Each year the Institute of Healthcare Improvement hold a major forum on Improving Clinical Office Practice.

This year ‘Improving Patient Care in the Office Practice and the Community’ is the 11th such forum and will be held in Washington.

I’m currently posting from AA76 LA to Washington Dulles, so will keep ‘practice improvement’ informed of any new points of interest.

So far, I can report that in flight WiFi access ($12.95 per flight) works very well.

This can be used as the key component of a GP Management Plan and Team Care Arrangement. It can act as a communication tool between all providers involved in a patient’s care – are they all ‘on the same page’?.

It can also contain information for the patient about their conditions. This can be provided by a range of team members to assist in self management.

‘A4 Document Folders’ with plastic sleeves have been used by many practices.

The Patient Held Record may contain

• the patients current problems
• medical history
• current medication list
• key goals and targets, and progress towards them
• recent results (bloods, Xrays, ECGs, spirometer readings)
• specialist letters
• a care calendar
• referral letters to specialists, Xray and pathology
• information about their condition (handouts)

Doctors Grand Plaza have posted their story ‘The Blue Folder‘ to the APCC 1001 stories web site. This includes an example of “the care calendar” they have developed.

Your comments and suggestions are welcome.

Are there any pages or templates you have found useful to include in a Patient Held Medical Record?

He was a hard headed man....

“Life in the Fast Lane,
Surely make you lose your mind“

The Collins Street Medical Centre has developed a strategy that has been effective in changing their capacity to match their demand.

Why block up a 15 minute slot if all that is needed is a brief appointment for a script, a certificate, a referral or a normal result?

Andrew Knight has collected a number of variations on this idea in this article at our new sister site APCC Stories.

The people at Mt Barker/Balhannah Medical Clinic in South Australia were part of the second wave of the Collaborative back in 2005. They remind us that “care redesign” is one of the pillars of effective chronic care. That is you can’t keep doing the same thing and expect different results!

What did they do? Like many of the successful practices in the collaborative they created a new creature – the chronic disease coordinator.

Their story is on our new sister site at
http://stories.apcc.org.au/2009/11/the-rise-and-rise-of-the-chronic-care-coordinator/

As Ai-Vee Chua writes
“In the spirit of PDSAs, I am submitting one ’small’ step in the multitude of changes we have made (and will make) at our practice as a result of being involved in the APCC program…”

“Our waiting room is relatively small, but its walls have always been filled with many posters and signs (akin to the advertising noticeboards seen at many local shops!). Following one of the APCC workshops, we returned home and decided to create an electronic noticeboard.”

Recipe for an Electronic Noticeboard

Ingredients

1. One old laptop
2. Version of Powerpoint downloaded free from the Internet
3. PDF converter software
4. TV screen with wall bracket and cabling
5. One practice principal with an interest in IT and in being a handyman!

Method

1. Strip waiting room walls of existing posters/signs.
2. Download posters from the Internet where possible and use PDF converter software to tun these into Powerpoint slides; create versions of remaining posters/signs as Powerpoint slides; add some slides of beautiful scenery (so patients can momentarily dream that they are in South America and not in a doctors waiting room in Dubbo)
3. Mount wall bracket, mount TV screen onto wall bracket
4. Run cable from TV screen up through ceiling, across ceiling space, and down to laptop hidden in cupboard
5. Run repeated Powerpoint presentation throughout the day
6. Delegate one receptionist task of maintaining electronic noticeboard slides
7. Stick back a few posters/signs on areas of walls that require a re-touch paint job!

Thanks for that, Ai-vee.

Have you got an electronic noticeboard in your practice? Any suggestions for what works well? Have you developed a different solution? Let us know in the comments below.

But, alas, it has been usurped by the Smartpen. (http://smartpen.com.au) – A computer in a pen!

With the Smartpen , you can take notes, like an ordinary pen. (the Smartpen requires special paper, which you can print yourself)

Unlike a normal pen, the Smartpen also contains a microphone and an infrared camera. It records whatever is being written and makes an audio recording of what is being said at that same time.

At any subsequent time, you can touch your Smartpen on the particular written words on the page, and it will playback what was being said at the time.

So, in a consultation, if you make a note ‘abdominal pain’, you can later touch that word with your pen and it will replay what your patient actually said.

At a lecture, you can make brief notes, and if you later need clarification you can touch the appropriate word (or diagram) and you will hear the explanation given by the lecturer at the time you made the note.

How about that?

Furthermore, at the end of the day you plug your pen into your computer (!) All the pages you have written are automatically uploaded into the computer, and stored. No scanning required. The audio file is also uploaded, so you can still click on any word on the page (with your mouse), and hear what was happening at the time. You can also search your stored pages for particular words.

So, don’t take your laptop to a meeting – just your smartpen and the special pad.

(I’m not sure that I’ve ever gone back and looked at any notes I’ve made in a lecture. Perhaps with the smartpen I would.)

For those docs still using paper records, perhaps they could write their notes on the special paper and then automatically load them into the computer at the end of the day.

The smartpen does some other cool things that enable you to show off with style, always an important consideration with a new gadget. Draw a piano keyboard on a page, and then actually play it with your pen. Write 10 x 4, and the smartpen will come out with 40.

Can you think of a use for the Smartpen to improve your practice?

Let us know below.

How much of our capacity is lost bit by bit – chipped away in little inefficiencies? This story from Romsey Medical Centre appealed to me because it underlines a lesson it took me years learn. Here is how they tell it…

“It’s hard to choose just one from the most worthwhile collaboratives journey, however, the one that most stands out in my mind is ‘Tracking doctor starting times’, the graphing of which named (and sometimes shamed) each doctor’s performance in this area.

It basically measured how long after the 1st booked appointment the doctor actually saw the first patient and drew direct correlations between this and session times blowing out.

It was painfully obvious that those doctors who regularly started their session late, finished even later, and those who started on time fared much better. As a result, we have seen a behavioural shift in ‘promptness’ which has benefitted everybody; the doctor (not feeling so stressed by the end of a session), reception (not copping so much abuse from patients), and patients (not having to wait as long to see the doctor).

If that’s not a win/win/win, I don’t know what is!!!”

It is a tribute to the healthy team Romsey has developed that they were willing to put themselves under the microscope to improve this area of their performance. As Tony Lembke says 15 minutes late is not on time (see “Becoming a Time Lord”).

Lifestyle interventions for diabetes prevention continue to have benefits for patients 10 years down the track, according to recently published data from the Diabetes Prevention Program.

In the ‘Carve Out’ model for appointments, some appointments each day are kept reserved as ‘book on the day appointments’, for patients with acute conditions. In our practice, these are coloured green.

If ‘Demand is Finite and Predictable’, we should be able to look at our appointment history to anticipate the future acute requirements, and thereby determine how many appointments need to be carved out.

(Indeed, a few years ago we analysed the appointments over a whole year and found that the number of both acute and planned appointments was very consistent for any particular day of the week.)

Successfully carving out the right number of appointments proves to be harder than anticipated. Even if we know that we will require 54 acute appointments on a Monday, and ‘reserve’ them some weeks ahead of time, many of these reserved slots are mysteriously taken up beforehand. By the time Monday starts, there are always far less than 54 still ‘carved out’.

So in our practice we are now playing ‘Appointments Golf’.

It is way of scoring the success of the appointment system. It is also a means of ascertaining how many acute appointments you need each day, without having to tally them up.

The scorecard we use can be downloaded here.
Part of the scorecard looks like this.

At the start of each day, before the phones are switched on, the ‘early’ receptionist counts how many free appointments are available. (A – Acute at Start of Day”

At the end of the day, the ‘closing’ receptionist counts how many extras needed to be fitted in, “B – Extras at End of Day”and how many gaps there are where noone was booked “C – Gaps”. (an unnusual event). You should also tally how many people (if any) were turned away (hopefully an even more unnusual event!) “D – Unmet”

Your score for the day is
Number of Extras(B) – Number of Gaps(C) + Number Turned Away(D).

The lower the score, the better.
An eagle is zero. Birdie is between one and three. Par is four to six. Bogie is seven to nine. Double Bogie starts from ten.

And here’s the tip to improve your score!

The number of appointments you need to carve out to get zero on the same day of the week in one week’s time will be
Number of Free Appts at start of day (A) + Your Score for the Day (E)
This is the demand for acute appointments (F).

We have found that this number is amazingly consistent from Monday to Monday, Tuesday to Tuesday, etc.

Could you play Appointment Golf in your clinic? Let me know how you score.

Can you think of ways of adapting or extending Appointment Golf?

Do you think the ideal score is zero? Perhaps a few extras each day is a good thing?

Perhaps we should include a doctor and staff ‘zen score’, to determine how much zen was lost in a frazzled high scoring day.

Your questions and comments for this ‘virtual tabletop’ are very welcome below.

That’s 1001 stories to share!

Which brings us to the the ancient fable ‘Arabian Nights’.

The young bride Scheherazade appears doomed to be executed by her new husband, the king, on the morning after their wedding – a fate that had befallen a succession of his former wives. However, on their wedding night she begins a tale that is so beguiling that her husband, eager to find out how it ends, postpones her execution till the following day. The next night, having completed that tale, she begins another. Again the execution is postponed.

And so it goes, Schererazade beginning a new story for 1001 nights in a row. She eventually receives a royal pardon.

Which brings us back to the collaboratives’s ‘1001 Stories Project.’

Whenever we speak to one of our collaborative practices, it is fascinating to hear the improvements they have made – some small, some huge.
We are celebrating the 1001st practice by collecting just one improvement story from each of the 1001 participating practices.

As part of our aim of ‘making possible practice into usual practice’, we’ll collect and share these stories.

What story will your practice ‘share generously’? What one change idea can you tell us about us?

Have you changed the way you arrange practice meetings? Have you got a collaborative notice board? Are you handling your appointments differently? Do you have a system for maintaining registers of your chronic disease patients? Have you found new ways of engaging patients in self-management? Have you changed your practice team? Do you have better ways of integrating care? Have you redesigned parts of your clinic?

We need you to send us just one change you have made in your practice.

Let’s have them in to me at tony.lembke@improve.org.au

We’ll share them as ‘virtual tabletops’.

In the tradition of Scheherazade, I’ll post the first story from our clinic (’Appointment Golf’)

PS Remember, please send (at least) one change idea to tony.lembke@improve.org.au