Glendale Pediatrics is a nine-clinician pediatric group practice. The practice serves a largely middle-class suburban population and prides itself on the provision of preventive services. One of the physicians recently attended a continuing medical education program on preventive services. Upon her return, she decided to assess the practice's performance in this area. She and the other physicians were surprised when she distributed the results.

Among the findings were the following:

Sixty percent of children were behind schedule in at least one immunization.

Vision screening was conducted and recorded for only 15 percent of children.

Fifty percent of children were screened for anemia.

Twenty-five percent of children had their blood pressure recorded in the patient record.

Thirteen percent of children were screened for lead.

While the pediatricians were bewildered by these findings, the medical record and nursing staff found them consistent with their impressions. The findings were presented and discussed at the monthly staff meeting. Two physicians who together saw about 40 percent of all patients were adamant that their patients were current in their preventive services, and there was no need for a practice-wide effort to improve their preventive service rates. Unfortunately, the data were not linked to individual physicians and thus there was no way to verify their claim. Nonetheless, it was agreed that staff, including the two reluctant physicians, work as a team to address the problem.

The first meeting was scheduled over the noon hour. One of the physicians arrived at 12:20 while two others left early at 12:45. One of the nurses was out sick. No decisions were made, and the entire meeting was spent attempting to find a date and time for follow-up meetings.

At the next meeting, one physician stated that during an acute visit, physicians do not have time to go through the medical record to determine if a patient was behind on any preventive services. The other physicians agreed and decided that an electronic form should be developed listing all preventive services, and this should be linked to the electronic medical record. The nurses worked together after the meeting to design the form, known as the Preventive Services Chart (PSC).

When the physicians saw the form, they indicated that it was poorly designed. Not all relevant services and immunization schedules were included. The form was eliminated, and the physicians asked the nurses to redesign the form. The nurses consulted with the physician who attended the continuing education seminar to obtain information on the recommended preventive protocols. Based on this information, the form was redesigned with the immunization schedule and other information added. Confident that this was the right form, the new electronic form was rolled out.

When presented to the physicians, it was discovered that there was little agreement

among the physicians, and an argument broke out at the next meeting about the immunization schedules and protocols for screening.

After this meeting, one of the nurses in consultation with two physicians developed yet another form with separate columns for each physician's preventive services preferred protocol. The medical records staff, hearing about this new procedure informally over lunch, was skeptical about its feasibility. Moreover, when one of the nurses asked a physician when nurses would record this information, she was told that "nurses have it too easy in this practice . . . you have a great deal of downtime, and you certainly can find time to prepare charts for the next day's patients."

During the next three weeks, the following events transpired:

1. Nurses complained to the physicians that medical records staff were not making records available to them in time to do the preventive services review.

2. Medical records staff complained to the physicians that nurses were unrealistically requesting the next day's charts at 9:00 a.m. so that they could spend the day preparing for the next day's patients. They also reported that nurses were rude in their requests.

3. Physicians complained among themselves that preventive services information was absent for almost half of the patients, and they suspected that the information was inaccurate for a significant number of cases for which information was provided.

4. Nurses were spending an additional one to two hours in the office preparing for the next day's patients. They requested, and were denied, overtime pay.

5. Confusion was rampant when files were prepared for one physician, but another physician ended up seeing the patient. An even more difficult problem was caused by drop-in patients, for whom record reviews were not prepared. Nurses spent up to 30 minutes looking over these drop-in charts and recording the information on the PSC.

6. Two weeks after the system was implemented, one nurse quit abruptly at 3:00 and walked out.

7. One physician gave each parent a hard copy of the PSC and asked parents to record preventive services themselves since the physicians were "too busy to keep track of this."

After a month, the team met again. The physicians decided that the "solution" caused more problems than it solved. They decided to disband the team and work on the preventive services problem individually.

 

Identify areas where the team went wrong and became unsuccessful. Please help construct a format that would have been successful in addressing the issues found.