The Henry Ford Medical Group (HFMG), a large group practice of 1,000 physicians operating 32 ambulatory medical facilities is the primary care division of the Henry Ford Health System, a fully integrated health care delivery system. In 1991 HFMG undertook a system-wide effort -- The Primary Care Initiative -- established to improve patient access to primary health care. This article describes how HFMG leveraged its business partnership with Siemens Rolm Communications, Inc. to streamline the ambulatory care center work flow, achieve process improvements, and increase patient satisfaction.

The Primary Care Initiative was instituted as health care delivery was becoming increasingly more competitive. HFMG wanted to measure patient satisfaction as it related to convenient access to primary care services. Survey results in 1992 indicated that fewer than half of the patients questioned ranked appointment scheduling by telephone as "good" or "excellent." Patient comments included:

• "More people need to answer the phones."
• "A patient could be on hold for 20 minutes and then be told there are no more appointments."
• "You should be able to get advice on what to do without coming in."

HFMG quickly realized that these survey results highlighted significant problems. To remain competitive, HFMG needed to resolve its patient access problems.

HFMG began an aggressive process to identify a strategic direction focused on patient satisfaction. The process gained momentum and was put into motion through a series of retreats conducted with HFMG management and medical staff members. Survey results were used as a basis for brainstorming sessions to enhance ambulatory center work processes.

HFMG had operated as a business for many years but, like the vast majority of health care organizations, was just beginning to view patients as clients. Focused on improving patient satisfaction, HFMG’s management group developed specific strategic goals.

A key strategic goal was establishment of a telephone nurse triage gateway for each ambulatory care center. Availability of nurse advice would be a critical component of the centralized call group that would be formed at each ambulatory care center. HFMG realized that the telephone system was critical to this plan and that the work process redesign could be fully accomplished only with new telephone systems for the ambulatory care centers. Along with a system design that would streamline calls, HFMG staff and management needed detailed reporting capabilities.

According to Lori Potter, Project Manager, Clinical Services, "Before we could improve patient satisfaction we needed better information to help us more effectively manage our call center operations." Tools providing data about the call groups would be critical for management review of the process.

Prior to The Primary Care Initiative, individual sites or regions within the organization made telephone system decisions independently. As a result of The Primary Care Initiative the telephone system became a management tool, and HFMG realized the importance of partnering with a single telephone system vendor to equip the ambulatory care centers. Upper level management supported the decision to standardize and wanted the long term goals of HFMG to be factored into the selection process.

HFMG conducted an extensive vendor selection process evaluating the capabilities of all leading digital switch manufacturers. Their selection process targeted the following criteria:

• HFMG viewed the business relationship as a critical component in vendor evaluation.
• HFMG wanted the ability to leverage its presence across southeastern Michigan transparently to the patient.
• HFMG required a technology platform that would enable the nurse triage gateway and centralized call groups.
• HFMG believed that detailed system reporting data as an accessible management tool was essential.
• HFMG wanted incoming calls to be answered within 15 seconds.
• HFMG needed a competitively priced solution.

Based on these key selection criteria, HFMG selected Siemens Rolm. The relationship Siemens Rolm had with HFMG’s corporate parent, the Henry Ford Health System, began in 1987 when a Rolm 9000 was installed at Henry Ford Hospital.

Beth Anctil, Director of Access and Quality Improvement for HFMG, explained, "We selected Siemens Rolm (for the ambulatory care centers) because many other Henry Ford institutions had been successfully involved with them for years. In addition, the company could provide the support we needed to interpret the statistics we would be acquiring and leverage them into enhanced services for our patients."

Siemens Rolm did not propose the least expensive solution, but their proposal was extremely competitive. Evaluation of all HFMG criteria found Siemens Rolm’s proposed solution to be the most cost effective for the 32 sites of the primary care delivery network.

Siemens Rolm shared its corporate direction with HFMG, including disclosure of planned product offerings. Current and projected capabilities of the Siemens Rolm product line were extremely well suited to accommodate the evolving needs of HFMG. The features and functionalities of the 9200 and the (then) newly released 9751 Rel. 9006 equipped with Automatic Call Distribution (ACD) satisfied the call center requirements of HFMG. The reporting capabilities inherent with Siemens Rolm ACD technology allowed HFMG to review current operations and make day-to-day staffing changes. System reports would also be used by HFMG management teams to determine overall work process changes.

CorNet@ would provide the seamless system-wide networking that HFMG needed to leverage its presence transparently across southeastern Michigan. To accomplish its 15 second call answering goal, HFMG used Siemens Rolm’s call processing technology, Phonemail@@, as a system back-up for peak periods. Furthermore, CorNet allowed multiple HFMG facilities to use a single Phonemail system. Most importantly for HFMG, the Siemens Rolm solution included flexible service and support.

HFMG established an ambitious three year telecommunications redesign plan with an overall budget of approximately four million dollars. The HFMG staffing resources for each implementation was typically one representative at each location with the support of the two member Henry Ford Health Systems corporate telecommunications staff. Siemens Rolm worked with the Henry Ford team to accomplish its aggressive implementation schedule. According to Lori Potter, "Siemens Rolm did a great job -- at one point replacing nine switches over a two month period."

Implementation of the Siemens Rolm technology helped HFMG realize its primary objective -- improved patient satisfaction. Following the implementations, call group answer times plummeted from as much as twenty minutes overall to four minutes for customer service representatives and six minutes for nurses. Abandon rates dropped from 50% to 7.3% for nurses and from 18% to 4.2% for customer service representatives. Most importantly, patient satisfaction survey scores nearly doubled.

Careful analysis revealed daily call volume fluctuations for both nurses and customer service representatives. At specific times of the day HFMG was able to reallocate staff to accommodate the heavier call volumes. This flexible staffing allocation resulted in nurse response time dropping to 1.7 minutes while customer service representatives were able to answer calls in just 30 seconds.

According to Linda Shappel, Manager at HFMG’s Woodhaven facility, "Before implementation of the 9200, there had been a significant volume of complaints related to telephone answering. Since installation of the 9200 there have been relatively none."

She went on to say, "The relationship with the patients had always been good -- the improvement has been due to centralized staffing and the telephone equipment -- that’s what made the difference." Linda can monitor real-time activity within the group and if the call volume is high she can add staff to the group or direct overflow calls to the console.

While survey results did improve, it is interesting to note that the they did not improve in the year immediately following system implementation. HFMG management believes that the new structure had to be in operation for over a year before the patients’ perceptions truly improved. Following an early 16% jump in survey results gradual yearly increases have continued.

Further review of the ACD reports confirmed another suspicion of HFMG management: talk times were very long, especially with nurses. HFMG suspected that the long talk times were evidence of a problem within the patient access process. While telephone system upgrades had improved the process, HFMG realized it needed to conduct further analysis to determine the base cause of its access problem.

Data was compiled and the original medical and management staff teams resumed the retreat process. System statistics allowed the team to access the process and further define the organization’s goals. According to Lori Potter, "We wanted to identify where the organization currently was in relation to the goals that had been set and determine what should be done to close the gap."

HFMG had originally projected that 20% of calls could benefit from nurse triage. However, focused analysis determined that only 3% actually wanted nurse advice. During most triage calls nurses were attempting to assist patients who truly needed to see a doctor. This often resulted in patients resorting to an Emergency Room visit -- a much more costly alternative.

HFMG realized that the excessive nurse triage talk times were a symptom of the real patient access problem -- an insufficient number of same day appointments. Ms. Potter went on to say, "The retreats allowed us to step back and put down a foundation. We determined that appointment scheduling was the foundation -- this lead to the Open Access concept."

Open Access was based on the realization that the nurse triage approach had not proven to be effective. Appointment requests had to be handled in some other way. HFMG established "Open Access" to provide patients access to same day and future date appointments. Open Access required physician staffing changes and these changes needed to be complimented with call center design changes to accomplish a newly defined goal, "one call resolution."

Siemens Rolm worked with HFMG to redesign the call centers to accomplish the Open Access goal of "one call resolution." With one call resolution, HFMG wanted 90% of incoming calls to end at the customer service call group after the scheduling of either a same day or future date appointment. HFMG determined that only 10% of the incoming calls needed to be handled by a nurse or other staff member. Revised call center demands created the need for customized reports which Siemens Rolm and a business partner, Chadbourne, are developing.

With one call resolution, HFMG is working to establish regional and potentially system-wide centralized call group environments. Originally the call groups were centralized within a single ambulatory care center, but CorNet system-wide networking and call center design flexibility will allow call groups to extend across southeastern Michigan, throughout the HFMG system. Plans are in place to establish a regional centralized call center that will move the organization toward a more flexible team approach to call answering. With the centralized team approach HFMG expects improved patient satisfaction with estimated FTE savings of 20% or more.

The Open Access call center redesign also required that nurses be removed from the physical call group and directed back to patient care. However, mobile nurses must still be accessible for those callers that their triage can genuinely assist. HFMG is evaluating the use of Siemens Rolm wireless technology to enable timely transfer of triage calls to the mobile nurses.

HFMG was a pioneer in its approach to primary care. Similarly, it pioneered the strategic use of Siemens Rolm technology in an ambulatory care environment. HFMG is now positioning itself to take further advantage of the Siemens Rolm telecommunications network it began to implement in 1993. HFMG continues to meet The Primary Care Initiative goals as increased telecommunications functionality delivers improved access and increased patient satisfaction. Siemens Rolm technology continues to play a critical role in HFMG’s evolving primary care delivery.

@CorNet is the networking software of Siemens Rolm Communications, Inc.
@@ Phonemail is the voice processing product of Siemens Rolm Communications, Inc.

Primary Care Initiative Time Line