By Dale Shaller and Susan Edgman-Levitan

The Polyclinic Family Medicine Practice

Medical Dental Building
509 Olive Way, Suite 900
Seattle, WA 98122
206-860-4700
www.polyclinic.com

Watch a slide show of photos of The Polyclinic–Family Medicine Practice.

Key Personnel Interviewed

• Michael Tronolone, M.D., Medical Director
• Robbie Sherman, M.D., Family Practice Leader and Section Chief
• Lisa Ricco, Practice Manager
• Trish Raymer, M.D., Family Practice
• Kevin Hatfield, M.D., Family Practice
• Kelly White, M.D., Family Practice

Overview

The Family Medicine Practice of The Polyclinic is one of 12 primary care practices included in this case study project of high-performing patient-centered primary care practices. Practices were selected for study from a sample of more than 2,000 sites on the basis of their exceptional patient experience survey scores across multiple domains. The purpose of the case studies is to document models of high-quality, patient-centered care, and to extract lessons regarding the organizational factors and specific processes used by these practices to achieve favorable patient experiences.

The Polyclinic

The Polyclinic is a physician-led multi-specialty group practice located in downtown Seattle. It was established in 1917 and employs 107 physicians, including more than 30 primary care physicians and more than 70 specialists in most areas of medicine. The majority of its physicians are full-time, resulting in a full-time equivalent of about 98 doctors. The main campus includes an array of on-site services such as laboratory and X-ray services and outpatient surgery. The Polyclinic has several smaller satellite locations in Seattle, including the Family Practice site, which is the focus of this case study.

The Polyclinic Family Practice site scored above the 95th percentile on the American Medical Group Association (AMGA) patient survey questions related to doctor-patient communication, and in the upper quartile on questions about access and interaction with office staff. Key to the practice's success in achieving these scores is a strong team culture built on a shared set of values and commitment to patient-centered care acquired by many of the physician leaders during their primary care training. The physician leaders' values have been reinforced by the Polyclinic's overall organizational focus on "high-end personalized service" and a deliberate marketing strategy designed to attract and retain a loyal patient base in downtown Seattle.

A remodeled downtown location and the adoption of an "open access" strategy have helped to cement the patient-centered qualities of the practice. Open access is also known as advanced access or same-day scheduling. The transition to open-access scheduling required that the practice leaders work together in new ways and reinforced the team approach to meeting patient needs. The practice is not without challenges, however, which include competitive pressures for market share from other organizations in the downtown market and an ongoing need to sustain their patient-centered culture as the demands of expansion lead the practice to add new physicians and support staff.

Characteristics of the Local Market

The Polyclinic is in the heart of Seattle, a major urban center with a concentration of medical care facilities in the downtown area. The main campus is in an area known as "Pill Hill" because of the large number of major medical centers located here, such as the Virginia Mason Medical Center, Swedish Medical Center, Pacific Medical Centers, and the Minor and James Medical primary care group. These organizations comprise The Polyclinic's major competition in primary care.

The HMO market in Seattle is dominated by the Group Health Cooperative of Puget Sound, which enrolls about 20 to 25 percent of the population and is a major provider of primary care. The other 75 percent of the payer market is controlled largely by Regence Blue Shield and Premera Blue Cross through its preferred provider organization (PPO) products. PacifiCare has a relatively small HMO presence in the market. It is estimated that The Polyclinic controls 2 to 3 percent of the patient share in the greater Seattle market.

Mission, Structure and Governance

The mission of The Polyclinic is "to promote the health of patients by providing high-quality, comprehensive, personalized health care." According to Michael Tronolone, M.D., who became the clinic's first full-time medical director in 2003, The Polyclinic aims to aggressively occupy a market niche as the "high end service provider" in Seattle, based on the "Nordstrom model" of customer service—a reference to the famed Nordstrom's Department Store, whose flagship store is in the neighborhood. The high doctor-to-ancillary staff ratio at the clinic reflects this strategy, as the clinic strives to distinguish itself as a provider with ready access to physician services and with a "one-stop shopping" approach to medical care.

This marketing strategy was developed by senior management in consultation with the physician leaders as a way to distinguish The Polyclinic in the crowded, highly competitive Seattle market. A strategic planning process undertaken in 2003–2004 involved focus groups with patients that revealed a high degree of patient loyalty. According to Dr. Tronolone, senior leadership decided to embark on a strategy of "providing great service to existing patients to get more patients."

The clinic also launched a marketing and communications campaign targeted at the growing residential and working population in the downtown area, focusing on convenient access, for example during the early morning and lunch hours. The recent decision to expand and remodel the downtown Family Practice rather than expand into the suburbs as other provider groups had recently done is an integral part of this strategy. Dr. Tronolone attributes the clinic's recent growth to this combination of a commitment to patient-centered care and savvy in reinforcing and expanding the clinic's historical downtown niche.

The Polyclinic is governed by a board of physician directors. Physicians are eligible for nomination to shareholder status following a two-year evaluation and performance review process. Once a shareholder, physicians are no longer "at will" employees of the organization but rather full voting partners with an equal say in the governance of the organization. According to several physicians interviewed, this buy-in and "ownership" contributes to strong loyalty to the clinic and its success. All physicians sign on to a "physician compact" that specifies both their responsibilities and rewards as a member of the organization.

Payer Mix and Patient Population

The Polyclinic has the following payer mix:

The practice serves approximately 78,000 patients.

Physical Characteristics of the Family Practice Site

The Family Practice site is 10 blocks from The Polyclinic's main campus in the heart of the city's retail and shopping district. It occupies the newly renovated ninth floor of the 20-story historic Medical Dental Building, which is also undergoing a major renovation.

Access to the practice is through a bank of elevators in the building lobby, currently under construction. The elevators open into a large lobby entrance and patient waiting area. A smaller, private waiting area off the main waiting room is designed specifically for children, with age appropriate furnishings, books, and toys. The entire space has a polished, high-end look and feel, with spot lighting and rich wood and earthy green and beige tones. Large windows provide abundant natural light.

Patients are directed by signage to a bank of three registration windows for family practice. Patient registration for dermatology is located beyond the general registration area for additional patient privacy.

Patients receive a form upon registration that is tailored to the nature of their visit. When called for their exam, patients are greeted by a staff member and accompanied through a door into an inner area consisting of two pods or clusters. At the center of each pod is a large square workstation where the nurses and medical assistants have their desks. Around the perimeter of the square are countertops and spaces for specific tasks such as weighing patients and eye exams. This pod structure was created to enhance both communication and efficiency among staff. An important design element is the "dictation station," a bank of three booths where doctors stand to enter notes, write orders, and do dictation immediately following a patient visit. The design of these stations encourages interaction between clinicians and ancillary staff, such as impromptu consultations, or follow-up with patients.

Around the perimeter of each pod, on the outside walls of the floor, are patient exam rooms and private doctor offices. There is also a smaller lab, procedure room in dermatology, and larger lab for phlebotomy (blood draws). A lounge area for staff includes a kitchen and several large tables.

Physician Staff

The Family Practice site includes seven Family Medicine physicians. Interviews about what drives patient-centered care in the practice were conducted with four of the seven physicians who were available during the site visit.

Robbie Sherman, M.D.
Dr. Robbie Sherman has been with the practice since 1998 and is currently the practice leader as well as section chief for family medicine. She received her M.D. from the University of Washington and completed her residency at Providence Hospital (which has since been acquired by Swedish Medical Center). Before coming to The Polyclinic, Dr. Sherman was in a small private practice that focused on obstetrical care for low-income women. When discussing her previous positions, she describes a "failed model" of patient care characterized by a hierarchical, centralized administrative approach that stifled physician autonomy, collegiality, and job satisfaction. This experience led her to embrace an alternative approach focused on team building.

According to Dr. Sherman—as well as the practice manager and all of physicians interviewed—a defining moment in the life of the practice was the design and implementation of the open-access model. Open access, also known as advanced access or same-day scheduling, is a method of scheduling in which all patients can receive an appointment slot on the day they call, almost always with their personal physician. Rather than booking each physician's time weeks or even months in advance, this model leaves about half of the day open; the other third is booked only with clinically necessary follow-up visits and appointments for patients who chose not to come on the day they called (typically no more than 25 percent of patients).

The idea for open access emerged in 2000 during the World Trade Organization riots that took place in downtown Seattle. During the civil unrest, the practice temporarily moved up to the main campus, where an open-access initiative was underway in another service department. Impressed with the efficiency and improvements in patient flow, the family practice doctors decided to try it out after they moved back into their regular space, and hired a local consultant to help them.

Dr. Sherman believes that the process of moving to open access was instrumental in bringing the physicians and staff together to take a "total look" at how the practice functions, including patient flow and physician-staff interaction, and to develop methods for building teamwork. An important example is the regular use of a "huddle" at the end of the day. After the last patient has left, the physicians and staff in the same pod meet for a five-minute "huddle" to review what went well that day and what did not go well. The outcome of the huddle is to immediately identify strategies for addressing problems that will be put into practice the very next day.

Trish Raymer, M.D.
Dr. Trish Raymer also was trained at the University of Washington School of Medicine and completed her residency at Providence Medical Center. She worked with Dr. Sherman prior to joining The Polyclinic in 1988 and is also committed to a collegial, supportive work environment for both physicians and staff. She describes the physician group as "very tight." She also works closely with her nurse, and says their patients notice their high level of teamwork, characterized by an easy and friendly rapport which is not typical in all medical practices.

Dr. Raymer will make house calls to patients in their homes on occasion if the situation suggests the need. She also will visit her patients in the hospital and is very positive about the hospitalist program at The Polyclinic, which directly employs three full-time hospitalists who coordinate inpatient care at Swedish Medical Center. Hospitalists help manage patients throughout the continuum of hospital care, often seeing patients in the ER and then following them as they progress through their hospital stay and help in their transition to post-hospital care. Because the hospitalists belong to The Polyclinic, they have good relationships with the primary care doctors whose patients they are managing; this connection supports good communication between the physicians as well as patient trust.

Kelly White, M.D.
Dr. Kelly White is one of the newest physicians at the clinic, having joined in August 2006. While he trained at the University of Colorado, he did his residency in Seattle at Swedish Medical Center. Dr. White cites "getting the right docs" and "ownership model" at The Polyclinic, which he believes drive physicians and staff to be service-oriented since they will make or break the business on the basis of their performance. He was previously in a salaried practice, which he believes did not provide incentives to excel in patient care. He also credits the annual all-clinic and family practice retreats with helping to build an informed and committed physician staff.

Kevin Hatfield, M.D.
Dr. Kevin Hatfield received his M.D. from Case Western Reserve University but also did his residency in Seattle at Providence. Along with open access, Dr. Hatfield credits the pairing of nurse/medical assistants with physicians as an important factor driving patient-centered care. The practice originally had one medical assistant assigned to each doctor. They experimented for a year or so with a rotation model, which the doctors did not like because of the lack of continuity among staff and with patients. The practice now has a modified approach where two doctors are paired with one nurse in a pod, and also have access in the pod to a triage nurse.

Support Staff

Lisa Ricco, practice manager, supervises the entire ancillary and support staff of about 25 employees on site, ranging from receptionists to nurses. Ms. Ricco has been with The Polyclinic for 10 years, seven of which have been with the Family Practice. She not only personally performed all of the office functions she now supervises but also helped design many of them. She echoes many of the comments made by the physician staff regarding the cohesiveness of the team, not only among the physicians and among the staff, but between the physicians and staff. Ms. Ricco's says the physician staff are all involved in practice decision-making and are open to change and innovation, constantly revising and adapting systems and processes to improve care.

Systems Supporting Patient-Centered Care

Following are major systems and organizational supports that appear to be key factors in promoting patient-centered care at the Polyclinic Family Medicine practice:

Open-Access Scheduling
Despite a tough transition and "difficult first year," the open access system is viewed by staff as a key to their success, encouraging teamwork among the doctors and a culture focused on "meeting today's demand today." The daily "huddle" is a central feature of the open-access model.

The Built Environment
As noted, the entire Family Practice moved into its new office space in October 2006. In the year prior to the move, Ms. Ricco helped organize staff input into the design of the new space, with recommendations based on observation of patient flow and other processes. For example, she and another staff person were personally responsible for the selection of the kid-friendly furniture in the special waiting room for children.

Patient Input and Feedback
In addition to the annual AMGA patient survey, the clinic developed its own custom survey in 2005 to determine specific types of services that patients wanted to see on site, as the new space was designed. This survey led them to include the dermatology practice, and also identified the need to add an endocrinologist, in the future, and an allergy specialist. Patient feedback postcards (called "Comments and Commendations") are located in boxes placed strategically throughout the clinic locations.

Information Management System
The Polyclinic does not have a full-scale electronic health record but does have a sophisticated, information management system called "Misys" that has been in place for about two years. Misys includes three components used extensively at the Family Practice site: 1) "Vision," an electronic patient scheduling system; 2) "Orders Management," for entering ancillary, lab, and procedure orders; and 3) "Enabled," a program for dictation and retrieving lab, image, and test results. All physicians have access to the Enabled system both in their offices and remotely. The system does not include a patient portal. A pilot program is currently underway to test secure email messaging with patients in the clinic's concierge practice.

Human Resource Policies

The Polyclinic Family Practice follows several important human resource strategies that contribute to a staff culture and work environment supportive of patient-centered care, including:

• Staff hiring practices: Ms. Ricco looks for team players and communication skills in potential staff hires. Each potential hire is given a two-day trial period. The retention rate is very high, with turnover usually related to promotions, maternity, or a change in location.
• Staff involvement and regular meetings: Ms. Ricco holds regular meetings with staff and works to involve them in planning office systems and procedures. For example, various staff were consulted in designing the new space on the 9th floor. Ms. Ricco meets monthly with just the physician staff. The Polyclinic holds quarterly meetings for all staff.
• Staff training: In addition to on-the-job training unique to each position, The Polyclinic conducts an organization-wide training initiative in June-July of each year based on a particular theme or campaign. The timing of this annual training is designed to precede the annual patient survey conducted by AMGA in September. The training is an all-day event with a professional facilitator, and the campaign is designed to reinforce the training with supportive messages. In 2005, the training campaign focused on customer service for all patients. In 2006, the focus was on internal communications among staff and departments.
• Staff surveys and feedback: The HR department at the clinic conducts quarterly employee satisfaction surveys, primarily focused on organization-level issues.
• Employee recognition and rewards: A variety of employee rewards are used at both the practice site and clinic level. Ms. Ricco gives out $5 Starbucks gift cards frequently. The clinic sponsors an "employee of the month" award based on nominations, and the Family Practice has had half a dozen of its staff receive this award. There is also a team of the month or quarter, and the Family Practice team is currently up for this award. An employee activity committee sponsors events for employees, such as "casino night." In addition to competitive compensation, the clinic provides tuition reimbursement and recent improvements to the 401-K plan.

Physician Compensation

Physician compensation is based primarily on productivity (approximately 95%). Two years ago, the clinic began to assign 5 percent of compensation on the basis of performance, as measured by a combination of: 1) AMGA patient satisfaction scores, 2) participation in quality initiatives, and 3) clinic "citizenship," meaning service on committees. The patient survey data is used as a threshold, such that if a physician scores below the 50th percentile, they must submit a plan for improvement. Dr. Tronolone noted that some doctors have expressed concern that an annual survey does not give them sufficient information to monitor and improve their own practice.

Bonus payments to physicians are based on a mix of productivity (65%), patient satisfaction (15%), and tenure (20%). A bonus was paid in 2005 but not in 2006.

Conclusions

The Polyclinic Family Practice has achieved high levels of patient-centered care through a strong team culture that builds on a common set of values and commitment to patient-centered care acquired in the primary care training experience of the core physician leaders. These core values have been reinforced by the Polyclinic's overall organizational focus on "high-end personalized service." The physician leaders in the practice have built a strong rapport with the administrative and clinical support staff, led by a trusted and competent practice manager. The recent transition to an open access approach to scheduling has contributed further to the practice's culture of teamwork. Everyone has "bought in" to a strong patient-centered focus, and this is also reflected throughout the practice's hiring, training, and compensation policies.

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This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Fund-sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied organizations' experiences in ways that may aid their own efforts to become high performers. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case studies series is not an endorsement by the Fund for receipt of health care from the institution.