Arthritis & Rheumatism, Volume 63,
November 2011 Abstract Supplement

Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Chicago, Illinois November 4-9, 2011.

A Clinical Microsystem Analysis of An Academic Rheumatology Practice Is High-Yield for Identifying Improvement Opportunities.

Riblet,  Natalie B., Zbehlik,  Alicia J., Cheung,  Yvonne Y., Albert,  Daniel A.


The objective of this project was to complete a microsystem analysis of the Division of Rheumatology at Dartmouth-Hitchcock Medical Center (DHMC) as a basis for continual quality improvement work. We focused primarily on access and sufficiency of staffing as these problems are shared by many Rheumatology practices.


The Division of Rheumatology at DHMC is a referral-based, academic medical practice located in a tertiary care center in rural New Hampshire. In April and May 2011, we performed a detailed analysis of the Division of Rheumatology using a clinical microsystems approach. Data was obtained from the computerized Hitchcock Database Reporting System, a review of medical records, staff surveys and directly observations of routine clinic processes. Qualitative analysis included patient and staff interviews and a round-table discussion.


Our findings indicate that access to the Division of Rheumatology is poor, with third next available new appointment being 107 days on May 1, 2011. Access acutely worsened with the introduction of a new electronic health record (EHR) in April 2011 from a baseline of 81 days on March 27, 2011. Stratified analysis of third next available appointment by staff provider clinical full time equivalent showed no statistically significant variation from the mean. Of approximately 12,500 patients seen annually, almost 3500 appointments were cancelled during 2010. Of these cancellations, 63% were due to inconvenient time or date. The initiation of an exit secretary to include patients in the scheduling process in January 2011 decreased the cancellations due to inconvenient day or time to 58%. Practice patterns included a lower than benchmark new patient to established patient ratio (17% DHMC vs. 38% benchmark), and fewer nurses per provider than Medical Group Management Association (MGMA) benchmarks (0.03 DHMC vs. 0.49 benchmark). Only one fifth of providers who responded to a survey during this time frame felt they had adequate nursing support. Clinic efficiency was negatively impacted by insufficient communication, providers leaving exam rooms to obtain paperwork and prescriptions, and lack of "huddles" to anticipate bottlenecks in flow. Formal data collection, analysis and display are not currently integrated into the daily work of the practice.


This analysis identifies multiple opportunities for improving access and work flows within the Division of Rheumatology at DHMC. Contextual factors such as adopting a new EHR may adversely impact patient access, at least temporarily. Interventions that include patients in the workflow such as an exit secretary may decrease redundant work. Incorporating meaningful use measures into the EHR's daily workflows may facilitate continual improvement and enhance patient care and outcomes. Access may be improved by adopting open access and patient initiated scheduling models. Microsystem analysis may benefit other Rheumatology practices by identifying high-yield targets for improvement and engaging stakeholders in improvement efforts.

To cite this abstract, please use the following information:
Riblet, Natalie B., Zbehlik, Alicia J., Cheung, Yvonne Y., Albert, Daniel A.; A Clinical Microsystem Analysis of An Academic Rheumatology Practice Is High-Yield for Identifying Improvement Opportunities. [abstract]. Arthritis Rheum 2011;63 Suppl 10 :2051

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