Chapter 5. Systems of Practice and Office Management

It is widely recognized that the US health care system does not provide every American with the quality of care they deserve. Broad gaps in quality were documented in a recent report from the Institute of Medicine1 and in studies showing that children receive less than half of recommended acute, preventive, and chronic care.2 The Institute of Medicine proposed a set of 6 expectations that high-performing health care should achieve—safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity—and described steps to promote more evidence-based practice.

Pediatricians want to provide the best care they can for their patients, but extensive research indicates that much of the quality of care achieved is determined by the specific processes or systems of care delivery in place in the practice. The challenge of providing the best care is heightened by ongoing change in the nature of morbidity, the development of new knowledge, and the evolution of technology. For example, the increasing importance of psychosocial morbidities, the growing prevalence of children with chronic illness, the complexity of immunization schedules, and the advent of electronic medical record systems imply a need to adopt new approaches and tools and linkages to accomplish many of the things that cannot be done in the office (see Chapter 1). Thus, processes for care delivery cannot remain static. They must evolve over time as patients’ needs and patterns of illness change and new discoveries emerge.

Multiple studies have documented the long interval between health care innovation and use in practice.3-6 Traditional methods of translating research findings into practice, such as peer-reviewed publications and continuing medical education, are passive and slow,7,8 and the passive provision of information is rarely effective in helping busy clinicians adapt new knowledge to practice.9

All practices have systems and processes to organize the work of caring for patients. Practice systems often develop on a somewhat ad hoc basis to address specific issues or problems. More contemporary approaches create practice-based systems that are linked directly to improving the Institute of Medicine’s six dimensions of quality. A practical approach for organizing care is to institute processes to manage the most common types of conditions encountered. This chapter highlights major practice systems for four key areas of care (prevention, acute care, chronic care, and access and efficiency) and cites evidence-based resources that can support efforts to adapt these systems to all types of practice settings to optimize patients’ health outcomes.

A system is a “set of interrelated processes carried out by multiple individuals to achieve a purpose.”10 A primary practice, a specialty clinic, or a unit in a hospital can be thought of as a small, organized group of clinicians and staff working together with a shared clinical purpose to provide care for a defined set of patients. Many practices are part of a larger organization and are embedded in a legal, financial, social, and regulatory environment.11 Note that the term system does not necessarily involve an elaborate operational structure. Good systems often simply outline how specific tasks are accomplished and who is responsible and ensure that the necessary tools and training are available to support the responsible individuals.

Prevention

Preventive care is the most frequent reason for pediatric office visits, accounting for 20% to 25% of all pediatric office visits and a much greater proportion of visits for children under age 2 years.12 The scope of well-child care is very broad, and the number of potential topics to be covered during preventive care visits far exceeds the 18 to 22 minutes that are typically available. Therefore, effective delivery of preventive care depends on tailoring the visit to closely meet families’ needs. Evidence shows that the use of structured tools to elicit parents’ concerns, the identification of psychosocial risk factors, anticipatory guidance about developmental concerns, and problem-focused counseling about behavior and development are efficacious in tailoring care to families’ needs.13 Implementing these approaches through specific practice-based systems that support preventive care make it possible to meet parents’ needs and improve the quality of care.14

Table 5-1 lists specific processes that can be implemented to achieve the goals of providing needed anticipatory guidance; addressing parents’ concerns about their child’s learning, development, and behavior; identifying children at risk; providing a strong and streamlined link to community resources for families who need or want them; and promoting optimal parent-child relationships. These changes emphasize several key points. First, establishing officewide guidelines or standards about the timing and content of preventive care enables practices to adopt tools, such as preventive services summaries and structured developmental assessment instruments, which can be implemented by staff other than the physician. Second, previsit planning reduces total visit time and helps to focus the content of the visit on identified risks and concerns. Third, the content and duration of preventive care visits should be based on the unique needs of the child and family. Higher-risk/higher-need families should receive more targeted screening and a substantially greater amount of information in anticipation of normal developmental transitions and in response to identified risks and problems. Such families are likely to need more services from other service providers in the community, which will require more clinician and office staff time to integrate and coordinate care. In summary, these changes promote tiered or risk-based care that is more individualized, more appropriate, and more effective. Additional resources for improving preventive care are provided at: http://brightfutures.aap.org and http://www.commonwealthfund.org/innovations.

Chronic Illness Care

Wagner’s chronic illness care model (see Fig. 5-1) provides a useful, evidence-based framework for organizing changes to the system of chronic illness care that result in improved outcomes for patients.15,16 The model includes clinical information systems, delivery-system design, decision support, and patient and family self-management support. The clinical information system enables caregivers to access data and use registries for care and to provide regular feedback; this information technology also facilitates scheduling and patient tracking. The delivery-system design component comprises the use of planned encounters, clarity in the roles and responsibilities of team members, appropriate training of team members, and the use of regular meetings of the care team to review performance. Decision support means access to evidence-based information and the use of care protocols that are integrated into the practice systems. Family and patient self-management support refers to the methods used by the clinical practice to increase families’ confidence and skills to effectively manage chronic illness at home on a daily basis.

The specific changes practices can make to promote better chronic illness care are in many respects similar to those described for preventive care. A registry is a powerful tool that enables staff other than the physician to identify patients with chronic illnesses and implement needed care. Registries can also serve as a tool for implementing a recall system by enabling the practice to identify which patients have not returned at appropriate intervals. Implementation of a population registry requires adoption of practicewide guidelines and standards. Agreement about which services to provide and when to provide them enables staff to take responsibility for core elements of care delivery. Care protocols also minimize the risk that patient needs are overlooked. Once a practice decides on a guideline for care, protocols can be developed to identify the role of the care team in distributing the work of undertaking chronic care. Agreement on guidelines also supports the concept of stratifying care on the basis of severity of illness so that resources for care management can be more effectively deployed. Once these basic changes have been accomplished, practices can concentrate more effort on selecting appropriate educational materials and promoting patients’ and families’ ability to manage their own disease (eg, through motivational interviewing). More detailed information about tools and strategies to support chronic illness care are available in Section 9 and at the following websites: http://www.improvingchroniccare.org; http://www.acponline.org/clinical_information/guidelines; http://www.aafp.org/online/en/home.html; http://aap.org (ADHD toolkit and eQUIP).

Acute Care

The core processes for supporting acute care are in many ways similar to those required to achieve effective preventive and chronic care. Developing processes for the management of the most common acute problems, such as otitis media, pharyngitis, fever, gastroenteritis, and asthma, enables practices to provide more consistent and reliable care. Clinical practice guidelines are now readily accessible for many of these conditions. Guidelines can provide a much needed interface between evidence and practice.17 By distilling relevant clinical research and making it readily available, guidelines can point the way to higher-quality, evidence-based, and more cost-effective care. Many guideline recommendations are embedded in companion documents and processes to promote easy access to the best evidence at the point of care. These tools may include a clinical pathway, standing order sets, a parent edition of the guideline, an education record, and discharge goals and instructions for patients.

Access and Efficiency

Modern approaches to scheduling and management of office flow make it possible to create processes that provide patients the opportunity to see their own physician when they choose.18 To improve office flow, a practice must manage its total resources (supply) to provide care. When the resources are managed well, openness or space in the clinic (capacity) is created. In an optimal system, a practice provides enough capacity for health services to meet the demands of its patient population at the time the demand occurs. This is a fundamental shift from the complex scheduling systems and wide variety of appointment types and lengths that resulted in long waits to see clinicians.

Systems known as open or advanced access take advantage of practices’ ability to predict demand and respond to it effectively.19 Although many pediatric practices allow same-day appointments for acute care visits, these newer approaches expand same-day access to include routine and preventive care. This model is based on the principle that when supply and demand are in balance (or equilibrium), there is no need for waits in the system. Evidence is emerging that such systems result in higher continuity of patients with their own physician, resulting in improvements in outcomes of preventive and chronic illness care.20,21

Strategies for creating a system for advanced access involve 3 main principles19: (1) reducing the amount of demand, making it easier for the system to absorb current or future levels of demand by maximizing activity at appointments and increasing the interval between appointments; (2) redesigning the system to increase supply by making the clinic more efficient; and (3) matching supply with demand through effective use of appointment data. A more detailed list of changes is given in Table 5-2.22

Managing the types of changes required to provide effective clinical operations depends on effective leadership and support systems to create an ongoing emphasis on the continual improvement of the practice system. Many resources are available through the American Academy of Pediatrics and other practice management organizations to enable practices to develop and implement approaches to financial management, human resources management, and information systems. As a general principle of system development and continual improvement, it is advisable to introduce changes in a single area of the clinical setting to gain experience and achieve improved results before implementing changes to the next area. This incremental approach minimizes the risk of disrupting the practice and promotes confidence that change can be made without compromising care delivery during transition.