Hectic pace pressures medical practices on quality

Patient safety experts say making the most of electronic systems and standardizing office procedures can help doctors and staffers feel less rushed.

By — Posted June 18, 2012

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The physicians, nurses and clerical support staffers in medical offices say the frenetic work pace and high patient volume are making it harder to provide top-notch care.

More than 70% feel rushed when taking care of patients, and 52% say there are too many patients for the number of doctors and other health professionals in the office. Forty-one percent believe their office “has too many patients to be able to handle everything effectively,” said an Agency for Healthcare Research and Quality survey of 23,679 people working in 934 U.S. medical offices that was released in June.

Physician leaders, practicing doctors, and experts on quality improvement and practice management said the survey results illustrate how the pressure to see more patients in less time amid declining physician payment is placing great strain on the professionals charged with delivering timely, effective and safe care. Those practice realities can translate into problems such as medication errors, missed test results and unnecessary trips to the emergency department, experts said.

“In many practice situations, the pace just does feel too fast,” said David Shute, MD, medical director of GreenField Health, an eight-physician primary care clinic in Portland, Ore. “It’s well understood that when humans are given too many tasks to focus on at once and there is too much time pressure, the error rates go up. This survey highlights a big problem.”

Fifty-one percent of the respondents report problems with workflow in the office, and 39% said their clinics are more disorganized than they should be. A majority of the respondents, 51%, said the clinics’ owners “aren’t investing enough resources to improve the quality of care.” Nearly a third agreed that “in this office, getting more work done is more important than quality of care.”

The survey, conducted between November 2009 and October 2011, comes as pressure grows to focus on preventing harm in the office setting. The American Medical Association issued a report in December 2011 that reviewed a decade of ambulatory-care safety studies and documented widespread problems such as incorrect prescribing, misdiagnoses, missed test results and poor communication in physician offices. The AMA report called for more practice-based research and high-level initiatives to target key safety problems in outpatient care.

Primary care especially stressed

About 75% of the clinics AHRQ surveyed were owned by a hospital or a health system, and 62% had fully implemented electronic health records. Nearly half were family medicine practices. This suggests that the trends of tighter integration of ambulatory clinics within health systems and a greater shift away from paper-based charting systems will not be cure-alls for the stressors in primary care clinics, experts said.

“There’s no question that primary care is really feeling the push,” said Mary Pat Whaley, a Durham, N.C., practice management consultant. “It doesn’t make any difference if they are in an independent physician practice or a hospital or an integrated health system. It’s just really intense.”

Among the safety and quality problems noted by respondents were: delays in appointments; test results and medical records being unavailable when needed; misfiled patient information; broken medical equipment; and out-of-date medication lists.

“The more pressure there is, the more mistakes can occur, and the more you need systematic ways of protecting your patients,” said David L. Bronson, MD, president of the American College of Physicians.

Ditching paper is a critical first step to ensuring safety in physician offices, but not the last one, said Dr. Bronson, also president of Cleveland Clinic Regional Hospitals.

“Going electronic is a tool, but you have to implement it appropriately,” he said. “You still need office systems and a protocol on how messages are handled, and a protocol on drawing blood to confirm you get the right patient. That this John Smith is the correct John Smith and get the other validations necessary to confirm that the appropriate tests are being done. You have to have those fail-safes implemented into your systems, especially when you have a busy, frenetic office.”

Simply having more people — more physicians, more nurses, more support staff — is not the whole fix to the quality and safety problems in office settings, said Hardeep Singh, MD, MPH, chief of the health policy and quality program at the Houston Veterans Affairs Health Services Research & Development Center of Excellence.

“It’s a lot about the other part of fixing your system and your processes,” Dr. Singh said. “That starts with the leadership types of issues, fixing the workflow in a chaotic outpatient environment. Obviously, that includes using technology to the optimal setting — not just throwing an EHR in the office and now you’ve got an EHR and thinking you’ve got nothing more to worry about. You’ve got to make your EHR work for your practice.”

Minimizing the phone-call flood

Relatively simple changes can help tame the pace in physician practices, experts said. For example, only 52% of respondents said their practices had fully implemented electronic prescribing, and 93% said they had been contacted by a pharmacy to clarify a prescription order within the last year.

Failure to handle incoming phone calls properly can lead to a vicious cycle, as patients who do not get their questions answered just call again and again. That can make clerks feel as though they are under siege, said Whaley, who has nearly three decades of experience as a practice manager. Clinics should ask for a study of incoming phone calls, identify peak times when more help is needed and answer routine questions on their websites, she said.

More than 80% of respondents to the AHRQ survey said their offices have good teamwork and do a good job of tracking patient care issues and following up with patients. There were no clear differences across specialties such as family medicine, cardiology and pediatrics.

Physician-owned practices had the highest positive ratings on the survey’s “patient safety culture” metrics. Single-specialty practices with one or two physicians were likelier to be rated as “excellent” or “very good” overall on patient safety, compared with multispecialty clinics of 14 or more doctors.

A deeper concern in the AHRQ survey is how comfortable office staffers feel about discussing problems. Nearly half said it “is difficult to voice disagreement in this office,” and they believe their mistakes are held against them.

“That problem with culture is a clear barrier to improvement,” said Jeff Brady, MD, MPH, patient safety portfolio lead at AHRQ’s Center for Quality Improvement and Patient Safety. “If you have this barrier where there’s not a willingness to hear about problems, No. 1, and solve them, No. 2, then it doesn’t bode well for making improvements.”

Doctors and other clinic leaders should set a tone that welcomes constructive suggestions about workflow and systems processes, addresses them, and tries to test new ways of working that could help patients, said Dr. Shute, of GreenField Health, an independent physician practice.

At GreenField, everyone addresses one another using first names. Physicians and medical assistants have football-type huddles a few times daily to catch up on their to-do lists, close loops and tie up loose ends.

“The first thing we need to do is see our co-workers as colleagues, not as servants,” Dr. Shute said. “The minute we do that as physicians, openness goes way up and, frankly, the work stress goes down.”

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Patient safety problems that practices encounter

About two-thirds of physicians, nurses and medical office staffers rate their clinics as “very good” or “excellent” when it comes to the systems and processes in place to prevent, catch and correct problems that could affect patients adversely. In a recent survey, substantial minorities of respondents cited some areas where problems happen at least once a month in their clinics.

48%: Pharmacy contacted the office to clarify or correct a prescription
29%: Patient’s medication list not updated during the visit
27%: Lab or imaging test results not available when needed
21%: Patient unable to get appointment within 48 hours for serious problem
16%: Patient’s chart or medical record not available when needed
9%: Medical equipment not working properly or needed repair or replacement
8%: Critical abnormal test result not followed up within one business day
8%: Medical information filed, scanned or entered into wrong patient’s chart or medical record
3%: Wrong chart or medical record used for patient

Source: “2012 User Comparative Database Report: Medical Office Survey on Patient Safety Culture,” Agency for Healthcare Research and Quality, May (link)

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External links

“2012 User Comparative Database Report: Medical Office Survey on Patient Safety Culture,” Agency for Healthcare Research and Quality, May (link)

“Research in Ambulatory Patient Safety 2000-2010: A 10-year review,” American Medical Association, December 2011 (link)

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