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Wednesday May 08, 2013

Teamwork Key to Improving Quality of Care

I've been interested in the patient-centered medical home (PCMH) since the Future of Family Medicine report recommended that every American should have a medical home back in 2004. I was on the AAFP's Commission on Practice Enhancement (now the Commission on Quality and Practice) from 2006-2010, and the concept was a hot topic for our commission.

When my multi-specialty medical group in New Mexico decided to implement the PCMH in our own clinics, I served on an advisory committee that helped make it happen. When it was time to implement electronic health records (EHRs), my clinic was the guinea pig. We got our EHR up and running before the system was rolled out to the whole group. Today, all 10 of our primary care clinics have achieved National Committee for Quality Assurance Level 3 PCMH recognition.

Although teamwork was critical to the progress we made as a larger organization, looking back I realized we hadn't done enough team building in our own clinic. So beginning in 2011, we worked to improve our practice -- which has 30 employees, including three physicians and three nurse practitioners -- by establishing a high-functioning team dedicated to addressing issues specific to certain diseases, conditions or issues.

We didn't dive right in. It was a deliberate process. We spent six months carefully crafting mission and vision statements and setting goals and objectives.

It might sound like slow going, but it was worth it. Our staff members -- both clinical and office -- now own the concept of working together and are invested in it. We believe in it, and that's huge.

Every Monday morning, we meet to review a list of objectives and select new projects to begin. We have made some significant strides, but quality improvement never ends.

Our diabetes team started with a simple project to become familiar with the process of foot exams. Physicians and nurses, me included, were not consistently performing foot exams for every patient with diabetes. And when they were being performed, the results were not consistently recorded in the right place in our EHR. Our team devised new protocols to ensure that the exams are performed and recorded in a consistent, retrievable manner.

Our pain management team extensively reviewed the new state regulations for opioid prescribing and monitoring to make sure patient agreements are signed and that regular screenings are performed. We added several instruments to our EHR and made it easy for everyone to learn and use them. Now, every patient on long-term opioids has a signed agreement, documentation on a statewide database, periodic urine drug screening and a treatment plan.

Some projects are more complex. One team is working toward a goal of having every patient in our practice aged 18 years and older have an advance directive. They are establishing a process to introduce the concept to patients and to follow up and ensure forms are returned. It's not an easy task. But after surveys, training and EHR modification, the process is poised to encourage and track patients' use of the advance directive at whatever level they deem appropriate with our guidance. Our method has been spread to our other primary care clinics, making it easier to approach this sensitive subject.

The work we've done is a step beyond what PCMH recognition calls for, but this is what the PCMH truly is about. It has resulted in better care for patients and more satisfying work for employees. Team building has been a very rewarding process, with no end in sight. It is the future because it is continuous quality improvement that is now part of our clinic culture.

What team work successes have you experienced on your road to PCMH transformation?

Richard Madden, M.D., is a member of the AAFP Board of Directors.


I think that the PCMH is great for patient care and that Family Physicians do it better than anyone. What I don't like is that we have been providing this concierge care for free for so many years that no one is willing to reimburse us for the significant use of time and resources to keep the PCMH intact. For this plan to work Family Physicians need significant reimbursement for those who work on production and RVUs.

Posted by Scott Peschke on May 09, 2013 at 05:06 PM CDT #

What is the requirement under PCMH for recording advance directive? Is it met by just handing information handout to pt OR does a conversation need to occur between the physician and patient. In our office there is some contraversy about this. Some feel the MA should just handout the MOLST form however I am concerned that is dangerous without appropriate explanation

Posted by Mary Ellen Ritchie MD on July 24, 2014 at 12:21 PM CDT #

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