Innovations in Outpatient Care

reprinted from Issue 15, Fall 2012 of Frontiers of Medicine (PDF)

With the quality and safety revolution of the last decade, so much of the initial energy has been focused on the inpatient setting," says Niraj Sehgal, MD, MPH, associate chair for quality improvement and patient safety. Yet most health care is delivered in the ambulatory or outpatient setting – through clinics, rather than through hospitalizations. "We have an opportunity to proactively transform our ambulatory care systems to provide the highest quality care in a patient-centered fashion," says Sehgal.

The Department of Medicine provides care in three diverse settings within San Francisco: UCSF Medical Center, San Francisco General Hospital (SFGH) and the San Francisco Veterans Affairs Medical Center (SFVAMC). All three sites are working to improve ambulatory care.

UCSF Medical Center

At UCSF Medical Center, the Department of Medicine has appointed service chiefs for each specialty – such as cardiology and rheumatology – to lead ambulatory care improvements. Also, multi-specialty working groups focused on operations, quality and safety, and finance will develop strategies for achieving specific milestones – for example, ensuring that 70 percent of new patients are scheduled and seen within two weeks of referral. Past quality improvement efforts were often siloed within individual specialties, but this multidisciplinary approach will speed development of improvements and facilitate rapid sharing and adaptation of successful models across the department. "Our main goal is to optimize the patient experience, using mechanisms that support physicians and synchronize and leverage our efforts," says Ralph Gonzales, MD, MSPH, associate chair for ambulatory care and clinical innovation.

San Francisco General Hospital

One of SFGH’s many innovations is developing computer-based registries for patients who have been treated for conditions such as thyroid or colon cancer. "There’s a temptation to have a patient come back every three months so you don’t lose track of them, but depending on their condition, they may only need to be seen once a year," says Alice Chen, MD, MPH, chief integration officer at SFGH. "The registries allow us to risk stratify patients, proactively reaching out to patients who need to be seen more frequently." Tailoring the frequency of follow-up visits helps ensure that patients receive the care they need, while also freeing up appointments for other patients who urgently need specialty care. This is critical, since the wait time for some SFGH specialty appointments can be weeks to months.

"Access to care is part of quality, and at SFGH, we are always trying to find innovative ways to do more with less," says Chen. "We have a growing cadre of really dynamic leaders who are redesigning and improving our systems, and evaluating and disseminating ways to improve clinical care."

San Francisco Veterans Affairs Medical Center

At the SFVAMC, patients now receive care from an entire team, which includes a provider, registered nurse, licensed vocational nurse and clerk. Recently, the teams were expanded to include medical residents, nurse practitioner students, social work interns and other health profession trainees. Teams "huddle" a few times a week to divvy up tasks and better coordinate care of patients – for example, having a nurse pre-order labs for the morning of a diabetic patient’s upcoming visit, so he and his doctor can discuss the results and adjust medications during the appointment. The goal is to have every team member working at the top of his or her license.

"To efficiently and cost-effectively deliver care, we are going to have to do it in teams," says Maya Dulay, MD, assistant director of medical practice at the SFVAMC. "But to teach people how to do this, you need to put them in a functional team. Teamwork also requires a different skill set, so we’ve developed a formal curriculum to teach things like how to communicate interprofessionally and delegate the appropriate tasks."

All of these efforts reinforce the Department of Medicine’s commitment to innovation in ambulatory care. "Sharing best practices across our diverse care settings is a real opportunity we have, and must take advantage of, moving forward," says Sehgal.

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