Workflow Redesign

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C AL I FORNIA HEALTHCARE FOUNDATION

June 2010

Workflow Redesign: A Model for California Clinics

Introduction Patient flow, particularly initial patient access

and cycle time, is crucial to community clinic

practice efficiency and capacity, which in

turn affects revenue and provider and patient

satisfaction.1 As a clinic improves patient access,

it increases the timeliness of patient care, and

thus may improve outcomes, and in some cases

the odds that a patient will receive care at all.

Balancing appointment supply and demand, and

establishing and managing provider panels, can

increase access and improve practice efficiency

and patient satisfaction. Moreover, effective

panels and resulting continuity can strengthen

prevention efforts, improve outcomes for patients

with diseases that can be detected early, and

help manage chronic conditions through regular

monitoring.

Improved access and practice efficiency, and

resulting clinical improvement, depend on

factors specific to each clinic — such as goals

and priorities, physician preferences, and

patient population — which together constitute

a particular practice system. While there

are many approaches a clinic might take to

address individual aspects of practice efficiency,

meaningful practice redesign requires a thorough

understanding of the practice’s patient care

processes and identification of practice-specific

strategies for improving efficiency. Such practice

redesign requires a multi-component approach,

which can be enabled and enhanced by the

application of a comprehensive, field-tested

framework for change.

In 2007, the California Primary Care Association

(CPCA), funded by the federal Bureau of Primary

Health Care and facilitated by Mark Murray and

Associates, launched the Optimizing Primary

Care Collaborative (OPCC) as a one-year learning

project. The collaborative, with 21 community

clinic teams, was designed to reduce patient

flow delays in primary care settings and to

improve clinical care. Following the first year’s

work, in 2008 the same partners organized a

second OPCC, with additional funding from

the California HealthCare Foundation (CHCF).

A total of 24 community health clinics from

California and Arizona participated in the

2008 OPCC. The collaborative used a learning

community framework to help clinic teams set

goals, collect data, and measure effects.

Upon completion of OPCC in 2009, CHCF

supported an evaluation of its methods and

outcomes by White Mountain Research Associates

(White Mountain). The evaluation found that the

level of improvement varied among clinic sites, but

that there was marked overall success: Virtually all

participants saw improvements, with 88 percent

of teams reporting positive changes in at least

two access and patient satisfaction measures,

and 63 percent reporting positive changes in

three or more of these measures. The greatest

improvements were in access and cycle time.

Most clinics also undertook the calculating of

practitioner panels, to help manage both provider

efficiency and patient care. Notably, virtually

all teams reported that the OPCC framework

introduced them to new approaches to system

2 | California HealtHCare foundation

improvement or helped them to use known redesign

approaches in a more strategic way.

The evaluation provided clear evidence that the OPCC

learning community framework is a viable vehicle for

introducing not just particular patient flow improvements

but true system redesign. The value of adopting strategies

used by peers, and of troubleshooting issues in a learning

community environment, was broadly reported by the

participating teams. The findings suggest that the OPCC

framework has strong potential as a model for other

community clinics throughout California. This issue

brief summarizes the OPCC project, and is intended to

complement the evaluation report prepared by White

Mountain and published simultaneously with this brief.2

Project Background

Strategies for Patient Flow Improvement

It is well-understood among researchers that improving

patient flow is key to increasing medical practice

efficiency and capacity, which can both generate more

revenue and improve patient and provider satisfaction.3

Better patient flow depends on practice-specific factors,

including goals and priorities, provider practice style,

and patient characteristics.4 Collaborative improvement

strategies, using “whole system” approaches to optimize

patient flow, have been implemented across a range of

health care settings.5

Practice-specific strategies that can optimize patient flow

might involve shaping demand, matching supply and

demand, and increasing capacity, and could include:

Reducing the number of appointment types; ◾◾

Reducing backlog;◾◾

Extending return visit intervals (within a ◾◾

clinically appropriate range);

Predicting and anticipating patient needs;◾◾

Managing bottlenecks;◾◾

Maximizing visit activity to reduce future demand;◾◾

Supplementing face-to-face visits through other ◾◾

media (e.g., telephone advice and triage, email, and

group visits);

Expanding the role of nurses and non-clinician ◾◾

staff, thus reducing non-clinical tasks performed by

physicians;

Balancing capacity and demand on a daily, weekly, ◾◾

and long-term basis; and

Synchronizing patients, information, and resources ◾◾

within the office.6

Collaboratives to Facilitate System Redesign In 2007, CPCA launched the first OPCC initiative,

supported by the federal Bureau of Primary Health Care

and facilitated by Mark Murray and Associates. This was

a one-year learning collaborative designed to reduce delays

in access to care and at appointments, to improve clinical

care with a special focus on cancer, and to improve

provider and staff satisfaction. A total of 21 teams from

the Health Disparities Collaborative’s Pacific West Cluster

region completed the 2007 OPCC.7

OPCC was offered again, beginning in April 2008,

with goals similar to the 2007 collaborative. Each 2008

OPCC team was charged with creating three project aims

within three categories of primary care optimization:

access, office efficiency, and clinical care. OPCC Phase I

activities, with 16 community health clinic teams (15

from California, one from Arizona), included a pre-work

teleconference cycle, five “learning sessions” (the first and

last of which were in-person meetings), five one-hour

monthly team teleconferences, and team reports. Phase II

activities, with eight teams, also included quarterly team

calls and reports. During the course of the collaborative,

team improvements were documented regarding access,

office efficiency, and clinical care, as well as team efforts

Workflow Redesign: A Model for California Clinics | 3

regarding program sustainability and internal spread of

the redesign processes.

In 2009, CHCF funded White Mountain to conduct an

evaluation of OPCC to document program successes,

challenges faced, and evidence of sustainability and

spread. Both quantitative and qualitative methods were

used to evaluate the learning community, including

success in improving access, office efficiency, and clinical

care outcomes. A combination of surveys and interviews

with community clinic staff was used to document

OPCC’s longer-term impact on system-level sustainability

and on the spread of change strategies, tools, and

resources to other clinic sites.

Project Findings The framework for OPCC, after the establishment of

teams, included setting goals, systematically collecting

data, implementing and testing changes, and measuring

impact, including the potential for sustainability. These

components were applied to three areas of practice

concern: access to care, office efficiency, and clinical care.

Goal Setting At the beginning of the collaborative, each team

developed a set of goals regarding access, efficiency, and

clinical care. Each team determined for itself those goals

it believed were both important and attainable for its

practice.

Access to Care and Office Efficiency Goals Improving access to care, in the context of OPCC,

meant reducing the time between a patient’s request for

an appointment and the availability of one. For “short”

appointments with a primary care provider (PCP), many

teams sought to achieve same- or next-day access for their

patients, while a few teams set their access goal at between

two and five days. Some teams extended the time-frame

for “long” appointments, and a few teams concentrated

their access aims on increasing after-hours appointments.

Some teams also worked on reducing patient no-shows.

Another aspect of improving access addressed in the

collaborative was balancing supply (the number of

appointment slots each provider could offer per time

period) and demand (the number of patient visits

requested per time period). A practice with more supply

than demand wastes resources and loses revenue by

failing to make use of available provider time. On the

other hand, a practice with greater demand than supply

experiences access delays, which affect patient satisfaction

and, ultimately, health.

Many teams also sought to identify and/or determine

the proper size of provider panels. This was seen as

contributing to overall efficiency and also as a way

for the practice to better assess and track clinical care,

especially for periodic screenings and chronic disease

care. Establishing provider panels can improve patient

satisfaction, help define workloads, predict patient

demand, reveal differences in provider productivity,

improve clinical outcomes, and reduce costs. Some teams

also sought to improve appointment continuity (patients

being seen by their regular PCP), which was considerably

easier to achieve once provider panels were determined.

The other most prominent OPCC office efficiency goal

was reduction in cycle time—the time between a patient’s

arrival at and departure from an office appointment.

About half of the teams aimed to reduce overall cycle

times to an hour or less, while other teams aimed for

45 minutes. Some teams targeted specific aspects of their

practice for this goal (e.g., pediatric appointments).

Clinical Care Goals Clinical care goals varied considerably, in both focus and

target populations, across the various OPCC teams. They

included increases in the overall rate of patients who

received:

Screenings for various cancers (mammograms; pap ◾◾

tests; prostate examinations; colon examinations);

Vaccinations; ◾◾

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LDL screening; and ◾◾

Diabetes management (inclusion in a registry; ◾◾

follow-up; retinal screening; A1c reduction; and

self-management).

Data Collection and Reporting Because OPCC teams varied in organizational structure,

staff and management support, available resources, patient

population, and other organizational and team-specific

factors, data collection and reporting differed considerably

across teams and measures. As shown in Figure 1, the

number of teams reporting on specific measures ranged

from only 19 percent for continuity to 94 percent

for access, with only 25 percent reporting on clinical

measures. However, at least half of all teams reported on

five tracking measures, and 80 percent of teams reported

on four.

Performance Measures Within the data collection limitations noted above,

significant improvements were documented for access

to care and cycle time. Almost every OPCC team was

able to document positive changes in at least one access

measure. Of the 16 teams that reported data across

both Phase I and Phase II of the 2008 OPCC, 14 teams

(88 percent) reported positive changes in at least two

access measures, and ten teams (63 percent) reported

positive changes in three or more of these measures.

Positive changes in either short or long next available

appointments were reported by 75 percent of teams.

Over half of reporting teams from 2008 documented

reductions in cycle time. Also notably, 81 percent of

teams were able to calculate their panel sizes, and some

of these were able to determine the most appropriate

panel size for their individual providers. The results, by

category, can be summarized as follows:

Access. Three-fourths of all teams reporting access data

substantially reduced access time, as measured by the days

to the third next available appointment, for either short

or long appointment types, and across multiple provider

panels.

Cycle Time. Of 11 teams reporting on average cycle

time, six demonstrated overall decreases and/or decreases

for at least one of their clinics. Additionally, six teams

reported cycle times of 60 minutes or less.

Supply/Demand. Few teams managed to provide data on

changes in supply and demand ratio, but of the ten teams

that initially documented greater supply than demand

(out of 13 teams reporting on the issue), five teams were

able to achieve a better balance.

Figure 1. OPCC Teams Overall Performance, by Measurement Category, 2008 – 09

A C C e S S t o C A R e A v e R A G e D e l A y * C y C l e t I M e

S u P P l y / D e M A n D

n o - S h o w R A t e C o n t I n u I t y

C l I n I C A l M e A S u R e S P A n e l S I z e †

teams Reporting on Measure

Phase I: 92%

Phase II: 100%

Overall: 94%

Phase I: 75%

Phase II: 50%

Overall: 69%

Phase I: 83%

Phase II: 75%

Overall: 81%

Phase I: 83%

Phase II: 100%

Overall: 88%

Phase I: 17%

Phase II: 25%

Overall: 19%

Phase I: 25%

Phase II: 25%

Overall: 25%

Phase I: 83%

Phase II: 75%

Overall: 81%

teams Reporting Positive

Changes in Measure

(as % of all teams reporting data)

Phase I: 75%

Phase II: 75%

Overall: 75%

Phase I: 56%

Phase II: 50%

Overall: 55%

Insufficient data

Phase I: 50%

Phase II: 50%

Overall: 50%

Phase I: > 90% (1 of 2 teams)

Phase II: > 90% (1 of 1 team)

No overall pattern, but each of four teams reporting had improvement in at least one measure or from one provider.

Phase I: 83%

Phase II: 75%

Overall: 81%

*Third next available appointment — short or long. †Team documentation of its panel sizes.

Workflow Redesign: A Model for California Clinics | 5

No-Show Rate. Of 14 teams tracking no-show rates,

50 percent reported an improvement.

Clinical Measures. Only four teams reported on clinical

measures but each of those showed improvement in

at least one measure. The improvements included one

overall team increase and one provider increase in the rate

of mammogram screenings, one provider increase in pap

test rates, one clinic increase in colon cancer screenings,

and one clinic increase in provider-patient discussions

about cancer screenings.

Panel Size. Most teams had not calculated individual

provider panels before the beginning of OPCC, let alone

determined what “ideal” provider panel sizes would be

for their individual providers. So, the fact that 13 of 16

teams (81 percent) were able to calculate individual panel

sizes during the course of the collaborative indicated

significant progress. Four of those teams also managed

to determine appropriate, practice-specific panel sizes for

their individual providers.

OPCC Impact: Responses from Team Leaders Post-project interviews were conducted with clinic team

leaders from both the 2007 and 2008 collaboratives. The

interviews sought information on how specific strategies

for change affected operational processes and efficiencies.

The interviews also sought responses on the participating

clinics’ plans for sustaining positive changes. Finally, the

interviews sought feedback regarding the collaborative

methods used by the project staff.

A Web-based survey also was conducted with team

leaders and other core team members from OPCC.

The survey focused primarily on the extent to which

participants used the various strategies for redesigning

access, office efficiency, and clinical care as taught through

the collaborative. The survey also documented perceived

benefits gained and barriers encountered in implementing

the various redesign strategies.

Specific Change Strategies Team leaders were asked about specific system-level

change strategies introduced at their sites through the

collaboratives. In particular, they were asked which

strategies were most and least successful, and which ones

they continue to use. The following change strategies were

reported to be the most successful and continue to be

used.

Regularizing Broad Collaboration All teams sought, in various ways, to institute broadly

collaborative elements into their regular practice

processes. Some teams had group “huddles” each morning

to sort out the day’s priorities, while others held regular,

brief (half-hour) cross-disciplinary meetings to generate

ideas about what works and what does not, as a way to

engage staff in providing routine feedback and developing

creative solutions. A number of groups also focused on

using a team-based approach to care, which included

pairing medical assistants (MA) with providers, and

sometimes creating “teamlets” pairing a physician, nurse

practitioner, or MA with a health coach.

Establishing and Managing Panels Defining panels is a crucial practice redesign strategy,

since panel size ultimately can affect patient satisfaction,

help define workload, predict patient demand, reveal

differences in provider productivity, improve clinical

outcomes, and reduce costs (by improving continuity

and outcomes, and by appropriately reducing return visit

intervals).8 During the course of OPCC, participating

groups began to measure and manage panels — both

a practice panel (the group’s patients) and individual

provider panels, making certain that all patients were

assigned to a particular provider. Some groups instituted

the “four-cut” method both to establish individual

provider panels and to make a patient assignment for

each specific visit.9 Making every clinician responsible for

his/her own patients can enable clinics to measure both

how those patients are doing and how the clinician is

performing.

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Reducing Backlog Almost all OPCC groups introduced backlog reduction

strategies. Some added more appointments each day,

by starting earlier or ending later, or by adding more

provider “sessions” (scheduled work periods, usually

half-days) per week. Each of these strategies, it should

be noted, requires increased staff support. Some

teams implemented an “open access” system, leaving

appointment slots available so that patients could have

a same-day visit with their assigned provider. And some

teams implemented a reminder system for managing

“fail-to-keep” appointments.

Balancing Supply and Demand Groups instituted a variety of methods to reduce

imbalances in supply and demand. Some teams reduced

the number of appointment types, since each added

appointment type creates a channel of appointments,

some of which can become clogged while others remain

unfilled. Other teams learned to balance daily supply and

demand through contingency scheduling plans. These

plans included building in scheduling flexibility (not

trying to schedule the same number of appointments for

each day) and modifying supply based on recognition

of and response to patient population demand patterns

(day-of-the-week and seasonal). Other contingency

planning involved post-vacation scheduling — leaving

blocks of open time for a provider returning from

vacation to see those patients who deferred appointments

during the provider’s absence.

Some teams addressed supply and demand variations by

seeking to reduce demand. One method for doing so

was to lengthen the time between return visits (within

medically appropriate time-frames), thus allowing

for shorter access times for other panel patients and

permitting more patients overall to be served. Another

demand-reduction method used by some teams was that

of improving continuity (which, in turn, depended on

establishment of provider panels). If patients are seen by

someone other than their regular provider, they are more

likely to seek an additional appointment to see “their”

provider, even if that is medically unnecessary. Thus,

lack of continuity increases demand-per-patient, which

ultimately limits the total number of patients who can be

served by that clinic.

Changing Phone Triage A number of teams changed their phone triage process so

that every patient who requests a same-day appointment

gets one without first having to go through a nurse.

Patients were still offered the option of first speaking

with a triage nurse, and a large proportion of patients

chose to do so, in many cases obviating the need for an

appointment. Some teams also set up a patient call-back

process that triaged urgent and non-urgent phone

messages, thereby eliminating many phone interruptions

for staff and resulting in more timely return calls.

Developing Cycle Efficiencies Teams developed various ways to increase office efficiency,

which not only moved patients through the visit

cycle more quickly but also freed up time to provide

faster initial patient access and, ultimately, allowed

Pay-Per-Visit Can Work Against Making Changes Most OPCC-participating clinics are reimbursed on a pay-per-visit basis. As a result, there can appear to be a conflict between some changes in office processes (e.g., reducing visits-per-patient and shifting tasks from clinicians whose time is billable to non-clinicians) and the financial interests of the clinic. Thus some clinic leaders among OPCC participants initially resisted certain changes that in the short-run reduced the number of billable patient visits. This resistance can be overcome, however, when leadership understands that if the number of visits-per-patient and the amount of provider non-clinical time are both reduced, the clinic can use the provider time it gains to expand its patient population. By so doing, it can again reach just as many or more billable visits while even better meeting its mission by serving more patients overall.

Workflow Redesign: A Model for California Clinics | 7

clinicians — physicians and nurse practitioners — to serve

more patients. These efficiency methods included:

Performing care team workload analysis, which ◾◾

examines the work clinicians have been doing and

should be doing, then ensuring that each staff

member handles tasks that reach the full level of their

competency, freeing others from tasks that they are

no longer needed to perform;

Shifting non-clinical work away from clinicians, such ◾◾

as by training MAs to do most patient education;

Conducting interruption studies, which analyze the ◾◾

nature and frequency of interruptions to clinical

visits, in order to reduce those interruptions;

Flow-mapping office processes (e.g., intake, ◾◾

laboratory and specialty referral, prescription refills)

in order to spot and rectify inefficiencies;

Standardizing patient examination rooms, so that any ◾◾

clinician can see any patient in any available room,

and feel comfortable doing so; and

Improving visit preparation by making sure that ◾◾

examination rooms are stocked with necessary

supplies, including those particular to the specific

visit, and by checking the patient chart to ensure that

all necessary patient information (e.g., lab results,

notes from previous visits) is included.

unexpected Consequences Teams were asked about unintended or unexpected

consequences — positive or negative — that resulted from

their redesign processes. Several teams reported that they

had anticipated resistance from providers but instead

found little such resistance, and provider satisfaction

improved. A number of teams also noted a positive

impact at the staff level, including a reduction in staff

turnover. One team reported less nonproductive work

as a result of increased continuity of care (for example,

less responding to calls from upset patients); similarly,

another team noted that its receptionist’s overall phone

time with patients was dramatically reduced. A number

of teams reported that their MAs expressed greater

work satisfaction due to their pairing exclusively with

one provider; these teams reported that providers, too,

were pleased with the effects of pairing. Finally, during

the course of the collaboration, one team rediscovered

the value of a chronic disease management system and

regained its focus on making it operational.

Only one team reported continuing negative

consequences, which included resistance to provider

panels and difficulty establishing a stable support team

around one provider. This team is trying different

strategies to overcome these barriers and to create a more

functional team.

Sustainability and Spread Teams from the 2007 collaborative were asked whether

they had developed specific plans for sustaining the

gains they had made through implementation of their

practice redesign strategies. Most teams reported having

struggled with developing sustainability plans, due

to some or all of the following: competing program

priorities; lack of commitment from management; staff

shortage or turnover; limited infrastructure; difficulty in

creating stable and/or cross-disciplinary teams; lack of an

automated data collection system; lack of staff buy-in; and

resistance to change in role definitions. Also, most Phase I

teams from the 2008 OPCC reported that it was simply

too early in the process (at the time the interviews were

conducted) for them to think about sustainability.

Some teams did manage to make efforts toward

sustainability. These included embedding the redesign

strategies, from the beginning of the collaborative, into

their daily, routine care operations and expanding them

beyond the OPCC project. Other efforts regarding

sustainability involved obtaining solid institutional

support, including from the medical director and chief

operating officer. Another consisted of maintaining

vigilance around measurement (particularly with panel

8 | California HealtHCare foundation

size), permitting ongoing course corrections based on the

data collected, with an eye toward framing the redesign as

part of the routine quality improvement process.

Teams were also asked whether they had spread their

practice redesign within their health care delivery

system — deeper within the improvement team, to the

practice team from the improvement team, or from the

practice or improvement team to an entirely new entity.

All teams reported that they were interested in spreading

the lessons learned, but few were in a position to spread

full-scale to other sites. This may be due, in part, to the

relatively short follow-up period between the time when

2007 OPCC teams completed the collaborative and

the time when the follow-up interviews were completed

(about eight months) and the even shorter follow-up

for 2008 Phase I OPCC teams (about four months).

However, almost all the teams reported “testing the

waters” with other clinics to seek provider and senior

management buy-in, and a few teams reported drafting

plans for spread to some of their larger clinics and/or

making presentations to other clinics about their practice

redesign efforts. A couple of teams reported success in

spreading particular redesign elements (such as calculating

provider panels and improving cycle time) to other sites

within their own health care system. Teams also have been

strategically integrating some redesign elements into their

overall quality improvement processes as a vehicle for

spread to other sites.

Feedback from Program “Dropouts” The evaluators interviewed team leaders from clinics

that began but did not complete the 2007 or 2008

OPCC (Phase I) collaborative. When asked about their

primary reasons for not continuing in the collaborative,

all cited the non-readiness of their clinic to participate

and/or organizational factors; that is, none pointed to

the perceived value of the collaborative itself. In fact,

most of these dropout teams were enthusiastic about

the collaborative’s potential; one of these teams reported

that it had adopted several strategies suggested by the

collaborative and hoped to participate in the future.

One team cited, as its reason for dropping out,

its simultaneous participation in another, similar

collaborative and an inability to sustain both. Another

clinic dropped out because its practice management

system was not equipped to accomplish the required data

collection, and adding the necessary resources to do so

would have severely strained its already critical financial

situation. Other team leaders similarly noted that the

timing was wrong for their clinic given its financial

instability and/or lack of resources needed to fully

participate.

What Would You Do Differently? Regarding the collaborative’s impact on access and office efficiency, the teams were asked what they would do differently if they had the chance to begin the collaborative again. The following are selected responses from team leaders:

“ Took a long time to adopt the teamlet approach and would have liked to do this sooner.”•

“ Unless there is buy-in from leadership, it isn’t worth investing in this.”•

“Need to make sure the infrastructure is there first.”•

“ Involve more MAs on the team to get their investment.”•

“Would streamline data collection.”•

“ Would have gone to an easier/smaller site first to get a ‘win’.”•

“Try to get panel size right off the bat.”•

“ Would have involved a few more people — key support staff (receptionist, MA) — other than just the management staff to • immerse clinic in OPCC culture.”

Workflow Redesign: A Model for California Clinics | 9

Leaders from teams that dropped out were also asked

what they would have done differently. One team

leader reported that, before committing to the project,

she would have more carefully reviewed her clinic’s

finances because of the collaborative’s “resource-intensive

approach.”

Conclusion OPCC is one of only a handful of comprehensive

programs designed to help health care delivery systems

provide timely and efficient patient care by way of system

redesign. Through OPCC, CPCA project staff and its

consultants were able to offer a unique set of skills to

community health clinics for transforming and leveraging

the way they deliver care to their patients. OPCC helped

clinics offer patients same-day appointments, standardize

appointment lengths, complete work in a timely fashion,

and develop appropriate panel sizes so providers could

effectively manage their patients. Together, these redesign

elements helped increase patient and provider satisfaction

and improve patient health.

Although the success of OPCC was variable across sites,

virtually all participating clinics documented positive

changes in at least one patient flow measure for some or

all of their provider teams. These findings are particularly

noteworthy given the organizational instability and

economic uncertainty faced by a number of these

community clinics.

The results of post-project interviews and surveys suggest

that the learning community framework is a particularly

appropriate vehicle for introducing practice teams to

improvement models. The value of adopting strategies

used by peers, and of troubleshooting issues in a true

learning community environment, was a consistent theme

in reports from the participating teams. There were varied

opinions about the most effective program strategies,

but teams consistently gave high ratings to the measures

tracking, to the interactive and in-person learning

sessions, and generally to the assistance received from

the consultants. Ideally (budgets allowing), teams would

have liked more one-on-one tailored and on-site technical

assistance, a comprehensive strategy for including senior

leaders in the redesign process, and more assistance

achieving “buy-in” from other providers and staff.

Follow-Up Web Survey Confirmed Results 2008 OPCC teams participated in a Web-based survey following completion of the collaborative, to supplement the direct interviews conducted. The survey focused on adoption of practice redesign strategies, the benefits and barriers to continued use of these strategies, and the overall impact on target outcomes. All 2008 Phase I teams participated in the survey, as did all but one team from Phase II. Respondents included both those who were involved in direct patient care and those in other roles (e.g., administration, management, data support, IT, and quality improvement).

New Design Strategies. Most teams reported that the design strategies they used were either entirely new to them or an expansion of existing strategies in new directions. This supports the results from the interviews, which indicated that many teams were introduced to new approaches to improving clinical care at the systems level and/or used redesign approaches that they had previously adopted but in a more strategic way.

Implementation Effort. Most teams reported that it was moderately difficult to implement the redesign strategies and time-consuming for providers and staff to learn how to use them. Nonetheless, two-thirds of team leaders reported that it was “extremely likely” their teams would continue to track measures to monitor improvements in access and office efficiency, with only 4 percent of respondents unsure whether their site would continue with measures monitoring.

The Business Case. About one-fourth of team leaders reported moderate to strong financial improvements as a result of OPCC. As for specific analyses related to financial benefits from redesign, 58 percent of teams reported working on the business case during their OPCC time, with another 12 percent reporting that they had begun to work on it following OPCC.

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On the whole, the positive response by participants

in the OPCC projects suggests that this collaborative

framework has strong potential for a larger rollout to

other community clinics. Such a large-scale effort, with

appropriate funding levels and organizational support,

could serve as a catalyst for a more general shift in the

way health care is provided in community health centers

and clinics throughout California.

A c k n o w l e d g m e n t s For their assistance with the preparation of this issue brief,

the California HealthCare Foundation would like to thank:

Vanesscia Bates of the California Primary Care Association;

Mark Murray, M.D., M.P.A. of Mark Murray and Associates;

Barbara Boushon, R.N., B.S.N.; and Seth Emont, Ph.D.,

and Nancy Emont, Ph.D., of White Mountain Research

Associates, L.L.C.

A b o u t t h e F o u n d At i o n The California HealthCare Foundation is an independent

philanthropy committed to improving the way health care

is delivered and financed in California. By promoting

innovations in care and broader access to information, our

goal is to ensure that all Californians can get the care they

need, when they need it, at a price they can afford. For more

information, visit www.chcf.org.

e n d n o t e s 1. Access to care is used in this brief to refer to the time

between a patient’s request for an appointment and the

appointment offered. Cycle time means the time from

patient check-in to completion of the medical visit.

2. White Mountain Research Associates, L.L.C. (S. Emont

and N. Emont). Evaluation of the Optimizing Primary Care

Collaborative. California HealthCare Foundation. 2010.

3. See, e.g., Nolan, T.W., M.W. Schall, D.W. Berwick, and

J. Roessner. Guide to Reducing Delays and Waiting Times.

Institute for Healthcare Improvement, 1996; Backer,

L.A. “Strategies for Better Patient Flow and Cycle Time.”

Family Practice Management, June 2002; Institute for

Healthcare Improvement. Optimizing Patient Flow: Moving

Patients Smoothly through Acute Care Settings. Innovation

Series, 2003.

4. Backer, L.A., 2002; Institute for Healthcare Improvement,

2003.

5. Walley, P., K. Silvester, and R. Steyn. Sept/Oct 2006.

“Managing Variation in Demand: Lessons from the

UK National Health Service.” Journal of Healthcare

Management 51 (5); 309–22.

6. Institute for Healthcare Improvement. Improving Access

and Efficiency in Specialty Practices. Breakthrough Series.

October 2004; Boushon, B., L. Provost, J. Gagnon, and

P. Carver. 2006. “Using a Virtual Breakthrough Series

Collaborative to Improve Access in Primary Care.” Journal

on Quality and Patient Safety 32 (10); 573–84.

7. The 2007 OPCC included clinic teams from Alaska,

Arizona, California, Hawaii, Idaho, Nevada, Oregon, and

Washington.

8. Murray, M., M. Davies, and B. Boushon. April 2007.

“Panel Size: How Many Patients Can One Doctor

Manage?” Family Practice Management, American Academy

of Family Physicians, 44–51.

9. Under the four-cut method, a patient who has seen only

one provider for all previous visits is assigned to that

provider for his or her current visit. A patient who has

seen more than one provider is assigned to the provider

he or she has seen most often. A patient who has seen

multiple providers equally is assigned to the provider who

performed the patient’s most recent physical or health

check. Remaining patients, who have not had a sentinel

exam, are assigned to the provider they saw most recently.