Outcome of Evaluation

This effort resulted in an Interim Report by the task force that summarized the findings of team members and identified a series of general and specific recommendations for change at UT Southwestern.  The findings were supplemented by the results of interviews of employees and patients by an independent external company, and by consultation with a nationally prominent expert in customer service who recently spent a year studying the Mayo Clinic’s programs.  A more specific draft of action items with timetables and costs was then developed, and all of these materials and plans were reviewed by an external panel of exceptionally distinguished leaders drawn from among the leading healthcare institutions in the nation, who met in Dallas with UT Southwestern’s task force to evaluate the institution’s plans. After external review the Clinical Department Chairs, led by their executive committee met frequently with the UT administration to determine the priorities of the project.

The plan envisions a series of projects that will be started and completed over a four-year period beginning in January, 2003 although some of the activities that are identified as part of the plan are already underway.  Resources required for success include capital for the acquisition of medical equipment, particularly computer hardware and software that is vital to the improvement of practice infrastructure, including that needed for the creation of an electronic medical record system.  Calculations of the costs also include increases in operating support that will be needed to initiate and sustain the changes proposed in the program plan.  These include infrastructure support (e.g., operation of   information systems, enhanced personnel training, etc.) and support for teams of physicians and nurses who, in an insurance reimbursement environment that rewards quantity of encounters rather than quality of service, are nevertheless committed to devoting all the time necessary to provide exemplary patient service.

Implementation of the Plan

The specific plans for change in the clinical practice at UT Southwestern, are extensive, complex, and projected to be costly in both time and effort. Because undertaking this change clearly calls for a multi-year effort, each action item has been identified with a start and completion date

Priorities were established considering the following criteria:

 Centrality to the overall plan itself
Relative practicality of early implementation
Extent to which the project is already underway
Availability of financial and human resources

Each of the projects has a designated “key individual” who will have principal responsibility for achieving the specific programmatic elements.  Each project is also identified with one or more of the following general goals of the action plan:

GOAL I—Culture:  Establish and sustain an institution-wide culture among the faculty and staff that consistently values and fosters excellence in clinical care. Utilize objective practice data to document performance and to provide incentives for the optimal delivery of patient care. Ensure that high quality patient centered clinical care is regarded as equal in importance to education and research in the institution’s mission and culture, and that individuals whose principal activity is to provide excellent clinical care are highly valued, respected, and rewarded by the institution.

GOAL II—Organization:  Reorganize the central administration of the clinical care delivery system to improve and sustain efficient patient-oriented service, utilizing “best practice” models. Consolidate the management of hospitals, outpatient clinics, and the physician group practices under a single executive administration to assure seamless care.  Establish an office with a senior clinical manager as its head, assisted by task forces of high level clinical leaders, who is charged with the responsibility of implementing the clinical transformation plan and assuring on-going, consistent provision of patient-centered services.  Assure appropriate input from all major stakeholders.  Reorganize individual clinical service units, as appropriate to promote excellence in patient-centered care.  Evaluate and “right-size” each clinical service unit to meet the needs of the institution and its patients in an optimal way.

GOAL III—Electronic Medical Record:  Install a comprehensive Electronic Medical Record System including clinical documentation, web-based patient access, physician order entry, messaging capabilities, and prescription writing tools, linked with registration and scheduling as well as a fully deployed Picture Archiving Communication System (PACS).  Integrate the planning and management of all clinical information systems under a single management.

GOAL IV—Human Resources:  Recruit national-level leadership for the management of clinical personnel activities.  Change the current system for hiring, evaluating, compensating, and promoting clinical personnel.  Implement an improved, mandatory, on-going training system. Augment and enhance the supervision of clinical personnel.  Evaluate and re-design the human resource functions, ensuring that key job descriptions are clear, and that the best possible individuals are appointed in all key positions.

GOAL V—Telephones:  Improve telephone service to ensure efficient, reliable, courteous telephone access to UT Southwestern’s clinical services by patients and referring physicians.

GOAL VI—Scheduling and Registration:  Improve patient scheduling and registration systems to enhance the process of accessing the clinics, to increase the efficiency and accuracy of the appointment and billing processes, and to eliminate redundancy in the collection of patient data.

GOAL VII—Access:  Create programs to facilitate access to UT Southwestern’s clinical services by our employees and their families, and by other  self-identified groups of patients and referring physicians with special UT Southwestern relationships.

GOAL VIII—Innovative Diagnostic and Treatment Modalities: Create programs and systems to ensure that UT Southwestern patients have access to state-of-the-art diagnostic and therapeutic modalities, specifically including the latest diagnostic imaging technologies and a broad array of clinical trials. Establish programs in biostatistics, epidemiology and bioinformatics to advance clinical endeavors that rely on these disciplines. Ensure that patient centered care is linked to UT Southwestern’s clinical research programs through excellent clinical trial and imaging programs, in order to enhance the attractiveness of the institution to the best clinicians.

Phase I Projects
Highest priority actions

Phase I, Action 1:  Identify excellence in patient care (including physician expertise, state-of-the-art technology, and delivery of patient centered services) as an explicit part of the mission of the institution in mission statements and long range planning documents. Adopt a concise “credo” for courteous and efficient patient service, and instill it throughout the institution’s culture through a well-publicized campaign that emphasizes the importance of patient service to the well being of patients and to the sense of accomplishment on the campus.  Hold regular meetings with faculty and staff to reinforce the mandate for change, and disseminate documents that “make the case” for the new goals and process.  Establish a special committee of clinical chairs and service leaders to guide the development of all aspects of the clinical transformation, and ensure that faculty clinical leaders play a significant role in practice policy and governance.

Phase I, Action 2:  Plan and implement the consolidation of the management of UMC hospital facilities, UT Southwestern outpatient clinics and the physician practice under a unified structure, with a chief clinical executive that reports to the President of UT Southwestern while maintaining the fiduciary role and the policy and oversight authority of the UMC Board of Directors.  Employ administrative leaders from a national talent pool in a manner that is competitive with the nation’s leading academic medical centers.  Establish a management and governance structure for all clinical programs that assures meaningful input and oversight by faculty leaders as well as by community board members. Establish a high-level office held by a senior clinical executive manager charged with leading the implementation of the clinical transformation project and assuring a constant focus on making the changes necessary for the consistent provision of excellent patient services.  Create a task force of key clinical managers responsible for implementing specific elements in the plan.  Appoint a high level internal advisory group of clinical chiefs, hospital and nursing executives, and information system, human resources, and financial affairs leaders to provide regular input and serve as a communication link throughout the organization.  Appoint an external advisory group of lay leaders to provide consumer perspective and to serve as a communication link with the community of UT Southwestern patients and supporters.  Establish clear mechanisms for measuring and monitoring progress and for clarifying priorities.

Phase I, Action 3: Reorganize human resources management for outpatient clinic and hospital personnel under the direction of a senior human resources officer reporting to the consolidated management of the hospitals and clinics.  Recruit the chief human resources officer for clinical services from an experienced national talent pool.  Define the relationship between the university’s HR department and the HR function that serves the clinical program.  Formulate clear job descriptions and scope of responsibility for all executive human resource positions and ensure that each position is filled with the best possible individual.

Phase I, Action 4: Organize all UT Southwestern and UMC information resources under a single Chief Information Officer (CIO).  Create a consolidated plan for the development of hospital, outpatient clinic, and physician practice information systems for administration and patient management.

Phase I, Action 5: Develop and implement a consistent, standardized policy across all clinical services for automated telephone services, including a strictly limited number of options before a person is reached who can handle the caller’s issue. Standardize policies regarding number of rings allowed before answers, maximum allowed time on hold before intervention, etc. Limit voice mail to strictly defined, pre-approved situations where call-back or processing is handled within 2 hours.

Phase I, Action 6: Conduct training by outside telephone training specialists in telephone courtesy, customer service skills in telephone usage, and problem solving, for all clinical employees with responsibility for telephone communication with patients.  Require employees to pass competency tests as part of the training activity. Institute mandatory evaluation and re-training for each telephone service employee every six months. Develop the capability to provide internal training in future years.

Phase I, Action 7: Create a “decision support” analysis unit at UT Southwestern to provide high-quality, timely data on physician productivity, patient satisfaction, clinic resource utilization, and patient service variables such as wait times, bumping activity, telephone metrics, etc.  Provide informatics support tools to this unit.

Phase I, Action 8: Revise and implement new, simplified, consistent, practice-wide codes for visit types (i.e., “new,” “established,” “complex,” “simple,” etc.) to facilitate appointment scheduling and analyses.

Phase I, Action 9:  Fully implement the EPIC electronic medical record system in all UTSW outpatient clinics and in UMC over the next three years.  Fully implement the physician order entry capability of the EPIC EMR in all outpatient clinics and in UMC.  Until implementation of a single electronic record is effected, progressively consolidate current records into a single, unified paper-based system and sequentially phase out duplicate paper records.

Phase I, Action 10: Fully implement PACS throughout the clinical practice. Upgrade all imaging units to be PACS compatible. Upgrade high-resolution monitors in selected clinical areas where required.

Phase I, Action 11: Organize the management of each clinic under a physician medical director and a non-physician manager, who are accountable to institutionally-determined standards of clinic performance and who are rewarded accordingly.

Phase I, Action 12: Articulate explicit expectations that clinical chairs and clinical service leaders must achieve comprehensive excellence in patient care within their areas of responsibility, including the consistent delivery of high quality patient service. Clarify explicitly that performance evaluations of these individuals are based to a major extent on criteria that measure success in delivery of patient services by their department or division, as well as traditional academic measures, and establish incentive/merit plans that directly tie a portion of their compensation to the attainment of pre-agreed goals for the entire department and/or service.

Phase I, Action 13: Study and adopt empirical performance standards for clinic employees based upon customer service and productivity goals.  Begin performance measurement programs, and design incentive programs based upon measurable achievements of individual employees and overall clinic goals.

Phase I, Action 14: Create a single, practice-wide patient registration process that is manned by personnel trained in patient demographics and the details of insurance coverage.  To the extent possible, construct this as a “back room” function conducted through telephone interviews before patients appear in clinics.  Registration personnel on hand in clinics will be trained and managed by the clinic-wide registration center.

Phase I, Action 15:  Create a series of model small practice groups led by outstanding clinician leaders, first in primary care and later in selected specialties, that assume responsibilities for total patient care.  Establish the principle that the group and its members are accountable and rewarded for excellent continuity of care both within their clinic and for all referrals throughout the campus. Implement group goals and incentives for productivity and patient service.

Phase I, Action 16: Carefully study and define the projected optimal size for each clinical outpatient service.  Adopt plans and timetables for achieving the desired clinical caseloads in each service.

Phase I, Action 17: Establish case manager positions in primary care clinics, cancer, cardiovascular services, neurology and other appropriate specialties as part of the small practice modules described, to assist the physicians and the patients in the coordination of diagnostic and treatment plans.

Phase II Projects

Phase II, Action 1: Create a call center for primary care in concert with a common scheduling service.  Create combined units to handle telephone and scheduling services first for primary care clinics and subsequently for selected specialty clinics.

Phase II, Action 2: Adopt and publish faculty and clinic productivity standards, including physician schedules, for all clinical services, initially in primary care and subsequently in medical and surgical specialties.

Phase II, Action 3: Develop and implement an electronic master patient index (EMPI) to improve registration, medical record, and billing accuracy.

Phase II, Action 4: Evaluate and incrementally implement a practice wide document imaging system to incorporate outside patient records and current UTSW paper records into the EPIC electronic medical record.

Phase II, Action 5: Develop and implement a plan to phase in new network-based telephone systems to ensure an excellent telephone infrastructure, with budgets and timetables for regular equipment and systems upgrades.  Explore the feasibility of systematically utilizing e mail and other internet-based communications to partially replace telephonic communications, and develop plans and allocate resources accordingly.
 
Phase II, Action 6:  Adopt the use of a consistent, appropriate dress and behavior standard for individuals with patient contact in UT Southwestern clinical areas after having appointed a committee of employees to recommend these standards.  Formally prohibit “casual Fridays” in UT Southwestern clinical areas.  Design a suitable blazer for “front office” personnel and require its use.

Phase II, Action 7: Reorganize current clinical training programs to establish a special training center for clinical personnel that features a strong service training philosophy.  Formulate clear job descriptions, lines of authority, and areas of responsibility for all training direction and ensure that well-qualified customer-oriented individuals fill all such positions.  Investigate the approaches of the Disney Institute and other successful service training methodologies, and adopt the best approach for our setting.  Adopt a curriculum and require competency testing before assignment of personnel to the clinics. Require periodic retraining and “re-certification” of clinical employees in service quality.

Phase II, Action 8: Create employee recognition programs based upon patient service measures and patient satisfaction indicators.

Phase II, Action 9: Establish a patient advisory committee to meet regularly to provide patient feedback and suggestions on issues related to patient service and satisfaction.  Evaluate and consider outsourcing the management of patient satisfaction testing.  Retain a consultant to review available methodologies and instruments and assist in the selection of the best systems.  Consider telephone surveys using carefully considered sampling methodology.  Establish goals for patient survey scores at all levels of the institution and publish the results.

Phase II, Action 10: Establish new job titles, recruitment methods and criteria which highlight customer service and productivity goals. Develop and implement a policy to “hire for attitude” and “train for skills.”  Give hiring decisions to individuals with a vested interest in the success of the clinical practice.

Phase II, Action 11: Adopt and implement formulas for the subsidy of primary care and selected specialties.  Change the current system of supporting primary care on the basis of “block grant” departmental allocations to a system based on objective, measurable productivity standards.

Phase II, Action 12: Adopt plans in each clinic to ensure that patients receive appointments within pre-determined acceptable time frames. Develop plans for  “Open Access” care systems in primary care and selected support areas, such as pre-operative evaluation. Adopt standards for convenient access for all medical and surgical specialties. Require department and clinical service line leaders to guarantee access to care for internal UT Southwestern referrals within defined and agreed upon time periods. 

Phase II, Action 13: After consultation with service industry experts, initiate a quality-control oversight system to monitor adherence to telephone standards, including the use of “mystery callers.”  Score employees on efficiency and etiquette in their management of calls and communicate results to supervisors.

Phase II, Action 14: Review, reorganize and improve handling of patient complaints and billing inquiries practice-wide.  Consolidate these functions in a patient advocacy office that takes ownership of complaints and inquiries, that is empowered to find solutions, and that has standards and timetables for resolution.

Phase II, Action 15: Review clinical faculty compensation and incentive plans and carefully modify them as necessary to insure the presence of appropriate productivity, delivery cost, and patient service variables based on measurable data.  Include clinical service leaders in the creation of faculty incentive plans involving their faculty, along with clinical chairs and UT Southwestern administration. Develop institutional policies and guidelines that ensure that the setting of faculty clinical compensation reflects an appropriate balance in the priorities of clinical productivity, expertise, and patient service; clearly articulate the need of importance of these three aspects of clinical care in institutional expectations.

Phase II, Action 16: Develop a plan and commit resources for the establishment of a leading program in clinical trials at UT Southwestern Medical Center, including investment in clinical trials infrastructure, research nurses and other personnel to support the management of clinical trials, and faculty support.  Encourage and provide incentives for new faculty to undertake clinical trials activities, and, where there are gaps, recruit senior faculty with extensive clinical trial experience to serve as trailblazers for an expanded clinical trials program.  Adopt measurable goals for the clinical trials program (including patient numbers and satisfaction, and number of new therapies offered in multiple specialties) and document the program’s progress.

Phase III Projects

Phase III, Action 1: Implement the Epic electronic registration and scheduling system to link these processes with clinical documentation and patient communication systems.

Phase III, Action 2: Create a special program to ensure the provision of convenient access and exemplary clinical care and service for UT Southwestern employees and their families.  Make the program known on campus, and encourage its use. Assign individual Patient Service personnel to specialize in assisting employees and their families with appointment scheduling, inquiries about their care, and insurance and billing questions they may have.  Give personalized support to employees and their families hospitalized in our facilities.

Phase III, Action 3: Develop and implement a plan to properly inform target constituencies, both internal and external, about UT Southwestern’s commitment and achievements in the area of patient services, as well as about our clinical expertise and advanced medical technology.  Restructure the clinical marketing and public information effort to develop an effective, coordinated approach for all clinical services.  Re-evaluate the use of outside marketing and advertising firms.  Develop careful job descriptions for key marketing and public affairs positions and ensure that the best possible people are appointed to each position.

Phase III, Action 4: Implement the Clarity EMR Management Reporting System to provide data on utilization of resources in the practice, scheduling efficiency, wait times, appointment bumps and other performance data.

Phase III, Action 5: Evaluate and implement trans-departmental “service line” faculty groups for delivery of care in selected disease categories (for example, cancer, heart disease, etc.).

Phase III, Action 6: Initiate call management and referral tracking software as well as triage-based management of routine prescriptions, results, records, insurance and billing inquiries. Expand “Speech Works” voice recognition system.  Institute a system for monitoring and ensuring timely “call-backs” for all patients.

Phase III, Action 7: Evaluate and implement information system modules for management of specific patient data in oncology and heart services.

Phase III, Action 8: Create a liaison office for referring physicians who are not part of the regular UT Southwestern faculty.  Make periodic in person calls on those physicians who interact regularly with the UT Southwestern practice to insure that their needs are being met and their questions addressed.  Create a special telephone line for referring physicians to use for any purpose, and have staff in this office take responsibility for seeing that they get appropriate levels of service.

Phase III, Action 9: Design and implement a distinctive Executive Physicals Program that emphasizes patient education and preventive care in an attractive, convenient, and unhurried setting.  Publicize the program to target audiences.

Conclusion
Addressing the service issues in our medical practice will be a complex, lengthy, and costly undertaking.  It will require a concentration of effort by all faculty and staff engaged in patient care at UT Southwestern and supporting facilities and a significant commitment of both institutional and private resources to achieve change.  It will entail efforts to develop a service-oriented culture across the medical center, changing human resources practices, re-engineering many clinical operations, extensive introduction of electronic information technologies (including medical record and imaging capabilities), overhaul of the entire telephone system, and the introduction of targeted innovative treatment modalities.  Our plans indicate a requirement for a large amount of private capital support; at the same time, the reallocation of about $10 million per year in recurring practice income and other unrestricted institutional funds will also be necessary to achieve the goals of the project.

It should be stressed that the plan for improving UT Southwestern’s clinical services represents a commitment to implement major changes that will impact the entire culture of the institution.  The changes are not aimed at making marginal incremental improvements, but rather at producing a fundamental transformation of the quality of service of our patient’s experience.  These changes will create a patient-centered culture that will have profound benefits to our education programs as well as to the quality of clinical care we provide.  Implementation of the plan will begin immediately, and we anticipate immediate benefits; but it is important to note that this project will be an on-going enterprise that will continue to produce progressive improvements over a time-frame spanning several years.