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Workflow Innovations to Enhance Well-being

First displayed as an interactive exhibit at Internal Medicine Meeting 2019, the resources below capture workflow innovations to improve and enhance physicians’ and medical teams’ well-being and professional satisfaction in both ambulatory and hospital settings.

Well-Being Exhibit IM2019
The Workflow Innovations exhibit at Internal Medicine Meeting 2019.

ACP aims to continuously improve and enhance well-being through innovative workflows. Please bookmark and continue to check this page for additional tools and resources. To peruse workflow innovations posted on social media, please visit the twitter topic #ACPWorkflow.

For questions, please contact the ACP Well-being and Professional Satisfaction team at acpwellbeing@acponline.org.


Legend for Resources

Level of evidence:

  • (***) published evidence
  • (**) tools available to help
  • (*) anecdotal evidence only

Relative cost:

  • ($) minimal time and money
  • ($$) moderate time and money
  • ($$$) major investment of time and money

General Exhibit References:

  • *** Linzer M, Poplau S, Grossman E, Varkey A, Yale S, Williams E, et al. A cluster randomized trial of interventions to improve work conditions and clinician burnout in primary care: results from the Healthy Work Place (HWP) study. J Gen Intern Med. 2015;30:1105-11. [PMID: 25724571] doi:10.1007/s11606-015-3235-4
  • ** Practice Advisor Module: Making the Case to Address Clinician Burnout (Free with registration through December 31, 2019)

What can we do before the ambulatory visit?

  • Previsit phone call/text/letter reminder *** $
    • Toscos T, Carpenter M, Flanagan M, Kunjan K, Doebbeling BN. Identifying successful practices to overcome access to care challenges in community health centers: a "positive deviance" approach. Health Serv Res Manag Epidemiol. 2018;5:2333392817743406. [PMID: 29552599] doi:10.1177/2333392817743406
  • Preregistration process for new patients ** $$
  • Managing patient and care team expectations * $
  • Scrub/prep charts ** $$

Ambulatory day of visit

  • Standardized room setup and stocking ** $
  • Team huddles ** *** $$
    • Provost SM, Lanham  HJ, Leykum  LK, McDaniel  RR  Jr, Pugh  J. Health care huddles: managing complexity to achieve high reliability.  Health Care Manage Rev. 2015;40(1):2-12. [PMID: 24589926] doi:10.1097/HMR.0000000000000009  

    • Team huddles tool

  • Team documentation, scribes ** *** $$$
    • Martel ML, Imdieke BH, Holm KM, Poplau S, Heegaard WG, Pryor JL, et al. Developing a medical scribe program at an academic hospital: the Hennepin County Medical Center experience. Jt Comm J Qual Patient Saf. 2018;44:238-49. [PMID: 29759257] doi:10.1016/j.jcjq.2018.01.001

      Ommaya AK, Cipriano PF, Hoyt DB, Horvath KA, Tang P, Paz HL, et al. Care-Centered Clinical Documentation in the Digital Environment: Solutions to Alleviate Burnout. NAM Perspectives. Discussion Paper. Washington, DC: The National Academies Press; 2018.

      Helfrich CD, Dolan ED, Simonetti J, Reid RJ, Joos S, Wakefield BJ, et al. Elements of team-based care in a patient-centered medical home are associated with lower burnout among VA primary care employees. J Gen Intern Med. 2014;29 Suppl 2:S659-66. doi:10.1007/s11606-013-2702-z

    • Risk mitigation tool for team documentation

  • Standing orders and protocols ** *** $
    • McCarthy BD, Yood MU, Bolton MB, Boohaker EA, MacWilliam CH, Young MJ. Redesigning primary care processes to improve the offering of mammography. The use of clinic protocols by nonphysicians. J Gen Intern Med. 1997;12:357-63. [PMID: 9192253]
    • Standing orders and protocols tool
  • Collaborative medication management ** $

Ambulatory post visit

  • Proactive follow-up scheduling * $
  • End-of-day huddle *** $$
    • Rodriguez HP, Meredith LS, Hamilton AB, Yano EM, Rubenstein LV. Huddle up!: the adoption and use of structured team communication for VA medical home implementation. Health Care Manage Rev. 2015;40:286-99. [PMID: 25029511] doi:10.1097/HMR.0000000000000036

      Stewart EE, Johnson BC. Improve office efficiency in mere minutes. Fam Pract Manag. 2007;14:27-9. [PMID: 17598631]
  • Prior authorization process ** *** $$
  • Previsit lab testing ** *** $$
    • Kabcenell AI, Langley J, Hupke C. Innovations in Planned Care. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2006. (Available on www.IHI.org.)

    • Previsit lab testing tool

  • Lab follow-up algorithms, communication (44% of diagnostic erros) *** $$
    • ​Schiff GD, Hasan O, Kim S, Abrams R, Cosby K, Lambert BL, et al. Diagnostic error in medicine: analysis of 583 physician-reported errors. Arch Intern Med. 2009;169:1881-7. [PMID: 19901140] doi:10.1001/archinternmed.2009.333

Ambulatory referrals to consultants

  • Referral checklist (urgency, clinical question, pertinent data sets) ** $$
  • Closing the referral loop ** $$
  • E-Consultation *** $$
    • Edwards HB, Marques E, Hollingworth W, Horwood J, Farr M, Bernard E, et al. Use of a primary care online consultation system, by whom, when and why: evaluation of a pilot observational study in 36 general practices in South West England. BMJ Open. 2017;7:e016901. [PMID: 29167106] doi:10.1136/bmjopen-2017-016901
  • Agreed communication plan *** $$
    • Tuot DS, Sewell JL, Day L, Leeds K, Chen AH. Increasing access to specialty care: patient discharges from a gastroenterology clinic. Am J Manag Care. 2014;20:812-9. [PMID: 25365684]
    • Varkey AB, Manwell LB, Brown RL, Montague E, Laiteerapong N, Burgess D, et al. Impact of work conditions and minority patient populations on quality and errors. Health Serv Res Manag Epidemiol. 2016;3:2333392815625997. [PMID: 28462273] doi:10.1177/2333392815625997

Ambulatory in-between visits

  • Postvisit phone call follow-up * $
  • Team in-basket management ** *** $$
    • Sinsky C, Colligan L, Li L, Prgomet M, Reynolds S, Goeders L, et al. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med. 2016;165:753-760. [PMID: 27595430] doi:10.7326/M16-0961

      Eaton P. Managing messages. Fam Pract Manag. 2012;19:25-9. [PMID: 22991907]

      Shanafelt TD, Dyrbye LN, Sinsky C, Hasan O, Satele D, Sloan J, et al. Relationship Between Clerical Burden and Characteristics of the Electronic Environment With Physician Burnout and Professional Satisfaction. Mayo Clin Proc. 2016;91:836-48. [PMID: 27313121] doi:10.1016/j.mayocp.2016.05.007

    • Team in-basket management tool

  • Population health monitoring ** *** $$
    • Montori VM, Dinneen SF, Gorman CA, Zimmerman BR, Rizza RA, Bjornsen SS, et al; Translation Project Investigator Group. The impact of planned care and a diabetes electronic management system on community-based diabetes care: the Mayo Health System Diabetes Translation Project. Diabetes Care. 2002;25:1952-7. [PMID: 12401738]
    • Population health tool (Free with registration through December 31, 2019)
  • Automatic notification of acute visits, hospitalization, and procedures *** $$
    • Unruh MA, Jung HY, Kaushal R, Vest JR. Hospitalization event notifications and reductions in readmissions of Medicare fee-for-service beneficiaries in the Bronx, New York. J Am Med Inform Assoc. 2017;24:e150-e156. [PMID: 28395059] doi:10.1093/jamia/ocw139

      Hunchak C, Tannenbaum D, Roberts M, Shah T, Tisma P, Ovens H, et al. Closing the circle of care: implementation of a web-based communication tool to improve emergency department discharge communication with family physicians. CJEM. 2015;17:123-30. [PMID: 25927256] doi:10.2310/8000.2014.141327

Ambulatory acute care

  • Same-day or walk-in visits *** $$
    • Glass DP, Kanter MH, Jacobsen SJ, Minardi PM. The impact of improving access to primary care. J Eval Clin Pract. 2017;23:1451-1458. [PMID: 28984018] doi:10.1111/jep.12821

      Degani N. Impact of advanced (open) access scheduling on patients with chronic diseases: an evidence-based analysis. Ont Health Technol Assess Ser. 2013;13:1-48. [PMID: 24133569]
  • Virtual visits *** $$$
    • Rohrer JE, Angstman KB, Adamson SC, Bernard ME, Bachman JW, Morgan ME. Impact of online primary care visits on standard costs: a pilot study. Popul Health Manag. 2010;13:59-63. [PMID: 20415617] doi:10.1089/pop.2009.0018

  • Triage protocols/algorithms (virtual triage) *** $$
    • Ansell D, Crispo JAG, Simard B, Bjerre LM. Interventions to reduce wait times for primary care appointments: a systematic review. BMC Health Serv Res. 2017;17:295. [PMID: 28427444] doi:10.1186/s12913-017-2219-y

      Murdoch J, Varley A, Fletcher E, Britten N, Price L, Calitri R, et al. Implementing telephone triage in general practice: a process evaluation of a cluster randomised controlled trial. BMC Fam Pract. 2015;16:47. [PMID: 25887747] doi:10.1186/s12875-015-0263-4

Transition from ambulatory to hospital

  • Consider outpatient treatment with close follow-up (infusion center) * $$
  • Facilitate direct admission process * $$
    • Leyenaar JK, Lagu T, Lindenauer PK. Direct admission to the hospital: An alternative approach to hospitalization. J Hosp Med. 2016;11:303-5. [PMID: 26588666] doi:10.1002/jhm.2512
  • Standardize communication to ED and admitting team $$

Hospital admission

  • Team building with ED and ambulatory staff ** $$
  • Standard order sets with periodic review and updating *** $$
    • Siekman N, Hilger R. High users of healthcare: Strategies to improve care, reduce costs. Cleve Clin J Med. 2018;85:25-31. [PMID: 29328897] doi:10.3949/ccjm.85a.16082

  • Set and follow communication guidelines between ED and hospitalist staff ** $$
  • Rapid access protocol and point person to assure patient admitted to the appropriate level of care (observation, floor, stepdown unit, ICU) *** $$
    • Howell E, Bessman E, Marshall R, Wright S. Hospitalist bed management effecting throughput from the emergency department to the intensive care unit. J Crit Care. 2010;25:184-9. [PMID: 19828284] doi:10.1016/j.jcrc.2009.08.004

  • Care plan for complex, frequently admitted patients *** $$
    • Howell E, Bessman E, Marshall R, Wright S. Hospitalist bed management effecting throughput from the emergency department to the intensive care unit. J Crit Care. 2010;25:184-9. [PMID: 19828284] doi:10.1016/j.jcrc.2009.08.004

Routine hospital care

  • Geographic assignment of patients and their care teams *** $$$
  • Team space that encourages clinical discussions about patients, minimizes interruptions * $$
  • Computerized order entry on rounds by team members (i.e., multidisciplinary rounds with nurse and pharmacist) *** $$
    • Monash B, Najafi N, Mourad M, Rajkomar A, Ranji SR, Fang MC, et al. Standardized Attending Rounds to Improve the Patient Experience: A Pragmatic Cluster Randomized Controlled Trial. J Hosp Med. 2017;12:143-149. [PMID: 28272589] doi:10.12788/jhm.2694

      Knoer SJ, Pastor JD 3rd, Phelps PK. Lessons learned from a pharmacy practice model change at an academic medical center. Am J Health Syst Pharm. 2010;67:1862-9. [PMID: 20966152] doi:10.2146/ajhp100210
  • Structured care management rounds with interprofessional team *** $$
    • Bhamidipati VS, Elliott DJ, Justice EM, Belleh E, Sonnad SS, Robinson EJ. Structure and outcomes of interdisciplinary rounds in hospitalized medicine patients: A systematic review and suggested taxonomy. J Hosp Med. 2016;11:513-23. [PMID: 26991337] doi:10.1002/jhm.2575

      Ellrodt G, Glasener R, Cadorette B, Kradel K, Bercury C, Ferrarin A, et al; Multidisciplinary Rounds Team. Multidisciplinary rounds (MDR): an implementation system for sustained improvement in the American Heart Association's Get With The Guidelines program. Crit Pathw Cardiol. 2007;6:106-16. [PMID: 17804970]

Acute care for hospitalized patients

  • Rapid response and code teams, with ongoing training and assessment, including mock codes *** $$
    • Maharaj R, Raffaele I, Wendon J. Rapid response systems: a systematic review and meta-analysis. Crit Care. 2015;19:254. [PMID: 26070457].

  • Pause after a patient dies (highlights humanity) *** $
    • Eng J, Schulman E, Jhanwar SM, Shah MK. Patient death debriefing sessions to support residents' emotional reactions to patient deaths. J Grad Med Educ. 2015;7:430-6. [PMID: 26457151]
  • Post–rapid response and code debrief with team building *** $
    • Eng J, Schulman E, Jhanwar SM, Shah MK. Patient death debriefing sessions to support residents' emotional reactions to patient deaths. J Grad Med Educ. 2015;7:430-6. [PMID: 26457151]

      Gauthier S, Richardson L. A code blue debriefing session to foster resiliency. Med Educ. 2016;50:566-7. [PMID: 27072450]

  • Standard communication with consultants (urgency, question, pertinent data, follow-up expectations) ** $$
  • Proactively manage ICU patients collaboratively with nursing staff *** $$
    • Kim SH, Chan CW, Olivares M, Escobar GJ. Association among ICU congestion, ICU admission decision, and patient outcomes. Crit Care Med. 2016;44:1814-21. [PMID: 27332046]

Discharge to home

  • Prescription room service (meds filled before discharge) *** $$
    • Hatoun J, Bair-Merritt M, Cabral H, Moses J. Increasing medication possession at discharge for patients with asthma: the Meds-in-Hand Project. Pediatrics. 2016;137:e20150461. [PMID: 26912205].

  • Confirmed follow-up appointments made before patient leaves *** $$
    • Hansen LO, Greenwald JL, Budnitz T, Howell E, Halasyamani L, Maynard G, et al. Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8:421-7. [PMID: 23873709].

  • Interprofessional discharge “time out” *** $
    • Ruggiero J, Smith J, Copeland J, Boxer B. Discharge time out: an innovative nurse-driven protocol for medication reconciliation. Medsurg Nurs. 2015;24:165-72. [PMID: 26285371].

Discharge to another facility

  • Virtual visits with receiving facility staff *** $$
    • Moore AB, Krupp JE, Dufour AB, Sircar M, Travison TG, Abrams A, et al. Improving transitions to postacute care for elderly patients using a novel video-conferencing program: ECHO-Care Transitions. Am J Med. 2017;130:1199-1204. [PMID: 28551043].

      Schnipper JL, Kirwin JL, Cotugno MC, Wahlstrom SA, Brown BA, Tarvin E, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166:565-71. [PMID: 16534045]

  • Interprofessional discharge “time out” (DDEMAP) * $$
  • Pharmacist-led medication reconciliation *** $$
    • Schnipper JL, Kirwin JL, Cotugno MC, Wahlstrom SA, Brown BA, Tarvin E, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166:565-71. [PMID: 16534045].

      Arnold ME, Buys L, Fullas F. Impact of pharmacist intervention in conjunction with outpatient physician follow-up visits after hospital discharge on readmission rate. Am J Health Syst Pharm. 2015;72:S36-42. [PMID: 25991594]

  • Electronic health information exchange *** $$
    • Usher M, Sahni N, Herrigel D, Simon G, Melton GB, Joseph A, et al. Diagnostic discordance, health information exchange, and inter-hospital transfer outcomes: a population study. J Gen Intern Med. 2018;33:1447-1453. [PMID: 29845466].
  • Team discharge documentation * $$
  • Discharge checklist *** $$
    • Garg T, Lee JY, Evans KH, Chen J, Shieh L. Development and evaluation of an electronic health record-based best-practice discharge checklist for hospital patients. Jt Comm J Qual Patient Saf. 2015;41:126-31. [PMID: 25977128].

Hospital post discharge

  • Pending lab reports and mechanism to “close the loop” *** $$
    • El-Kareh R, Roy C, Williams DH, Poon EG. Impact of automated alerts on follow-up of post-discharge microbiology results: a cluster randomized controlled trial. J Gen Intern Med. 2012;27:1243-50. [PMID: 22278302].
  • Postdischarge follow-up call *** $$
    • Harrison JD, Auerbach AD, Quinn K, Kynoch E, Mourad M. Assessing the impact of nurse post-discharge telephone calls on 30-day hospital readmission rates. J Gen Intern Med. 2014;29:1519-25. [PMID: 25103122].
  • Warm handoff between hospitalist and ambulatory team *** $
    • Pantilat SZ, Lindenauer PK, Katz PP, Wachter RM. Primary care physician attitudes regarding communication with hospitalists. Am J Med. 2001;111:15S-20S. [PMID: 11790363].

Transitions from the hospital

  • Discharge summary templates *** $$
    • Dean SM, Gilmore-Bykovskyi A, Buchanan J, Ehlenfeldt B, Kind AJ. Design and hospitalwide implementation of a standardized discharge summary in an electronic health record. Jt Comm J Qual Patient Saf. 2016;42:555-AP11. [PMID: 28334559].

  • Timely receipt of discharge summaries by outpatient providers *** $$
    • Dean SM, Gilmore-Bykovskyi A, Buchanan J, Ehlenfeldt B, Kind AJ. Design and hospitalwide implementation of a standardized discharge summary in an electronic health record. Jt Comm J Qual Patient Saf. 2016;42:555-AP11. [PMID: 28334559].
  • Training to create clear and concise discharge summaries, with important results and accurate medication list *** $$
    • Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297:831-41. [PMID: 17327525]

  • Postdischarge follow-up clinic *** $$$
    • Doctoroff L. Postdischarge clinics and hospitalists: a review of the evidence and existing models. J Hosp Med. 2017;12:467-471. [PMID: 28574540]
  • Scheduled follow-up appointment before discharge *** ** $$
    • Field TS, Ogarek J, Garber L, Reed G, Gurwitz JH. Association of early post-discharge follow-up by a primary care physician and 30-day rehospitalization among older adults. J Gen Intern Med. 2015;30:565-71. [PMID: 25451987]

      Riverin BD, Strumpf EC, Naimi AI, Li P. Optimal timing of physician visits after hospital discharge to reduce readmission. Health Serv Res. 2018;53:4682-4703. [PMID: 29766499]

    • Scheduled follow-up tool

Summary: Workflow for well-being

  • Good patient care is intrinsic to well-being.
  • Well-being is intrinsic to good patient care!
  • Organizational initiatives can drive better care and better clinician well-being.
  • Break processes of care into actionable steps with specific areas amenable to workflow redesign.

Full list of contributors

See what others are saying on social media

#ACPWorkflow

Contributors to Workflow Innovations to Enhance Well-being

Eileen Barrett, MD, MPH, FACP,
University of New Mexico

Micah Beachy, DO, FACP,
University of Nebraska Medical Center

Lauren Doctoroff, MD,
Beth Israel Deaconess Medical Center

Lida Fatemi, DO, MPH,
University of New Mexico

Susan Hingle, MD, MACP,
SIU School of Medicine

Elizabeth Lawrence, MD, FACP,
University of New Mexico

Mark Linzer, MD, MACP,
Hennepin County Medical Center

Maricruz Merino, MD, FACP,
Gallup Indian Medical Center

Sondra Miles, MD,
North Colorado Medical Center

Sara Poplau,
Hennepin County Medical Center

Jonathan Ripp, MD,
Mount Sinai

Christine A. Sinsky, MD, FACP,
American Medical Association

Cynthia D. Smith, MD, FACP,
American College of Physicians

Richard M. Wardrop III, MD, PhD, FAAP, FACP,
University of Mississippi Medical Center