Perceptions of Ambulatory Workflow Changes in an Academic Primary Care Setting

Abstract

As health care moves to a value-based system, the need for team-based models of care becomes increasingly important to adequately address the growing number of clinical quality metrics required of health care providers. Finding ways to better engage certified medical assistants (CMAs) in the process allows providers to focus on more complex tasks while improving the efficiency of each office visit. Although the roles and responsibilities for CMAs across the specialties can vary widely, standardizing the work can be a helpful step in scaling best practices across an institution. This article presents the results of a survey that evaluated various components of a CMA workflow in adult primary care practices within an academic medical center. Although the survey identified improved engagement and satisfaction with standardized changes overall, it also showed time constraints and provider discretion forcing unplanned modifications. Reviewing and reconciling medications seemed to be the most challenging for CMA staff, leading us to reconsider their involvement in this aspect of each visit. It will be important to continue innovating and testing team-based care models to keep up with the demands of a quality-based health care system.

Value-Based Healthcare From the Perspective of the Healthcare Professional: A Systematic Literature Review

“…Analysis revealed 10 specific behaviors that professionals pursued in VBHC, next to acting upon their professional standards ( 68 ). These interconnected and mutually reinforcing behaviors, as visualized in Figure 4 , are to (1) focus on what matters to patients and adopt other VBHC mindsets ( 24 , 31 – 33 , 47 , 50 , 52 , 53 , 61 , 62 ), (2) measure outcomes ( 14 , 24 , 31 – 35 , 44 , 56 , 68 ), (3) learn and improve care ( 14 , 24 , 31 – 34 , 47 , 53 , 62 , 66 , 68 – 70 ), (4) organize care around the full cycle of disease ( 24 , 32 , 44 , 45 , 54 , 60 , 61 , 64 , 66 , 70 – 73 ), (5) participate in population health and prevention ( 24 , 62 , 66 , 70 , 72 ), (6) discuss value in the clinical encounter ( 31 , 47 , 50 , 55 , 56 , 58 , 63 , 64 , 74 , 75 ), (7) involve patient representatives ( 24 , 31 – 33 , 50 ), (8) take accountability for patients and resources ( …”

“…Concerning culture, participants called for culture change ( 24 , 31 , 47 , 56 ) and mentioned the need for specific cultures, particularly cultures that are transparent and blame-free ( 14 , 31 , 48 , 53 , 56 , 66 , 69 , 72 ). Related to HR and capacity, studies discussed staffing constraints ( 33 , 49 , 59 , 61 ), the importance of staff stability ( 24 , 59 , 66 ), staff composition including the use of alternative providers and medical assistants [e.g., ( 14 , 24 , 33 , 35 , 60 , 64 – 66 , 71 , 72 , 76 )] and specific open job positions ( 33 , 34 , 62 , 72 , 78 ). Remarks made about organizational facilities and approaches involved professionals' desire for dedicated VBHC time ( 14 , 59 , 66 ), step-by-step implementation ( 34 , 35 , 56 , 72 , 76 ), and an overall supportive environment ( 24 , 31 , 53 , 54 , 56 , 57 , 59 , 62 , 65 , 66 , 72 , 73 ) with specific attention for engaged leadership ( 14 , 33 , 35 , …”

“…Related to professionals' roles and behaviors, studies described VBHC as a bottom-up initiative (14,24,31,32,34,47,53,54) that expanded roles and established new roles such as the "contact nurse" function (14,24,32,56,(60)(61)(62)(63)(64)(65)(66). Engaged leadership was studied in terms of necessity, leadership approaches, competence, personal characteristics, as well as professions that were suggested to take up leadership roles (33,34,54,66,67).…”

“…Organizational support and legitimacy VBHC resource ( 24) "Even if it was impossible to make use of all the patient representatives' opinions and experiences, participants were proud of their cooperation with the representatives as this contributed to the legitimacy of their implementation work" (24) Environment resource (24,33,48,50,69) "Over time, participants came to understand the importance of the hospital director's unequivocal standpoint that VBHC was to be used as a management tool. This standpoint gave legitimacy to decisions within the teams" (33) Environment demand (24,32,33,35,55,72,76) "Participants felt they had been thrown into the deep end when it came to implementation work" (33) Pride VBHC resource ( 24) "[…] participants were proud of their cooperation with the representatives as this contributed to the legitimacy of their implementation work" (24) complexity with new tasks in VBHC as a result of task expansion (60). The second study suggested information overload due to working with care pathways (73).…”

“…This observation underlines the need for organizations to better support their employees by providing the necessary resources and designing appropriate organizational structures and interventions to "The focus on value for the patient, emphasized by the hospital management team, contributed to their feelings of 'enthusiasm for the concept and strong engagement in implementation work" (24) Engagement being moderated by demands ( 24) "These hindrances contributed to decreasing engagement in carrying the process forward. […] Engagement for VBHC also decreased when participants did not see any actual activity or result of their implementation work" (24) Being energized (24, 66) "I think even greater sense of meaning that we're all working towards the greater good of patient health and well-being, and I think that genuinely energized people" (66) Having joy in practice ( 66) "All but one of the practices indicated that their transformation efforts led to increased joy of practice" (66) Joy in practice being moderated by demands (66) "The one outlier practice indicated increased sense of purpose and mission and did not indicate decrease in joy or well-being, but did acknowledge that increased work necessary for practice transformation moderated increased joy of practice" (66) Increased Job Satisfaction (24,32,44,60,66) "All participants in the structured interviews noted improved job satisfaction after the transition period, given the new sense of employee engagement and accountability" (44)…”