours.
Benefits
The number of patients enrolled in the Nurse Managed Clinics has
steadily increased every quarter over the past three years. There
has been a reduction in the number of patients returning to their
Medical Clinics prior to their next appointment, and surveys have
indicated increased patient satisfaction. Physicians were originally
resistant, but have become enthusiastic about the clinics and
have been sending increasing numbers of referrals.
Contact Person: Carol Wermuth, MSN, MBA, RN
Service: Nursing Service
Facility: Chillicothe, OH VAMC
Number: (614) 773-1141 Ext 7365 or FTS (700) 975-7365
In 1991, we asked staff and resident physicians in our General
Medicine Clinic about clinic operational issues. When we reviewed
the list of personnel needs that were identified, we determined
that almost all of the functions could be performed by non-nursing
staff. We developed positions for Medical Assistants (MAs) and
trained them to fill these needs in the clinics. The MAs were
certified to perform arterial and venous punctures, spirometry,
cerumen removal, and exercise electrocardiography. They also support
the nursing staff in transporting patients, obtaining and retrieving
records, and entering laboratory orders into the computer system.
Benefits
To assess the impact of the MAs, we interviewed patients and collected
data before and after the development of this new position. Waiting
time in the laboratory drawing area was reduced from 13 minutes
in 1992 to 9 minutes in 1994. The interval between the appointment
time and the time the patient was seen by a physician decreased
from 29 to 26 minutes. The time physicians spent with the patient
in the examination room decreased from 35 to 26 minutes, and the
overall clinic visit time was reduced by three minutes.
Contact Persons: Lisa J. Cochran and Traci Fox
Service: Ambulatory Care Service
Facility: Portland, OR VAMC
Number: (503) 721-7897
Until June 1993, the medical service at the Walla Walla VAMC was
organized into separate inpatient and outpatient services with
physicians assigned exclusively to one or the other. Outpatients
were treated in a busy clinic that attempted to have patients
see the same outpatient physician at each visit; however, patients
often saw numerous physicians over a period of time. Patients
also often interacted with many nurses and clerks during a single
visit and waited in long lines at a centralized check-in desk.
When a patient was admitted, an inpatient physician was assigned
on a rotation basis; thus, patients usually had a different physician
for each admission. Staff turnover was high and satisfaction low;
limited resources and increasing workload demanded that we do
more. A multidisciplinary process action team was chartered to
develop a system in which one physician provided both inpatient
and outpatient care to an assigned group of patients.
After months of careful design by the process action team, the
Private Practice Model was implemented in June 1993. Each veteran
was assigned to one of four primary care teams, each consisting
of two physicians, two registered nurses, and a clerk. Each physician
has a primary caseload of 600 to 700 patients for which he provides
inpatient, outpatient, and NHCU care. The team operates as a joint
practice in which one physician covers the other's patients during
any absence. The RNs provide patient care during clinic visits,
serve as the patient's telephone contact person, and ensure continuity
of care for their group of patients. With the opening of the Ambulatory
Care addition, we now have 0.5 social workers assigned to each
team and a clinical dietitian available in the area.
Benefits
| Ratio of Admissions to Outpatients Visits | ||
| Percent of Visits that are Unscheduled | ||
| No Shows for scheduled appointments (Medicine) | ||
| Waiting time to schedule new appointments | ||
| Clinic waiting time |
In addition, the average daily census for Medical Service has
dropped to 13.3 in FY 1995 from 26 in FY 1992 and 20.4 in FY 1993.
Staff turnover has also declined for all disciplines.
Name: Winifred Graham, RN and Angela Stevenson, RN
Service: Nursing Service
Facility: Walla Walla, WA VAMC
Number: (509) 525-5200 or FTS (700) 434-2594
T he firm system was implemented in the medical services at Lakeside
VAMC and at Northwestern University Medical School in 1990. However,
this re-organization affected only inpatient care at Lakeside.
Lack of an ambulatory care component impeded the delivery of care:
continuity was lacking, patients were often unable to identify
their provider, unscheduled care was managed in the ER/Triage
area, and patients requiring close follow-up in the ambulatory
setting were often seen by a different provider at every visit.
On July 1, 1994, after more than one year of multidisciplinary
planning, the ambulatory firm system was implemented and integrated
into the existing system. Each of the three firms were structured
to provide longitudinal care, interim care, and unscheduled care.
Although longitudinal care is the primary function of the firms,
the other two components provide improved continuity of care:
Interim care involves the frequent, close monitoring of patients
between visits to the primary care physician or following hospital
discharge; unscheduled care allows patients to have quick access
to care outside the ER/Triage setting with the care provided by
clinicians familiar with them.
To provide these three functions, staff from multiple services
were selected to join the firms. Nine full-time general medicine
attendings, 61 medical residents, nine nurses, three clinical
pharmacists, three dietitians, three social workers, and six MAS
staff were distributed equally across the firms. In addition,
an ambulatory block rotation was developed which involved two
medical residents per firm per month. At each of its half-day
clinics, each firm usually has two medical residents on block
rotation, two to three other medical residents, a clinical pharmacist,
a nurse case manager, and two precepting attending physicians
managing all three functions. The medical residents not on block
rotation provide longitudinal care. Unscheduled care is handled
by a block rotation resident and attending preceptor. Interim
care is provided by the other block rotation resident, the clinical
pharmacist, an RN case manager, and a precepting attending physician.
To improve communication between providers, a log book of patients
is maintained for the interim area; it is used to record the specific
problems and target goals of the patients scheduled. Acting as
a liaison between the inpatient and outpatient components of the
firm, the RN case managers make rounds on the inpatient wards
twice per week and see these patients in the interim area if rapid
follow-up is needed.
Benefits
A pre-post patient survey demonstrated a statistically significant
13% increase in the proportion of veterans that rated their care
good to very good. There was a 20% increase in the proportion
of veterans that knew the name of their physician. Medical resident
and staff satisfaction surveys revealed that both were pleased
with firm implementation. Further, they believed that care was
good and had improved since implementation. Medical residents
were positive about the changes in the educational environment
and the support of precepting attending physicians. Following
implementation, longitudinal care visits increased by 14%; the
total number of unscheduled visits to the facility increased by
13%, while the number of patients seen in the ER/Triage area dropped
by 46%. Consequently, we have increased the amount of care provided,
improved the continuity of care, improved patient and staff satisfaction,
improved the educational environment, and changed the location
in which care is delivered.
Contact Person: Brian Schmitt, MD
Service: Ambulatory Care Service
Facility: Lakeside VAMC, Chicago, IL
Number: (312) 640-2230 or FTS (700) 788-3099
The Dayton VAMC initiated a Prime Care Service to increase patient
satisfaction and provide continuity of care. However, patients
admitted to the hospital are frequently not treated by their Prime
Care physician, leaving a gap in their continuity of care. An
inpatient liaison nurse position was created in the outpatient
Prime Care clinic to help bridge this gap, as well as to assist
inpatient staff physicians in coordinating hospital care. Currently,
two of the four Prime Care teams have established this position.
The inpatient liaison nurse duties are performed by a registered
nurse from each of the participating outpatient Prime Care clinic
teams; the position is rotated among the team's nurses on a monthly
basis.
The inpatient liaison nurse visits all team patients admitted
to the hospital. The initial visit provides the patient with a
contact person from his outpatient treatment team. During subsequent
visits, the liaison nurse reinforces patient education relating
to the disease process and medications, and assists with referrals
to the community health nurse. The liaison nurse also works closely
with the treating inpatient physicians to arrange and follow-up
on referrals to ancillary services, and to identify patients who
would benefit from special outpatient services, e.g., intensive
diabetic education, home health care, or outpatient procedures.
At the time of discharge, the liaison nurse reviews the discharge
medications with the patient and answers any questions he or she
may have. The liaison nurse also ensures that the patient has
a follow-up appointment in the Prime Care clinic and is given
the appropriate Prime Care telephone numbers. The completion of
these tasks by the outpatient Prime Care nurse requires approximately
two hours per day.
Benefits
Continuity of care is improved during hospitalizations, and patients
appreciate seeing a familiar face. The liaison nurse's review
of discharge instructions helps to eliminate potential lapses,
such as omission of discharge medication orders and lack of Prime
Care follow-up appointments, which could result from a Prime Care
patient being admitted to another service. The contact with the
liaison nurse also appears to make the patient more likely to
call the Prime Care team regarding his health care after discharge.
Contact Person: Brenda Moore
Service: Medical Service
Facility: Dayton, OH VAMC
Number: (513) 262-2112 or FTS (700) 950-6511 Ext 2112
A "continuity of care" model of health care delivery
became fully operational at the Marion VAMC in October 1994. Before
then, outpatient physicians were seeing the bulk of patients,
both scheduled and unscheduled, often as many as 40-50 patients
per physician per day. Unnecessary admissions were frequent due
to the inability to comprehensively evaluate each outpatient;
crowding and long waits for outpatient care were common and led
to complaints among both patients and staff; medications and treatment
plans were frequently changed, based on the idiosyncrasies of
each physician's practice; length of stays were extended, unnecessary
tests ordered, and accessibility into the system was at times
next to impossible. An interdisciplinary Quality Improvement Team
was charged by Medical Service with the task of developing and
instituting a "continuity of care" model.
The first of six clinics opened in January 1994, with full implementation
nine months later. Each clinic team has two to three MDs sharing
the responsibility of providing both inpatient and outpatient
care for 800 to 1,000 patients. Each team also has one RN selected
by the clinic physicians and one patient services advisor from
MAS. There has been a realignment of staff within support services
with one clinical pharmacist, one social worker, and one clinical
dietitian assigned to cover two clinics.
Each clinic team has two exam rooms, a distinct waiting/reception
area, and a nursing office; it holds its clinic eight half days
per week, divided appropriately among the physicians on that team,
with both a.m. and p.m. slots for each physician to accommodate
patients' scheduling needs. Weekend rounds are made by one team
physician for all team inpatients. Each clinic team has a color
coded identity, with direct telephone access for the patients
assigned to that team. Telephone triage is used to improve patient
accessibility to the system, decrease the number of unscheduled
visits, and improve timeliness of care.
The clinic teams are self-directed, with responsibility first
to the patients they serve, then to the team itself, and finally
to their respective services. The team approach leads to an emphasis
on patient education and disease prevention. Thursday afternoons
are free of scheduled patients to allow for team meetings, education
of team members, and interdisciplinary patient education clinics.
Benefits
Ninety-six percent of the patients in the Continuity of Care clinics
are seen by their provider within 15 minutes of their scheduled
appointment time. Eighty percent of patients calling for nurse
or physician intervention have their needs met via telephone,
while the remaining 20% are given an appointment to report to
the clinic. The average daily inpatient census for Medicine has
been reduced by 30%, at the same time that we are attracting approximately
100 new patients per month. There has also been a 60% reduction
in "No Shows" for medicine appointments, and the readmission
rate has been reduced by approximately 50%. Patient comments glow
with praise for the new system, and there has been a significant
decrease in the number of patient complaints. Team members have
responded positively to the increased autonomy, and have gained
considerable satisfaction from being accountable to a set group
of patients.
Contact Person: Susan D. Fowler, RN, BSN
Service: Chief of Staff
Facility: Marion, IL VAMC
Number: (618) 997-5311 or FTS (700) 276-0306
After establishment of a primary care program at North Chicago
VAMC, patients were still being seen by non-primary care providers
when they presented to the walk-in area without an appointment.
A survey covering a period of approximately 30 working days found
that only 24% of the "walk-in" primary care patients
were evaluated by their primary care team. Clearly, we needed
to improve the access of walk-in patients to their primary care
providers.
The following actions were taken:
Benefits
To assess the effectiveness of these actions, the proportion of
primary care walk-in patients seen by their team has been periodically
examined. The percentage increased to 92% during our most recent
data collection period. However, as a result of further refinement
and improvement, we believe that 100% of primary care patients
are currently seen by their primary care providers on the same
day that they present to the Triage/Urgent Care area.
Contact Persons: Frank A. Maldonado, MD; and Carol A. Foran, RN
Service: Ambulatory Care Service
Facility: North Chicago, IL VAMC
Number: (708) 578-3770 or FTS (700) 384-4242
All patients in the medical center are assigned to either the
Red, Blue, or Green Academic Global Care Team (AGCT). Each team
sees an average of 2,200 patients per month, with 8-10 new patients
per week. The teams provide or coordinate all of the patient's
medical, subspecialty, surgical, and psychosocial care. The goal
is to establish an integrated, collaborative, health management
plan, coordinated by a single provider, to ensure the optimal
treatment of all of the patient's problems over time. Each primary
care provider has a panel of regularly scheduled "continuity"
patients.
Within each AGCT, "mini-teams" link one team attending
with one nurse practitioner or physician assistant and up to seven
internal medicine residents. Each primary care provider's panel
of patients is cross-covered by other members of the "mini-team,"
and when house staff finish their residency training, their panels
of patients are taken over by incoming residents assigned to the
same "mini-team." The primary care provider assumes
accountability for patient care, regardless of which "mini-team"
member sees his or her patient. The faculty attending physician
assures the quality of care for the entire "mini-team."
Since veterans seeking health care in VA medical centers are known
to have high rates of mental health impairment, a psychiatrist
and a social worker are included on each team. Psychiatrists provide
direct patient care as well as formal and informal consultation
to primary care physicians, and participate in educational programs
designed to increase detection of common mental health problems
such as depression. Social workers provide counseling and case
management.
Physician Team Leaders are responsible for coordinating the health
care duties of the six health disciplines on their teams and the
team's interactions with other medical center services. Team Leaders
work closely with their Team Managers who supervise all clerical
personnel and facilitate clinical care by monitoring patient flow
and handling any patient complaints. The individual discipline's
responsibilities are as follows:
Team Empowerment
When the PACE program was first being developed, a commitment
was made to empower the interdisciplinary AGCTs to do their own
decision-making and to create an atmosphere in which teamwork
and education would flourish. One afternoon per month, scheduled
clinic activities are suspended for each team. During these education
afternoons, the team has case conferences, in-service training
on new policies and procedures, guest speakers, and an opportunity
to discuss and solve team administrative problems. All team members
attend and exchange ideas and share concerns. The monthly education
day reinforces the concept of a team as a problem-solving group
with the power to initiate change.
Team empowerment has meant that the teams are autonomous and have
developed different styles; they carry out PACE procedures and
policies in ways that are most effective and efficient for their
personnel. This is very much in keeping with the plan to empower
the teams to determine their own practices and take responsibility
for their actions.
Matrix Management
In designing an organizational structure for the three AGCTs,
it quickly became apparent that some type of matrix management
system would have to be instituted for the teams to function in
an interdisciplinary manner. A matrix management system is an
organizational structure which empowers two managers from different
organizational units to exercise a degree of supervisory control
over an individual worker. (The concept originated in the 1960's
in large manufacturing corporations where project teams were developed
by assignment of team members from different disciplines or professions).
Matrices have the benefit of linking staff from different disciplines
to a specific team while maintaining linkages to the parent services.
In the PACE matrix, all clinical staff members report jointly
to their physician team leader as well as to their parent service.
The teams (and more specifically their respective team leaders
and administrative team managers) assign and supervise the daily
routine and responsibilities of staff members, including integration
of their clinical activities with the team, scheduling of clinical
activities and vacations, educational responsibilities, etc. The
service, generally represented by an associate chief for the service's
ambulatory care section, is largely responsible for supervising
the professional duties of the staff member through staff development,
service-specific quality assurance, individual reviews, and related
mechanisms.
The exact nature of the matrix varies from service to service
and was negotiated independently for each discipline. Across all
services, the minimum level of control the AGCT exercises consists
of joint recruitment and selection of team staff, rating each
staff member's teamwork, and negotiating work flow directly with
the team member(s).
The matrix is also carried out at the top level of supervision
where practical. The administrative team managers report jointly
to their respective team leaders and to the PACE Operations Officer.
The Associate Chiefs of Ambulatory Care for Nursing, Pharmacy
and Social Work Services report jointly to their parent service
and to the physician Chief of PACE. The three senior internist
team leaders report formally to the Chief of PACE, but also have
a structured relationship, particularly for academic purposes,
with the Chief of Medicine. The same is true for the PACE senior
psychiatrist, who reports to the Chief of PACE and Chief of Psychiatry.
Benefits
Continuity of care has improved. Compared to one year earlier,
more patients reported receiving all or most of their care within
their designated PACE team by 1993 (16.1% increase; p<.01).
The proportion of patients who saw a physician continuously anywhere
at Sepulveda VAMC increased by almost 10% (p<.05), and the
proportion of patients who received continuity of care in PACE
increased even more, by 18.7% (p<.01). When we adjusted for
age, health status, and number of clinic visits in the previous
year, we found even greater differences for each type of continuity
(team, individual provider, and PACE provider) (p<.001).
More patients received scheduled appointments compared to walk-in
care during the pre- compared to the post-PACE period. Percentages
of scheduled appointments rose from 46% in 1991 to 73% in 1992
and 1993.
Assigning all patients in the medical center to one of the three
AGCTs has also greatly improved the handling of patient complaints.
The majority of these complaints focus on a problem the patient
is having dealing with the system, e.g., inability to get an appointment,
lack of understanding of the system, lack of understanding of
treatment plans, etc. Since the teams are "where the buck
stops," both clinically and administratively, patients quickly
learned to go to their Team Managers to get straight answers to
questions, and the teams know how to get the patient through any
obstructing "red tape." Additionally, most patient complaints
that do reach the medical center director's office are such that
they can be referred to the Team Managers for resolution.
To assess the impact of including a psychiatrist and social worker
on each AGCT, we have examined several variables relating to depression.
Fewer patients reported symptoms of depression in 1993 (20.5%)
compared to 1992 (25.8%) (p<.001), but the detection of depression
increased by 23.7% from 1992 to 1993 (p<.05). The increase
in detection of depression was even higher after we controlled
for health status (including mental health symptoms), number of
visits to clinic, and age (p<.001). However, when we accounted
for these factors, PACE patients were no more likely to report
that they had been helped for their depression in 1994 than in
1992 and 1993 (p=.20). Consequently, we have undertaken a major
quality improvement project to improve care for depression in
primary care.
Contact Person: Lugina S. Evans, OTR
Service: Primary Ambulatory Care and Education (PACE)
Facility: Sepulveda, CA VAMC
Number: (818) 895-9400 or FTS (700) 966-9400
T he information system in existence during the planning stages
of PACE was the VA's Decentralized Hospital Computing Program
(DHCP). This system, while quite extensive and far reaching in
its scope, was primarily geared towards administrative data collection
and appointment management. It had limited capabilities for ad
hoc queries by end-users against its databases, stored limited
clinical information (essentially only laboratory test results
and medication profiles) and had primitive user interfaces consisting
of roll-and-scroll line oriented information displays. Users had
to enter commands and information into the system in a preset
order as prompted by the system. Generally, it was difficult to
vary this order, to correct erroneous data entry, or to review
or redisplay just viewed information. Though this system has continued
to evolve, it was anticipated that it would not meet all of the
information needs required for PACE without significant enhancement.
Consequently, when PACE was first being developed, an informatics
team comprised of an M.D. informatics expert, a Ph.D. level researcher
with a computer science and operations research background, a
personal computer programmer, a hardware support person, a part-time
DHCP programmer, and a part-time user support person was given
the task of reorganizing our computer information systems to provide
easy access for clinicians and administrators in ambulatory care.
The resulting system is called the Ambulatory Care Information
System (ACIS) and offers a graphical user interface to clerks,
nurses, doctors, and administrators for collecting and reviewing
clinical and operations information. ACIS currently encompasses
Local and Wide Area Network connectivity among roughly 300 IBM
compatible personal computers. These systems exist in multiple
configurations from 386SX-25mhz to pentium machines, with the
majority being 486DX2-66mhz. All run Microsoft Windows or Windows
for Workgroups. Computers are located in examination rooms, attending
offices and conference areas, clinical and non-clinical clerical
and administrative areas, pharmacist offices, and nursing stations.
Machines are connected to one another, to network file servers,
and to the hospital mainframe via class III ethernet and a fiberoptic
backbone, and use the Microsoft Lan Manager Network operating
system. A number of examination rooms are served by pen-based
laptop computers and wireless ethernet links. We currently have
four OS-2 based server systems on the network, managing security
and file access, as well as several Windows for Workgroups data
servers. The network is connected directly to DHCP through fiber,
and workstations communicate with DHCP via Decserver serial connections,
TCP/IP and/or LAT protocols. Gateways on the fiber backbone provide
Wide Area Connectivity to the VA-wide network (IDCU) and to the
UCLA Campus network via T1 links.
New software applications provide accessible and clinically useful
programs that are capable of uploading information from local
Windows-based workstations to DHCP and downloading information
from DHCP to local workstations. The table on the next page provides
a summary of the software applications.
Benefits
The ACIS supplies greatly enhanced tools for analysis of clinic
operations and access to clinical information by providers during
a patient visit. Currently, the complete ACIS is in use at the
Sepulveda and Charleston VAMCs. Various components, especially
telephone triage, have been exported to additional sites. In general,
ACIS should integrate well with any DHCP site. Effective implementation
requires significant hardware investment and probably a half-time
user support person who is proficient with personal computers.
Contact Person: Steven H. Rappaport, MD
Service: Primary Ambulatory Care and Education (PACE)
Facility: Sepulveda, CA VAMC
Number: (818) 895-9400 or FTS (700) 966-9400
Medical residents participating in VAMC Northport's Primary Care
(PC) Clinics experience a "managed care" model of coordinated,
comprehensive, and personalized primary care while gaining experience
in direct medical treatment. Recently, the PC staff focused on
improving clinic efficiency, with the goal of reducing the waiting
time for new appointments. Since assessment of resident productivity
might be beneficial in achieving this goal, an instrument was
created to monitor the time residents spend in clinic and the
number of patients they see. The instrument was also designed
to identify the frequency of encounters with patients with specific
medical conditions for the purpose of residency accreditation.
Residents identify the number of patients seen during a clinic
session and the range of primary diagnoses encountered on a survey
form created using the Teleform Software Program. Upon arrival
at the clinic, the resident receives a blank form with the time
of arrival filled in by the clerk. Upon departure, the completed
sheets are handed to the clerk who then marks the time out. Use
of this instrument is explained at the time residents are oriented
to their clinic responsibilities. They are informed that clinic
attendance, which is mandatory, will be monitored, and accountability
required; notification of the Clinic Manager and the Residency
Supervisor is necessary for approval of schedule changes. The
Teleform data is analyzed using a Microsoft Excel Software program.
The number of patients seen per session and per hour and the amount
of experience with various medical diagnoses is tabulated.
Benefits
Initial assessment revealed a need to increase the number of new
patients seen by residents and the amount of time they spent participating
in clinics. This resulted in the opening of additional new patient
appointment slots and the development of a new patient scheduling
mechanism to increase resident productivity and improve the continuity
and efficiency of patient care in the PC clinics. Monitoring of
residents' experience with various diagnoses is also now possible.
Contact Person: Linda Mermelstein, MD, MPH
Service: Chief of Staff
Facility: Northport, NY VAMC
Number: (516) 261-4400 Ext 7910 or FTS (700) 663-7910
When we initiated primary care, each patient was assigned a specific
physician as primary care provider. However, this action by itself
did not fully achieve the goals of primary care, which include
comprehensiveness, continuity, and accessibility. Since many primary
care physicians were not working full-time in the outpatient clinics,
they were often unavailable when their clinics were not scheduled.
Even during clinic hours, physicians were fully occupied attending
to scheduled patients and could not respond readily to patient
concerns that arose between scheduled visits. These limitations
adversely affected the comprehensiveness and continuity of the
care we provided.
To address these problems, a group of primary care nurse case
managers were recruited. Each patient was assigned a primary care
nurse in addition to a primary care physician. The nurses work
with either one full-time physician (equivalent of 8 half-day
clinic sessions per week) or with two to three part-time physicians.
The RNs and physicians work together as teams.
The RN case manager's responsibilities include the following:
A series of practice guidelines are being developed for the common
problems seen in Ambulatory Care. The RN case managers will be
responsible for monitoring compliance with these recommendations
and, in some cases, for initiating interventions. For example,
the RN will monitor compliance with and assist in implementing
recommended preventive medicine practices for diabetic care such
as annual eye examinations and regular hemoglobin A1C's.
Benefits
Evaluation of this system has shown a 20-25% decrease in the number
of walk-in visits. Chart monitoring has shown marked improvement
in regular recording of vital signs, weight, medication use, and
adverse drug reactions. Many favorable comments have been received
from patients as this system provides them with an identified
individual whom they regularly see during their scheduled visits
and who is available to provide assistance at other times. This
is an important development in a system that was often faceless
and difficult to access. Physician reaction has been extremely
favorable as the RN case managers provide the physicians with
an important element of support, allowing them to spend more time
on complex medical issues.
Contact Persons: Michael Mayo-Smith, MD and Marcia Lorang, RNP
Service: Ambulatory Care and Nursing Services
Facility: Manchester, NH VAMC
Number: (603) 624-4366 Ext 6047 or FTS (700) 837-6011
D ata on overall and individual provider productivity are tracked
daily and summarized monthly in an electronically generated management
report. The report is used to examine provider performance and
to identify outliers. Indicators include patients scheduled per
session, patients seen per session, patient no show and cancellation
rates, clinic cancellation rate, walk-ins seen, and provider panel
sizes. The data can be aggregated for an individual provider or
as an overall average for all providers. Since the provider who
actually sees the patient is at times different from the scheduled
provider, our Medical Informatics section recently developed the
capability for our clinic clerks to enter the provider who saw
the patient in a "provider seen" field in DHCP.
Benefits
Examination of the above data convinced us to increase by 30%
the number of patients scheduled per half-day session for each
primary care staff physician. Use of these data has also enabled
us to optimize our scheduling processes to reduce the average
waiting time to the next available appointment in primary care
clinics. The "provider seen" field in DHCP provides
a more accurate accounting of provider productivity; the capability
to electronically generate an automated provider productivity
report saves the many man-hours that would be required to manually
prepare a monthly productivity report.
Contact Person: Kenneth E. Klotz, Jr., MD
Service: Ambulatory Care Service
Facility: Richard L. Roudebush VAMC, Indianapolis, IN
Number: (317) 635-7401 or FTS (700) 332-3057
T he Seattle VAMC developed primary care teams within the General
Medicine Clinic in 1993. With the new emphasis on primary care
providers and teams came the need to be able to readily identify
which team a patient was assigned to. This information needed
to be accessible to many medical center staff even when the medical
record was not available, making a computer based flag or field
in DHCP the most reasonable way to present this information.
A computer option was created under the Patient Inquiry File which
allows input of the primary provider and team responsible for
patient care. The field contains the name and beeper number of
the primary provider and the name and extension of the individual
to be called if the provider is not available. This information
is available in a look-up capability under the patent inquiry
DHCP menu option. For the General Medicine Clinic, the backup
individual is usually the RN working with the team.
The program was automated for patients enrolled in the General
Internal Medicine Clinic (GIMC) and identifies patients, matches
them with their provider and their clinic team, and extracts the
necessary information regarding beeper numbers from the DHCP telephone
directory. Manual input is currently used when providers outside
of the GIMC are assigned primary provider responsibilities. With
the recent identification of subspecialists in Medicine and specialists
in Mental Health as potential primary providers, further automation
is being reviewed. Our plans also include displaying the information
on the screen when patient information is brought up on the computer,
as well as printing the name of the primary provider and team
assignment on action profiles that are used throughout the medical
center.
The program also allows identification of a primary provider's
patient panel. A primary provider database has been created, allowing
providers to review the number of visits in other clinics for
patients within their panel. This database is also being used
to identify patients who do not yet have a primary provider and
to develop strategies for making the most appropriate assignment.
Benefits
This DHCP capability allows staff caring for a patient to readily
identify the primary provider responsible for the patient's care
and facilitates communications with that provider, thus improving
continuity of care. The capability also helps to prevent duplication
of testing, confusion over medications, and unnecessary referrals.
Contact Person: W. Paul Nichol, MD
Service: Ambulatory Care Service
Facility: VA Puget Sound Health Care System, Seattle, WA
Number: (206) 764-2360 or FTS (700) 396-2360
Las Vegas VAMC developed its outpatient POW Program as a primary
care unit, with an interdisciplinary POW treatment team led by
the POW physician, who provides ongoing medical care in addition
to performing the protocol examination. The team of a physician,
psychologist, social worker, and a secretary has remained stable
over the past ten years, personalizing care through long-term
relationships with patients and their families. The patient population
has grown from the initial 25 in 1983 to a current active caseload
of 280; a case management model has helped facilitate this growth.
By virtue of their enrollment in the POW Clinic, former prisoners
of war are enrolled in the Primary Care Unit of which the POW
Clinic is a sub-unit. After admission to the Ambulatory Care Center
(ACC) and screening by the Acute Care Nurse, a new POW patient
is referred to the secretary who serves as the point of contact
for all POWs. If medical attention is needed that day, the POW
is escorted to the Primary Care Unit to be seen in POW Clinic
or, in the absence of the POW physician, by a physician in the
Primary Care Unit. A follow-up appointment, in the latter case,
is made in the POW Clinic. If immediate care is not required,
the first available appointment is made in the POW Clinic. During
the initial contact, the POW is introduced to the social worker/POW
Coordinator and the POW Program Support Group. Clinic procedures
are explained, and a business card with the names and telephone
numbers of primary care providers is provided.
Coordinated, comprehensive care with provider continuity permits
a change in focus from acute care to prevention and wellness.
Ongoing care may include evaluation and treatment by specialists
in the ACC's Specialty Care Unit or in an inpatient setting. In
either case, treatment is coordinated with the POW Clinic, and
the patient is referred back to the POW Clinic for primary care.
Several factors make this program unique. First, the protocol
physician is the primary care provider for all POWs, and the protocol
is made a working part of the treatment record. Second, from the
outset the POW Clinic was identified as a Primary Care Unit, with
an identified multidisciplinary treatment team providing services
for a well defined patient population. Finally, one individual
serves as the contact person and case manager. This function,
along with a telephone triage system, improves accessibility to
and timeliness of needed services.
Benefits
The primary benefit is customer satisfaction: Our POW patients
are generous with their praise of the program and the treatment
team. POWs from other areas of the country frequently tell us
how different our program is from that of other VAMCs and how
much they appreciate the specialized care they receive here.
Contact Person: Wyn Rhys-Jones, MD
Service: Medical Service
Facility: Las Vegas, NV VAMC
Number: (702) 386-3211 or FTS (700) 386-3597