Northwest Family Physicians, a family medicine-focused medical group in the West Metro, was highlighted twice in December as a high-performing practice. They were highlighted by a Stanford Medicine/Peterson Center on Healthcare study as one of 11 highest performing primary care medical groups nationally for providing high-quality, low-cost care. They were also one of the lowest-cost medical groups in the inaugural release of MNCM’s Total Cost of Care report.
The Stanford study identified 10 features that high-performing primary care sites had in common, including physicians adhering to quality guidelines and choosing tests and treatments wisely; in-sourcing some needed tests and procedures; say close to patients after referring them outside the group; close the loop with patients after hospital discharges; maximize the abilities of staff members; and balance physician compensation between service volume and quality or utilization goals.
To learn more about how Northwest Family Physicians achieved this success and how they want to continue, we talked to Dr. James Welters, Northwest’s President and Chief Medical Officer.
Q: You don’t achieve this by accident. How long has Northwest taken a very active, focused approach to making care affordable for its patients, and where did that start? Was it a groundswell or did it start from the top?
We’ve focused on providing low-cost, high-quality care for over 20 years. It was part of the early capitation models, which focused on maintaining low cost care. And very early on, our leadership pushed for utilization management, generic drug use and other low-cost options.
Our first continuous quality improvement project was in 1995 and focused on patients with diabetes. We found that it’s often little things that make a huge difference. Diabetes patients would come in for something unrelated – a cold or the flu – and the staff working with them wouldn’t connect the fact that they had diabetes and were, perhaps, overdue for some tests.
This was back in the paper chart days. So we did something very simple – we changed the color of the chart. Every patient coming in who had diabetes got a pink chart. That alone made a huge difference in our quality of care – no matter what they came in for, we were able to talk to them about how they were managing their diabetes. We extended that idea to other conditions, as appropriate.
The other thing we focused on at that time was that the physician can’t do it all. Everyone has to be involved is providing high-quality care. Along with the pink charts, everyone was involved. The front desk saw that chart and could attach a check list about what tests the patient needed. The nurses or lab technicians were empowered to order those labs even before the doctor had seen the patient. And so on. Everyone had to be involved.
Q: How did you build an internal culture that was focused on delivering high quality, low cost care? How did you get buy-in from physicians and staff?
We have a very intentional culture. We’ll never stop improving. Even if we’re ranked highly in certain areas or by certain organizations, that’s not always where we want to be internally. For example, our original Optimal Diabetes Care score many years ago was in the low teens, but was one of best in the state at the time.
One advantage to being a smaller medical group is that buy-in for that vision can be easier to attain. There’s more accountability. When you’re an owner of the group, you have to step up. That spreads down to staff, and then we need to make them feel empowered to make decisions that support that culture. There’s also an element that’s continuity: five of our physicians have been here for 20 or more years.
About 10 years ago, we participated in some Institute for Clinical Systems Improvement (ICSI) workgroups about creating a culture of quality. We brought back ideas and began to talk to our staff about them. We meet with all physicians and staff on a regular basis, and those meetings focus on providing high-quality, low-cost care amongst other things.
We also began a quality bonus program five or six years ago. The goals are set at the beginning of the year – they might be based on MNCM, SQRMS (the Minnesota Department of Health’s Statewide Quality and Reporting Measurement System) or internal metrics. We choose goals that have lots of staff input and control, and we focus on both goals to achieve a number and improvement goals.
If the clinic hits the target, everyone in clinic gets a bonus – from the front desk to the business office. We used to do provider bonuses, but that didn’t inspire the teamwork we wanted. This program has been very motivating, especially at end of year when a clinic is getting close to hitting a mark. The numbers are posted monthly for all staff to see, so everyone knows where they’re at and what needs to be done.
Q: How did you involve patients in your efforts?
As an independent primary care group, we listen closely to both our patients and what our internal staff have to say about the services we’re providing. We ask ourselves what else we can do. And the biggest thing we’ve heard all around is to provide services at lower cost.
We began doing patient surveys long before they were required. We also review patient complaints at a regular multi-disciplinary meeting and consider what adjustments we might make to our processes to address them.
Additionally, the major committee within our medical group that helps design the day-to-day experiences and processes is also a multi-disciplinary group that has included a patient representative for the past five years. We also have a patient advisory council that meets every other month.
Q: What are a few examples of tangible changes you’ve made that other medical groups could consider trying out in their practices?
As much as possible, deal with as many things the patient needs in a single visit. It reduces cost, is more convenient for the patient and reduces the chance that the patient doesn’t make another visit. The cold is never just a cold. It’s the reason the patient contacts us, but we use that opening to say, let’s look at what else you need. The same thing goes for with labs, radiology or pharmacy. Do it that day if possible.
To further that idea, our group has physicians who have enhanced their skills so we can provide more tests and procedures in primary care that might otherwise be referred out. We have physician who are trained to do stress echocardiograms, allergy testing, colonoscopies or endoscopies, laryngoscopies and skin removals. Our physicians get educated and trained on these procedures, and then share the knowledge. Patients have told us they prefer to get the treatment at our clinics – it’s more convenient and they’re more comfortable. And there is a huge difference in cost. There is no facility fee, so it’s generally less than half the price to do them in the office. We’ve also seen higher rates of quality and patient satisfaction since we began doing that, such as higher rates of our patients getting colonoscopies.
We have also tried to use our electronic medical record to the fullest extent possible. We have lots of pop ups and messages that remind staff when a patient is due for something. We also produce monthly reports by provider for which patients are due for preventive care or tests, and we contact them ahead of time – not when they’re already late. The front desk, nurses and lab staff are all involved in that process. If a patient calls in for a prescription refill or other purpose, these reminders allow us to catch them and get them scheduled to come in for that care.