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Improving Health Care Delivery: The "Learning Collaborative" Approach

The "learning collaborative" approach, in which clinical staff work together to redesign their systems to become more patient-focused and efficient, holds promise for many health care settings. While learning collaboratives have not been readily available to providers in underserved communities, four under-resourced community health centers in New York were able to use this approach to make dramatic improvements in key operations: getting patients in and out of the center quickly; offering appointments with the patient's primary care provider on demand; enhancing revenue collections; and attracting and retaining patients.

Issue: Community health centers deliver primary health care to much of New York City's low-income population. But the delivery of health care services at these centers can be improved. There often are delays in access to care, making it difficult to get an appointment. Inefficiencies in patient flow are common, resulting in office visits that are needlessly long. Operational inefficiencies often lead to financial strain.

Objective and Intervention: The nonprofit Primary Care Development Corporation (PCDC) sought to improve patient care delivery at four New York City community health clinics through the use of "learning collaboratives." In such collaboratives, providers from various health care organizations work together to improve a common process of care by sharing experiences and best practices.

Organization: The Primary Care Development Corporation (PCDC) is a nonprofit organization whose mission is to help to build a sustainable primary care infrastructure in underserved communities through construction loans and technical assistance. It has worked with dozens of health centers in New York City to streamline and improve their systems since its founding in 1994.

Key Measures: Each of the four participating health clinics focused on a different access of health care delivery. The Jerome Belsen Health Center aimed to redesign office visits through the patients' perspective; the Union Health Center aimed to provide advanced access through appointments on demand; the Brownsville Multi-Service Family Healthy Center aimed to collect revenues efficiently throughout the entire collection process; and the Urban Health Plan adopted targeted marketing strategies to increase and sustain patient volume in a competitive environment.

Process: PCDC's learning collaboratives are modeled after the Institute for Healthcare Improvement's Breakthrough Series Model. PCDC provides clinical, technical, and social support to health care organizations in order to help them make dramatic improvements in specific clinical and operational areas. To participate in a learning collaborative, an organization appoints several staff members to a team. Over the course of six to eight months, teams from various organizations that share common goals meet in learning sessions. They learn from expert faculty how to improve their performance and share progress reports. The period between learning sessions is called the "action period"; during this time, teams work intensely to implement what they have learned at the learning sessions, using the Plan-Do-Study-Act cycle. Once a redesign model has been achieved, team members help to disseminate the model throughout the organization.

Results: The data from these four collaboratives support the effectiveness of the learning collaborative model for implementing change, and suggest that this approach can lead to significant and lasting improvements in underserved areas. The Bronx-based Jerome Belson Center, which serves developmentally disabled patients:

  • Reduced total visit time from 68 minutes to 41 minutes;
  • Increased productivity by 58%, enabling them to see more patients per hour.
Manhattan's Union Health Center:

  • Developed on-demand appointment system, enabling patients to obtain appointments with their own doctors, when needed;
  • Reduced cycle time by 93%;
  • Reduced patient no-show rate.
The Brownsville Multi-Service Family Health Center, in Brooklyn:

  • Increased reimbursement per visit by 55%;
  • Improved operations to eliminate lag times between service and billing;
  • Decreased insurance claim rejections;
  • Increased patient visit volume in the adult medical care unit by 5%, turning around several years of decline in patient volume.
Urban Health Plan in the South Bronx:

  • Created an in-house marketing effort to increase and sustain patient volume through outreach to the community;
  • Significantly improved both employee and customer satisfaction.

Lessons Learned: PCDC has evolved five principles to guide the success of learning collaboratives. These are: 1) building a high-functioning team; 2) cultivating leadership support and involvement; 3) tracking data and mapping the process from the patient's perspective; 4) opening lines of communication; and 5) using the expertise of coaches and program leaders. Each of the case study reports, under Related Resources at right, describes specific lessons from their experiences. Sustaining the processes that were changed so that benefits continue to accrue beyond the end of the collaboratives is the primary challenge for the health care organizations. "We have to combat the belief that changes are permanent, or what we call the myth of the self-maintaining innovation," said Ronda Kotelchuck, PCDC's executive director. This requires not just new processes but transforming the way people work, including expanding their responsibilities and instilling sense of accountability to their patients. In addition, leadership at the health care organizations needs to communicate to their employees that the new processes are an intrinsic part of the organizational culture.

For Further Information: Contact Matthew Chin, Director of Health Care, Primary Care Development Corporation, at [email protected].

August 2005

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