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ABSTRACT
Purpose In 2013-14, 2 clinics in the Watertown Regional Medical Center (WRMC; in southern Wisconsin) launched a new delivery model, “TEAM (Together Each person Achieves More) Primary Care,” as part of a quality improvement project to enhance the delivery experience for the patient, physician, and medical assistant (MA). New work flows, roles, and responsibilities were designed to reduce cycle time, increase patient time with physicians and staff, and reduce patient wait times.
Methods The new model increased the ratio of MAs to physicians from a baseline MA:MD ratio of 1:1 to 3:2, and trained MAs to assume expanded roles during exam-room entry and discharge, including assisting with documentation during the patient visit. A process engineer timed patient visits. The process engineer and a human resources associate conducted surveys to assess the level of satisfaction for patients, physicians, and MAs.
Results Cycle time decreased by a mean of 6 minutes, from 44 to 38 minutes per patient; time with staff increased a mean of 2 minutes, from 24 to 26 minutes per patient; and waiting time decreased from 9 to 2 minutes per patient. Qualitative interviews with patients, physicians, and MAs identified a high level of satisfaction with the new model.
Conclusion The higher staffing ratios and expanded roles for MAs in the new model improved workflow, increased the face time between patients and their physician and MA, and decreased patient wait times. The TEAM model also appeared to improve patient, physician, and MA satisfaction. We faced many challenges while implementing the new model, which could be further evaluated during wide adoption.
In recent years, we observed that our physicians, nurses, and medical assistants (MAs) appeared to be spending more time on administrative and clerical tasks—including tasks in the exam room with the patient—and less time engaged in direct patient care.1,2 We recognized these factors contribute to burnout and threaten staff retention and anticipated that a new model would improve physician time spent in direct patient care, decrease the demands of administrative tasks, and increase patient, physician, and MA satisfaction.3-6 Burnout, known to affect more than half of US physicians, has a negative impact on quality of care and patient safety and satisfaction.7-11 Improving workflow has been shown to reduce burnout.12
Watertown Regional Medical Center (WRMC) is a small, financially stable integrated delivery system in rural southern Wisconsin, composed of a 90-bed hospital, 10 primary care clinics (7 owned and 3 affiliated), and 24 employed physicians in 9 specialties. Two clinics within WRMC launched a new delivery model, “TEAM (Together Each person Achieves More) Primary Care,” to improve the delivery experience for the entire team, defined as the patient, physician, and MA. New workflows, roles, and responsibilities were designed to reduce cycle time (the total amount of time patients spent in the clinic from check-in to check-out), increase the total time a patient spent with staff (physician and MA or in point-of-care testing and radiology), and reduce the total time a patient spent waiting.13
We describe here WRMC’s experience in developing and implementing workflow improvements as a means of reducing burnout and improving satisfaction.
Continue to: METHODS
METHODS
We selected 2 WRMC sites for TEAM re-engineering based on their experience with quality-improvement projects and perceived likelihood of success with a new transformation initiative. In early 2013, WRMC charged one physician (JM), 2 MAs, the clinic scheduler, and the clinic administrator with designing the details of the model including evaluation metrics. WRMC provided a .5 FTE process engineer (MS) to assist with the design and implementation of the model at no extra expense to the clinics. The model was implemented in late 2013 and into 2014 after regular TEAM planning meetings and observational visits to non-WRMC sites identified as examples of best practices in improving outpatient primary care patient satisfaction: Bellin Health (Green Bay, Wis); ThedaCare (Appleton, Wis); the University of Utah (Salt Lake City); and the University of Wisconsin Health Yahara Clinic (Madison, Wis).
TEAM model
The TEAM model—so named to create top-of-mind awareness of its benefits—increased the MA:MD ratio, maintained consistent team composition so that physician/MA teams learned to work together and become more efficient, and added new MA responsibilities. We trained MAs to assist with documentation in the exam room to ensure that physician time was spent in face-to-face direct patient care.14-20 In these ways, we sought not only to increase patient satisfaction but also to enhance our own “joy in practice,” defined primarily by a high level of work-life satisfaction, a low level of burnout, and a feeling that the medical practice is fulfilling.21
In our traditional model, an MA retrieved the patient from the waiting room, conducted initial assessment in the exam room, and then left the patient to wait for the physician to enter. Once the physician entered and conducted the exam, the patient would be left alone again to wait for the MA to return. In our revised model (TABLE 1), we assigned one MA to each patient from arrival to discharge. After greeting the patient in the waiting room, the MA conducted an initial patient interview in the exam room, then remained in the room with the physician to document the visit. After the physician exited the exam room, the MA completed follow-up orders and provided the patient with a visit summary.
To facilitate consistency throughout the day, we designed a workflow similar to those created in lean models originally designed to increase efficiency in the manufacturing industry (TABLE 2). Visual and electronic cues triggered each step of the process and coordinated the movement of MAs and MDs. Cues included the conventional flag system outside each exam room, an electronic messaging system within the electronic health record (EHR) to indicate when a patient was ready to be seen, and a whiteboard in an area visible to all team members on which we wrote lab and radiology requests.
We experimented with the MA:MD ratio to identify the most effective and efficient team composition. On alternating weeks, we assigned one MA to one MD, 2 MAs to one MD, or 3 MAs to 2 MDs. Additionally, with the 2:1 MA:MD ratio, we varied the visit length in 2 tests; one spanning 30 minutes and the other 20 minutes. The MDs and MAs were seated at side-by-side workstations to make communication easier. We developed protocols and checklists that allowed MAs to enter health maintenance orders and conduct point-of-care testing before the physician entered the room. Such details included immunization management, strep screens, urine analyses, diabetic foot exams, extremity x-ray films, and mammogram and colonoscopy referrals.
Continue to: To prepare MAs...
To prepare MAs, we obtained special permission for team documentation from our Chief Information Officer and developed associated policies and procedures. A physician assistant (PA) trained each MA, introducing the structure and content of subjective, objective, assessment, and plan (SOAP) notes. Training was continuous, as PAs provided feedback when MAs began team documentation. The MAs documented visits using templates, free form, and quick text. We measured visit cycle-time, face time with staff, and patient waiting times. A process engineer with a stopwatch observed and timed the flow (but did not enter the exam room). We also conducted patient interviews immediately post-visit and administered anonymous questionnaires to clinic staff at different phases of the model. Physicians and MAs met weekly to evaluate the design.
We used qualitative interviews of patients, physicians, and MAs to identify the level of satisfaction with the new model. During the first week of implementation, a nurse and our process engineer conducted brief in-person surveys with approximately 20 post-visit patients. Patients, chosen by convenience, were asked if the visit addressed their concerns, whether they left with a thorough understanding of next steps, and if their wait time was acceptable. Twice during the implementation phase, a human resources associate distributed 9-item anonymous questionnaires to staff members during scheduled department meetings.
RESULTS
Times per activity with different MA:MD ratios and visit lengths are shown in TABLE 3. After 6 months, cycle time decreased by a mean of 6 minutes, from 44 to 38 minutes per patient; time with staff increased by a mean of 2 minutes, from 24 to 26 minutes per patient; and wait time decreased by a mean of 7 minutes, from 9 to 2 minutes per patient. We concluded the MA:MD ratio of 3:2 was most efficient because the 2:1 model left MAs with excess non-patient time.
Our delivery model received consistently positive comments from patients. Many expressed gratitude for the extra set of ears and eyes guiding them through the process. One recalled the “old days” when a nurse joined the doctor in the exam room. Another appreciated that both the MA and physician could answer follow-up questions over the phone.
Employee satisfaction
Surveys to assess satisfaction were distributed to all employees whether they were involved in the new model or not. Sixteen employees responded to the pre-implementation questionnaire and 18 responded to the post-implementation one distributed 7 months later. The questionnaires showed an increase in employee satisfaction scores from 3.70 to 3.89 on a 5-point Likert scale, with 5 ranking highest. “I am learning from [Dr. Milford] and understanding things more fully,” wrote one respondent. Another said, “Dr. Milford and his clinical support staff are less stressed.” Individual observations such as, “I can leave sooner with less work left to do,” and “All documentation is done before [the] patient leaves,” reflect the reduction in time that patient records remained open or incomplete. Some physicians reported a reduction in at-home or after-hours work, from about 2 to 4 hours per day to approximately one hour per day.
Continue to: Additional outcomes
Additional outcomes
The TEAM model allowed us to more easily integrate new initiatives into our practice and meet quality metrics by placing needed components within our workflow and checklist. For example, achieving Stage II Meaningful Use measures required that we print and furnish patients with a visit summary and a reminder to access our portal; something we easily incorporated into the MAs’ expanded responsibilities. We also met specific predetermined quality metrics that were part of a payment-withhold program. During the study period, we achieved scores at the 90th percentile and earned back our total withhold.
Finally, more of our patients completed advanced care planning discussions than the other 7 sites in our Honoring Choices Wisconsin cohort. This was achieved not only by integrating the process into our checklist, but because the MAs observed the MD-led patient conversations which they then emulated, presenting the advanced care planning information to patients before or after MD time with the patient.
Errors and defects in care
With ongoing provider guidance and reinforcement, MAs became integral members of the primary care team. They were empowered through protocols to manage and order health maintenance testing and provide needed immunizations. They also began to identify potentially overlooked aspects of care. For example, MAs prompted physicians to retake vital signs, adjust medications, order labs, discuss previous lab results, and pursue specialty referrals or follow-up care.
Billing
Although we tracked billing, the TEAM model was not designed to influence revenue. We noted no significant change in level of evaluation and management billed regardless of staffing ratio. While our panel size increased as we implemented the new process, this change could have been due to normal variation. We do see opportunity to affect future billing by having coders train MAs, which could enhance documentation and increase revenue.
DISCUSSION
The TEAM Primary Care model reduced the time our patients sat unattended, increased our opportunities to meaningfully interact with them, and seemed to reduce our administrative load. By identifying and implementing ways to work as a more cohesive, interconnected unit, we began to address our work as a team rather than as individuals. After implementing the model, we noted several instances where the MAs caught potential errors in care, although we did not consistently track or measure changes in the rate of these occurrences.
Continue to: Achieving these results also came with...
Achieving these results also came with challenges. Investing in and maintaining a new model opened our eyes to unforeseen inconsistencies in our staff profile and to the cost and administrative support needed for implementation. Moreover, our entire team (patients, MAs, and physicians) had to undergo a major cultural shift to adopt a new model.
Personnel variation
We discovered that implementing and sustaining organization change is highly dependent on constancy in human resources. When one team member was on vacation, sick, or leaving the practice, the process tended to fall apart. Hiring replacements and training employees well enough to fill in at a moment’s notice proved difficult. Bringing new employees into this process was also labor intensive. Despite team members being very engaged in change, these staffing inconsistencies caused significant stress and necessitated pauses in the implementation of the new model (reflected in the timeline of our measures). Larger organizational buy-in and support would allow us to hire and train a larger pool of MAs in anticipation of these fluctuations.
Cost
Our small, rural family practice took advantage of WRMC’s Primary Care Transformation project and the half-time process engineer and additional MA they provided. We question whether this model could be implemented without such support. While a process engineer might not prove necessary, expertise in process improvement is vital to help design and measure workflow and to identify opportunities for improvement.
Cultural change
Adopting a new model required asking every member of the team (patient, MA, and physician) to accommodate change and tolerate disruption. We anticipated patients might resist having an additional person in the room. All patients were informed of our new model at the beginning of the visit and told they could opt out. While we did not document patient resistance, JM recalled only 2 patients who expressed a desire not to have the MA present because of personal and sensitive issues. It’s possible some patients did not feel comfortable opting out. But many patients expressed gratitude for having an extra set of ears and eyes to guide them through the visit.
It was more challenging to support MAs as they stepped out of their comfort zone to assist with documentation. It took time for MAs to grow accustomed to the protocols and checklists essential to our workflow. Without protocols, any point-of-care testing that could have been completed at the beginning of the appointment had to be done at the end. This disrupted our workflow and increased patient wait times.
Continue to: We correctly predicted MAs would have...
We correctly predicted MAs would have difficulty documenting the assessment, plan, and medical decision making. We discovered that MAs more easily categorized and articulated information when we reframed the assessment and plan in first-person and placed it under “Patient instructions.” For this to occur, physicians had to learn to accurately articulate their thought process and instructions to the patient.
When training was provided, as previously described, MAs grasped the subjective section quickly. Surprisingly, they had most difficulty understanding terminology within the objective section. In the future, we would avert this problem by working closely with the human resource department. We believe there should be a newly defined position and additional training for MAs in these roles, since duties such as patient-coaching and documentation assistance may warrant separate certification.
Limitations
Our findings should be interpreted in light of several limitations. Implementing the new model was carried out in a single organization. The patients who were selected and agreed to be interviewed may have differed from the patient population as a whole. We did not measure some important outcomes, such as cost effectiveness and patient morbidity. We did not analyze the data to determine whether the apparent improvements in wait time and cycle time were statistically significant. In addition, measurement of any adverse effects was beyond the scope of this study.
Looking forward
The traditional model of physicians working individually with minimal support staff is no longer viable. To echo our co-author (CAS)’s recent statements on physician dissatisfaction, “The days of hero medicine, with the doctor doing it all, belong in the past.”21 The new model appeared to alleviate some administrative burdens and increase physician time with patients. Pressures to achieve quality measures and growing administrative tasks have altered the role and responsibilities of each member of the team.
Any sustainable system must address the larger crisis of physician dissatisfaction.7,22 We cannot focus on a single perspective—patient, physician, or MA—at the expense of the system as a whole. If the health care system is to resolve the epidemic of burnout and physician dissatisfaction, new approaches to patient care must be imagined and realized. Although we faced many challenges in implementing and evaluating the TEAM model, attempts to overcome these challenges appear justified because of our overall favorable impression of it. Innovations like the TEAM Primary Care model may help us improve the well-being of not just our patients but also our health professionals and the health care industry as a whole.
CORRESPONDENCE
James Milford, MD, Three Oaks Health, S.C., 480 Village Walk Lane, Suite F, Johnson Creek, WI 53038; jam@threeoakshealthcare.com.
SUPPORT
Although the Watertown Regional Medical Center has provided general funding for its Primary Care Transformation project, no dollars were specifically earmarked for the TEAM Primary Care process. Support for editorial services in preparing this article was provided by Dr. James Milford.
PRIOR PRESENTATIONS
Co-author Michael R. Strasser, MPA, presented this project at the 2015 i-PrACTISE conference in Madison, Wis, April 12-14, 2015. http://www.fammed.wisc.edu/i-practise/. The proceedings were not published or recorded.
ACKNOWLEDGMENT
We thank Annalynn Skipper and Masarah Van Eyck for their valuable edits.
1. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med. 2016;165:753-760.
2. McDonald CJ, Callaghan FM, Weissman A, et al. Use of internist’s free time by ambulatory care electronic medical record systems. JAMA Intern Med. 2014;174:1860-1863.
3. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91:836-848.
4. Friedberg MW, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Available at: http://www.rand.org/pubs/research_reports/RR439.html#key-findings. Accessed October 25, 2016.
5. Babbott S, Manwell LB, Brown R, et al. Electronic medical records and physician stress in primary care: results from the MEMO study. J Am Med Inform Assoc. 2014;21:e100-e106.
6. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press. 2001.
7. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clinic Proc. 2015;90:1600-1613.
8. DeMatteo MR, Sherbourne CD, Hays RD, et al. Physicians’ characteristics influence patients’ adherence to medical treatment: Results from the Medical Outcomes Study. Health Psychol. 1993;12:93-102.
9. Shanafelt TD, Bradley KA, Wipf JE, et al. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136:358-367.
10. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251:995-1000.
11. Haas JS, Cook EF, Puopolo AL, et al. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med. 2000;15:122-128.
12. Linzer M, Poplau S, Grossman E, et al. A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) Study. J Gen Intern Med. 2015;30:1105-1011.
13. Ferrer RL, Mody-Bailey P, Jaén CR, et al. A medical assistant-based program to promote healthy behaviors in primary care. Ann Fam Med. 2009;7:504-512.
14. Sinsky CA, Williard-Grace R, Schutzbank AM, et al. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11:272-278.
15. Reuben DB, Knudsen J, Senelick W, et al. The effect of a physician partner program on physician efficiency and patient satisfaction. JAMA Intern Med. 2014;174:1190-1193.
16. Hopkins K, Sinsky CA. Team-based care: saving time and improving efficiency. Fam Pract Manag. 2014;21:23-29.
17. Yan C, Rose S, Rothberg MB, et al. Physician, scribe, and patient perspectives on clinical scribes in primary care. J Gen Intern Med. 2016;31:990-995.
18. Misra-Hebert AD, Rabovsky A, Yan C, et al. A team-based model of primary care delivery and physician-patient interaction. Am J Med. 2015;128:1025-1028.
19. Anderson RJ. Optimizing the role of nursing staff to enhance physician productivity: one physician’s journey. Fam Pract Manag. 2013;20:18-22.
20. Anderson P, Halley MD. A new approach to making your doctor-nurse team more productive. Fam Pract Manag. 2008:15:35-40.
21. Sinsky CA. Dissatisfaction among Wisconsin physicians is part of a serious national trend. Wis Med J. 2015;114:132-133.
22. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12:573-576.
ABSTRACT
Purpose In 2013-14, 2 clinics in the Watertown Regional Medical Center (WRMC; in southern Wisconsin) launched a new delivery model, “TEAM (Together Each person Achieves More) Primary Care,” as part of a quality improvement project to enhance the delivery experience for the patient, physician, and medical assistant (MA). New work flows, roles, and responsibilities were designed to reduce cycle time, increase patient time with physicians and staff, and reduce patient wait times.
Methods The new model increased the ratio of MAs to physicians from a baseline MA:MD ratio of 1:1 to 3:2, and trained MAs to assume expanded roles during exam-room entry and discharge, including assisting with documentation during the patient visit. A process engineer timed patient visits. The process engineer and a human resources associate conducted surveys to assess the level of satisfaction for patients, physicians, and MAs.
Results Cycle time decreased by a mean of 6 minutes, from 44 to 38 minutes per patient; time with staff increased a mean of 2 minutes, from 24 to 26 minutes per patient; and waiting time decreased from 9 to 2 minutes per patient. Qualitative interviews with patients, physicians, and MAs identified a high level of satisfaction with the new model.
Conclusion The higher staffing ratios and expanded roles for MAs in the new model improved workflow, increased the face time between patients and their physician and MA, and decreased patient wait times. The TEAM model also appeared to improve patient, physician, and MA satisfaction. We faced many challenges while implementing the new model, which could be further evaluated during wide adoption.
In recent years, we observed that our physicians, nurses, and medical assistants (MAs) appeared to be spending more time on administrative and clerical tasks—including tasks in the exam room with the patient—and less time engaged in direct patient care.1,2 We recognized these factors contribute to burnout and threaten staff retention and anticipated that a new model would improve physician time spent in direct patient care, decrease the demands of administrative tasks, and increase patient, physician, and MA satisfaction.3-6 Burnout, known to affect more than half of US physicians, has a negative impact on quality of care and patient safety and satisfaction.7-11 Improving workflow has been shown to reduce burnout.12
Watertown Regional Medical Center (WRMC) is a small, financially stable integrated delivery system in rural southern Wisconsin, composed of a 90-bed hospital, 10 primary care clinics (7 owned and 3 affiliated), and 24 employed physicians in 9 specialties. Two clinics within WRMC launched a new delivery model, “TEAM (Together Each person Achieves More) Primary Care,” to improve the delivery experience for the entire team, defined as the patient, physician, and MA. New workflows, roles, and responsibilities were designed to reduce cycle time (the total amount of time patients spent in the clinic from check-in to check-out), increase the total time a patient spent with staff (physician and MA or in point-of-care testing and radiology), and reduce the total time a patient spent waiting.13
We describe here WRMC’s experience in developing and implementing workflow improvements as a means of reducing burnout and improving satisfaction.
Continue to: METHODS
METHODS
We selected 2 WRMC sites for TEAM re-engineering based on their experience with quality-improvement projects and perceived likelihood of success with a new transformation initiative. In early 2013, WRMC charged one physician (JM), 2 MAs, the clinic scheduler, and the clinic administrator with designing the details of the model including evaluation metrics. WRMC provided a .5 FTE process engineer (MS) to assist with the design and implementation of the model at no extra expense to the clinics. The model was implemented in late 2013 and into 2014 after regular TEAM planning meetings and observational visits to non-WRMC sites identified as examples of best practices in improving outpatient primary care patient satisfaction: Bellin Health (Green Bay, Wis); ThedaCare (Appleton, Wis); the University of Utah (Salt Lake City); and the University of Wisconsin Health Yahara Clinic (Madison, Wis).
TEAM model
The TEAM model—so named to create top-of-mind awareness of its benefits—increased the MA:MD ratio, maintained consistent team composition so that physician/MA teams learned to work together and become more efficient, and added new MA responsibilities. We trained MAs to assist with documentation in the exam room to ensure that physician time was spent in face-to-face direct patient care.14-20 In these ways, we sought not only to increase patient satisfaction but also to enhance our own “joy in practice,” defined primarily by a high level of work-life satisfaction, a low level of burnout, and a feeling that the medical practice is fulfilling.21
In our traditional model, an MA retrieved the patient from the waiting room, conducted initial assessment in the exam room, and then left the patient to wait for the physician to enter. Once the physician entered and conducted the exam, the patient would be left alone again to wait for the MA to return. In our revised model (TABLE 1), we assigned one MA to each patient from arrival to discharge. After greeting the patient in the waiting room, the MA conducted an initial patient interview in the exam room, then remained in the room with the physician to document the visit. After the physician exited the exam room, the MA completed follow-up orders and provided the patient with a visit summary.
To facilitate consistency throughout the day, we designed a workflow similar to those created in lean models originally designed to increase efficiency in the manufacturing industry (TABLE 2). Visual and electronic cues triggered each step of the process and coordinated the movement of MAs and MDs. Cues included the conventional flag system outside each exam room, an electronic messaging system within the electronic health record (EHR) to indicate when a patient was ready to be seen, and a whiteboard in an area visible to all team members on which we wrote lab and radiology requests.
We experimented with the MA:MD ratio to identify the most effective and efficient team composition. On alternating weeks, we assigned one MA to one MD, 2 MAs to one MD, or 3 MAs to 2 MDs. Additionally, with the 2:1 MA:MD ratio, we varied the visit length in 2 tests; one spanning 30 minutes and the other 20 minutes. The MDs and MAs were seated at side-by-side workstations to make communication easier. We developed protocols and checklists that allowed MAs to enter health maintenance orders and conduct point-of-care testing before the physician entered the room. Such details included immunization management, strep screens, urine analyses, diabetic foot exams, extremity x-ray films, and mammogram and colonoscopy referrals.
Continue to: To prepare MAs...
To prepare MAs, we obtained special permission for team documentation from our Chief Information Officer and developed associated policies and procedures. A physician assistant (PA) trained each MA, introducing the structure and content of subjective, objective, assessment, and plan (SOAP) notes. Training was continuous, as PAs provided feedback when MAs began team documentation. The MAs documented visits using templates, free form, and quick text. We measured visit cycle-time, face time with staff, and patient waiting times. A process engineer with a stopwatch observed and timed the flow (but did not enter the exam room). We also conducted patient interviews immediately post-visit and administered anonymous questionnaires to clinic staff at different phases of the model. Physicians and MAs met weekly to evaluate the design.
We used qualitative interviews of patients, physicians, and MAs to identify the level of satisfaction with the new model. During the first week of implementation, a nurse and our process engineer conducted brief in-person surveys with approximately 20 post-visit patients. Patients, chosen by convenience, were asked if the visit addressed their concerns, whether they left with a thorough understanding of next steps, and if their wait time was acceptable. Twice during the implementation phase, a human resources associate distributed 9-item anonymous questionnaires to staff members during scheduled department meetings.
RESULTS
Times per activity with different MA:MD ratios and visit lengths are shown in TABLE 3. After 6 months, cycle time decreased by a mean of 6 minutes, from 44 to 38 minutes per patient; time with staff increased by a mean of 2 minutes, from 24 to 26 minutes per patient; and wait time decreased by a mean of 7 minutes, from 9 to 2 minutes per patient. We concluded the MA:MD ratio of 3:2 was most efficient because the 2:1 model left MAs with excess non-patient time.
Our delivery model received consistently positive comments from patients. Many expressed gratitude for the extra set of ears and eyes guiding them through the process. One recalled the “old days” when a nurse joined the doctor in the exam room. Another appreciated that both the MA and physician could answer follow-up questions over the phone.
Employee satisfaction
Surveys to assess satisfaction were distributed to all employees whether they were involved in the new model or not. Sixteen employees responded to the pre-implementation questionnaire and 18 responded to the post-implementation one distributed 7 months later. The questionnaires showed an increase in employee satisfaction scores from 3.70 to 3.89 on a 5-point Likert scale, with 5 ranking highest. “I am learning from [Dr. Milford] and understanding things more fully,” wrote one respondent. Another said, “Dr. Milford and his clinical support staff are less stressed.” Individual observations such as, “I can leave sooner with less work left to do,” and “All documentation is done before [the] patient leaves,” reflect the reduction in time that patient records remained open or incomplete. Some physicians reported a reduction in at-home or after-hours work, from about 2 to 4 hours per day to approximately one hour per day.
Continue to: Additional outcomes
Additional outcomes
The TEAM model allowed us to more easily integrate new initiatives into our practice and meet quality metrics by placing needed components within our workflow and checklist. For example, achieving Stage II Meaningful Use measures required that we print and furnish patients with a visit summary and a reminder to access our portal; something we easily incorporated into the MAs’ expanded responsibilities. We also met specific predetermined quality metrics that were part of a payment-withhold program. During the study period, we achieved scores at the 90th percentile and earned back our total withhold.
Finally, more of our patients completed advanced care planning discussions than the other 7 sites in our Honoring Choices Wisconsin cohort. This was achieved not only by integrating the process into our checklist, but because the MAs observed the MD-led patient conversations which they then emulated, presenting the advanced care planning information to patients before or after MD time with the patient.
Errors and defects in care
With ongoing provider guidance and reinforcement, MAs became integral members of the primary care team. They were empowered through protocols to manage and order health maintenance testing and provide needed immunizations. They also began to identify potentially overlooked aspects of care. For example, MAs prompted physicians to retake vital signs, adjust medications, order labs, discuss previous lab results, and pursue specialty referrals or follow-up care.
Billing
Although we tracked billing, the TEAM model was not designed to influence revenue. We noted no significant change in level of evaluation and management billed regardless of staffing ratio. While our panel size increased as we implemented the new process, this change could have been due to normal variation. We do see opportunity to affect future billing by having coders train MAs, which could enhance documentation and increase revenue.
DISCUSSION
The TEAM Primary Care model reduced the time our patients sat unattended, increased our opportunities to meaningfully interact with them, and seemed to reduce our administrative load. By identifying and implementing ways to work as a more cohesive, interconnected unit, we began to address our work as a team rather than as individuals. After implementing the model, we noted several instances where the MAs caught potential errors in care, although we did not consistently track or measure changes in the rate of these occurrences.
Continue to: Achieving these results also came with...
Achieving these results also came with challenges. Investing in and maintaining a new model opened our eyes to unforeseen inconsistencies in our staff profile and to the cost and administrative support needed for implementation. Moreover, our entire team (patients, MAs, and physicians) had to undergo a major cultural shift to adopt a new model.
Personnel variation
We discovered that implementing and sustaining organization change is highly dependent on constancy in human resources. When one team member was on vacation, sick, or leaving the practice, the process tended to fall apart. Hiring replacements and training employees well enough to fill in at a moment’s notice proved difficult. Bringing new employees into this process was also labor intensive. Despite team members being very engaged in change, these staffing inconsistencies caused significant stress and necessitated pauses in the implementation of the new model (reflected in the timeline of our measures). Larger organizational buy-in and support would allow us to hire and train a larger pool of MAs in anticipation of these fluctuations.
Cost
Our small, rural family practice took advantage of WRMC’s Primary Care Transformation project and the half-time process engineer and additional MA they provided. We question whether this model could be implemented without such support. While a process engineer might not prove necessary, expertise in process improvement is vital to help design and measure workflow and to identify opportunities for improvement.
Cultural change
Adopting a new model required asking every member of the team (patient, MA, and physician) to accommodate change and tolerate disruption. We anticipated patients might resist having an additional person in the room. All patients were informed of our new model at the beginning of the visit and told they could opt out. While we did not document patient resistance, JM recalled only 2 patients who expressed a desire not to have the MA present because of personal and sensitive issues. It’s possible some patients did not feel comfortable opting out. But many patients expressed gratitude for having an extra set of ears and eyes to guide them through the visit.
It was more challenging to support MAs as they stepped out of their comfort zone to assist with documentation. It took time for MAs to grow accustomed to the protocols and checklists essential to our workflow. Without protocols, any point-of-care testing that could have been completed at the beginning of the appointment had to be done at the end. This disrupted our workflow and increased patient wait times.
Continue to: We correctly predicted MAs would have...
We correctly predicted MAs would have difficulty documenting the assessment, plan, and medical decision making. We discovered that MAs more easily categorized and articulated information when we reframed the assessment and plan in first-person and placed it under “Patient instructions.” For this to occur, physicians had to learn to accurately articulate their thought process and instructions to the patient.
When training was provided, as previously described, MAs grasped the subjective section quickly. Surprisingly, they had most difficulty understanding terminology within the objective section. In the future, we would avert this problem by working closely with the human resource department. We believe there should be a newly defined position and additional training for MAs in these roles, since duties such as patient-coaching and documentation assistance may warrant separate certification.
Limitations
Our findings should be interpreted in light of several limitations. Implementing the new model was carried out in a single organization. The patients who were selected and agreed to be interviewed may have differed from the patient population as a whole. We did not measure some important outcomes, such as cost effectiveness and patient morbidity. We did not analyze the data to determine whether the apparent improvements in wait time and cycle time were statistically significant. In addition, measurement of any adverse effects was beyond the scope of this study.
Looking forward
The traditional model of physicians working individually with minimal support staff is no longer viable. To echo our co-author (CAS)’s recent statements on physician dissatisfaction, “The days of hero medicine, with the doctor doing it all, belong in the past.”21 The new model appeared to alleviate some administrative burdens and increase physician time with patients. Pressures to achieve quality measures and growing administrative tasks have altered the role and responsibilities of each member of the team.
Any sustainable system must address the larger crisis of physician dissatisfaction.7,22 We cannot focus on a single perspective—patient, physician, or MA—at the expense of the system as a whole. If the health care system is to resolve the epidemic of burnout and physician dissatisfaction, new approaches to patient care must be imagined and realized. Although we faced many challenges in implementing and evaluating the TEAM model, attempts to overcome these challenges appear justified because of our overall favorable impression of it. Innovations like the TEAM Primary Care model may help us improve the well-being of not just our patients but also our health professionals and the health care industry as a whole.
CORRESPONDENCE
James Milford, MD, Three Oaks Health, S.C., 480 Village Walk Lane, Suite F, Johnson Creek, WI 53038; jam@threeoakshealthcare.com.
SUPPORT
Although the Watertown Regional Medical Center has provided general funding for its Primary Care Transformation project, no dollars were specifically earmarked for the TEAM Primary Care process. Support for editorial services in preparing this article was provided by Dr. James Milford.
PRIOR PRESENTATIONS
Co-author Michael R. Strasser, MPA, presented this project at the 2015 i-PrACTISE conference in Madison, Wis, April 12-14, 2015. http://www.fammed.wisc.edu/i-practise/. The proceedings were not published or recorded.
ACKNOWLEDGMENT
We thank Annalynn Skipper and Masarah Van Eyck for their valuable edits.
ABSTRACT
Purpose In 2013-14, 2 clinics in the Watertown Regional Medical Center (WRMC; in southern Wisconsin) launched a new delivery model, “TEAM (Together Each person Achieves More) Primary Care,” as part of a quality improvement project to enhance the delivery experience for the patient, physician, and medical assistant (MA). New work flows, roles, and responsibilities were designed to reduce cycle time, increase patient time with physicians and staff, and reduce patient wait times.
Methods The new model increased the ratio of MAs to physicians from a baseline MA:MD ratio of 1:1 to 3:2, and trained MAs to assume expanded roles during exam-room entry and discharge, including assisting with documentation during the patient visit. A process engineer timed patient visits. The process engineer and a human resources associate conducted surveys to assess the level of satisfaction for patients, physicians, and MAs.
Results Cycle time decreased by a mean of 6 minutes, from 44 to 38 minutes per patient; time with staff increased a mean of 2 minutes, from 24 to 26 minutes per patient; and waiting time decreased from 9 to 2 minutes per patient. Qualitative interviews with patients, physicians, and MAs identified a high level of satisfaction with the new model.
Conclusion The higher staffing ratios and expanded roles for MAs in the new model improved workflow, increased the face time between patients and their physician and MA, and decreased patient wait times. The TEAM model also appeared to improve patient, physician, and MA satisfaction. We faced many challenges while implementing the new model, which could be further evaluated during wide adoption.
In recent years, we observed that our physicians, nurses, and medical assistants (MAs) appeared to be spending more time on administrative and clerical tasks—including tasks in the exam room with the patient—and less time engaged in direct patient care.1,2 We recognized these factors contribute to burnout and threaten staff retention and anticipated that a new model would improve physician time spent in direct patient care, decrease the demands of administrative tasks, and increase patient, physician, and MA satisfaction.3-6 Burnout, known to affect more than half of US physicians, has a negative impact on quality of care and patient safety and satisfaction.7-11 Improving workflow has been shown to reduce burnout.12
Watertown Regional Medical Center (WRMC) is a small, financially stable integrated delivery system in rural southern Wisconsin, composed of a 90-bed hospital, 10 primary care clinics (7 owned and 3 affiliated), and 24 employed physicians in 9 specialties. Two clinics within WRMC launched a new delivery model, “TEAM (Together Each person Achieves More) Primary Care,” to improve the delivery experience for the entire team, defined as the patient, physician, and MA. New workflows, roles, and responsibilities were designed to reduce cycle time (the total amount of time patients spent in the clinic from check-in to check-out), increase the total time a patient spent with staff (physician and MA or in point-of-care testing and radiology), and reduce the total time a patient spent waiting.13
We describe here WRMC’s experience in developing and implementing workflow improvements as a means of reducing burnout and improving satisfaction.
Continue to: METHODS
METHODS
We selected 2 WRMC sites for TEAM re-engineering based on their experience with quality-improvement projects and perceived likelihood of success with a new transformation initiative. In early 2013, WRMC charged one physician (JM), 2 MAs, the clinic scheduler, and the clinic administrator with designing the details of the model including evaluation metrics. WRMC provided a .5 FTE process engineer (MS) to assist with the design and implementation of the model at no extra expense to the clinics. The model was implemented in late 2013 and into 2014 after regular TEAM planning meetings and observational visits to non-WRMC sites identified as examples of best practices in improving outpatient primary care patient satisfaction: Bellin Health (Green Bay, Wis); ThedaCare (Appleton, Wis); the University of Utah (Salt Lake City); and the University of Wisconsin Health Yahara Clinic (Madison, Wis).
TEAM model
The TEAM model—so named to create top-of-mind awareness of its benefits—increased the MA:MD ratio, maintained consistent team composition so that physician/MA teams learned to work together and become more efficient, and added new MA responsibilities. We trained MAs to assist with documentation in the exam room to ensure that physician time was spent in face-to-face direct patient care.14-20 In these ways, we sought not only to increase patient satisfaction but also to enhance our own “joy in practice,” defined primarily by a high level of work-life satisfaction, a low level of burnout, and a feeling that the medical practice is fulfilling.21
In our traditional model, an MA retrieved the patient from the waiting room, conducted initial assessment in the exam room, and then left the patient to wait for the physician to enter. Once the physician entered and conducted the exam, the patient would be left alone again to wait for the MA to return. In our revised model (TABLE 1), we assigned one MA to each patient from arrival to discharge. After greeting the patient in the waiting room, the MA conducted an initial patient interview in the exam room, then remained in the room with the physician to document the visit. After the physician exited the exam room, the MA completed follow-up orders and provided the patient with a visit summary.
To facilitate consistency throughout the day, we designed a workflow similar to those created in lean models originally designed to increase efficiency in the manufacturing industry (TABLE 2). Visual and electronic cues triggered each step of the process and coordinated the movement of MAs and MDs. Cues included the conventional flag system outside each exam room, an electronic messaging system within the electronic health record (EHR) to indicate when a patient was ready to be seen, and a whiteboard in an area visible to all team members on which we wrote lab and radiology requests.
We experimented with the MA:MD ratio to identify the most effective and efficient team composition. On alternating weeks, we assigned one MA to one MD, 2 MAs to one MD, or 3 MAs to 2 MDs. Additionally, with the 2:1 MA:MD ratio, we varied the visit length in 2 tests; one spanning 30 minutes and the other 20 minutes. The MDs and MAs were seated at side-by-side workstations to make communication easier. We developed protocols and checklists that allowed MAs to enter health maintenance orders and conduct point-of-care testing before the physician entered the room. Such details included immunization management, strep screens, urine analyses, diabetic foot exams, extremity x-ray films, and mammogram and colonoscopy referrals.
Continue to: To prepare MAs...
To prepare MAs, we obtained special permission for team documentation from our Chief Information Officer and developed associated policies and procedures. A physician assistant (PA) trained each MA, introducing the structure and content of subjective, objective, assessment, and plan (SOAP) notes. Training was continuous, as PAs provided feedback when MAs began team documentation. The MAs documented visits using templates, free form, and quick text. We measured visit cycle-time, face time with staff, and patient waiting times. A process engineer with a stopwatch observed and timed the flow (but did not enter the exam room). We also conducted patient interviews immediately post-visit and administered anonymous questionnaires to clinic staff at different phases of the model. Physicians and MAs met weekly to evaluate the design.
We used qualitative interviews of patients, physicians, and MAs to identify the level of satisfaction with the new model. During the first week of implementation, a nurse and our process engineer conducted brief in-person surveys with approximately 20 post-visit patients. Patients, chosen by convenience, were asked if the visit addressed their concerns, whether they left with a thorough understanding of next steps, and if their wait time was acceptable. Twice during the implementation phase, a human resources associate distributed 9-item anonymous questionnaires to staff members during scheduled department meetings.
RESULTS
Times per activity with different MA:MD ratios and visit lengths are shown in TABLE 3. After 6 months, cycle time decreased by a mean of 6 minutes, from 44 to 38 minutes per patient; time with staff increased by a mean of 2 minutes, from 24 to 26 minutes per patient; and wait time decreased by a mean of 7 minutes, from 9 to 2 minutes per patient. We concluded the MA:MD ratio of 3:2 was most efficient because the 2:1 model left MAs with excess non-patient time.
Our delivery model received consistently positive comments from patients. Many expressed gratitude for the extra set of ears and eyes guiding them through the process. One recalled the “old days” when a nurse joined the doctor in the exam room. Another appreciated that both the MA and physician could answer follow-up questions over the phone.
Employee satisfaction
Surveys to assess satisfaction were distributed to all employees whether they were involved in the new model or not. Sixteen employees responded to the pre-implementation questionnaire and 18 responded to the post-implementation one distributed 7 months later. The questionnaires showed an increase in employee satisfaction scores from 3.70 to 3.89 on a 5-point Likert scale, with 5 ranking highest. “I am learning from [Dr. Milford] and understanding things more fully,” wrote one respondent. Another said, “Dr. Milford and his clinical support staff are less stressed.” Individual observations such as, “I can leave sooner with less work left to do,” and “All documentation is done before [the] patient leaves,” reflect the reduction in time that patient records remained open or incomplete. Some physicians reported a reduction in at-home or after-hours work, from about 2 to 4 hours per day to approximately one hour per day.
Continue to: Additional outcomes
Additional outcomes
The TEAM model allowed us to more easily integrate new initiatives into our practice and meet quality metrics by placing needed components within our workflow and checklist. For example, achieving Stage II Meaningful Use measures required that we print and furnish patients with a visit summary and a reminder to access our portal; something we easily incorporated into the MAs’ expanded responsibilities. We also met specific predetermined quality metrics that were part of a payment-withhold program. During the study period, we achieved scores at the 90th percentile and earned back our total withhold.
Finally, more of our patients completed advanced care planning discussions than the other 7 sites in our Honoring Choices Wisconsin cohort. This was achieved not only by integrating the process into our checklist, but because the MAs observed the MD-led patient conversations which they then emulated, presenting the advanced care planning information to patients before or after MD time with the patient.
Errors and defects in care
With ongoing provider guidance and reinforcement, MAs became integral members of the primary care team. They were empowered through protocols to manage and order health maintenance testing and provide needed immunizations. They also began to identify potentially overlooked aspects of care. For example, MAs prompted physicians to retake vital signs, adjust medications, order labs, discuss previous lab results, and pursue specialty referrals or follow-up care.
Billing
Although we tracked billing, the TEAM model was not designed to influence revenue. We noted no significant change in level of evaluation and management billed regardless of staffing ratio. While our panel size increased as we implemented the new process, this change could have been due to normal variation. We do see opportunity to affect future billing by having coders train MAs, which could enhance documentation and increase revenue.
DISCUSSION
The TEAM Primary Care model reduced the time our patients sat unattended, increased our opportunities to meaningfully interact with them, and seemed to reduce our administrative load. By identifying and implementing ways to work as a more cohesive, interconnected unit, we began to address our work as a team rather than as individuals. After implementing the model, we noted several instances where the MAs caught potential errors in care, although we did not consistently track or measure changes in the rate of these occurrences.
Continue to: Achieving these results also came with...
Achieving these results also came with challenges. Investing in and maintaining a new model opened our eyes to unforeseen inconsistencies in our staff profile and to the cost and administrative support needed for implementation. Moreover, our entire team (patients, MAs, and physicians) had to undergo a major cultural shift to adopt a new model.
Personnel variation
We discovered that implementing and sustaining organization change is highly dependent on constancy in human resources. When one team member was on vacation, sick, or leaving the practice, the process tended to fall apart. Hiring replacements and training employees well enough to fill in at a moment’s notice proved difficult. Bringing new employees into this process was also labor intensive. Despite team members being very engaged in change, these staffing inconsistencies caused significant stress and necessitated pauses in the implementation of the new model (reflected in the timeline of our measures). Larger organizational buy-in and support would allow us to hire and train a larger pool of MAs in anticipation of these fluctuations.
Cost
Our small, rural family practice took advantage of WRMC’s Primary Care Transformation project and the half-time process engineer and additional MA they provided. We question whether this model could be implemented without such support. While a process engineer might not prove necessary, expertise in process improvement is vital to help design and measure workflow and to identify opportunities for improvement.
Cultural change
Adopting a new model required asking every member of the team (patient, MA, and physician) to accommodate change and tolerate disruption. We anticipated patients might resist having an additional person in the room. All patients were informed of our new model at the beginning of the visit and told they could opt out. While we did not document patient resistance, JM recalled only 2 patients who expressed a desire not to have the MA present because of personal and sensitive issues. It’s possible some patients did not feel comfortable opting out. But many patients expressed gratitude for having an extra set of ears and eyes to guide them through the visit.
It was more challenging to support MAs as they stepped out of their comfort zone to assist with documentation. It took time for MAs to grow accustomed to the protocols and checklists essential to our workflow. Without protocols, any point-of-care testing that could have been completed at the beginning of the appointment had to be done at the end. This disrupted our workflow and increased patient wait times.
Continue to: We correctly predicted MAs would have...
We correctly predicted MAs would have difficulty documenting the assessment, plan, and medical decision making. We discovered that MAs more easily categorized and articulated information when we reframed the assessment and plan in first-person and placed it under “Patient instructions.” For this to occur, physicians had to learn to accurately articulate their thought process and instructions to the patient.
When training was provided, as previously described, MAs grasped the subjective section quickly. Surprisingly, they had most difficulty understanding terminology within the objective section. In the future, we would avert this problem by working closely with the human resource department. We believe there should be a newly defined position and additional training for MAs in these roles, since duties such as patient-coaching and documentation assistance may warrant separate certification.
Limitations
Our findings should be interpreted in light of several limitations. Implementing the new model was carried out in a single organization. The patients who were selected and agreed to be interviewed may have differed from the patient population as a whole. We did not measure some important outcomes, such as cost effectiveness and patient morbidity. We did not analyze the data to determine whether the apparent improvements in wait time and cycle time were statistically significant. In addition, measurement of any adverse effects was beyond the scope of this study.
Looking forward
The traditional model of physicians working individually with minimal support staff is no longer viable. To echo our co-author (CAS)’s recent statements on physician dissatisfaction, “The days of hero medicine, with the doctor doing it all, belong in the past.”21 The new model appeared to alleviate some administrative burdens and increase physician time with patients. Pressures to achieve quality measures and growing administrative tasks have altered the role and responsibilities of each member of the team.
Any sustainable system must address the larger crisis of physician dissatisfaction.7,22 We cannot focus on a single perspective—patient, physician, or MA—at the expense of the system as a whole. If the health care system is to resolve the epidemic of burnout and physician dissatisfaction, new approaches to patient care must be imagined and realized. Although we faced many challenges in implementing and evaluating the TEAM model, attempts to overcome these challenges appear justified because of our overall favorable impression of it. Innovations like the TEAM Primary Care model may help us improve the well-being of not just our patients but also our health professionals and the health care industry as a whole.
CORRESPONDENCE
James Milford, MD, Three Oaks Health, S.C., 480 Village Walk Lane, Suite F, Johnson Creek, WI 53038; jam@threeoakshealthcare.com.
SUPPORT
Although the Watertown Regional Medical Center has provided general funding for its Primary Care Transformation project, no dollars were specifically earmarked for the TEAM Primary Care process. Support for editorial services in preparing this article was provided by Dr. James Milford.
PRIOR PRESENTATIONS
Co-author Michael R. Strasser, MPA, presented this project at the 2015 i-PrACTISE conference in Madison, Wis, April 12-14, 2015. http://www.fammed.wisc.edu/i-practise/. The proceedings were not published or recorded.
ACKNOWLEDGMENT
We thank Annalynn Skipper and Masarah Van Eyck for their valuable edits.
1. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med. 2016;165:753-760.
2. McDonald CJ, Callaghan FM, Weissman A, et al. Use of internist’s free time by ambulatory care electronic medical record systems. JAMA Intern Med. 2014;174:1860-1863.
3. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91:836-848.
4. Friedberg MW, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Available at: http://www.rand.org/pubs/research_reports/RR439.html#key-findings. Accessed October 25, 2016.
5. Babbott S, Manwell LB, Brown R, et al. Electronic medical records and physician stress in primary care: results from the MEMO study. J Am Med Inform Assoc. 2014;21:e100-e106.
6. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press. 2001.
7. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clinic Proc. 2015;90:1600-1613.
8. DeMatteo MR, Sherbourne CD, Hays RD, et al. Physicians’ characteristics influence patients’ adherence to medical treatment: Results from the Medical Outcomes Study. Health Psychol. 1993;12:93-102.
9. Shanafelt TD, Bradley KA, Wipf JE, et al. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136:358-367.
10. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251:995-1000.
11. Haas JS, Cook EF, Puopolo AL, et al. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med. 2000;15:122-128.
12. Linzer M, Poplau S, Grossman E, et al. A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) Study. J Gen Intern Med. 2015;30:1105-1011.
13. Ferrer RL, Mody-Bailey P, Jaén CR, et al. A medical assistant-based program to promote healthy behaviors in primary care. Ann Fam Med. 2009;7:504-512.
14. Sinsky CA, Williard-Grace R, Schutzbank AM, et al. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11:272-278.
15. Reuben DB, Knudsen J, Senelick W, et al. The effect of a physician partner program on physician efficiency and patient satisfaction. JAMA Intern Med. 2014;174:1190-1193.
16. Hopkins K, Sinsky CA. Team-based care: saving time and improving efficiency. Fam Pract Manag. 2014;21:23-29.
17. Yan C, Rose S, Rothberg MB, et al. Physician, scribe, and patient perspectives on clinical scribes in primary care. J Gen Intern Med. 2016;31:990-995.
18. Misra-Hebert AD, Rabovsky A, Yan C, et al. A team-based model of primary care delivery and physician-patient interaction. Am J Med. 2015;128:1025-1028.
19. Anderson RJ. Optimizing the role of nursing staff to enhance physician productivity: one physician’s journey. Fam Pract Manag. 2013;20:18-22.
20. Anderson P, Halley MD. A new approach to making your doctor-nurse team more productive. Fam Pract Manag. 2008:15:35-40.
21. Sinsky CA. Dissatisfaction among Wisconsin physicians is part of a serious national trend. Wis Med J. 2015;114:132-133.
22. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12:573-576.
1. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med. 2016;165:753-760.
2. McDonald CJ, Callaghan FM, Weissman A, et al. Use of internist’s free time by ambulatory care electronic medical record systems. JAMA Intern Med. 2014;174:1860-1863.
3. Shanafelt TD, Dyrbye LN, Sinsky C, et al. Relationship between clerical burden and characteristics of the electronic environment with physician burnout and professional satisfaction. Mayo Clin Proc. 2016;91:836-848.
4. Friedberg MW, Chen PG, Van Busum KR, et al. Factors affecting physician professional satisfaction and their implications for patient care, health systems, and health policy. Available at: http://www.rand.org/pubs/research_reports/RR439.html#key-findings. Accessed October 25, 2016.
5. Babbott S, Manwell LB, Brown R, et al. Electronic medical records and physician stress in primary care: results from the MEMO study. J Am Med Inform Assoc. 2014;21:e100-e106.
6. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press. 2001.
7. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clinic Proc. 2015;90:1600-1613.
8. DeMatteo MR, Sherbourne CD, Hays RD, et al. Physicians’ characteristics influence patients’ adherence to medical treatment: Results from the Medical Outcomes Study. Health Psychol. 1993;12:93-102.
9. Shanafelt TD, Bradley KA, Wipf JE, et al. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med. 2002;136:358-367.
10. Shanafelt TD, Balch CM, Bechamps G, et al. Burnout and medical errors among American surgeons. Ann Surg. 2010;251:995-1000.
11. Haas JS, Cook EF, Puopolo AL, et al. Is the professional satisfaction of general internists associated with patient satisfaction? J Gen Intern Med. 2000;15:122-128.
12. Linzer M, Poplau S, Grossman E, et al. A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) Study. J Gen Intern Med. 2015;30:1105-1011.
13. Ferrer RL, Mody-Bailey P, Jaén CR, et al. A medical assistant-based program to promote healthy behaviors in primary care. Ann Fam Med. 2009;7:504-512.
14. Sinsky CA, Williard-Grace R, Schutzbank AM, et al. In search of joy in practice: a report of 23 high-functioning primary care practices. Ann Fam Med. 2013;11:272-278.
15. Reuben DB, Knudsen J, Senelick W, et al. The effect of a physician partner program on physician efficiency and patient satisfaction. JAMA Intern Med. 2014;174:1190-1193.
16. Hopkins K, Sinsky CA. Team-based care: saving time and improving efficiency. Fam Pract Manag. 2014;21:23-29.
17. Yan C, Rose S, Rothberg MB, et al. Physician, scribe, and patient perspectives on clinical scribes in primary care. J Gen Intern Med. 2016;31:990-995.
18. Misra-Hebert AD, Rabovsky A, Yan C, et al. A team-based model of primary care delivery and physician-patient interaction. Am J Med. 2015;128:1025-1028.
19. Anderson RJ. Optimizing the role of nursing staff to enhance physician productivity: one physician’s journey. Fam Pract Manag. 2013;20:18-22.
20. Anderson P, Halley MD. A new approach to making your doctor-nurse team more productive. Fam Pract Manag. 2008:15:35-40.
21. Sinsky CA. Dissatisfaction among Wisconsin physicians is part of a serious national trend. Wis Med J. 2015;114:132-133.
22. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12:573-576.
