Jerome Carter, MD October 18, 2016

Clearly, Typical Primary Care, LLC has problems with patient communications; the question is what to do about them. The first step is recognizing that some type of “system” is needed to make sure all patient interactions are handled properly. In this setting, a system is a set of related processes that assure every communication receives a timely response and is tracked until a satisfactory conclusion. Like every practice, Typical Primary Care, LLC created its communications management strategy with the best of intentions. It simply failed to account for all the many ways things could go wrong. Accordingly, even though there are policies and procedures for managing patient interactions, there is no holistic system that assumes things go wrong and prepares for mishaps in advance.

When first looking at communications problems, it is helpful to look at a few basic traits of the policies and procedures currently in place and ask if they are efficient, effective, and well-documented (1). (Here, well-documented applies to both the policies and procedures as well as the outcomes that result from following those policies and procedures).

Efficiency
Efficient processes produce an outcome with the least amount of resource usage and in the shortest amount of time. A lost sticky note from a pulled chart requires something be done again (e.g., calling the patient again to find out why they contacted the practice). Any time steps are added, ad-hoc, to a process or some steps must be repeated because of lost/missing data (e.g, lost on-call notes), inefficiency is present. Inefficiency wastes staff time, and in this case, can upset patients.

Call wait-time may be a sign of inefficiency either as a result of insufficient staffing or poor use of current staff (e.g., no specific person is assigned to answer calls).

Effectiveness
Effectiveness is a measure of the degree to which the outcomes of a process meet expectations. Effective processes always result in the desired outcomes. If patients have to contact the practice multiple times about the same issue, then the process is ineffective. If mailed (voice or paper) appointment reminders do not lower the no-show rate, then that process is ineffective.

Documentation
Proper documentation is an important part of clinical care. Every patient communication along with the final outcomes of those interactions are critical for both clinical and legal reasons.
Lost sticky notes or EHR notes that are buried behind an obscure menu item can be harmful to the patient and detrimental to the practice (e.g., the lost on-call note from the patient with back pain and dysuria could be long-standing pyelonephritis).

Being able to judge clinical processes based on efficiency, effectiveness, and documentation quality is a good first-step toward improving them. However, this knowledge alone offers no specific guidance on where to start. Below is a “diagnostic” list of things to look for when it becomes obvious a practice has poorly-performing processes. They are listed by issue (ultimately, why the process is performing poorly) and symptoms/signs (what one observes when looking at poorly performing processes).


Issue: Communication process workflows are not well-defined

  • No detailed process workflow model available - This may seem obvious, but aside from EHR implementation, in my experience, few practices bother to look at workflows in any formal way. Even when a formal set of policies and procedures has been created, the next step of creating a realistic workflow model and testing that model in the real world is rare. Doing an analysis and creating a model of the “before” and “after” process provides an opportunity for all involved to form a consensus on what should happen, who should do what, and what documentation is required. A visual model is better than text for getting the details across. As the saying goes: “A picture is worth a thousand words.”

  • Staff workarounds – If there is more than one way to do something, then there is no particular way. Workarounds are common, and they are a sure sign that everyone is not on the same page. Most commonly, I see them result from poor/insufficient training, especially in high-turnover practices. A new person shows up, gets a few hours of “do it this way” training, and then is thrown into action.

  • No tracking of process state or outcomes – Often patient communications are handled in a manner that does not permit tracking their state. A request for a refill can be handled in a discrete, one-off fashion—a patient contacts the practice, speaks to someone, and the matter is closed. Symptom-related calls require a different approach because the underlying problem is unknown and potentially serious. These interactions require a way to track them so that follow-up is assured. For example, a patient calling about new back pain may be given an appointment. If the patient misses the appointment, she may be lost to follow-up until the problem is more serious.
    • Process-state tracking would not only alert the practice that someone with new back pain did not keep an appointment (as opposed to simply noting it as a missed appointment), but also offer to initiate contact with the patient to arrange a visit. Process-outcome tracking would require that a final disposition be entered (e.g., patient went to ER, problem resolved, patient contacted and new visit scheduled).


Issue: Employees poorly trained

  • Training is haphazard or ineffective – Too often, training for new employees lasts only as long as needed to put them to work. Of course, ineffective training easily leads to workarounds, especially if new hires are shy about asking for help. I have seen so many cases where the policy/procedure manual is a back-shelf reference that is rarely used. Over time, with high staff-turnover, the official way of doing things is easily lost.

  • High turnover – Staff turnover is a problem that is hard to address; it is a fact of outpatient care. However, staffing issues can be mitigated somewhat with good training practices. Workflow technology can help by vesting the “how-to” of practice policies and procedures in an executable workflow model. New employees don’t have to remember every little detail of how things work; they simply have to use the software.


Issue: Patients do not receive timely feedback

  • No specific person assigned to manage communications – Whoever answers, takes the call. This may work if there a system enforcing call documentation and managing follow-up; otherwise, things will get lost.

  • Information-poor practice website – Commonly-requested information should be on a website. New patients should receive an information booklet with similar information.

  • Insufficient staff – The best way to determine if this is the case (assuming it is not obvious) is by diagramming the office call volume and workflow. What may seem to be insufficient staff may really be a failure to specialize. Rather than everyone doing the same thing poorly, let a dedicated person do it well.

  • No standard way to monitor failures to contact patients or assure follow-up –When patients do not show for appointments, they fall off the radar.


Issue: Inadequate documentation

  • No standard way to catalog messages – Sticky notes (or notes quickly scribbled in a chart or typed in the EHR) and lack key data such as date, time, reason, disposition, follow-up required, etc.
    • Every staff person documents in a different way.
    • There is no central location where all communications can be reviewed.
    • No final disposition is required for every communication.

At this point, we have hints of what to look for when determining if processes are not meeting expectations, but that is only one side of the coin. Knowing what a good process is, is just as important, which is the subject of the next installment.

  1. Carter JH. From Process analysis to product evaluation. In: Carter JH. Electronic Health Records, Second Edition. Philadelphia, PA: American College of Physicians; 2008.

Up next: What is a good process?