By Dale Shaller and Susan Edgman-Levitan

Wheaton Franciscan Medical Group

3801 Spring Street
Racine, WI 53405
262-687-4011
www.wfhealthcare.org/racine


Please click on the image above to watch a slide show of photos of the Wheaton Franciscan Medical Group.

The Spring Street site of the Wheaton Franciscan Medical Group (WFMG) is one of 12 primary care sites featured in Commonwealth Fund case studies of patient-centered practices. The site visit was conducted by Dale Shaller on Tuesday, March 27, 2007.

Key Personnel Interviewed
Tracy Dorlack, R.N., Director, Quality Management
Karen Adams, R.N., Director, Medical Practice Operations
Robin Gallagher, Operations Manager
Sue Kratowicz, R.N., Site Manager
Dee Oberst, R.N., Internal Medicine
Lori Stapleman, C.S.A., Internal Medicine
Karen Fondren, M.O.A., Internal Medicine
Anne Stelter, Coordinator, Family Medicine
Jenny Wietfeldt, R.N., Family Medicine
Sabrina Santos, M.O.A., Family Medicine
Rudy Byron, M.D., Department Chair, Family Medicine
Sheryl Hansen, N.P., Internal Medicine

Overview

The Spring Street site of the Wheaton Franciscan Medical Group (WFMG) is one of 12 primary care practices featured in Commonwealth Fund case studies of high-performing patient-centered primary care practices. Practices were selected from a sample of over 2,000 sites on the basis of their exceptional scores across multiple domains on patient experience surveys. 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 Spring Street site of WFMG scored at the 90th percentile on the American Medical Group Association (AMGA) patient survey domains related to access, and above the 85th percentile on domains related to doctor–patient communication and interaction with office staff. These exceptional scores appear to stem at least in part from the organization-wide commitment to service excellence that is supported from the top levels of management to the frontline clinical and administrative staff throughout the WFMG. The site visit identified numerous processes that exemplify this service commitment, such as an ongoing communication training program for all employees (termed "associates"), comprehensive employee rewards and recognition programs, and a strong focus on physician and staff performance reviews based on multiple evaluation criteria.

Characteristics of the Local Market

Racine is a city of approximately 80,000 residents located south of Milwaukee, Wisconsin, on the western shore of Lake Michigan. Wheaton Franciscan Healthcare is the third largest employer in Racine. Other major employers in the market are SC Johnson, Putzmeister (auto supplies), Insinkerator, a company that makes household products and food service equipment, and the city and schools.

History, Structure, and Governance

In 1993, the former Kurten Medical Group and Racine Medical Group consolidated to form the All Saints Medical Group. In 1994, All Saints Medical Group became affiliated with the two large hospitals in Racine, St. Luke's Hospital and St. Mary's Medical Center, which now operate together as Wheaton Franciscan Healthcare–All Saints. These consolidations were driven largely by an interest in collaboration and reducing duplication of services. In July 2006, the All Saints Medical Group merged with the Covenant Medical Group in Milwaukee to form the Wheaton Franciscan Medical Group, whose parent organization is Wheaton Franciscan Healthcare, with corporate offices in Glendale, Wisconsin, and Wheaton, Wisconsin. The Wheaton Franciscan Medical Group (WFMG) is a multi-specialty group with more than 260 physicians in over 40 practice sites. The Spring Street site is one of the largest, located adjacent to the Wheaton Franciscan Healthcare–All Saints Spring Street campus.

The mission of Wheaton Franciscan Healthcare is "living out the healing ministry of Jesus by providing exceptional and compassionate health care service that promotes the dignity and well being of the people we serve." As Quality Management director Tracy Dorlack, R.N., says, WFMG pays more than "lip service" to this mission, and it was clear throughout the site visit that the organization is hardwired by the mission and values of this Catholic ministry. The mission drives everything, including the spiritual reflections that start each meeting, the "daily connection" calendar on every desk, the weekly key operational updates, and the rounding performed by senior leaders through every department and floor.

Dedication to customer service has been paramount for the last five to six years, as exemplified by the All Saints competition for the Malcolm Baldrige National Quality Award and its recruitment of the Studer Group, a health care consulting group, to guide the organizational commitment to quality. This commitment to service emanates from the very top, with the active and visible presence of Ken Buser, president and CEO of Wheaton Franciscan Healthcare–All Saints, and Loren Meyer, M.D., president and CEO of WFMG. An example of this commitment is the "Ticket to Ride" campaign introduced by Mr. Buser, which outlines a commitment to the following five standards of behavior: Respect, Integrity, Development, Excellence, and Stewardship. All associates are encouraged to "get on the bus."

Governance of the WFMG is divided into three market areas: south (Racine), north (northern Milwaukee), and central (southern Milwaukee). Each market area has department chairs in the major specialties. Rudy Byron, M.D., who participated in this site visit, is chair of the Family Medicine Department for the South Market. A Department Chair Council meets every two weeks, along with the regional directors of quality, operations, and finance. Ms. Dorlack is the director of quality for all three WFMG markets.

Payer Mix and Patient Population

According to Ms. Dorlack, WFMG controls about 60 percent of the local health care market. The major competitor is the Aurora Health System, which has several primary care practice sites in the area.

The payer mix of the practice, which notably includes a relatively high percentage of Medicare and Medicaid, breaks down as:

The practice has no capitated payments for patients. Managed care plans in the market include Humana and United Health Group. MEI is a local employer-based purchasing organization that controls about 10 percent of the market.

Physical Characteristics of the Site

The Spring Street site for the WFMG Internal Medicine and Family Medicine practices is located in a large office building next to the Spring Street campus of Wheaton Franciscan Healthcare–All Saints, just north of downtown Racine. Ample free patient parking is available in a large lot in front of the building. A circle drive makes patient drop-offs and pick-ups convenient.

The Internal Medicine and Family Medicine practice sites are located on different floors but the layout of the two practices is very similar. The practices are clearly marked and photos of the physicians are on display in the patient waiting areas.

Waiting areas are equipped with color TV monitors that are set to broadcasts of CNN; reading materials and aquariums are also located in the waiting areas. Patients check in at a large reception desk and are brought in for appointments to a series of exam rooms through a door next to reception.

Exam rooms are very neat and well equipped. Exam rooms include the name, photo, and brief biographical sketch of the nurse and medical assistant assigned to each physician. Exam rooms also post physician and associate recognition awards and news articles.

Each physician has a private office. The staff shares a large kitchen and meeting room.

Staff hallways have numerous bulletin boards displaying associate awards for AIDET (see below) and notices related to each of the pillars of service excellence promoted throughout the organization.

Systems and Practices Supporting Patient-Centered Care

A major portion of the site visit was conducted in a group interview format with representative staff from the Family Medicine and Internal Medicine practices. These interviews identified the following major systems, practices, and organizational supports as key factors in promoting patient-centered care at WFMG:

Staff Communications and Training
Employee (associate) communications and training comprise a prominent theme at WFMG. Examples include the following:

• AIDET. AIDET is a communications training program introduced to WFMG by the Studer Group based on the following five fundamental features of patient communication (which the acronym AIDET stands for): Acknowledge, Introduce, Duration, Explanation, and Thank you. Physicians and staff are trained in AIDET to facilitate communication with patients as well as with each other. Where this program has been adopted within WFMG, it has become an integral part of the culture. Associates wear AIDET buttons to indicate they have been trained and are on board with the program.
• Daily Connection: The daily connection is a time set aside by each practice or department to focus on the organization's mission and to acknowledge an operational point or special staff person, often using the daily quotation from the All Saints tear-off calendar. Each day's quotation has been contributed by an associate, who is acknowledged by name on the quotation.
• Key Operational Updates: The key operational updates are weekly internal memos that highlight daily events and recognize associate awards and other achievements.
• Regular meetings: Routine meetings are held at varying intervals, depending on the group. For example, the medical group leadership team meets twice a month. Department heads meet once a month. Higher-level meetings are held twice a year.
• Training Institutes: Every associate attends a one-day training program after three months of employment. Managers and directors attend on off-campus Leadership Development Institute, focusing on specific topics such as "Walking the Path of Leadership."
• Rounding with a Purpose: Managers follow an explicit "roadmap" known as a Rounding Log as they make rounds to help focus their observation of specific problems, such as system issues or supply needs, which need to be addressed.

Patient Involvement and Feedback

• Patient focus groups: Associates have involved patients in focus groups to identify opportunities to improve service. Examples of ideas generated or validated by patients include: adjusting the temperature in exam rooms (the rooms had been too cold), adding trash cans in the waiting rooms, and placing Kleenex in the exam rooms.
• Use of patient survey data: WFMG uses a continuous survey protocol, in which five patients per physician are surveyed each week using the AMGA survey. Data are analyzed by department every two weeks. Quarterly reports are given to each physician and their department chair. These results are also included in the annual "360" performance evaluation review (see below).
• Pride Line: The Pride Line is a confidential telephone line available to patients to leave a message with either their compliments or complaints. The line is monitored closely and patients are promised a quick response if they have called to register a problem. Call volume on the line runs high, with a ratio of compliments to complaints of approximately 3:1.
• Customer service recovery: Associates have access to a package of service recovery notes and gifts to send to patients after a service failure, such as an overly long wait time or missing test results. A form and system for recording action taken facilitates the service recovery program.

Patient Information and Access

• Extended hours: The medical group has a Prompt Care service that is open seven days a week, with the following hours:
  Monday–Friday: 8 a.m. to 8 p.m.
  Saturday: 8 a.m. to 12 p.m.
  Sunday: 12 p.m. to 4 p.m. (walk-in basis)
• Telephone response time: A major overhaul is being planned for the medical group's telephone system in order to increase response time to less than 30 seconds. The current system handles a huge volume of calls with assistance from an in-house call center with over 100 full-time operators.
• Information systems: The medical group is currently gearing up for a major new information system that will support multiple clinical and administrative functions. The Web site for the medical group will soon be upgraded as well.
• Phone Tree: Patients have the option to call for their test results within 48 hours using an assigned PIN. If results are not normal, the patient is contacted directly.

Associate Rewards and Recognition

Associate reward and recognition programs are a major focus at WFMG. Examples include:

• Hats Off: A thank-you note that is available for recognition of any associate by another associate.
• Service Excellence Compliment: A certificate that can be awarded at any time by one associate to another.
• Heart of All Saints: An associate is acknowledged each week system-wide through an article in the organizational newsletter, which is often picked up in the local community paper. The recognized associate receives a personal visit from a senior leader and also has access to a highly prized popcorn machine for the week.
• Pillar Awards: These are special awards presented at Leadership Development Institute meetings.

Physician Staff

The physician staff in the Internal Medicine practice includes nine full-time doctors and two nurse practitioners. The Family Medicine practice includes four full-time doctors. Each physician has an assigned nurse and medical assistant.

Interviews during this site visit were conducted with two of the health care provider staff, Rudy Byron, M.D., and Sheryl Hansen, N.P.

Rudy Byron, M.D.: Dr. Byron serves as chair of the WFMG South Market Family Medicine Department. He has been with the practice for seven years. When asked what factors he believes help account for the high patient survey scores at WFMG, Dr. Byron offered the following:

• Patients value and respond to a style of communication that elicits their input and involves them in decision-making. Dr. Byron outlined a typical patient encounter to illustrate his point, including his practice of using an encounter form to capture everything he can during the visit and then dictating his notes while the patient is still there so he or she can weigh in. He also described a recent visit by an elderly woman with diabetes who is reluctant to see a doctor. He explained the communication techniques he used to put her at ease, elicit information from her, and prepare her for a gradual course of treatment involving an increase in her medications and a series of follow-up tests. His point was that it pays to take a long-term perspective of the patient relationship in order to "win the marathon, not the sprint" by building the trust and confidence needed to ensure patient adherence to prescribed treatments. The organization has tried to systematize such patient encounters to achieve a consistent standard of patient care.
• The integrated nature of the group practice is a key factor to successful patient-centered care because it leads to a seamless approach to care that can involve multiple clinicians, departments, and allied professionals.

Sheryl Hansen, N.P: Ms. Hansen has been with WFMG for 18 years, the last nine as a nurse practitioner. Factors Ms. Hansen considers key to this patient-centered practice include:

• The high ethical standards called for throughout the Wheaton Franciscan Healthcare–All Saints emphasize caring for and being compassionate toward patients. Ms. Hansen believes this ethic is shared by all associates, who try to "meet patients where they are."
• The organization supports the freedom to incorporate a spiritual and emotional dimension into the physical aspects of healing. For example, there is acceptance but not an expectation of prayer in the exam room.
• The use of nurse practitioners facilitates a flexible and responsive approach to patient care, since nurse practitioners often have longer patient visits than physicians. This extra time often leads to close relationships with patients and their families.
• The intense focus on performance goals and accountability raises the standard of practice. Each department has specific performance goals across a range of metrics that are aligned with the organization's mission and core values, which include service excellence.
• The use of peer feedback in performance reviews and regular meetings is very helpful in maintaining practice standards and the overall culture of service.
• The hospitalist program is top notch and provides an important source of support to primary care clinicians. (Hospitalists are physicians or nurse practitioners specially trained to manage the care of hospitalized patients throughout the continuum of their inpatient stay.) The program works because of the superb communication between the hospitalists and the primary care physicians. For example, there are regular reports on the progress of hospitalized patients, including notification when a patient is discharged.

Both physicians and nurse practitioners will make occasional home visits. Neither uses e-mail because they feel it is not compatible with the communication style and preferences of their patients.

A final factor noted by both Dr. Byron and Ms. Hansen is the quality of the work environment and culture of collegiality, both of which promote a healthy balance between work and other aspects of life.

Human Resource and Compensation Policies

WFMG places a strong emphasis on individual performance goals and accountability, involving every single employee. All physicians at WFMG are employed and receive a base salary tied to production RVUs. RVUs, or "relative value units," are standardized factors based on estimates of the labor required to deliver medical services. Higher RVUs lead to greater reimbursement and are therefore tied to higher physician compensation. Comprehensive physician performance reviews are conducted annually using an extensive "360" evaluation process, involving both physician peer and staff feedback. Evaluation criteria include: mission integration, clinical excellence, service excellence, financial viability, physician partner, and employer of choice. These criteria are mapped and tracked with explicit objective measures on a detailed form. According to Ms. Dorlack, there was some initial pushback around goal setting, including patient service, but all physicians are held accountable and there has been increasing acceptance.

All staff members also undergo extensive performance evaluations. The Performance Excellence Program provides each staff member with specific goals and evaluation criteria that are periodically assessed. Detailed forms facilitate this assessment.

Hiring practices at WFMG follow "behavioral-based interview" methods. Following an initial screening by the system's Human Resources department, individual site managers conduct interviews involving various other associates.

Physician recruitment is also based on behavioral interview techniques.

Conclusions

The delivery of primary care at the Wheaton Franciscan Medical Group exemplifies an organization-wide commitment to service excellence that is supported from the top levels of management to the frontline clinical and administrative staff. The religious foundation for this commitment is evident throughout the various systems and operations observed at the Spring Street site. A strong focus on comprehensive physician and staff performance reviews based on multiple evaluation criteria, including patient experience scores, also serves to reinforce this commitment among WFMG physicians and staff on an ongoing basis.

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.