The University of Missouri first joined Clinics First for the February 2019 meeting. We had spent the previous two years really focusing on the experience of our residents on our inpatient service. We noticed an increase in the number of our residents who were pursuing careers as hospitalists, primarily because they enjoyed their time in the hospital more than their time in clinic. We decided we wanted our continuity clinics to be the place where residents got the best education and most looked forward to going.
One of the benefits of attending the Collaboration meeting in Kansas City was learning that we were already doing a number of things that Clinic First promotes. We are already doing data driven improvement and are proud of the dashboard we give to residents monthly. It also includes population health metrics reports that compare the residents’ patients to our practice and to national benchmarks.
We already utilize continuity scheduling algorithms that prioritize scheduling patients with their resident provider and with a team provider if the resident is not in clinic.
Same-day access is provided by keeping some appointment slots for each provider open until shortly before the day of the appointment, our “frozen slots.”
We have reliable systems exist for coverage of EMR in-boxes and urgent patient issues when residents are away from clinic or on busy rotations and our patients are carefully transitioned to new providers when residents graduate. We have developed transition of care templates and require graduating residents to complete these notes on their most complicated patients.
We strive to schedule our R1s in clinic 2-3 half days per week and our senior residents 3-4 half days per week, but now we are planning to track actual time in clinic as a percent of residency training.
We agree that a 1:4 attending to resident ratio in clinic is too high, especially with R1s or procedures, so we are closer to a 1:2-3 ratio. With this smaller ratio, attendings are encouraged to do more "active attending." They should do literature searches on issues seen in clinic that day, give feedback on one note per resident per session, and strive to give at least one educational tidbit (or "on the fly teaching") per patient discussed. We also encourage attendings to "shadow" residents, meaning they go into the exam room with the resident and specifically give them feedback on things they would be unable to evaluate if they were sitting in the conference room waiting for the resident to check out (how they delegate to their nurse, how they deliver patient education, documentation efficiency, etc.).
Although we are doing many things well in our clinics, we believe we can do better. In May 2019, we identified the University of Missouri Clinic First goals:
- Increase resident continuity
- Increase total resident time in clinic
- Increase resident satisfaction in clinic
- Build stable clinic teams that give residents, staff, and patients a sense of belonging.
To date, we have made the following progress on our goals:
Goal 1: Increase resident continuity
a. We have defined current continuity measures
b. We are educating residents how to correctly assign PCP designation in the EMR
c. Educate residents about how to build a continuity panel
d. Scheduling guidelines prioritize the PCP
e. Our EMR notifies residents when one of their continuity patients is being seen by another provider so they have the opportunity to say "I can see that patient instead."
f. We set departmental continuity goals (R1 60%, R2 70%, R3 80%, faculty 80%)
g. We believe getting the schedule out farther in advance is the most impactful thing we can do to increase continuity. This allows residents to schedule the patient they are seeing back for follow up at the time of the visit. Our goal was to have the schedule out through June 2020 by September 2019. This year we were only able to get the schedule out through April 2020 by October 2019. We have purchased scheduling software which we believe will help us better accomplish this goal next year.
Goal 2: Increase total resident time in clinic
a. We have struggled to obtain accurate reports detailing exactly how often our residents are in clinic, and expressing that as a percent of total training time. We are working with administration to figure out how to accomplish this without hand counting clinic sessions.
b. Previously we thought it was better for patient access to have our residents scheduled in clinic multiple half days per week, rather than only a few whole days per week. However, we learned at the Clinic First meeting that it is much less stressful for residents to immerse themselves either in clinic or in their rotation, rather than running between the two on multiple days. We are using our partnership system (where two residents function as one on inpatient services) to get our residents into clinic more often, and do entire clinic days more often.
c. For years our residents heard the goal of 1650 clinic visits required to graduate. We have talked a lot about raising the bar and expecting 2000 visits for our residents.
d. When residents are on night float rotations or intense inpatient rotations, they may not be scheduled in clinic four half days per week. Previously, the expectation was then when you were on an elective rotation you had to have at least four half days in clinic per week. Over the years, residents requested more and more time out of clinic when on their elective rotations (citing unique educational opportunities on their rotation that they didn't wish to miss). We have gone back to "cracking down" on the clinic expectation during electives.
Goal 3: Increase resident satisfaction in clinic.
Goal 4: Build stable clinic teams
a. One of our four continuity clinic sites is a large suburban clinic. In an attempt to give it a more intimate feel, we divided it into three teams. Each team has its own physicians, nurses, and patient service representatives. Previously, resident physicians had been spread out equally among all three teams. July 2019 we congregated all the residents on the same team. There are still some faculty on this team as well. Placing all the residents on one team allows them to socialize, consult each other, go to lunch together, and build more comradery.
b. We are now prioritizing scheduling each resident to work with the same nurse each clinic session. We are tracking how often that happens. When it does not happen, we are tracking the reasons why (nurse worked with faculty member, nurse on vacation, etc.).
c. We created a Clinic Immersion rotation for our first year residents this past summer. Each incoming resident was scheduled for a 2 week clinic immersion rotation during the first four months of residency. During this rotation, they had more clinics than usual scheduled so that they could become very comfortable in their clinics. We also included dedicated time for them to meet with ancillary staff so that they would get to know all the staff and appreciate their contributions to the practice. Several first year residents said this was their favorite part of residency so far!
d. We created a committee at our South Providence clinic called the SPIRE committee (South Providence Improving the Resident Experience). This committee is comprised of the medical director, a Clinic First faculty, a resident, a nurse, and a patient service representative.
e. We are considering creating a "resident only" pool of nurses to decrease the number of nurses with whom residents might work.
Finally, we’d like to share a few representative quotes from residents regarding our progress to date:
"I love the residents being on the same team, and working with the same PSRs. I like that even when I’m not working with my nurse, she’s nearby so we can say hi or chat. I think clinic is going really well!"
"I think the best thing is that for the most part our patients are actually our patients. They know me as their doctor, and may have never met the attending. This gives a lot of ownership over our patients and makes clinic more fulfilling. "
"Clinic is definitely more enjoyable when I work with the same group of people. We know each other's personalities, our workflow - everything just seems to run smoother. I think it's great that the residency is focused on continuity among the staff and trying to pair the residents with the same nurses."
