Hoboken University Medical Center-New York Medical College Residency Program

When we started the AFMRD Clinic First Collaborative our three main goals were to improve scheduling of residents in clinic to optimize continuity and resident engagement, improve empanelment and engage residents in clinic transformation. We have made great strides in all our goals thanks to the clear roadmap created by the collaborative and the building blocks for providing excellent care and training.

We first learned about the two plus two mini block schedules at our kick off conference. This concept fit our current model perfectly as we already had a similar version of this for our third-year residents. It made perfect sense for the resident to be completely present in the inpatient rotation or outpatient rotation. Too often residents were assigned to clinic once per week for a few hours, feeling inadequate rushing out of the hospital, being late to clinic and not being fully present during the afternoon session. We teamed up all our residents into co-year dyads, each year has 4 pairs. We negotiated the change from 1 month “inpatient” rotations to 2-week rotations with many of our teaching partners. While the “inpatient or away” resident is not in clinic for two weeks, the “outpatient or clinic” co-resident is responsible for their partner’s electronic health record inbox, lab results and administrative clinic duties. Residents sing out to each other any pending tests or patient follow up issues important for patient quality. As a preceptor I notice residents are more likely to follow protocols or change behavior if there is constant repetition and practice. The two plus two schedules would not have been possible for our first-year residents without the 40-week waiver we received, and we would not have known about the waiver if it wasn’t for the clinic first collaborative.

Working closely with the scheduling department has helped ensure continuity within the two resident team structure. Team continuity from the patient perspective is 83% for our third-year residents and on average patients are only seeing two providers per year. To improve access, we have blocked off twenty percent of each resident’s schedule for same-day access. The same day appointment can only be used by residents for urgent follow up for their own patient within one week of the appointment or it can be used by any scheduler within 24 hours of the appointment time for urgent care. Thanks to one of our webinars I learned how to track our access.  Our average third next available appointment is 17 days, the longest being 38 days! The report shed light on how busy or not busy some providers are, there were outliers and I adjusted rotation schedules accordingly. 

We learned about high functioning practices where they are sharing the care well with nursing staff.  We mostly care for patients with Medicaid and charity care at our site so unfortunately, we will not be able to hire more medical assistants any time soon. We did realize however that we have a lot of medical students and using the training model for the medical assistants has helped us better utilize the time and efforts of the medical students.

We tried to implement a transition clinic for patients discharged from the hospital. This has been surprisingly difficult to implement since our inpatient structure recently changed. We have identified a regularly scheduled time and resident for this clinic however the patient show rate is very low. We must do more outreach to the new inpatient attendings and work closely with the scheduling department to maximize the transition clinic.

Next steps for us is to continue to make progress on our current efforts and focus more on data-driven improvement. We are just barely getting to work well with our EMR and hope to expand our ability to run useful and timely reports. Most of our current reports are done manually through randomized chart audits. Furthermore, we recently surveyed residents and patients on their satisfaction and will be working on improving on any deficits found. Practice transformation is hard and very slow, we are grateful to the clinic first collaborative for their support and mentorship, our patients, residents and staff have all benefitted.

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