Nitzali Rivera loves her job as a licensed practical nurse (LPN) at the Union Square office of Cambridge Health Alliance in Somerville, Massachusetts.
She is assigned exclusively to Kirsten Meisinger, M.D., medical staff president and regional medical director of CHA. They work in partnership to determine the course of treatment for every patient. “[Meisinger] goes through every single patient with me," Rivera says, “and says 'this is what the patient is coming in for, what do you think we should do? Let me share what I'm thinking.'"
This level of cooperation and mutual respect is not always the norm. And it wasn't always this way at Union Square. Previously, Rivera says, the staff “viewed doctors as gods, lifesavers, and we treated them that way." But as the practice sought to transform its care to fit a patient-centered medical home (PCMH) model, leaders began to realize they could build stronger, more personal relationships with their patients by better utilizing all their team members .
Ongoing research conducted by athenahealth confirms this approach. A 2018 survey of 1,400 physicians found that 'capable' healthcare organizations — those that invest in and empower frontline employees — create the foundation for physician wellbeing, financial success, and better outcomes at lower cost.
More specifically, data from the initial research show that physicians working in team-based practices are 25 percent less likely to show signs of burnout than those who work in practices with limited delegation. And 70 percent of physicians in team-oriented practices report a deep sense of fulfillment from their work.
Every team member matters
CHA Union Square has put this approach into action, aiming to make every member of the care team empowered and responsible.
It starts at the very beginning, with the hiring process. Leadership only hires clinicians who understand and accept this team approach. The most important element? Including everyone in the hiring process. MAs, nurse practitioners, front-desk staff, every single title at CHA interviews each candidate and explains the way they do things. “And we tell them this is why it's such a great place to work," says Rivera.
Meisinger reports that staff and providers often have very different impressions of candidates — and leadership takes those varying viewpoints seriously. In fact, Meisinger says, “If staff really don't like someone and providers do, we tend to give the staff voice a little more weight, because it's harder for them, they aren't at the top of the hierarchy."
Raising up MAs and RNs
Early on, Meisinger set a goal of growing the title of medical assistant, which Rivera was at the time, inviting MAs to be part of providing and improving patient care. It's a model of care that not only breeds strong relationships within the team, it leads to deeper, closer connections with patients.
Assigning each MA exclusively to a single physician means patients see the same medical assistant every time they come in. This, combined with the increased trust and responsibilities Meisinger gave her, allowed Rivera to begin taking charge of patient relationships. “I began getting to know all these patients, getting to know their stories — they started asking for me instead of 'the doctor'."
Long-time patients came to see Rivera as family – even inviting her to birthday parties and weddings. And, Rivera says, “it made a huge difference in the patients' lives; they always know who to go to, who to ask for whenever they call, and they know that I know them."
It's not just medical assistants who feel more capable under CHA Union Square's model. Each and every member of the staff is considered to have valuable information that can improve patient care.
When teams huddle in the morning, MAs and RNs, who often have the closest relationship with the patient, explain what is bringing the patient in and what approach would be most advisable. And patient panels are reviewed weekly, by chronic disease, with a specific team member responsible for each condition. MAs gather and assess all the available data on each diabetes patient and RNs do the same for all patients with depression. This kind of team approach makes the review extremely fast and efficient.
Weekly meetings are also a chance for any member of the team who has a relationship with the patient to share what they know about the patient's life that might affect the care plan. Often it is the nurse, not the physician, who follows up, frequently scheduling a one-hour visit with any patient who is struggling, to get to the bottom of what challenges they are facing, what kind of care plans and goals are realistic.
Front-desk staff, first line of care
And then there is the front-desk staff. “The last title that we implemented into the team was the receptionist," says Rivera, “and I said to [Meisinger], 'I don't know why we didn't do this sooner.'" It turns out that the receptionists had, for years, been chatting with patients, finding out about their children, their jobs, their health complaints — in other words, developing deep personal relationships with them. And these relationships put the front-desk staff in a unique position to connect with patients about their care.
When a patient with fever and cold symptoms called looking for an appointment, the CHA receptionist not only got her in to be seen, she also determined that the patient was overdue for a mammogram. The receptionist got the patient in for a mammogram that same day, which identified early stage breast cancer — today the woman is cancer-free.
“We shared this and other stories in the staff meetings, and it really empowered and motivated us," Rivera says. “Seeing the results made everyone realize 'Wow, we're saving lives.'"
One intentional outcome of the move to empower staff is that providers feel confident in offloading tasks they once would have kept to themselves.
Before a visit, physicians outline any tests or procedures they are planning, so the MAs can have the patient and the room fully prepped. “They let us know precisely what they want us to do," says Rivera, “and we take care of it, giving them the full appointment time to take care of what the patient is there for."
Since MAs now know which patients need more time and how each provider likes to work, they have taken over responsibility for provider scheduling, which has streamlined patient flow. “Sometimes the providers used to spend almost 40 minutes with each patient when a 15-minute appointment was booked," Rivera recalls. “Now we are really trying to take care of everything we can."
The result for providers is significant: CHA Union Square has physician burnout rates that are 30 percent lower than the CHA average, and they are in the 98th percentile nationally for physician engagement. Armed with that knowledge, Rivera and Meisinger are taking their data and their insights on the road, sharing them with other CHA practices in the hopes that everyone can implement a similar kind of approach.
“It was such a crazy and amazing change," says Rivera. “It went from the provider being in the middle of the circle to opening up the circle of providers to include all of us, and putting the patient in the middle — and that's what really matters."
Lia Novotny is contributing editor of athenaInsight.