Improving the physical layout of your practice
One of the benefits of peer learning in the National Demonstration Project (NDP) was seeing how each practice’s physical setup could either benefit or hinder their delivery of care. In most practices, the front office was literally "up front" -- the first area that patients see. Everything else, from the physical size of the office to the layout, varied based on the services offered at each practice. Some practices provided a full complement of ambulatory ancillary services on site. Others outsourced nearly all ancillaries. Most practices admitted they were not happy with their physical layouts. Hardly any of the layouts supported medical home activities.
In changing a medical practice into a medical home, physical layout is important and can dramatically affect communication among team members. Many of the successful practices ensured that team members worked in close proximity to one other. Their offices were arranged in "pods" so that all members of a team -- e.g., receptionist, nurse and physician -- could easily talk with one other during the work day. Hospitals have long done this with the nurses' station, which is the hub from which all patient care flows. This physical proximity of team members helps with the informal communication that is necessary throughout the day to keep care moving forward. The advantage of such a layout argues against grouping "front office" and "back office" in physically separate locations, centralizing off-site appointment scheduling or sequestering physicians in their offices. The medical home is a concept that manages the controlled chaos of a family medicine practice. Physically supporting communication as the chaos unfolds during the day is critical to maintaining a patient-centered focus.
Direct patient care areas require some degree of privacy but are best positioned right off the central "communication hub." Some offices have a wheel-and-spoke model with the communication station at the center and three to five exam rooms surrounding them. Ancillary departments, such as lab and radiology, are best placed centrally so each pod can get to them easily. The fewer steps required for staff (and ill patients), the more efficient the practice will be. (You can read more about design efficiency in TransforMed practices here.)
The penultimate example of physical layout supporting the patient-centered medical home is the "medical neighborhood." Fellow family physician Christopher Crow, MD, in Plano, Texas, has assembled such a layout. He calls it a “medical village.” He has assembled common medical service providers, like mammography and orthopedics, around his clinic. By bringing services conveniently and directly to his patients, he has achieved some of the best quality results in the country.
Changing your office design does not necessarily have to cost a lot of money. Simple steps such as moving scales and desks to a more central location can make a huge difference. However, services that touch patients, such as scheduling and nursing inquiries, should be decentralized and personal. The value of family medicine is the personal touch. If we lose sense of that, we have lost the whole idea of the medical home.
Medical home ideas with low fiscal notes
Financial barriers to the medical home transformation process can be great. Why not select strategies that require no financial investment? The next great barrier is time. Why not select strategies that require very little money or time? They do exist.
The TransforMed national demonstration project was clear: The practice team needs to be solid prior to embarking on any other changes. So, why not start with the team? Ask yourself the following questions:
- Is every person on the team working to the limits of their degree?
- Is there more that a particular team member wants to do or could do?
- Is our communication as effective as it could be?
- Do we have protected time to work on our practice and communicate about it?
- Are negative, undermining or passive-aggressive behaviors present in the practice?
If you answered yes to any of these questions, you can likely do some work on team building.
Team building can be as simple as looking at the weekly schedule and carving out (not necessarily adding) one hour for a weekly team meeting. Treat the staff to lunch or just a snack and make an agenda about things in the practice that don’t work quite right. Ask staff to help form the agenda. Then sit down and discuss these items. Allow staff to participate in coming up with solutions. Make a time-line for implementation of the solutions. The next week, return to the agenda, following up on last week’s items and adding new ones. The items you tackle need not be large. They can be small, such as changing the way information/paperwork flows from the front office to the back to speed up patient through-put.
Another item that you may want to start with is researching software and electronic health records (EHRs). Commit to spending 30 minutes per week, or to reading one article per week, for the next two months. If you have been planning to implement new software or an EHR, this short time commitment can get you started on the right road. Use networking tools such as AAFP e-mail discussion lists, Center for Health IT peer reviews or TransforMed's Delta Exchange to get questions answered and real-life references on software.
You could also take an assessment to understand your practice's readiness for change and medical home implementation. Check out the AAFP’s Patient Centered Medical Home checklist or TransforMed’s MHIQ. These tools will help identify the areas in which you are most ready for and most need change. They are free and take only a few minutes to complete.
Some practice members can also educate themselves about the components of the medical home and how to best implement them. There are many free resources to help, including TransforMed, MGMA the Institute for Healthcare Improvement and the AAFP. Even pharmaceutical companies are forming free medical home implementation tools. Team members can then educate the rest of the practice members.
Whatever you choose, realize that anything worth doing (I happen to think the medical home is definitely worth doing) requires some personal investment. But it does not necessarily have to be money.
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About the Author
Melissa Gerdes, MD, is a family physician practicing at Methodist Family Health Center – South Arlington in Arlington, Texas, and former president of the Texas Academy of Family Physicians.
Note: This blog is no longer updated; this is archived content.
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