Process, process, process

When cardiologist Doug Morris was named CEO of the Emory Clinic two years ago, he told colleagues that to respond successfully to the transformations occurring in medicine, "we must mimic the space industry and other modern industries that combine high risk and complexity." That means, he continued, moving from the heroic, test pilot model of a reputational physician (think Chuck Yeager in a white coat) to one of an astronaut, not only equally talented and dedicated to patients but also a team player who can develop and adhere to medical protocols. Those protocols are important because they can improve consistency of care, eliminate errors, and lower costs.

That's where the fighter pilots come in. The Emory Transplant Center first brought the Afterburner, Inc. consulting team on board for help in fine-tuning reliability of performance and adherence to protocols. Transplantation and subsequent lifelong therapy to prevent transplant rejection depend on complex treatment plans involving a team of surgeons, physicians, nurses, and other clinicians. In the transplant world, there is no time for delays, no room for mavericks, no excuse for not collecting and using data for continuous improvement.

With coaching from the Afterburner group, Emory's team learned to approach the care of patients like fighter pilots who "execute missions in the most hostile environments on earth." They followed a detailed cycle of planning, training, briefing, executing, and debriefing (What went right? What could have gone better?) and then revamped plans accordingly, re-training and beginning the cycle all over again. Processes are continually monitored, always in evolution, better today than yesterday, not yet as good as tomorrow.

After seeing the success of the "flawless execution" technique in transplant surgery, the transplant section's leadership began applying the method to myriad, day-to-day operating procedures throughout the patient enterprise—answering phones, sending lab results to patients, and handling billing and dozens of other nitty-gritty details that can make a big difference in a patient's experience.

Penny Castellano, chief medical officer for clinical operations and chief quality officer for the clinic, says the approach is "intentional design to the max." Clinic and section leaders decide the outcomes they want and then design a process to make that outcome happen each and every time. For example, the core clinic team led by Castellano determined that checking in a patient for an appointment with maximum efficiency and patient satisfaction involves 10 steps. They rolled out the process and coached the front desk staff on adopting a new, electronically based workflow. Once the standard operating procedure went live, staff members became the clinic's own "Blue Angels," using the same brief-execute-debrief cycle that underlies the Navy pilots' precise aerobatic maneuvers.

The New York Giants give the Afterburners credit for helping them move from a struggling team to victory in the 2012 Super Bowl. "When we make a touchdown," says Castellano, "we improve the patient experience for thousands patients. That's exciting. That is quality improvement."

The issue of competence aside, "quality" once meant simply being nice and, of course, nice still matters. That's why every Emory Clinic staffer who will interact with the public, either face-to-face or by phone, not only is required to have a college degree and clearly defined, problem-solving skills but also has to complete an interview with Don Brunn, clinic president and chief operating officer, before being hired. ("Let's be honest," he says, "our old way of hiring and training didn't always work. This does.")

In more recent years, quality has evolved to a science that requires health systems to demonstrate processes and outcomes that signify best-practice activities. Accreditors and regulators (as well as payers) score health systems accordingly. In 2012, Emory University Hospital (EUH) ranked second in national University HealthSystem Consortium rankings for quality, and EUH Midtown sixth—marking the first time two hospitals in the same system have made the top 10 in the list. However, no such agency exists for ambulatory care. When it comes to setting up an infrastructure on which to build standard operating procedures, ambulatory care is pretty much uncharted territory, says Brunn. The Emory Clinic is out to change that.

Easier patient access

For decades, the Emory Clinic meant the familiar building on Clifton Road with the blue awning, which in time grew to include a second building, Clinic B, connected by tunnels and to EUH. The clinic also expanded to have a presence at EUH Midtown. In the 1990s, it was a big deal when primary care and orthopedics departments moved into separate buildings. Separate, but still nearby.

That's changing rapidly of late. At last count, the clinic now extends to 79 practices located in 30 different buildings. Most distant is the Emory Heart and Vascular Center of Middle Georgia in Dublin, population 16,201 (2010 figures), 150 miles from Atlanta. There, Emory Clinic cardiologist Martha Smith sees patients, 18 to 98 years of age, from Laurens and a dozen surrounding counties. Smith also spends one day a week in more rural Dodge County, where she grew up. Although patients still have to come to Atlanta for the most highly specialized care, some of that is changing too, thanks to telemedicine and clinicians who work with their off-campus colleagues. For example, Emory renal transplant clinicians hold a regular clinic in Smith's Dublin office, sparing patients the six-hour round trip to Atlanta. Look for more such changes, says Morris, as the clinic responds to the state's changing demographics and health care needs, and "we find new ways (and places) to make it easier for Georgians to access clinic services."

At the original clinic in Atlanta, ongoing renovations are making things better for patients and families. Some changes are subtle. Doors are wider, and exam rooms now have loveseats, making it easier for family members to sit. Patient and family advisers volunteer their time and suggest helpful changes in areas from signage to check-in instructions.

Other changes are more encompassing. Related disciplines—for example neurosurgery, orthopedics, and physiatry—work on one floor, making it simpler for patients to get their care in one day and one place. Not sure what a headache means? Gregory Esper's new general neurology program takes the intense focus on figuring out a patient's problem (think House, played by Marcus Welby) and marries it to Emory's broad strengths in neurologic diagnosis and care of some of the most highly complex, obscure conditions. All that takes place in nearby clinics.

The new plan isn't just about sites. It follows clinic doctors wherever they go. For example, as a hospitalist with a foot in two worlds of health care, Jason Stein focuses on improving ease of transition between outpatient and inpatient care. Clinic doctors who practice in the hospital, such as EUH emergency department (ED) director Matthew Keadey and Emory cardiologists have condensed the time from arrival in the ED to cardiac catheterization down to 40 minutes, one of the shortest anywhere in the nation. Simply getting older, like the rest of us? Thanks to Ted Johnson, the clinic's geriatricians now work in primary care sites, not just at Emory's Wesley Woods Center, the main campus for geriatric clinical services.

Going electronic

While Smith sometimes misses not running into her colleagues for a quick cup of coffee, medically they might as well be next door, thanks to phone, Internet, telemedicine, and, increasingly, the Emory electronic medical record, EeMR (pronounced ee-mer).

Once, like medical practices everywhere, physicians recorded the clinic's medical records by hand or dictated them after the patient left, each doctor adding new information, diary fashion, to the previously recorded history. Ideally, the file folder was retrieved from a records department and delivered to the next doctor's office before a patient arrived. However, having the file folder follow the patient got more complicated when sites expanded. Files usually jostled along by shuttles, and on more than one occasion, had to be rushed from site to site by taxi. And yes, sometimes a file went temporarily AWOL, leaving a frustrated doctor asking patients for the information that was in the missing chart.

The clinic began a rudimentary electronic record in the early 1990s, which evolved into EeMR, launched in 2005. At first, some clinicians, those of the hunt-and-peck variety on a keyboard, complained about the new computer-based process—but once they tried it, they never looked back. The advantages of instant, full access to a patient's medical history, lab results, even images, trumped tradition.

Going electronic also meant that physicians could send prescriptions directly to the patient's chosen pharmacy, saying goodbye to possible mistakes in interpreting handwriting and hello to automated checking for dosage errors or potentially harmful interactions.

At the end of 2012, a new access portal will allow patients to use a computer to fill out questionnaires, update medications, and securely ask questions.

Breaking (un)sound barriers

"Discovered here, practiced here, taught here" is the mantra of the Emory Clinic, and Emory's research arm gives patients access to expertise unavailable elsewhere in the region. For example, Emory clinicians are shaping new treatments from minimally invasive placement of heart valves to precisely targeted drug delivery to the retina to new approaches to multiple myeloma and lung cancer. Emory clinician Helen Mayberg is a pioneer in deep-brain stimulation for patients whose severe depression has failed to respond to other treatments. Stephen Warren, the world's leading expert in fragile X syndrome, the most common cause of inherited intellectual disability, directs the clinic's newest section in human and medical genetics.

The payoff in combining research and clinical practice is both immediate (with hundreds of clinical trials available) and long-range. "The team player approach to health care is changing the Emory Clinic for the good," says Morris, "but if somebody says he or she can do something better, then we test the premise. If it works, we implement it, and it becomes our new protocol. Whether for diagnosis, treatment, or delivery of health care, our goal is to keep breaking sound barriers."  EH

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