6
Southwestern Surgical Congress Optimal utilization of a breast care advanced practice clinician Katie W. Russell, M.D., Mary C. Mone, R.N., B.S.E., Victoria J. Serpico, A.P.R.N., Cori Ward, M.B.A., Joanna Lynch, P.A.-C., Leigh A. Neumayer, M.D., Edward W. Nelson, M.D.* Department of Surgery, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132, USA KEYWORDS: Advanced practice clinician; Nurse practitioner; Physician assistant; Independent breast care clinic; Improved utilization; Lean principles Abstract BACKGROUND: Incorporation of ‘‘lean’’ business philosophy within health care has the goal of add- ing value by reducing cost and improving quality. Applying these principles to the role of Advance Practice Clinicians (APCs) is relevant because they have become essential members of the healthcare team. METHODS: An independent surgical breast care clinic directed by an APC was created with mea- surements of success to include the following: time to obtain an appointment, financial viability, and patient/APC/MD satisfaction. RESULTS: During the study period, there was a trend toward a decreased median time to obtain an appointment. Monthly APC charges increased from $388 to $30,800. The mean provider satisfaction score by Press Ganey was 96% for the APC and 95.8% for the surgeon. Both clinicians expressed sig- nificant satisfaction with clinic development. CONCLUSIONS: Overall, initiation of an APC breast clinic met the proposed goals of success. The use of lean philosophy demonstrates that implementation of change can result in added value in patient care. Ó 2014 Elsevier Inc. All rights reserved. In the healthcare environment of today, providing higher value by increasing quality while lowering cost challenges the structure of how care is organized and delivered. 1–3 Increased demands on healthcare systems and providers from the Affordable Care Act, resident work hour restric- tions, and the influx of 80 million older adults from the ‘‘baby boomer’’ generation add additional pressure on a system already known primarily for excessive expense and inefficiencies. 4,5 In cancer care alone, data from the National Cancer Institute and Association of American Medical Colleges project that while the number of patients needing care for cancer will increase by 48% between 2005 and 2020, the corresponding increase in the physician oncology workforce will increase by only 14%. 6,7 Pro- posals are abundant and change imperative to accommo- date healthcare evolution and to maximize productivity while improving the value of health care. 8 Advanced Practice Clinicians (APCs) have become more an essential member of the healthcare team. Research has shown that the addition of APCs across multiple specialties can add continuity, increase patient satisfaction, improve compliance, and often provide more affordable care. 9,10 Specifically in the area of breast care, British The authors declare no conflicts of interest. * Corresponding author. Tel.: 11-801-581-7738; fax: 11-801-585- 0168. E-mail address: [email protected] Manuscript received April 22, 2014; revised manuscript September 2, 2014 0002-9610/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2014.09.007 The American Journal of Surgery (2014) 208, 1054-1059

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Page 1: Russell et al AJS 2014

The American Journal of Surgery (2014) 208, 1054-1059

Southwestern Surgical Congress

Optimal utilization of a breast care advancedpractice clinician

Katie W. Russell, M.D., Mary C. Mone, R.N., B.S.E.,Victoria J. Serpico, A.P.R.N., Cori Ward, M.B.A., Joanna Lynch, P.A.-C.,Leigh A. Neumayer, M.D., Edward W. Nelson, M.D.*

Department of Surgery, University of Utah, 30 North 1900

East, Salt Lake City, UT 84132, USA

KEYWORDS:Advanced practiceclinician;Nurse practitioner;Physician assistant;Independent breastcare clinic;Improved utilization;Lean principles

The authors declare no conflicts of i

* Corresponding author. Tel.: 11-8

0168.

E-mail address: edward.nelson@hsc

Manuscript received April 22, 2014;

2014

0002-9610/$ - see front matter � 2014

http://dx.doi.org/10.1016/j.amjsurg.20

AbstractBACKGROUND: Incorporation of ‘‘lean’’ business philosophy within health care has the goal of add-

ing value by reducing cost and improving quality. Applying these principles to the role of AdvancePractice Clinicians (APCs) is relevant because they have become essential members of the healthcareteam.

METHODS: An independent surgical breast care clinic directed by an APC was created with mea-surements of success to include the following: time to obtain an appointment, financial viability, andpatient/APC/MD satisfaction.

RESULTS: During the study period, there was a trend toward a decreased median time to obtain anappointment. Monthly APC charges increased from $388 to $30,800. The mean provider satisfactionscore by Press Ganey was 96% for the APC and 95.8% for the surgeon. Both clinicians expressed sig-nificant satisfaction with clinic development.

CONCLUSIONS: Overall, initiation of an APC breast clinic met the proposed goals of success. Theuse of lean philosophy demonstrates that implementation of change can result in added value in patientcare.� 2014 Elsevier Inc. All rights reserved.

In the healthcare environment of today, providing highervalue by increasing quality while lowering cost challengesthe structure of how care is organized and delivered.1–3

Increased demands on healthcare systems and providersfrom the Affordable Care Act, resident work hour restric-tions, and the influx of 80 million older adults from the‘‘baby boomer’’ generation add additional pressure on asystem already known primarily for excessive expense

nterest.

01-581-7738; fax: 11-801-585-

.utah.edu

revised manuscript September 2,

Elsevier Inc. All rights reserved.

14.09.007

and inefficiencies.4,5 In cancer care alone, data from theNational Cancer Institute and Association of AmericanMedical Colleges project that while the number of patientsneeding care for cancer will increase by 48% between 2005and 2020, the corresponding increase in the physicianoncology workforce will increase by only 14%.6,7 Pro-posals are abundant and change imperative to accommo-date healthcare evolution and to maximize productivitywhile improving the value of health care.8

Advanced Practice Clinicians (APCs) have becomemore an essential member of the healthcare team. Researchhas shown that the addition of APCs across multiplespecialties can add continuity, increase patient satisfaction,improve compliance, and often provide more affordablecare.9,10 Specifically in the area of breast care, British

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K.W. Russell et al. Optimal use of breast care APC 1055

literature dating back more than 20 years documents therole and value of nurse practitioners in breast oncologyand provides good evidence that there can be a high degreeof both patient and provider satisfaction when these ‘‘physi-cian extenders’’ are incorporated into a breast-focused prac-tice.11–13 Although a recent report from the Institute ofMedicine endorsed including APCs in a team approach tocancer care, a combined review from California and Mich-igan concluded that employment of APCs in breast cancercare remains modest, especially among surgeons.14,15

As part of an institution-wide philosophy that empha-sizes healthcare delivery based on adding value byincreasing quality while reducing cost, we designed a studyto optimize the role of a clinically skilled APC, in this casean Advanced Practice Registered Nurse, working as amember of our surgical breast cancer team. The initial goalwas to establish an independent breast clinic run by an APCwith back up by a well-established breast surgeon in acollaborative practice model for the future. The primarygoal of this study was to broaden the APC scope ofpractice, thus allowing her to work at the top of her license.Based on our assessment of other specific needs withmeasureable outcomes, we established the following sec-ondary goals of this new APC dedicated breast care clinic:a 50% reduction in time to obtain an appointment for a newpatient in the breast clinic; positive financial benefits; andimproved patient, surgeon, and APC satisfaction.

Patients and Methods

To facilitate this effort, we chose to use an approachfollowing ‘‘Lean Principles’’ previously well documentedas successful in maximizing ‘‘change for the best’’ or‘‘Kaizen’’ in medical care.16–18 Based on these principals,we assembled a team that comprised 2 breast surgeons, 2APCs, a Master of Business Administration trained admin-istrator, a surgical resident, and a research nurse. All partic-ipants underwent basic training in lean principles in aninstitutionally run course. The lean principle of ‘‘Gemba’’(‘‘going to the real place’’) was followed by the team mem-bers visiting the breast care clinic for an on-site evaluationand needs assessment. From this preliminary appraisal, afocused problem statement was developed: ‘‘the surgicalbreast clinic is a perfect environment for an independentAPC practice.’’ Regular team meetings were held and aprogress map was developed and refined that outlined thecurrent state of the surgical breast clinic, the noted limita-tions, possible changes, and proposed outcomes.

The entire time period over which data were collectedincluded the 4 months before establishing the APC clinic(October 2012 to January 2013) and the 11 months thatfollowed (February 2013 to December 2013). Data werecollected on those patients who were new to the system andthe initial clinic visit was termed ‘‘new patient visit’’(NPV). The variable was further described as the calculatedtime (days) to obtain this appointment with the value

determined by subtracting the date of the actual appoint-ment from the date the call was made to obtain anappointment. Financial data included all charges billedand collections received by the APC through the studyperiod. Patient satisfaction was determined by using PressGaney scores (Press Ganey Associates, Inc., South Bend,IN), reporting the mean value for the care provider based on10 specific questions.

After establishing the above parameters, an independentbreast clinic run by an APC was established and the APCbegan to see patients in January 2013. Scheduling for theAPC clinic was initially designed to accommodate follow-up patients or those likely to have benign conditions (eg,breast pain, history of cysts). With experience, the APCbegan initial evaluations of new referrals who were thenpresented to an attending surgeon. Additions to usual APCfunctions included the following: independent initial pa-tient evaluations and follow-up, ordering and acting ondiagnostic studies, and independent performance of minorprocedures such as Port-A-Cath removals, breast injectionsfor sentinel node procedures, and breast cyst aspirations.

Relevant data were collected in Microsoft Excel 2013and analyses were performed employing IBM SPSSStatistics Version 21 (Chicago, IL). A P value of lessthan .05 was considered statistically significant. Data forPress Ganey scores are reported as an average. Values fortime to appointment are reported as the median per month.

The study was submitted to our Institutional ReviewBoard for review, and it was determined that oversight wasnot necessary to review or report these data and received anexempt status.

Results

The total number of NPV in the surgical breast careclinic, including those seen by the surgeon and the inde-pendent APC, did not change from October 2012 toOctober 2013 (Fig. 1). Over this same period, the rangeof patients seen per month for the surgeon ranged from10 to 44 and from 3 to 16 for the APC.

The median number of days between calling for anappointment to being seen for an NPV fluctuated over thestudy interval, but when the time for APC and the surgeonare combined (per month), the trend steadily decreased(Fig. 2). The widest range of time to get an appointment ina single month for the surgeon before the APC clinic(October 2012 to January 2013) was 1 to 53 days (median11). In the 3 months after the APC clinic (February 2013 toApril 2013), this narrowed to a low range of 0 to 16 days(median 6). The median time comparing 2 similar time pe-riods for 2012 versus 2013 (February to October) is de-picted in Fig. 3. The median time is statistically lower for2013 as compared with 2012 (9 vs 16 days, respectively,P , .001; Mann–Whitney–Wilcoxon and Median testing).

The financial results of this independent APC breastclinic are seen in Table 1. The monthly charges billed by

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Figure 1 Total number of combined new patient visits by month of occurrence: surgeon plus APC. Institution of APC clinic is noted byarrow.

1056 The American Journal of Surgery, Vol 208, No 6, December 2014

the APC increased from a low of $388.00 just before start-ing the clinic to a high of $30,800.00 with correspondingcollections of $284.00 and increasing to a high of$9,075.00. The charges from October 2012 to December2013 totaled $190,986.00. In conjunction, monthly workrelative value units for the APC increased dramaticallyfrom 3 to 206 over the same period.

To evaluate patient satisfaction, Press Ganey scoreswere compiled from the breast care clinic setting for theAPC and the attending surgeon (March 2013 to December2013). The section for the standard care provider was used,which is based on 10 separate questions with an averagescore calculated. For the surgeon, 140 total patientsatisfaction forms were evaluated and the mean monthlyscore was 95.8 (range 87.2 to 100). For the APC, therewere 56 patient forms returned and the average standardcare provider score was 96 (range 83.8 to 100). PressGaney scores for the APC began in March 2013. The meanscore for the surgeon during the 4 months before addingthe APC to the clinic was 95.5 (October 2012 to January2013, n 5 92). From April 2013 to December 2013, thePress Ganey survey captured the score accessing the ‘‘abil-ity to get the desired appointment.’’ For the surgeon, the

Figure 2 Median number of days for new patient visit defined as the didate combined APC and surgeon time. Institution of APC clinic is note

mean score was 89.1 (n 5 110) and for the APC themean score was 87.8 (n 5 43).

For the period of study, no delays or failures in diagnosisof breast cancer were noted secondary to implementation ofthe APC clinic.

Comments

The makeup of the healthcare workforce in the UnitedStates and its relationship to changes in quality of the caredelivered represents a major concern to providers, payers,and patients.19 Historically, patients and payers have ex-pected that referrals for specific problems, such as breastcare, be seen by a specialized physician. However, whenfunctioning as part of a specialized team, expanding the re-sponsibilities and scope of practice of APCs has beenrecently shown to maximize productivity without compro-mising patient acceptance or satisfaction.14,20–22

Within the practice of breast care, there remains widevariation as to the exact role and level of participation ofAPCs. In a survey of breast care specialists in Californiaand Michigan, Friese et al found that while 39.6% of breast

fference between actual appointment date and call for appointmentd by arrow.

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Figure 3 Comparison of median number of days for new patient visit defined as the difference between actual appointment date and callfor appointment date: 2012 versus 2013 for combined APC and surgeon.

K.W. Russell et al. Optimal use of breast care APC 1057

practices employed APCs, there was a statistically lowerlikelihood of finding them in a breast surgeon’s practicewhen compared with that of a medical oncologist (28.7%vs 56.3%). In addition, APCs were more likely to beemployed by physicians in practice less than 10 years andin groups with more than 3 physician partners. The authorsconclude that increasing the now current modest utilizationof APCs in breast cancer care is one way to close the gapbetween demand and supply of cancer care.14

At our institution, as in healthcare delivery in general,there has been a renewed emphasis on changes in practicethat result in better value through increased quality atdecreased cost. Because we observed that the many APCswe employ may not be working to their full potential, wechose to approach the problem of optimal utilization of theAPCs using methods learned from lean philosophy

Table 1 Monthly charges, payments, and work RVU for APC over 15

Charges ($)

October 12 590.75November 12 590.75December 12 387.60January 13 748.90February 13 15,833.25March 13 10,249.16April 13 13,538.80May 13 14,750.87June 13 17,005.75July 13 8,859.22August 13 15,391.65September 13 19,912.80October 13 21,180.07November 13 21,146.17December 13 30,799.82Total 190,985.56

APC 5 Advance Practice Clinician; RVU 5 relative value units.

developed in the auto industry.16–18 A lean team wasassembled and an initial problem statement developedthat proposed to include better utilization of all APCs work-ing within our general surgery division, but it was soonnoted that this broad goal was not ‘‘SMART’’ (specific,measureable, attainable, relevant, and timely) accordingto lean principles. The goal was therefore revised andmade specific to the simple statement ‘‘the breast clinic isthe perfect environment for an independent APC practice.’’

Overall, after comparison of data pre and post initiation ofthe APC breast clinic, the stated goals of this project weregenerallymet. Although improvement in the time required toobtain a scheduled appointment with a surgical clinician didnot meet the goal of 50% overall reduction in time, there wasa trend toward a reduction in the time to being seen when theAPC clinic was added. Despite the fact that the surgeon gave

-month period

Net payments ($) Work RVU

369.05 4.85428.07 4.85283.94 3.08301.18 5.03

4,171.72 106.872,806.05 82.272,633.07 91.563,357.62 102.594,672.77 118.684,294.28 62.845,045.25 109.115,137.09 132.279,075.32 148.435,395.14 148.925,401.61 205.9853,372.16 1,327.33

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1058 The American Journal of Surgery, Vol 208, No 6, December 2014

up clinic time to accommodate the new APC clinic, the trendin the monthly total number of new patients seen wasunchanged. Financially, the new APC clinic was a successwith respect to increased capacity to charge for deliveredcare, reflected by the dramatic increase in charges andcollections for clinic care. Coincidentally, the supervisingsurgeon was able to devote more time to revenue productionin the operating room and academic pursuits in teaching andresearch. Because of the positive financial effects of thiscollaborative model, this APC clinic model is now our goalfor other APCs employed by our division. Additionally, thebreast APC now feels more clinically empowered to managepatients independently while still having the reassurance ofdirect physician back up if needed. The surgeon reportincreased satisfaction based on the ability to best use her timeand abilities for research, teaching, and clinical problems thatrequire specific expertise. Perhaps most importantly, largelybased on the timeliness and quality of theAPC appointments,patient satisfaction scores remained high or improved forboth providers.

The implementation of physician extenders is variableacross specialties and across settings (academic vs private).No single, perfect model can be adopted by all, andimproving the quality and delivery of health care willrequire each institution or practice to examine their ownstructure, needs, and limitations.

Parameters to evaluate improvement in care are alsodifficult to measure. The objective of this study was toevaluate changes in revenue, patient and provider satisfac-tion, and overall efficiency secondary to initiating anindependent APC breast clinic. Based on the results ofthis experience, we conclude that efficiency can comple-ment quality when surgeons take the opportunity todelegate responsibility so that all team members areworking at the top of their license. We believe this studyhas shown that in a surgical breast practice, the develop-ment of an independent APC-directed clinic can result in‘‘change for the better.’’

References

1. PorterME.Value-based health care delivery. Ann Surg 2008;248:503–9.

2. Porter ME, Teisberg EO. How physicians can change the future of

health care. JAMA 2007;297:1103–11.

3. Pollack RE. Value-based health care; the MD Anderson experience.

Ann Surg 2008;248:510–6.

4. Ku L, Jones K, Shin P, et al. The states’ next challenge – securing pri-

mary care for expanded medicaid populations. N Engl J Med 2011;

364:493–5.

5. King DE, Matheson E, Chirina S, et al. The status of baby boomers’

health in the United States: the healthiest generation? JAMA 2013;

173:385–6.

6. Erickson C, Salsberg E, Forte G, et al. Future supply and demand for

oncologists. J Oncol Pract 2007;3:79–86.

7. Association of American Medical Colleges: Recent Studies and Re-

ports on Physician Shortages in the US. Available at: https://www.

aamc.org/data/workforce/reports/. Accessed March 3, 2014 (https://

www.aamc.org/download/100598/data/recentworkforcestudies.pdf).

8. Fenton JJ, Jerant AF, Bertakis KD, et al. The cost of satisfaction,

health care utilization, expenditures, and mortality. Arch Intern Med

2012;172:405–11.

9. Wall S, Scudamore D, Chin J, et al. The evolving role of the pediatric

nurse practitioner in hospital medicine. J Hosp Med 2014;9:261–5.

10. Kapu AN, Kleinpell R, Pilon B. Quality and financial impact of adding

nurse practitioners to inpatient care teams. J Nurs Adm 2014;44:

87–96.

11. Garvican L, Grimsey E, Littlejohns P, et al. Satisfaction with clinical

nurse specialists in a breast care clinic: questionnaire survey. BMJ

1998;316:976–7.

12. English T. Medicine in the 1990s needs a team approach. BMJ 1997;

31:661–3.

13. Watson M, Denton S, Baum M, et al. Counselling breast cancer pa-

tients; a special nurse service. Couns Psychol Q 1988;1:25–34.

14. Friese CR, Hawley ST, Griggs JJ, et al. Employment of nurse practi-

tioners and physician assistants in breast cancer care. J Oncol Pract

2010;6:312–6.

15. Institute of Medicine. Ensuring Quality Cancer Care through the

Oncology Workforce: Sustaining Care in the 21st Century. Washing-

ton, DC: National Academies Press; 2009.

16. Kim CS, Spahlinger DA, Kin JM, et al. Lean health care: what can

hospitals learn from a world-class automaker? J Hosp Med 2006;1:

191–9.

17. Simon RW, Canacari EG. A practical guide to applying lean tools and

management principles to health care improvement projects. AORN J

2012;95:85–103. quiz 101–3.

18. Schweikhart SA, Dembe AE. The applicability of Lean and Six Sigma

techniques to clinical and translational research. J Investig Med 2009;

57:748–55.

19. Donelan K, DesRoches CM, Dittus RS, et al. Perspectives of physi-

cians and nurse practitioners on primary care practice. N Engl J

Med 2013;368:1898–906.

20. Ritchie A. Patients open to expanded role of physician assistants, NPs.

Med Econ 2013;90:52.

21. Role of advanced nurse practitioners and physician assistants in Wash-

ington state. J Oncol Pract 2010;6:37–8.

22. Buswell LA, Pote PR, Shulman LN. Provider practice models in

ambulatory oncology practice: analysis of productivity, revenue, and

provider and patient satisfaction. J Oncol Pract 2009;5:188–92.

Discussion

Discussant: Dr Emily K. Robinson (Houston, TX). Theuse of physician extenders in a breast clinic is a very inter-esting topic, and very timely, given the number of BabyBoomers that we have now and the number of patientswho are going to have breast cancer, to develop a modellike this. I congratulate you.

I do have several questions, though.When I initially read the paper, it seemed obvious that

time for appointments would go down if you added a clinic,but now it’s clarified that actually you have the samenumber of clinic days. I’m wondering how you had met thatparticular goal.

Additionally, as you said in the very beginning, value isquality divided by cost. You give us a lot of informationabout revenue, but have you actually decreased the cost perepisode of care for the patients that you are seeing?

Also, since you are decreasing the time to yourappointments, are you actually increasing the timelinessof your care for your cancer patients?

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K.W. Russell et al. Optimal use of breast care APC 1059

Along that line, is there any triage done of these patientsprior to them coming to clinic? Are all the cancer patientssent to an attending surgeon, or is it just first come, firstserve, everybody gets put into a clinic based on theappointment time?

Dr Katie Russell: The first question is, we did lose timewith one of our physicians. Our APC had more clinic spotsinitially than the attending physician, so we opened upmore spots on that day and actually since, our M.D. origi-nally completely was out of clinic and then, since, she’scome back a little bit and sees a couple of appointments,which goes along with your next question about the cancer.We do triage these patients. The original idea was that thiswould be a benign breast disease clinic. So we wanted tomake sure that the physician saw the cancer patients ontheir initial visit, and then, our APC would see all of thebenign disease. And that was initially the plan, and stillhow it goes most of the time. Every now and then, we’llcatch a cancer that was kind of triaged as being benign,and then we will have to get them in to see the physicianat another time, but we do triage the patients.

As far as decreasing the cost per patient, I think thebiggest thing that we have seen is just by increasing thebilling of our APC. So we have increased our revenue by

using her, because she was being used in the same situationas a resident, just go going to clinic and having to present tothe attending, just like we do as residents. But now our timeis better utilized because she no longer has to staff with anattending. And then she also is able to bill for her services,which she couldn’t do before when she was being overseenby a physician.

Dr Daniel Dent (San Antonio, TX). How has thisimpacted the resident experience? If I understoodcorrectly, Dr. Neumayer has won more teaching awardsthat you can count on two hands and now the residentsare not getting the opportunity to do breast clinic withher, at least on the days that the advanced practice clini-cian is doing it.

Dr Katie Russell: I think, as was alluded to in the lunch-time session, at the University of Utah we have doubled ourfaculty members, and we still only have five chief residents.As far as Dr. Neumayer’s clinic, she still has a Tuesdayclinic that our resident goes to for the entire day. So wehave a full day of Neumayer clinic, which is a great clinic.We actually have more autonomy in that clinic and lessnurse practitioner time in that clinic, and then her Thursdayclinic is primarily just a nurse practitioner clinic now. Soit’s been good for the residents.