“Just start work half an hour earlier.”
This is what the head of the care coordination committee for our patient-centered medical home executive committee work group recommended when we talked about our struggle getting the team together for early-morning pre-clinic huddles.
She suggested that if we started our usual practice morning at 8 o’clock we should just have everybody come in at 7:30 to load the dashboards for the morning session and have the doctors, nurse practitioners, nurses, medical techs, secretaries, and the remainder of the support staff, all get together and run the list of patients scheduled for the day.
As she said this, our practice administrator furrowed his brow.
He mentioned to her that this would require staff checking in earlier, and that our staff already works a staggered start time to accommodate people with different morning schedules, family responsibilities, and commuting times.
“A lot of overtime and a lot of cost. Who’s going to pay for this?” he asked.
She paused for a moment, and then suggested “Maybe you want to start the clinic day a half an hour later?”
Now the clinicians did the furrowing.
Who’s going to pay for that?
At the moment, volume leads directly to practitioners’ salaries, so a direct hit to a practice session in terms of number of patients seen is directly felt, unfortunately, in the pockets of providers, and, believe me, they do not take that lightly.
There are further issues with getting all the players to the table.
Our internal medicine residents in the practice have an academic conference that starts an hour before the morning practice session. Our nurses have a mandatory meeting with the entire nursing staff to go over the day’s issues. Our registrars have a mandatory 20-minute meeting before the start of their day, to go over the messages, tasks, and active issues from the day before, and any other departmental matters that have been brought up by leadership.
That’s a lot of meetings.
And now we are trying to add another one.
And with a lot of different members from a lot of different disciplines, all coming together from various places, with different start times for their work days.
This seems incredibly impractical, and trying to get this all worked out has proven to be incredibly frustrating.
Recognizing that the morning huddle has the potential to lead to remarkable improvements and efficiencies, and improved patient-centered care, this is definitely something we need to build into our work day, but figuring out how to get it done, in the right place, at the right time, with the right people, has been a daunting process.
This morning the outside temperature was 9°, the subways were jam-packed, the trains were running at least half an hour behind schedule, every intersection in the city was blocked with traffic, and the crosswalks were a foot deep in slush from the recent snowstorm. Nobody got to work on time. And yet somehow when we arrived, some providers were already three or four patients behind for the morning day practice session.
The feasibility of getting everybody together for a calm, thoughtful, purposeful morning huddle was dashed.
In an idealized world, a morning huddle will look at the schedule that lies ahead. See who’s missing necessary healthcare maintenance items, who’s overdue for disease specific testing, who had testing or a consult from an outside practitioner that needs to be entered in the current healthcare encounter for review by the clinician.
Who do we know is coming in for a preoperative evaluation, and we could set up the labs, chest x-ray, and EKG in advance of the session. We know who is coming in for their quarterly diabetes visit, and we can pre-order their point-of-care hemoglobin A1c, a visit with the diabetes educator, and time with the nutritionist. Who do we know is coming in needing a refill of a controlled substance, which would require us to pre-visit the New York State monitoring system to check on their recent prescription history.
The economies and efficiencies will ultimately make this pay off for everyone involved, but getting all the pieces of the puzzle together is going to take some doing.
In this idealized world, we know this will make us more efficient caregivers, make the patient experience at the office visit better, and hopefully lead to better care, more thorough and comprehensive care, and help make sure that things don’t slip through the cracks.
In an idealized world.
Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at Building the Patient-Centered Medical Home.