Tuesday, December 3, 2013

What would your ideal primary care office look like?

I have been both a provider of care and a patient in many primary care offices. As a provider, I often thought that the way things were laid out could be improved to make us more efficient. As a patient, I have often reflected how similar all physician offices are – front desk, with or without a glass window, relatively large waiting room and exam rooms arranged along corridors.  I can remember as a physician, coming out of a room and walking down the long corridors to find another member of our team, to ask for help with something. As a patient, I was once “forgotten” in an exam room over the lunch hour (I didn't complain too much because I had back pain and lying on my side on the exam table felt comfortable).

GBMC has embraced the patient-centered medical home concept. We have taken our existing primary care offices and have used them in a new way. On a recent visit to our Hunt Valley site at mid-afternoon I noticed that the waiting room was empty….the way we want it to be because we don’t want people waiting….and I realized that the waiting room was now just a lot of wasted space.

So I am very excited to tell you about a 3P going on this week on the ground floor of the North Pavilion on the GBMC campus. A team, led by Sarah Whiteford MD, and Ben Hand MD are designing the new home of Family Care Associates, one of our GBMA practices! Drs. Whiteford and Hand spent some time last month in Seattle at the Virginia Mason Institute, part of the Virginia  Mason Health System. Virginia Mason is a national leader in patient centered care and one of the first healthcare companies in the country to fully adopt Lean as a business model. A consultant from the Institute is guiding our team’s work this week.

Dr. Sarah Whiteford (left), Bryan Niles, construction project manager (center),
 and Dr. Ben Hand (right) work at designing a more efficient office that
 will not only enhance the patient experience but create more joy for the staff. 

Do you remember what a 3P is? We discussed the concept in What’s a 3P, the blog installment of October 26, 2012, when we talked about the process for designing our new inpatient pharmacy.

3P is a lean tool that stands for production, preparation, and process. The tool helps us invent new designs that follow lean principles and drive out waste. In this case, waste is defined as anything that the customer would not pay for. Most patients will pay for time discussing their problems with their doctors but are not excited about paying for waiting rooms or filling out forms.

Most physician offices use “batch” processing and move the patient from point A to point B to point C throughout the process. You come in and you wait. You are called to register and you wait. You are then called to have your vital signs and height and weight taken, you are brought to a room and you wait. Your physician or nurse practitioner comes in and deals with you and you wait to then be checked out of the office. The time waiting is nothing more than a characteristic of the design for patient flow.

If you were going to design the process that would be used for you as the patient how would you design it? I would like to arrive, be welcomed, brought to a room, my vital signs taken if necessary and then have my physician begin the visit with me. When he or she was done, I would like to leave with my instructions for the future.

Drs. Whiteford and Hand, along with medical assistants, care managers, and other members of their team now have the wonderful opportunity of designing a space that is better able to deliver care with less waste of time, effort and resources for all - I will be excited to see what they come up with! Stay tuned.


  1. Dr. Chessare,

    As a patient, I would love the scenario you described. It is ideal. Of course, there are times when patients must wait. If my healthcare needs required my doctor to take extra time I would hope that other patients could understand. My friend's FP told her, after she asked a quick question regarding her own medication at the end of her son's appointment, that she would have to schedule an additional appointment: "...Afterall, this is his appointment." It would not have taken much time for him to answer her. Family medicine implies taking care of families, not just individuals. Don't worry, this was not a GBMC practitioner. I bring up the situation to highlight that sometimes patients will need to wait, Emergent situations arise. The ideal, however, is what you describe, and it is appreciated.

    My late husband was a Family Practitioner. He made house calls up to the week he passed away. One or two patients flew thousands of miles to see him once or twice a year. In the late 1990s he was worried about patients feeling like cattle, and being charged for each and every blood pressure check--to the extent that they would stop coming to be seen. He said to me more than once, "Sometimes, you haven't covered the most important aspect of the visit until your hand is on the doorknob, you're starting to say goodbye and the patient says, "Oh, Doc, there's just one more thing..."
    Bob Wiedefeld always waited and took the time. His patients loved that. His patients were those of Hunt Manor Medical Group, a part of GBMC.
    I believe Bob would be proud of the direction you are going, incorporating a patient-centered medical home model.

    I am currently working in the mid-west for the home health and hospice agency of our local hospital. I remember my own years of working at GBMC very fondly. I am happy to see a physician at the helm! I recently visited Dr. Frank Sanzaro, one of the founding docs of HMMG. Bob joined "Hepner, Sanzaro & Wilson" about 30 years ago. I send my best to you, in continuing a legacy that Bob devoted his life to. You are so right to focus first on the needs of the patient and the community.


    1. Thanks very much, Suzy. Physicians work very hard. Our attempt to reduce patient waiting by reducing wasteful steps will not be at the expense of doctors. Our new design will make it easier for physicians to get their work done and will only be successful if the physicians can actually feel that their job is easier. That is why I am so excited that Drs. Hand and Whiteford are leading the design team. They must work smarter and not harder. I agree that patients will accept waiting if there is an emergency but they don't accept routine waiting because of poorly designed systems (nor should they). Thanks again for your insight.



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