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The Prema House experience…… the evolution of the practice team |
 Kingsley Pearson and his solo practice have taken an extraordinary journey in the last 18 months. Since joining the collaboratives program and introducing change management principles to the practice, he has been able to reopen his books, closed for nine years, and Prema House is now a three doctor practice.
What has happened at Dr Pearson’s practice may well have occurred without the collaboratives initiative, albeit more slowly but the program certainly provided the impetus and the structure for change.
“It was about changing my mindset – it opened me up to the need for and possibility of change and got me out of mindset of being constantly reactive to what was walking through the door,” Dr Pearson said.
The collaboratives showed him how to conduct a short term mini research program on his practice and how to adapt his appointment capacity to meet patient demand.
“You know the process really doesn’t take long and the changes can have an enormous impact. I really have become a believer in change – it has been an amazing journey,” he said.
Both the Prema House experience and the DVD in which Dr Pearson outlined his experiences were showcased again in the recent Melbourne workshop. The DVD has also been used in the Canadian collaboratives orientation to demonstrate how the collaboratives can work to effect considerable change.
Some of the problems Dr Pearson faced in Prema House included a large number of patients with chronic illnesses taking up practice capacity. Waiting times were excessive (40–60+ mins) and there was a 7-10 day delay for routine appointments.
Staff members were stressed by the relentless demand for appointments and having to say no to new patients. Dr Pearson was stressed because he was constantly running behind time.
Most of the solutions implemented in Prema House were designed and acted upon by Dr Pearson’s staff. Initial changes included the introduction of the 12 minute slip explaining to patients how to keep the practice running on time for everyone’s benefit; measuring actual demand for certain services such as flu vaccination; and the introduction of targeted locum practice nurse run clinics (fluvax/pneumovax, diabetes and healthy heart clinics) using Practice Staff Locums, the locum service arm of the division (see PSL for more information).
The overall effect of these two changes radically changed the practice and created a less stressful workplace for all. Quite simply, the waiting room unloaded, the “pressure cooker” feeling in the practice evaporated and the practice re-opened its books. Furthermore, patients were able to access an appointment within two days, with urgent patients always accommodated on the day.
Another plus was that patients welcomed the changes and felt part of the solution.
“We all felt more in control over the practice and that change was a good thing - even me! By June 2005 the whole practice felt balanced.”
However, patient demand soon surged through combination of a week’s holiday, winter illnesses, and the reopened books.
Dr Pearson decided to reexamine the patient demand and, implementing access measures learned at the collaboratives workshops, he quickly saw that 5% of Prema House’s diabetes and CHD patients were taking up 15% of the practice capacity. To free up demand he needed to try to reduce these visits to 2-3 a year. To help do this, he decided to employ a practice nurse.
The practice nurse role quickly evolved to that of a chronic disease practitioner who organised team care arrangements and liaised with the practitioner network. She and the chronic disease patient set patient goals and she acted as an ongoing motivator. She coordinated case conferences, and initiated home medicine reviews and recalls for SIP cycles, chronic care clinics, health assessments, as well as fulfilling traditional clinical roles.
The impact the CDP/PN has had on freeing up appointments can also be seen by the following reduction in visits. In the 11 months to July 2006, the average number of diabetes visits was reduced from 8.2 to 5.2 visits and the average number of coronary heart disease visits was reduced from 9.1 to 5.6 visits.
The changes have freed up to 20% of Dr Pearson’s appointment capacity.
A few headaches along the way…
It was not all smooth sailing. In late 2005 Dr Pearson was forced to close his books again as demand for appointments (200+ a week) began to exceed the capacity of the combined GP and PN appointments of 170-180 a week. This was due to a GP workforce shortage in Lismore and the inability to attract a second GP to the practice.
Serendipitously a highly qualified Canadian doctor who had previously worked for some years in Australia expressed interest in joining the practice. Dr Pearson set about negotiating the “tortuous path” to getting Area of Need Status approval. After a lengthy bureaucratic application process (application to approval took four months), Dr Rita Vinten was finally able to join the practice in May. Since then Prema House has re-opened the books and is again able to take appointments on the day.
“The change has been phenomenal. Once you open the door to change it seems to keep rolling on. We have just expanded further to include another GP, practice nurse and receptionist and our patients no longer have an access problem. What could be better than that?”
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