A guest column by the American College of Physicians, exclusive to KevinMD.com.

It’s been several years since we transformed our practice into a patient-centered medical home and started to truly work as a team. As I’ve written before, working as a team is one of the biggest reasons for my practice satisfaction increasing over the past few years.

While I am more satisfied with my practice than I have been in a long time, I would not say that practicing in this new model is without its frustrations. One of them has been the effort to standardize office processes and procedures. Most practicing physicians reject the development of “standardized” ways of doing things as being more appropriate for factory assembly lines and counter to the principles of individualized care that are the core of the patient-physician relationship. As a result, there can be tension between practice administrators who seem to want to standardize everything in the name of efficiency and reducing variability, and physicians and their support staff who want to do things their way.

In our practice, we’ve managed to navigate these waters by standardizing those processes that it makes sense to standardize and leaving the rest alone. So while we all need to enter tobacco use histories in the same field in our EHR, documentation of data that is not “mined” for reporting is left up to the physician. Referrals, from sending the request, recent office notes, and labs to tracking whether the patient showed up are handled in the same manner by medical assistants (MAs). All of us are expected to do pre-visit planning, but how it is done by each team varies slightly.

The importance of the team and the role of standardization hit home for me a few weeks ago when my MA went on leave for three months. We’ve worked together for a few years, and without a doubt, she has been my right hand (actually my left hand since I’m left-handed). My office manager refers to us as a “well-tuned machine,” and I have to agree. When I decide that I need something, more often than not she’s already working on it before I ask. My patients feel comfortable with her being their point of contact and communication with me.

Faced with the loss of my MA, I worried about whether I would have to do things that I had long ago delegated to others. Fortunately, one problem that I did not have was finding a replacement MA. While we can’t afford to overstaff our office, it is large enough to allow us some flexibility in how staff members are deployed. The bigger question was not whether I would have help – it was would I still have a “team”?

Fortunately, I did. This is where standardization came in. I did not have to “break in” my fill-in MA, a long-time staffer who was well-versed in our standard procedures and very capable of learning how I do the things that are not standardized. In fact, my regular MA spent a half-day teaching her my various quirks (I’m surprised she got it done in only a half day). While I don’t have the almost telepathic team that I’m accustomed to, I am still getting my work done as efficiently and hassle-light as I was before, to a great extent because most of the functions that were delegated to the MAs as part of our team-based model were amenable to standardization.

How relevant is this to the ultra-small practice, where getting staff to fill in for leaves, vacations, and resignations is a major headache? I think that much of it can be applied. Reviewing all the tasks that members of the staff perform and identifying the ones that can and should be standardized and which ones can be left to the individual is a good start.

Examples of tasks that might be standardized include:

• How non-interfaced labs results that you are tracking are entered into the EHR.
• How standing orders for flu immunization are handled.
• How medication refill requests are processed.
• What the MA does when he or she brings a patient into the exam room, such as obtain vital signs, medication reconciliation, and depression screens.
• How patients on warfarin are managed and monitored.

What are the lessons here? First, standardization of office processes and procedures is not incompatible with the “personal touch.” While each team member brings something unique to the team and the patients it serves, the ability to seamlessly reconfigure teams when necessary is valuable and does not diminish that uniqueness. Second, when “team-based care” is more than jargon, the importance of all members of the team, regardless of their title, license, or level of training, transcends being “just another body” to get things done. Finally, having a set of standard policies and procedures, while important, is not enough – members of the team must communicate, so each understands what the other expects of them and to allow the team to be more “personal” to patients and team members. This promotes greater provider satisfaction, one of the four components of the “quadruple aim.”

Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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