Incorporating staff in organizational changes

Over the last year, Clinica Family Health in Denver has experimented with its care team models, implementing what it has termed “co-visits” in some of its clinics. Under the program, registered nurses oversee the bulk of a patient visit, including intake, documentation and patient education, while the provider spends about 10 minutes examining and diagnosing. So far, the organization has seen an increase in both patient and staff satisfaction. 

“When you are working in the committee, you know the specific things … we need to fix what happened with the schedule, we need to fix what happened with triage.” — Karina Martinez, RN

“Our challenge was could we see more [patients], because we have demand, without double- and triple-booking providers. We know how terrible that feels to have added patients because nobody really wins,” explains Malia Davis, MSN, ANP, director of nursing services and clinical team development, Clinica Family Health, on why the practice decided to consider co-visits. “The provider is tired and rushed, and the patient waits a long time and maybe gets [a few] minutes of care. And it’s not great.” 

By incorporating co-visits into the schedule, Clinica can provide better patient access without taking extra time out of the providers’ schedules or double-booking. “The nurse does the bulk of the work in a co-visit — patients love it, nurses love it, and it is less work and burden on the provider,” Davis says. 

Creating buy-in Before implementing the co-visit model, Clinica set up a steering committee to determine the best way to make these changes. The committee included the vice president of clinical services, the director of nursing, the clinic directors for the two clinics who were involved in the pilot, the assistant nursing directors for two of the counties they serve, the project manager and the clinical medical directors for the sites.

“And then at a certain point and kind of early on, we realized that we wanted a nurse team manager there, someone who was doing the actual nursing work, and that proved to be really beneficial,” explains Jenna Osborne, RN, assistant director of nursing, Clinica Family Health. 

Karina Martinez, RN, joined the steering committee as the nurse team manager, which Osborne says was vital for the success of the program. Not only could the nurse team manager give her perspective on the project to the leadership, but also she could take the messages from the steering committee to the nursing staff and explain why certain changes were being made. “[Martinez] was a great communicator between the steering committee and the nursing staff,” Osborne says. 

Martinez agrees about the importance of being able to relay messages. “When you are working in the committee, you know the specific things … we need to fix what happened with the schedule, we need to fix what happened with triage,” says Martinez, adding that it helped ensure the new system was workable for the nursing staff.

However, Osborne believes that the practice could have included even more voices in the committee: “If we were to do it again, we would have a medical assistant (MA) team manager present because what we realized was we didn’t do the best job communicating with the MA team.” The new model included expectations of the MAs that weren’t made clear. The confusion could have been avoided if MAs were given a voice on the committee. 

“Take the time to think about who should be on that committee, who’s going to be able to take the messages back to the team and help keep the morale up and keep the team going,” Osborne recommends. “They’re the ones doing the work, so their communication is going to have a lot more weight when they’re talking with their team because they are doing it, too.”

Communicating change

Another important step in ensuring the implementation’s success was evaluating site readiness and leadership readiness, according to Devon Schrager, PA, MPH, clinical medical director, Pecos Clinic, Clinica Family Health. “Because throughout this process, a lot of the lessons learned were essentially around either miscommunication or lack of communication of an important point that then managed to snowball,” she says.

Schrager recommends making sure there are clear expectations for the leadership team on what needs to be done to both evaluate the readiness of their teams and to identify what needs to be done to create a more open environment for communication.  

One of the ways that Clinica improved communication was to provide a specific feedback protocol. In the new model, each care team is led by a nurse team manager and an MA team manager rather than by the providers. 

“Probably the base of all of this change is around communication and strengthening the teams via their communication,” Schrager says. Team managers needed to coach team members on providing and receiving effective feedback. “Empowering someone in a role such as an MA — who is not usually that prone to giving feedback to a provider, particularly if it’s not the most positive feedback — that path is what grows the team together,” she says.

The new model’s success may lead to its implementation at Clinica Family Health’s remaining sites, and the role of leadership in that success was important, Davis says. “That doesn’t just mean putting people in a room together and saying, ‘work together.’ It means our leadership is committed to developing our teams, which fosters respectful interactions between role and scope, a fun environment and really remembering that everything we do during the day is for the patient.”