Focusing on Performance Improvement Methodology in Primary Care

Namita Azad, MPH, MS

Montefiore Medical Group has managed to not only provide its patients better care, but it has shortened wait times for its patients, minimizing the amount of time they spend not receiving care at the doctor’s office.

While it recently received a Level 3 patient-centered medical home (PCMH) certification for its primary care centers, one of the highest in the nation, Montefiore has not stopped there, seeking to continue to improve its primary care delivery beyond that accreditation.

It has done so, according to Namita Azad, MPH, MS, a system transformation manager at Montefiore, by homogenizing its care and streamlining its patient throughput. The group’s primary care offices were met with nearly 900,000 patient visits in 2017, across 22 centers, and despite the volume, the offices have managed to reduce wasted patient minutes by 7.6% through efforts to streamline and shore up patient throughput—all while involving the patients in the process, something recommended by the National Committee for Quality Assurance (NCQA), which grants the PCMH certification.

“It’s a huge deal. Even a reduction from 5% to 10% results in many minutes saved,” Azad told MD Mag. “Before we begin any throughput changes, we need input from the patient. Every practice has a patient advisory council, where we make patients a part of the process.”

It’s helped not only the patients but the staff as well. “We got anecdotal feedback from the frontline staff, and across the board, we got positive responses,” Azad said. She noted that due to pre-visit planning sessions and improved follow-up, the providers feel more comfortable and prepared for visits.

Azad said that one of Montefiore’s primary goals is standardizing the care it provides to the patient. With more and more health systems growing larger, the little things in patient care can often get swept to the side. Maintaining that focus has been a point for Montefiore, and it’s been something that Azad attributes to simply following the recommendations from the NCQA for the gold-standard PCMH.

“As a result, we’re becoming more efficient with care and our proficiencies have become more streamlined,” Azad said. “A lot of the changes that reduced the time patients spend [on visits] was a result of pre-visit planning and follow-up post-visit. Doing that is a direct guideline from PCMH standards.”

But Montefiore tries to take it a step further by homing in on its patient-centric care. As medicine trends to a holistic approach, focusing on treating “the whole patient,” the trend in the Bronx-based medical system has to extend to primary care. “If they come to see their primary care provider, we’re talking with them about what happens outside the clinic, too,” Azad said.

For Azad, what sets truly Montefiore apart from other institutions is its commitment to process improvement. While it has become a trend in health care for institutions to provide process improvement strategies, she hasn’t seen it approached the way it is at Montefiore anywhere else.

“We have a system-wide fellowship that trains frontline staff on how to do performance improvement,” Azad said. “We train staff—we have quarterly learning collaborations, and a critical mass [of providers] have been trained here to do performance improvement. The application of that to everything that we do here sets us apart. We’re training frontline nurses, providers, clerical staff—really everyone.”

Montefiore Medical Group has practice transformation coaches, who are involved in daily process improvement exercises and coach frontline providers on ways to streamline primary care. At a system level, the Montefiore Institute for Performance Improvement also provides a 1-year intensive fellowship course from which a number of Montefiore Medical Group associates have graduated. “That’s the foundation of our improvement work,” Azad said.

In addition, the medical group hosts quarterly transformation collaboratives, where more than 200 people in the medical group come to learn about specific performance improvement methodologies. They deliver didactics and simulation exercises, all revolved around learning a specific methodology to improve the care they provide.

The focus on these improvements appears to be working, too. Paula Gonzalez, a Bronx resident and founder of Miss Gunday's Foundation, who—along with her 5 children—receives care at Montefiore, said in a statement that "they take each patient's care personally. You go in, you get undivided attention—and you truly feel taken care of."