IHP 505 Module 9 Final Project Example

Same-Week Access at Northgate Family Medicine: A Clinical Microsystem Improvement Proposal

[Student Name]

Southern New Hampshire University

IHP 505: Leadership in Clinical Microsystems

Module Nine Final Project

[Instructor Name]

[Date]

Same-Week Access at Northgate Family Medicine: A Clinical Microsystem Improvement Proposal

Executive Summary

Patients of Northgate, the composite family practice with some 11,000 people on its panel, wait an average of 28 days for the third next available routine appointment, loses 19% of appointments to no-shows and is losing staff to burnout and turnover. This proposal redesigns access through advanced access scheduling and team-based care, coordinated by a daily huddle and led in ways that build trust and protect staff. The target is a one-week wait or less for the third open appointment and a no-show rate of 12% within nine months, while cutting after-clinic documentation in half.

The Microsystem and Its Problem

Nelson et al. (2008) describe clinical microsystems as the front-line building blocks of health systems, each with its own aims, processes, information and results, and capable of improvement when its members study their work together. Northgate's assessment found access at the center of a reinforcing cycle: long waits lead to missed appointments and urgent care visits, squeezed-in same-day patients overload clinicians and medical assistants, overload drives after-hours charting and turnover and turnover slows every process further. Daily demand averaged about 190 requests against about 175 available slots, with more than a thousand future visits already clogging the schedule.

Evidence Base

Murray and Berwick (2003) showed that waits in primary care usually stem from backlog, day-to-day mismatch between supply and demand and fragmented schedules rather than too few clinicians, and they described a set of principles for reaching same-day or same-week access. Rose et al. (2011) systematically reviewed advanced access studies and found that waits usually fell and no-shows sometimes fell, while effects on satisfaction and continuity were mixed and study designs were weak. Bodenheimer and Sinsky (2014) argued that care of patients requires care of the care team, recommending shared team roles, pre-visit planning and reduced documentation burden. Together, the evidence supports advanced access paired with team-based care and careful measurement of both access and staff experience.

The Redesign

The redesign has four parts. Scheduling moves from seven appointment types to two, with about 60% of slots held open until the current week and contingency plans for predictable peaks. Team roles expand: medical assistants take on pre-visit planning and standing orders for refills and preventive care, and the nurse care manager takes over stable chronic disease check-ins by telephone. Teamlets pair each clinician with a stable medical assistant and a named front-desk contact. And patients are told plainly that routine visits can now be booked within the week.

Coordination Through a Daily Huddle

Provost et al. (2015) found that huddles help health care teams manage complexity by surfacing problems early and strengthening relationships. A ten-minute whole-team huddle before the first patient each day walks through today's openings against likely demand, calls out patients who need things readied, checks who is out and invites problems, with yesterday's access and no-show numbers on a whiteboard.

Implementation Phases

Months one and two prepare the clinic: templates change, refill and result work shifts to the team and each change is tested with one clinician or teamlet before spreading. Months three through five work down the backlog through paid, volunteer extra sessions and outreach to patients booked far ahead. From month six, open access begins, with weekly measurement guiding adjustments. Each change is tested in small cycles with written predictions.

Table 1. Aims and Measures

Note. Figures are illustrative for the composite clinic.

Leading the Change

Staff trust is a precondition. With only 38% of staff comfortable raising concerns, the practice manager commits to observable behaviors: asking front-line staff first at huddles, responding to every concern within two days, admitting mistakes openly and removing a task for every task added. A relational coordination survey found the front desk's connections to other roles weakest, so front-desk staff have a standing huddle agenda item and a representative on the design team.

Protecting Staff Well-Being

Because burnout already affects four of nine clinicians and turnover is high among medical assistants, the plan measures well-being by role every quarter, lets each role choose one work-life problem to fix, funds a protected daily hour for each clinician's paperwork from visits saved through team-based care and pauses backlog work if well-being scores fall for two consecutive months. Medical assistants taking on new responsibilities receive training and a pay adjustment.

Evaluation and Learning

The population health analyst will produce a weekly access dashboard showing third next available appointment by clinician, no-shows, backlog and same-day requests met, plotted as run charts with each change marked. Monthly, the design team will review balancing measures, including documentation time, overtime and continuity, and the quarterly well-being survey. Patient experience scores for ease of getting appointments will be reviewed each quarter by language. At nine months, the team will present results to the health system's primary care leadership, including what did not work, so other clinics can learn from Northgate's experience.

Budget

Costs are modest: about 60,000 dollars for extra backlog sessions, 12,000 dollars for medical assistant training and pay adjustments in the first year and minimal costs for templates and whiteboards. Savings come from recovered no-show capacity, fewer urgent care referrals under the health system's value-based contracts and lower turnover, each medical assistant replacement costing an estimated 8,000 dollars in recruiting and training.

Limitations

Evidence on advanced access comes mainly from before-and-after studies, and few studies examine clinics with Northgate's Medicaid and language mix. Some burnout drivers, such as electronic record design and pay scales, lie outside the clinic's control. The evaluation compares Northgate with its own baseline, so external changes could influence results.

Conclusion

Northgate's access problem is a microsystem problem, and its solution must come from the microsystem: a team that measures its own demand and supply, shares work, coordinates daily and is led in ways that earn trust. If the plan succeeds, patients will see their own clinician within the week, and the people caring for them will go home on time.

References

Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires care of the provider. Annals of Family Medicine, 12(6), 573-576. https://doi.org/10.1370/afm.1713

Murray, M., & Berwick, D. M. (2003). Advanced access: Reducing waiting and delays in primary care. JAMA, 289(8), 1035-1040. https://doi.org/10.1001/jama.289.8.1035

Nelson, E. C., Godfrey, M. M., Batalden, P. B., Berry, S. A., Bothe, A. E., McKinley, K. E., Melin, C. N., Muething, S. E., Moore, L. G., Nolan, T. W., & Wasson, J. H. (2008). Clinical microsystems, part 1: The building blocks of health systems. The Joint Commission Journal on Quality and Patient Safety, 34(7), 367-378. https://doi.org/10.1016/S1553-7250(08)34047-1

Provost, S. M., Lanham, H. J., Leykum, L. K., McDaniel, R. R., & Pugh, J. (2015). Health care huddles: Managing complexity to achieve high reliability. Health Care Management Review, 40(1), 2-12. https://doi.org/10.1097/HMR.0000000000000009

Rose, K. D., Ross, J. S., & Horwitz, L. I. (2011). Advanced access scheduling outcomes: A systematic review. Archives of Internal Medicine, 171(13), 1150-1159. https://doi.org/10.1001/archinternmed.2011.168