To prepare MAs, we obtained special permission for team documentation from our Chief Information Officer and developed associated policies and procedures. A physician assistant (PA) trained each MA, introducing the structure and content of subjective, objective, assessment, and plan (SOAP) notes. Training was continuous, as PAs provided feedback when MAs began team documentation. The MAs documented visits using templates, free form, and quick text. We measured visit cycle-time, face time with staff, and patient waiting times. A process engineer with a stopwatch observed and timed the flow (but did not enter the exam room). We also conducted patient interviews immediately post-visit and administered anonymous questionnaires to clinic staff at different phases of the model. Physicians and MAs met weekly to evaluate the design.
We used qualitative interviews of patients, physicians, and MAs to identify the level of satisfaction with the new model. During the first week of implementation, a nurse and our process engineer conducted brief in-person surveys with approximately 20 post-visit patients. Patients, chosen by convenience, were asked if the visit addressed their concerns, whether they left with a thorough understanding of next steps, and if their wait time was acceptable. Twice during the implementation phase, a human resources associate distributed 9-item anonymous questionnaires to staff members during scheduled department meetings.
RESULTS
Times per activity with different MA:MD ratios and visit lengths are shown in TABLE 3. After 6 months, cycle time decreased by a mean of 6 minutes, from 44 to 38 minutes per patient; time with staff increased by a mean of 2 minutes, from 24 to 26 minutes per patient; and wait time decreased by a mean of 7 minutes, from 9 to 2 minutes per patient. We concluded the MA:MD ratio of 3:2 was most efficient because the 2:1 model left MAs with excess non-patient time.
Our delivery model received consistently positive comments from patients. Many expressed gratitude for the extra set of ears and eyes guiding them through the process. One recalled the “old days” when a nurse joined the doctor in the exam room. Another appreciated that both the MA and physician could answer follow-up questions over the phone.
Employee satisfaction
Surveys to assess satisfaction were distributed to all employees whether they were involved in the new model or not. Sixteen employees responded to the pre-implementation questionnaire and 18 responded to the post-implementation one distributed 7 months later. The questionnaires showed an increase in employee satisfaction scores from 3.70 to 3.89 on a 5-point Likert scale, with 5 ranking highest. “I am learning from [Dr. Milford] and understanding things more fully,” wrote one respondent. Another said, “Dr. Milford and his clinical support staff are less stressed.” Individual observations such as, “I can leave sooner with less work left to do,” and “All documentation is done before [the] patient leaves,” reflect the reduction in time that patient records remained open or incomplete. Some physicians reported a reduction in at-home or after-hours work, from about 2 to 4 hours per day to approximately one hour per day.
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