Greenwood Family Medicine is a five-clinician family medicine practice serving a largely middle-class suburban population. In addition to the medical staff, the practice employs four nurses, one receptionist, and three medical records and insurance technicians.
The practice recently identified two priority areas: attention to family concerns and greater emphasis on ensuring the provision of timely preventive services. The latter effort was prompted by one of the physicians, who had recently attended a continuing medical education program on preventive services. Upon her return, she decided to assess the practice’s provision of preventive services.
With a nurse and one of the medical records technicians, she reviewed a sample of children’s patient charts. She and the other physicians were surprised when she distributed the results:
?? Half of the children were behind schedule in at least one immunization.
?? No patient charts noted that children had had vision screening.
?? Fifty percent of children had not had anemia screening.
?? Seventy-five percent of children had not had their blood pressure recorded in the chart.
?? Eighty-five percent had not had tuberculosis screening.
?? Eighty-seven percent of children had not been screened for lead exposure.
The medical staff was surprised by these findings, but medical records personnel and nursing staff found this information consistent with their impressions. The review indicated that even children who were seen for an annual physical were often not updated on preventive services?or if they were, this information was not recorded in the patient chart. It was felt that high patient volume made it impossible to ensure that appropriate preventive services were provided to all children. In addition, the practice saw many drop-in patients. The nurses felt that while these drop-ins caused added tension from the increased workload, they also presented an opportunity to check on patients’ needs for preventive services.
The findings were discussed at the monthly meeting for all staff, and it was decided to form a team to address the problem. A medical records technician was asked to schedule a meeting. It was decided that two nurses and four physicians would participate on this team.
The first meeting was scheduled over the noon hour (12:00 PM to 1:00 PM). One physician arrived at 12:20, while another had to leave early, at 12:45. Virtually the entire meeting was spent attempting to find an appropriate date and time for follow-up meetings.
At the next meeting, the physicians stated that during an acute visit, physicians simply do not have time to go through the chart to determine if a patient needs updating on preventive services. It was decided, therefore, that the nurses would review each chart for the day’s patients and fasten a form listing all preventive services. Services needing updating would be circled. The medical records staff was asked to design this form.
When the physicians saw the resulting form, they felt it was poorly designed. Some services were not included, and immunization schedule information was not included. The physicians asked the medical records technician to redesign the form. The technician and a nurse added the immunization schedule and other information. When presented to the physicians, they discovered disagreements in several areas. Immunization schedules differed, and practices varied on lead and TB screening. They decided that the form should include separate columns for each physician, each column specifying a physician’s preventive services preferences. A form was created reflecting each physician’s preventive service preferences.
After the new preventive services chart was developed, the nurses expressed concern about the lack of time available to record preventive services needs but agreed reluctantly to start reviewing charts and entering preventive service information on each chart. After 6 weeks of working with this system, the following events unfolded:
?? Nurses complained that medical records staff were not making charts available in time to do the preventive services review.
?? Physicians complained among themselves that preventive service information was incomplete or inaccurate in more than 50% of the cases.
?? Nurses were spending an additional 1 to 2 hours in the office preparing the next day’s files and complained that the charts were very hard to decipher. The nurses requested, and were denied, overtime pay. One nurse left the practice.
?? Confusion was rampant when charts were prepared for one physician but another physician actually saw the patient. This caused increased patient waiting time. An even more difficult problem was caused by drop-ins for whom the record review was not prepared. Nurses spent up to 30 minutes reviewing drop-in charts and recording relevant information. Backlogs resulted, and nurses neglected their other roles.
?? The system was eliminated, and physicians decided to independently deal with preventive services.
What is the central problem?
Be sure to briefly describe the main characters?
How does this issue impact team performance?
Why is team performance so critically important in Health Care delivery of quality services?
Evaluate the impact of this situation from a CQI perspective.
How could this impact issue impact patient care?
Consider the following:
What additional options could you as a Health Care Manager do to provide perspective?
Have you experienced challenges such as this as a team member?
In general, what impact did it have on team performance?
