Streamlined military workflow produces more patient appointments with fewer return visits

Both patients and physicians may benefit from a workflow system developed at military medical facilities and tested at a cancer center clinic, according to results of an efficiency study.

Called the Military Acuity Model, the method examines tasks performed by physicians and nurses and identifies jobs that can be safely assigned to support staff. The team, located at Johns Hopkins Kimmel Cancer Center clinic in Baltimore, Maryland, studied the model by applying it to activities involving 139 patients seen by oncologists at the Cancer Center's outpatient pancreatic cancer clinic.

The study evaluated a work flow method developed by the US Air Force; Johns Hopkins researchers Shereef Elnahal, MD, MBA, and Joseph Herman, MD; and consulting firm ProcessProxy Corporation.

The goal, the researchers reported in the Physician Leadership Journal (March 2015; pp 56-65), was to identify critical tasks that, if missed or mishandled, would cost patients and physicians time or lead to avoidable symptoms and emergency room visits.

“The fight against cancer is not only a biological one,” said Herman, the clinic's director and associate professor of radiation oncology and molecular radiation sciences at the Johns Hopkins University School of Medicine. “It also requires getting patients involved in treatment decisions and making care convenient, safe, and affordable for patients, and this is where I felt like we could improve.”

“The care we were providing was great, but we were limited by the number of patients we could see.”

The new workflow system, Herman said, helps the clinic see more patients and reduces some redundant and time-consuming work performed by oncologists. At the same time, the changes have helped patients avoid return visits to the clinic and emergency room for preventable problems.

Specifically, the clinic increased its daily patient volume by 31.4%, from an average of four patients per day to five patients per day. During the clinic's busy season, from January to July, doctors in the clinic saw 10 patients per day with the new workflow in place, up from five patients per day.

In the 30 days after patients' clinic visits, the percentage of patients who needed to call the clinic after their visits to discuss unresolved health issues decreased from 34% to 22%. The percentage of patients who had to go to the emergency room after their clinic visit also decreased, from 9.9% to 7.9%.

Led by Johns Hopkins radiation oncology resident Elnahal, the team identified six critical tasks that were reallocated to support staff, including the collection of pain assessment scores the morning of the clinic, assigning patients to specific doctors based on the patients' stage and comorbidities, and ensuring patients came to the clinic with the most up-to-date medical imaging.

“This allowed physicians to make treatment decisions faster and more confidently on the day of the clinic, affording them more time to address patients' symptoms and concerns,” said Elnahal.

The method used an existing two-member support team who managed these tasks, in addition to addressing social risk factors, such as substance abuse and insurance barriers.

“We are learning everything we can about patients before they walk in our door,” said Herman. “In the past, we would see patients in our clinic, look at their records, and then figure out what they need. It makes much more sense to properly triage people in advance, and that's what Dr. Elnahal's system does so well.”

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