• Streamlining Operations to Improve Care Quality

    By Lisa A. Eramo Jan 21, 2019

    UT Physicians achieved improvements in care quality through steps such as establishing standardized workflows, creating dashboards and consistent clinical protocols, and focusing on the patient experience.

    Leaders at UT Physicians, the clinical practice at McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), knew they needed a strategy to ensure operational efficiency and consistency across all care locations. The ultimate goal? To increase the quality of care for the patients served by the practice’s 1,800 physicians across 103 clinics. 

    The idea was that by gaining administrative efficiencies, providers could focus more directly on rendering high-quality care. In addition to improving the patient experience, such care would boost payment under eight different value-based payment programs in which the practice participated.

    Ambulatory Care Quality_Kimberly Alleman“We had policies that were very outdated, workflows within clinics that were varying, and reporting methods that were cumbersome,” said Kimberly Alleman, RN-BC (pictured at right), a member of the Coordinated Operational and Clinical Help (COACH) team, a group of 11 individuals leading process improvement projects at UT Physicians. 

    “Much of the information for quality metrics was gathered manually,” said Alleman. “We were at the point where something needed to change.” Alleman described the quality improvement initiative during a presentation at the Medical Group Management Association’s (MGMA's) 2018 annual conference.

    The practice’s chief ambulatory care officer led the effort by first visiting several other organizations to learn about best practices, Alleman said during the presentation. As a result, the following strategies were implemented.

    1. Creating Standardized Workflows

    Some physicians still used paper pads to prescribe medications—meaning they weren’t taking advantage of clinical decision support tools in the electronic health record (EHR), such as alerts for drug-drug interactions or patient allergies. The COACH team broke down silos within clinics to ensure all physicians were set up within the EHR to e-prescribe.

    Other areas of operation that benefited from standardized workflows included: 

    Referrals. The COACH team took a collaborative approach to help clinicians leverage direct messaging within the EHR so they could send secure messages to internal and external specialty clinics, notifying the clinics of referrals electronically. (Direct messaging is similar to secure web e-mail designed for the exchange of patient health information across different EHR networks.) 

    The COACH team also worked in conjunction with the EHR team to activate carbon-copy functionality in the EHR that allowed consulting clinicians to automatically send consult notes back to referring clinicians. Finally, the COACH team created an electronic process surrounding the scheduling and financial authorization of pediatric surgical procedures that expedited staff members’ processes; through this implementation, manual tracking and paper processes were significantly minimized. 

    Ambulatory Care Quality_Lindy Anderson-Papke“By streamlining the workflow for referrals, we’ve been able to provide better care for our patients,” said Lindy Anderson-Papke (pictured at right), COACH administrator, who co-presented with Alleman at the MGMA conference. “That way, patients don’t get lost in the process.”

    Sterilization. The COACH team and the Safety and Infection Prevention departments created policies and procedures for sterilizing instruments, and they continue to conduct ongoing audits to determine compliance. 

    Supply management. The COACH team identified individuals within each clinic who would be responsible for maintaining work areas with updated supplies for glucose reads, hemoglobin A1C tests, and other point-of-care tests.

    2. Streamlining Provider Documentation in the EHR 

    To ease the burden on clinicians, the COACH team worked with the EHR governance committee; various departments, including Quality, Compliance, and Revenue Cycle; physicians; and others to cross-map all quality programs. Then, the team ensured the EHR would prompt physicians to satisfy the most stringent requirements, which meant they would automatically satisfy the requirements for all other programs. 

    For example, the Merit-based Incentive Payment System requires physicians to document smoking status for individuals ages 13 and older, while the Delivery System Reform Incentive Payment program requires that step for patients ages 12 and older. When physicians document this information for all patients 12 and older, they automatically satisfy requirements for both programs.

    “We wanted to make sure we configured our EHR to meet the needs of the organization as a whole,” Anderson-Papke said during the presentation. “We wanted one easy way for our staff to document so they could get their work done in a timely and efficient manner.”

    3. Converting EHR Reports into Dashboards

    Alleman and Anderson-Papke worked with the data analytics team to create numerous real-time dashboards, giving leaders immediate answers to these and other questions:

    • How many daily messages are submitted via the portal?
    • How many prescription renewal requests do clinics receive daily?
    • How many denials do clinics receive daily, and from which payers?
    • What is each clinic’s performance on specific clinical quality measures vs. target rates? 

    Users can view most dashboards at the organizational, specialty, clinic, and individual clinician levels. Managers can also set alerts to be notified when data is trending outside the norm or organizational standard.

    Clinic managers also use dashboards to monitor staff productivity and quantify time spent working in the EHR. The dashboards allow managers to see how long it takes staff to complete certain tasks (e.g., submit refill requests or respond to messages in the portal), the number of tasks in progress, the number of tasks that have been active but unworked for more than a week, and more. 

    As UT Physicians implemented new protocols practice-wide, dashboards also helped managers distribute work to the departments that were best equipped to handle a task. For example, protocols developed for use in the patient access center and nurse triage department prevent work from being shifted to the clinical staff, allowing them to focus on direct patient care, Anderson-Papke said during the presentation. “These dashboards should be available on demand to clinical leadership so they can manage their clinics effectively,” she added during a follow-up interview with HFMA. “That’s really the ultimate goal.”

    4. Creating Consistent Clinical Protocols

    UT Physicians provided competency-based training for medical assistants, licensed vocational nurses, and registered nurses to support consistent processes for blood pressure measurement, medication management, and other tasks—all of which have corresponding quality measures. 

    Training doesn’t focus on specific metrics, Alleman said during an interview with HFMA. “When a clinical staff person is performing a blood pressure measurement on an individual, they shouldn’t need to think, ‘What metric am I meeting?’ Our message to them has been, ‘Follow clinical best practice.’ If they do this, they’ll meet the relevant metrics by default.”

    5. Achieving Patient-Centered Medical Home Status 

    PCMH status inherently fosters care coordination and care management, Anderson-Papke said during an interview. “With PCMH, you look at the current medical problems as well as the socioeconomic factors and family and social history of that patient,” she said. “You need to really think about how those factors impact the patient and their health.”

    The goal of focusing on whole-person care has motivated UT Physicians to seek PCMH certification for all 19 of its primary care practices. This effort requires hiring care teams that include case managers, community health workers, social workers, diabetes educators, and clinical pharmacists.

    6. Focusing on the Patient Experience

    Various leaders, including practice managers, medical directors, the director of patient access, and others convene during monthly meetings to discuss how the organization can improve the patient experience. Patients also sometimes attend these meetings and provide feedback. Since these meetings began, UT Physicians community-based clinics have seen an increase in the percentile ranking of 8.47 percent for their patient satisfaction scores.

    The various quality programs also promote an improved patient experience by putting the emphasis on value-based care. Through a focus on environmental, physical, behavioral, and preventive care, an improved patient experience is achieved. 

    A Look Ahead

    For UT Physicians, 2019 goals include the completion of various projects to standardize additional workflows and the creation of new dashboards for ad hoc reports. By focusing on process improvement and efficiency, the COACH team hopes to continue to improve the quality of care that patients receive.


    Lisa A. Eramo, MA, is a freelance healthcare journalist who contributes to various HIM and HIT trade publications and also assists clients with content marketing efforts. Read her work at www.lisaeramo.com.

    Interviewed for this article: Kimberly Alleman, BSN, RN-BC, CLSSBB, member of the Coordinated Operational and Clinical Help (COACH) team, UT Physicians, Houston; Lindy Anderson-Papke, MHA, CLSSBB, PCMH CEC, member of the COACH team, UT Physicians, Houston.

    This article is based in part on a presentation at the Medical Group Management Association’s 2018 annual conference, which took place Sept. 30-Oct. 3 in Boston.

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