Medical Clinic saves time with checklists, huddles Published Feb. 29, 2008 By By Lt. Col. Kathryn Mangion 15th Medical Operations Squadron MCGUIRE AFB, N.J. -- In healthcare, access and cost effectiveness is being addressed across the United States and throughout military medicine. A medical treatment facility that is accessible, safe, efficient and cost effective is desired. Annual military healthcare spending has more than doubled over the last few years rising to more than $36 billion. The Air Force is challenged to afford the modernization of their existing inventory to execute and sustain the mission. To this end the Air Force adopted Air Force Smart Operations 21. This program, also known as AFSO21, borrows some of the best business principles from the corporate world and applies them to our Air Force organization, structure and processes. The primary goal is to eliminate wastes in time, manpower and money. All Air Force leaders have been tasked to become LEAN and more productive through efficiency. The Air Force Medical Service is tasked to become LEAN and challenged to improve access, quality of care, cost effectiveness and efficiency within our current system; primarily outpatient clinics and services. AFSO21 LEAN principles include organizing and standardizing processes. The 305th Medical Group primary care clinic has implemented such strategies to improve the quality of care and efficiency in managing daily clinic operations. The 305th Medical Group's mission is to improve the health of those we serve. We want to prevent illness and injury, restore health, enhance human performance and sustain a fit and healthy force and do it all smartly, using AFSO21 principles. Like any mission, this requires a disciplined and accountable team approach. Just as when a flying squadron is tasked with a mission, there are many steps to plan and prepare for the execution: Assigning a crew specifically to fit the mission, filing a flight plan, ensuring equipment is available, fuel and supplies are to be ordered and loaded; cargo will need to be prepared, organized and secured. An outpatient clinic requires an assignment of a provider (pilot) to see patients and have a team assigned (crew) to be able to complete the mission. A schedule is filled with patients (cargo) and drop off schedule (appointment times). Exam rooms are loaded with equipment and supplies (fuel). Patients' charts need to be requested, gathered and reviewed before the flight plan is filed. Most of this often occurs 15 hours before the first scheduled patient (take-off time) "appointments minus 15 hours" (A-15 Hours). Like a C-17 aircrew preparing for a mission, the 305th Medical Group's primary care crew begins each mission day with a leadership crew brief. We meet daily at "appointments minus 30 minutes" to go over the available crew and the coverage required to complete the sortie. This meeting includes the flight commanders, the flight Chiefs, the NCOICs, element leaders, nurse manager and the highest ranking administrative technician. Discussion is led by the senior flight commander and each crew member is offered an opportunity to provide input. At A-15 minutes the crew is dispersed to assign and facilitate the "preflight inspections" for each individual primary care manager team or provider team. Each team pre-flights the day's appointment schedule with a checklist and a huddle. A huddle is a term from the quality management system the military health care system adopted to help minimize human errors in health care settings. The Team Strategies and Tools to Enhance Performance and Patient Safety, or Team STEPPS, program stresses teamwork and communication among doctors, nurses and other healthcare givers to improve quality, safety and efficiency across military health care. Each team pre-flights their schedule for required labs, rads, tests, results and referral notes. If the patient is coming for a profile update, the technician should print off the current profile from IMR so the provider can review with the patient. IMR checks are conducted for each active-duty AF visit. Additional questions to pose during a huddle may be to find out if a team member has an appointment or obligation away from the clinic and who will cover if they do have to leave. The integrated database (ICDB) for preventive health is reviewed and determined if the patient is due a preventive evaluation. Radio checks are performed between the provider and the technician. The radio is a communication tool used in primary care to help eliminate wasted time waiting or looking for team members when needed. Doing the pre-flight inspection on the appointment schedule and huddling before the start of patient flow alleviates many unnecessary delays and interruptions. Each team has prepared for the day, set expectations, and set common goals for patient safety and quality of care. After the pre-flight inspection, at A-5, the technician starts the engine, calling the first patient into the exam room. Wheels are off the runway when the provider enters the exam room at A-0 and the sortie departs on schedule with the goal of mission complete. Prior to landing and calling the mission a success, the primary care crew pulls out their pre-landing checklist. The many different facets that a PCM or provider team is supposed to manage for their empanelment has become complex; multiple electronic sources, multiple active-duty requirements and multiple patient demands have overwhelmed the clinic. Complex systems require complex methods, and a checklist serves to put us in a battle rhythm, to ensure all the critical tasks to complete the mission have been accomplished. Mission de-briefs or huddles are accomplished at the end of the day. A clinic checklist to prepare the crew for their next mission is followed prior to crew rest. Included in the abbreviated checklist for the clinic is the review of the Post Deployment Health Reassessment website. Has it been reviewed and acted upon? Were appointments booked/comments added to the spreadsheet? Has the locally-developed Individual Medical Readiness spreadsheet been reviewed and acted upon? Were comments on action taken to contact individuals typed on the IMR spreadsheet? Was tomorrow's schedule reviewed? All patients' 2766s updated? Was the PHA's PIMR updated? Have the exam rooms been re-stocked? T-Cons completed within 72 hours? If any answer is "no", the team cannot safely land their aircraft or complete the mission. All items on the checklist will be accomplished and verified by the provider and the flight chief before the team is released for the day. The flight commanders will review the signed checklists weekly to ensure the sortie was completed. The AFSO21 and TeamSTEPPS principles of organizing and standardizing processes to improve efficiency and productivity have been implemented within the primary care clinic at the 305th Medical Group in the form of team huddles and checklists. Radios have been added to help improve the flow of communication. Shaving off seconds in processes can add up to minutes saved in a patient encounter is needed in today's ever busy and demanding outpatient clinics.