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35 Managing theFamily Medicine Center
Fig. 35.1 The 10+3
Building Blocks of HighPerforming Teaching Clinics
407
Shared Vision ontheRole oftheFMC
Once the relevant stakeholders are identied, the next step is
to come to a shared understanding of mutual priorities and
clarify a shared vision or mission statement between the residency and clinic leadership to align their respective goals.
An important aspect of this is where the program philosophy
lies on the clinic-hospital spectrum. Traditional GME has
been very hospital-centric, where educational and scheduling
priorities center on inpatient and specialty training. As one
faculty preceptor has phrased it, “When I started in the clinic,
there was chaos. There were too many patients and we
couldn’t take good care of them. The culture of leadership
was, ‘Clinic it is what it is and there’s nothing we can do
about it’…. [The residents] always had someone sicker in
hospital they needed to go back to.… Clinic was leftovers—
the action was in the hospital” [1].
Recently, more programs are shifting away from the
“hospital- rst” paradigm and are adopting philosophies that
elevate the FMC in the residency training experience. One
example is Clinic First, which was initially coined by Neher
etal. [6] to refer to curriculum changes that supported continuity and outpatient clinical excellence. It was then
adapted by Gupta etal. to signify the philosophy of prioritizing the primary care clinic in residency training, and that
creating high-performing teaching clinics is essential to
meet the dual teaching and patient care missions of the residency clinic [7]. Clinic First is not a specic scheduling
model or template, but rather a broader philosophy with recommended action steps toward the goal of improving the
residency clinic.
A common misconception is that a Clinic First philosophy
has to mean “hospital/specialty second”—rather, the term is
used to highlight the fact that in traditional GME, the clinic
has been the “leftovers” of the resident learning experience
when it comes to priorities, scheduling, etc., and that to train
residents well in the ambulatory setting, it needs to be at least
elevated to match the level of attention and priority historically
given to other rotations. Depending on an individual residency
program’s training mission, this need not devalue other learning experiences, and several programs exemplifying the Clinic
First philosophy simultaneously identify primarily as unopposed programs dedicated to training full-spectrum family
medicine residents with strong skills in inpatient, obstetrics,
procedures, intensive care, etc. Programs that have been inpatient-focused have used Clinic First principles in different
ways and varying degrees and made individualized decisions
on how much it impacts other rotations. Rather than being in
conict with hospital/specialty- oriented experiences, often
times programs use Clinic First principles in ways that complement and enhance resident learning in all areas.
Regardless of whether or not a program uses the Clinic
First terminology, or a similar concept highlighting excellence in the FMC, the main goal is to align priorities between
residency and clinic leadership wherever possible through a
shared vision for improvement. This can often be done by
recognizing areas where improvement is a win-win—such as
when improving a workow in the clinic benets both patients
and learners. The shared vision should be made visible and
consistent to residents as well as clinic staff. Language around
improvement efforts should connect specic change initiatives to the greater shared mission of the FMC.
408
M. Kong and C. Lyon
Shared Leadership andChange Culture
This is relevant to another major component of engaged
leadership in the FMC—building a positive culture of change
that invites everyone to collaborate on improvements with
their respective expertise. Consider ways to instill systems
improvement and leadership skills throughout the clinic and
involve people from all levels: residents, staff, faculty, and
patients. Fostering staff champions and resident leaders in
the clinic will improve both engagement and work experience, as well as develop human capital for creating and sustaining positive change.
One approach to this is to develop a practice improvement
structure with frontline staff involvement. This may consist
of an overarching change team that meets frequently for
overall goals and planning, along with a structure for smaller,
focused workgroups for specic initiatives and workows.
Identify the who, when, where, what, and how of this structure, including how time and space is reserved for improvement work, how residents and staff are taught to co-lead
projects or workgroups, and how patient advisors and representatives are incorporated.
For example, at the Cambridge Health Alliance/Tufts
Family Medicine Residency, clinic improvements are structured via their Practice Improvement Team (PIT), which
consists of clinicians, residents, nurses, MAs, front desk
staff, behavioral health, and 2 patients [8]. Members are
nominated by their peers and serve for 1year, then other staff
get a chance to serve. The members report to and get suggestions from their peers. The PIT meets weekly for 2hours,
with each PIT member rotating as facilitator for 10weeks.
Facilitators collect agenda suggestions, set meeting agendas,
ll out and distribute meeting record sheets. During their
time as facilitator, members are mentored and taught leadership skills, including how to run effective meetings. The PIT
sends improvement suggestions to the management team
based on meeting discussions. This format fosters improvement ideas and leadership skills from all perspectives in the
clinic.
Embarking on improvement efforts in the FMC requires a
lot of work, and can often cause a lot of stress for staff, clinicians, and residents. Strategies for fostering a positive culture of change to ameliorate such stresses include establishing
ground rules for creating an environment that is both supportive and change-positive, such as rules for respectful
communication or for giving feedback. Power dynamics
often cause staff to not to feel comfortable giving honest
input about how things work in the clinic. Create comfortable ways for staff to give input, such as by using small
groups and open-ended facilitation of discussions, and invite
them to share their valuable expertise from their role.
Encourage using a lens of understanding systems that lead to
dysfunction, rather than attributing dysfunction to individuals. When responding to frustration or feedback, particularly
around stressful topics, consider using communication methods that are often used in patient care to approach change
management with staff and residents, such as motivational
interviewing skills, open-ended questions, and active
listening.
Scheduling
Resident scheduling is a complex process with many moving
parts, and underpins every other Building Block in the
FMC.Decisions around resident scheduling in the FMC, and
how much the FMC is prioritized in residents’ overall schedules, will rely on the shared vision between the clinic and
residency leadership, the strength of which sets the stage for
negotiation with stakeholders from other rotations.
Important overall principles to keep in mind when designing residents’ FMC schedules are consistency, predictability,
concentration of clinic time, and overall amount of time
spent in clinic during residency. These will affect how much
we can maximize continuity, access, team stability, and resident engagement in the FMC.
For example, if residents are inconsistently present in the
clinic, and the clinic does not get the residents’ clinic schedules until 1 or 2months in advance, clinics will struggle with
adjusting staff schedules, room availability, and providing
appointments to patients far enough ahead of time to optimize patient continuity. These problems worsen when there
are many last-minute changes to resident clinic schedules. In
contrast, when resident schedules are provided 6 to 12months
ahead of time, rarely change last minute, and are arranged
such that there are consistent numbers of residents in clinic
at a time, the FMC has maximum opportunity to coordinate
stafng, team and room assignments, and scheduling for
continuity patients.
Similarly, if resident schedules are consistent and predictable, but residents are only in clinic one half-day a week for
long stretches, this limits the degree to which residents are
available to provide patients with continuity of care. When
residents have clinic at least a few times a week for many
weeks, with short intervals of time that they are less present
in the clinic (e.g., 0–1 clinic sessions a week), this maximizes opportunities for continuity and minimizes coordination to cover residents’ panels while they are away.
Re-evaluating how much time residents spend in clinic during training overall, and increasing it when feasible, will
increase both access and opportunities for patient-centered
continuity.
Key questions to use when self-assessing resident schedules include:
35 Managing theFamily Medicine Center
409
• How many sessions per week do residents see patients in
clinic? How many weeks/blocks are there that residents
spend no clinic time? How many weeks/blocks with only
1 clinic session per week? How frequent are these weeks/
blocks with low clinic presence?
• Who makes the resident clinic schedules? What is the
process for going from overall residency rotation schedules to clinic schedules?
• How far in advance are residents’ overall schedules made?
How far in advance does the clinic scheduler know which
half-days a resident will be in clinic?
• How do the people responsible for residency schedules
and clinic schedules work together to coordinate schedules and resolve conicts?
• Once the clinic schedules are made, how often are they
changed? What rules are there about schedule changes
and who has authority to approve them?
• What are the minimum and maximum numbers of residents and faculty seeing patients in clinic in a given half
day? How much does this uctuate day to day?
Best practices for improving resident scheduling starts
with understanding and improving the predictability and
consistency, and minimizing variability in the scheduling
process. Most programs work with templates for residents’
overall schedules, but these may or may not have clinic sessions built in them in a way that is realistic for the clinic. For
example, when there are 2 residents in clinic one half day,
and 8 residents in the next, it’s often hard for the clinic to
reconcile this variability with stafng levels and numbers of
available clinic rooms. This then requires either moving residents or faculty from one team to another, or moving resident
clinics to different half-days altogether.
One best practice to address this is to adjust resident rota-
tion templates such that the number of residents scheduled to
be in clinic per half day is set to a specic target for every
half day. For example, the goal may be to have 6 residents
scheduled to be in clinic every morning and afternoon. This
reduces the need to change schedules later on due to rooming/stafng limits, and makes it more straightforward to
keep residents working with the same team members.
Because there ultimately will still be some unpredictability
in resident schedules, some creative strategies may be
needed. At University of North Carolina’s Family Medicine
Center, rather than having faculty members permanently
assigned to particular half-days for their clinic, faculty members identify different options for half-days they could be
available for clinics. The schedulers prioritize resident clinic
schedules rst, then ll in faculty clinic sessions around that
to meet their goal of having 16 clinicians in clinic each half
day [9].
Another best practice is to streamline the process of
scheduling between the residency schedulers and clinic
schedulers. Often times, sitting down with the staff members
who have to create the schedules to learn about the process
will reveal several areas with delays or redundant work. For
example, there may be a signicant delay between when
residents’ overall rotation schedules are set and when the
resident clinic sessions are conrmed for the clinic schedulers. Ideally, the rotation schedules specify resident clinic sessions at least a year in advance, and clinic schedulers can
work with this much further in advance than when they need
to open appointment schedules for patient scheduling and
staff assignments. Review who needs to know what and
when to make the respective scheduling processes as efcient as possible, and move up deadlines for nalizing schedules, when possible, to allow more time for clinic scheduling
and review for potential conicts. Creating detailed and specic workows with concrete deadlines, and documenting
these workows, will make the process more consistent and
transparent, and facilitate future training of new schedulers.
Areas where schedulers need to go back and forth to
resolve scheduling issues should be identied and minimized as much as possible, whether it is through re-adjusting resident rotation templates for future years, or creating
and enforcing rules about when clinic sessions are allowed
to be rescheduled. For example, how far in advance are
vacation or conference requests required to be made, and
who approves these? Is clinic stability factored into whether
or not changes are approved? If a change is requested past
the required deadline, does the requesting faculty or resident
have responsibility to help nd coverage or reschedule
patients? Does the residency have a back-up resident process such that the residents are not pulled from continuity
clinic to cover other rotations? Lastly, setting up close communication between the residency scheduler and clinic
scheduler can go a long way to minimize delays and redundant work related to resolving changes or scheduling conicts. This could be done via co-location (having residency
and clinic schedulers’ workspaces physically located next to
or very near one another), or by planning regular, specic
time points for checking and reconciling residency and
clinic schedules.
Some programs have also started having residents in
clinic for full days rather than half-days to minimize sameday conicts between outpatient and inpatient settings. This
allows residents to feel more immersed in the setting they
will be in for the day and improve their engagement and
focus, as opposed to having to run from one setting to another
in the middle of the day and requiring patient care transitions
that can sometimes bleed into the afternoon’s responsibilities
[10]. This may particularly benet residents earlier in training, when they have less experience and lower comfort levels
with the various settings in which they practice.
Beyond the traditional 4-week block rotation schedules,
some programs have opted to redesign their scheduling
410
M. Kong and C. Lyon
model completely in order to better meet their training and
clinical goals for residents. One such model has been termed
longitudinal interleaved residency training (LIRT) [11],
which involves scheduling major clinical experiences in
short, frequent repetitions longitudinally throughout residency training. For example, the scheduling model at Kaiser
Seattle Family Medicine has residents complete inpatient
medicine in 1–2week bursts and obstetrics in 3–4day shifts
[12]. They also increased the overall time spent in clinic for
residents and increased their continuity rates. Their goals
were to center residents’ experience of caring for a whole
panel of continuity patients from day one of intern year, and
to incorporate evidence on the educational benets of interleaving experiences repetitively over time into their curricular structure.
Another common model emerging among programs is
breaking traditional 4-week blocks into 2-week mini-blocks,
where every 2 weeks residents switch from an inpatient
mini-block to an outpatient one with several clinic sessions,
allowing residents to have a heavy clinic presence half of the
time in a month. Some programs have found this to improve
their continuity rates and residents’ learning satisfaction
[13–15]. In order to meet 40-week continuity clinic requirements, these programs may still include a half day of clinic
on inpatient mini-blocks. Another strategy to allow some
exibility in scheduling is to change rotations mid-week
rather than by calendar week, so that a 2-week clinic miniblock will span 3 calendar weeks. Some programs also stagger rotation start days between resident years and attendings
to minimize care transitions, for example, so the whole inpatient team does not turn over on the same day.
Whether a program embarks on a large scheduling overhaul or is making small adjustments to rotation templates,
changes usually require some negotiation with stakeholders
from other rotations, such as attendings and leadership of
specialty rotations. Explaining the signicance of residents’
clinic and the impacts on patient care can often be a good
starting point for conversations about these changes.
Thoughtful discussion with each major stakeholder can help
identify opportunities where the change impact can be minimized. Residency leaders may nd that the scheduling conicts do not actually occur where they are expected to, due to
other circumstances for the specialty or inpatient leaders,
while conicts may occur unexpectedly with others. When
no clear solution can be found, at times program leadership
must seek out creative alternatives, such as working with a
different specialty ofce to provide the desired learning
experience, or building the learning experience into the FMC
to provide the clinical exposure to residents there. If no better alternative exists, accommodations may need to be made
elsewhere in the templates to minimize the disruptive impact
on resident clinic scheduling.
Data-Driven Improvement
Another foundational building block is data-driven improvement, as the level to which data is used to drive improvement
in the clinic enables how well-informed and responsive our
improvement efforts will be for all of the Building Blocks.
This requires a robust way to obtain accurate and timely
data, as well as a culture and structure for disseminating and
using data for practical improvements.
For any given improvement area, choosing and measuring
metrics wisely is the rst step. This involves choosing metrics that accurately reect the current state and will reect
changes being made to intervene on the area. Data should be
timely, simple, trusted/validated, transparent, and tied to
individual actions. Each metric should be easily dened in
terms of a numerator and denominator, and knowing these
specic denitions will aid in building these metrics into
automated reports or dashboards. Each metric should be
drilled down to the clinician and team levels to be able to
analyze metrics with nuance, feel relevant and actionable to
individuals in the clinic, and to help identify high performers
with best practices to spread or those needing more assistance. Data should be made available frequently, ideally at
least monthly.
Ensuring that the metrics are validated and tracked accurately often requires collaboration with the clinic or health
systems’ data analyst(s), information technology (IT) representative, and/or electronic health record (EHR) champions.
Finding the right person or team among these individuals
with whom to build a partnership is important to have the
necessary expertise to create and revise data reports efciently. As many people in IT/EHR departments have little
idea what the front lines of a clinic look like, invite them to
the clinic to show them the reality of clinic operations and
examples of how patients are impacted by the necessary
data. Describe data requests in the language of numerators
and denominators to be specic and clear about what is
needed. Use residency requirements as well as stories demonstrating patient impact to illustrate why specic requests
for data are necessary and should be prioritized.
After reliable data is obtained, it also needs to be incorporated into clinic functioning in a way that supports a culture
of data-driven improvement. Data and improvement initiatives should be transparent and explained in language focusing on the patient impact. The goal is to foster a culture
where everyone in the clinic knows why the metrics are
important to the care for patients, and how everyone contributes to improving these in their daily work, rather than perceiving the metrics as numbers that are only important to
leadership teams as bureaucratic requirements but not
directly relevant to individual clinic or staff roles. Similarly,
it should be made clear to clinicians and staff that individual-
Days inclinic per year Visits per day
×
35 Managing theFamily Medicine Center
411
level metrics are not tracked and displayed to reprimand
individuals for lower performance, but rather to collaborate
as a clinic to understand barriers for particular metrics, and
identify best practices to improve clinic workows and systems for patient care and population management.
Making important data readily available via dashboards,
scorecards, or a data board/wall in the clinic that is updated
in a timely fashion and visually easy to understand is an
important component. Featured data could include a mix of
selected clinical quality, operational, utilization, patient
experience, and clinician/staff experience metrics. Using
color coding or line charts comparing trends over time with
goal targets can be effective ways to display data. A data
board placed centrally in the clinic space can act as a centerpiece for communication about current improvement
efforts.
Formal thought should be given to when and how clinicians and staff review priority data metrics. Time can be set
aside to do so at huddles or meetings. Time for teams or
clinician- medical assistant teamlets to meet together about
their patient panel’s metrics can be used to encourage shared
accountability for improving metrics and devise ideas to
improve metrics that are not at goal. Having data visibly displayed that shows comparisons by team can be a way to
encourage friendly competition for improving metrics.
Successes should be celebrated with recognition for the staff
and clinicians contributing to improving a metric. High performers can be asked to share their best practices at meetings. Frame language around poorly performing metrics not
as personal failures or grounds for individual shaming, but as
opportunities to understand and improve systems that contribute to these outcomes.
Consider building in additional structure for quality
improvement (QI) to engage all staff and clinicians, including residents. For example, if there are team meetings in the
clinic, consider setting aside time during these as working
meetings for improving a particular metric, with specic
action items and follow-up plans. Team-based projects can
be a good way to encourage multidisciplinary input and
engagement in Plan-Do-Study-Act (PDSA) cycles to
improve a metric or particular clinic workow.
Empanelment
Empanelment is a foundational Building Block as it is the
infrastructure for creating continuity relationships, organizing the data and work of primary care, promoting accountability and team-based care, and for balancing capacity with
demand. It is a continuous process involving ve steps:
assignment, calculating ideal panel size, weighting, reviewing/adjusting, and maintenance.
Assignment andIdeal Panel Sizes
Frequent issues with assigning patients in the FMC include
different health system or EHR customs around assigning
patients to residents. Residents may not be able to be clearly
identied as the primary care clinician (PCC) in the EHR,
making it difcult for schedulers to tell who the patient is
assigned to. Panel assignments may or may not be clearly
linked to teams. Strict policies and procedures need to be in
place around who is allowed to change the PCC assignment
to avoid inadvertent changes or automated defaults interfering with the accuracy of empanelment. Addressing these
issues may involve meeting with IT/EHR and/or health system leaders to explain the impact on patient care of inaccurate or unclear empanelment.
An important aspect of empanelment is deciding appropriate target panel sizes. While there are currently no formal
standards for panel sizes, understanding how to calculate
ideal panel size helps us understand the factors that should
go into target panel sizes and downstream effects of panel
size on access. Ideal panel size is the number of patients a
clinician can realistically care for, balancing the capacity for
care with the demand for care for those patients. We start
with a basic formula where capacity and demand in primary
care are equivalent [16]:
Average patientvisit
= ss per year Panel size×
The left side represents total available visits per year, or
capacity, while the right side represents visits created by
patients, or demand. There are some caveats to this approximation—it assumes a fee-for-service model where care is
primarily delivered through visits, and does not account for
inter-visit work, though the formula could be adjusted to
include a correction factor for this if desired. The demand
side is also calculated using historic data, so if patients are
chronically unable to access care in a timely fashion and
are turned away to urgent care options elsewhere, this may
underestimate patient demand. However, if we proceed
assuming it is a rough approximation, we can calculate the
ideal panel size where capacity equals demand by dividing
both sides by average patient visits per year:
Days in clinic per year Visits per day
Average patient visit×ss peryear
The number of average patient visits per year can be
obtained by taking the number of visits generated by a set of
patients, divided by the number of unique patients. This can
be done as a clinic average, or as a current PCC panel’s
average.
Ideal panelsize=
412
Weight factor forXtypeof patient
=
We can imagine how changing different factors, such as
increasing or decreasing a clinician’s number of clinic sessions in a year, will impact the ideal panel size. This can help
get a realistic sense of what panel size a resident can care for
each year depending on how many clinic sessions they have
and how many visits they complete in a clinic session.
In practice, residencies have a wide range of panel sizes
for residents, anywhere from 34 to 600in one survey [17].
First-year residents usually have the smallest panels that
later increase in their second and third years, since the lowest
number of patients per session are seen, and in many
residency schedules have the fewest number of clinic sessions overall. However, some residency programs have
decided to prioritize having residents carry full panels all
throughout residency to maximize opportunities for continuity of care. This requires increasing the number of clinic sessions done in intern year to account for the smaller number
of patients seen per session. For example, at Kaiser Seattle,
residents have full panels of 400–500 patients starting their
rst day of residency, with rst-year residents having clinic
4–5 half- days a week, while second years have clinic 3–4
and third years 2–3 half-days a week, respectively [18].
We can also consider the impacts of panel size on continuity and access, both of which are discussed later in this
chapter. In general, with all else being unchanged, a smaller
panel size for a resident leads to higher patient-centered continuity [19] as there are fewer patients needing continuity
appointments with that resident, and thus the resident’s
access metrics should improve. However, resident-centered
continuity will likely decrease, as the lower demand for
appointments with them leads to them seeing other clinician’s patients. Access for the clinic overall may worsen, as
the individual residents’ smaller panel size means additional
patients for the other clinicians in the clinic.
Panel Weighting
Reviewing and balancing panels should factor in all of the
above, in addition to ensuring a balance of patients from different demographics so that the resident has exposure to a
sufcient variety of patients. Clinics with accurate demographic or clinical condition data on their patients can also
use this data to apply weighting to their patient panels. This
is intended to adjust for certain patient groups needing more
care than others. For example, older patients with more
chronic conditions are expected to require more care than
young adults. Some health systems or EHRs may already
have a complexity weighting system that they use. Others
can start this process by starting with weighting for age,
using weight factors published by Mark Murray [16]. Clinics
can also use their own patients’ historic data to calculate
their local population’s weight factors using this formula:
M. Kong and C. Lyon
AveragevisitsforXtypeof pati
# eent
Averagevisitsforallpatients#
To calculate a weighted panel, the weight factor is multiplied by the number of patients meeting that criterion. The
difference between that and the raw number of patients can
be added to the overall panel size. For example, if a panel of
20 patients includes 3 patients who are 6-month-olds (who
have a weight factor of 5), those 3 patients actually “weigh”
as much as 3×5=15 patients. Thus, the weighted panel is
actually 12 patients heavier than the 3 physical patients originally represented, creating a weighted panel of 32.
If the clinic’s data systems have accurate ways to stratify
for patients with certain conditions, such as a diagnosis of
heart failure or a particular social determinant of health, various weighting factors can be calculated and applied to test
out a practical weighting model for the clinic’s patient population. With help from IT/EHR partners, these can be built
into automated reports so that panel size reports show both
the physical panel size (individual numbers of physical
patients) and the weighted panel size (panel size adjusted for
weighting factors), which in turn can be used to compare
with the target panel size to decide whether a clinician’s
panel should be open or closed to new patients.
Reviewing andAdjusting Panels
Protocols should be clearly outlined for ongoing review and
updating of panels, including how panels are reviewed with
clinicians, how reassignment requests are reviewed and
approved, what is done with inactive patients, how PCC
assignments are validated and communicated to patients,
how new patients are assigned, and how often panel sizes
and demographics are reviewed and adjusted. One key aspect
is dening whose responsibility it is to check and adjust panels, which involves gathering panel reports, making decisions around adjusting panel sizes and panel diversity, and
implementing the adjustments. These duties may be split
between different people, but their roles and the protocols to
complete them should be clear.
“Right-sizing” panels, meaning adjusting for panels that
are too large or too small compared to the target, may require
a combination of approaches. One is to adjust scheduling
templates and workows such that over-empaneled clinicians do not see new patients, while under-empaneled clinicians are available to have new patients scheduled with them.
Patients may need to be moved from one panel to another,
perhaps targeting patients who have not seen their originally
assigned PCC to be moved. Additional strategies require
addressing factors in the ideal panel size formula—either
increasing capacity via sessions in clinic or visits per ses-
35 Managing theFamily Medicine Center
413
sion, or reducing average number of patients per year by
reducing visit return rates, increasing services provided at
each visit, shifting care to non-PCC team members, or
improving continuity to reduce redundant visits.
Panel Transitions
In residency clinics, extra attention to the panel transition
process must be made as this happens every year when residents graduate. Clear protocols are needed to ensure that
patients are not lost in transition and complex patients are
handed off effectively [20]. When re-assigning patients to
new residents, multiple factors need to be considered:
• Re-balancing panel sizes and diversity
• Patient preferences and communication
• Longevity of the receiving clinician (e.g., a rising third
year would only be able to see that patient for very little
time)
• Team continuity
This is additionally complicated when transitioning pan-
els between resident years that have different panel sizes. Of
note, in programs that maintain similar panel sizes in all residency years (such as by increasing the number of clinic sessions in intern year), this complexity is minimized since all
residents have the same target panel size. This also makes it
easier to keep patients assigned to residents on the same
team, so that patients may continue having continuity with
staff members or other clinicians on that team.
A best practice around resident panel transitions is to cre-
ate a clear timeline to start this process many months before
graduation. Steps in the process should include:
• Closing graduating resident panels to new patients well in
advance
• Reviewing overall resident panels and panel sizes to identify particular discrepancies
• Giving graduating residents lists of their patients to review
and identify patients who would benet from specic
PCCs for reassignment (e.g., complex patients) and/or
proactive outreach/appointment scheduling to ensure
smooth transitions
• Graduating residents prepare handoffs for complex
patients, which may include chart notes, verbal sign-out
to inheriting PCCs, and/or a shared visit with the current
and future PCCs
• Patients not otherwise specied for certain PCCs are
assigned to new PCCs based on:
– who will be in the clinic the longest to encourage lon-
gitudinal continuity of care
– patient population data to balance panel diversity/
complexity
– patient-centered factors such as language concordance,
gender preferences, or keeping families of patients
assigned to the same panel (these factors may be identied during graduating residents’ reviews)
– attempts to maintain team continuity
• Patients are notied of their new PCC’s name and information with an opportunity to contact the clinic if a
change is desired
• Switching PCC assignments in the EHR so that new PCCs
receive future results and communications
• Gathering and reviewing panel lists to make sure no outdated PCC assignments remain
• Patients at high risk of being lost in transition may have
been identied by graduating residents’ review for a clinic
team member to track and perform outreach
Some residency programs have devised ways to make
this process more engaging for residents and patients. For
example, some programs have dedicated sessions with
meals provided for graduating residents to review their panels and prepare transition handoffs. Other programs dedicate additional support to transitioning patients, such as
sending transition packets to patients with letters from their
new PCCs and certicates of gratitude for helping teach
residents.
Team-Based Care
Due to the part-time nature of residents in the FMC, maximizing the stability of teams and teamlets becomes especially important. Here, we dene a teamlet as a clinician
paired with a medical assistant or equivalent role, with the
larger team consisting of multiple teamlets along with
extended care team members supporting those teamlets,
which may include registered nurses, behavioral health professionals, social workers, pharmacists, etc. [9].
In many clinics, clinicians may not have assigned medical
assistants, and instead just work with whomever is available
moment to moment. In others, clinicians may be paired with
particular medical assistants for a particular clinic session,
but not have a consistent person they work with over time.
Ideally, clinicians including residents are able to work in
stable teamlets, with the same medical assistant (or one of
the same 2–3 medical assistants) over time. Having stable
teamlets working together over time allows multiple benets: the teamlet can get to know their empaneled patients,
and vice versa; medical assistants can share responsibility
for the panel and population health, making their work more
meaningful; and a trustful working relationship can develop
between the clinician and medical assistant. With the parttime nature of residents, each medical assistant would still
work with several residents over the week, but if each time a
particular resident is scheduled to work in clinic they are able
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to work with the same medical assistant, they get to benet
from a stable teamlet.
Scheduling the same teamlets to work together consistently requires strategic scheduling templates to optimize
this process and minimize occasions where residents need to
be moved to different teams due to room limitations. Some
programs have built their resident rotation templates such
that for a given half-day, a certain number of residents are
scheduled to be in clinic from each team, so that there is even
team coverage and room usage per team over the course of a
week. A metric for team stability can be tracked by measuring the percentage of time a resident works with their
assigned medical assistant or on their assigned team out of
all of their half-days in clinic for a given period of time.
Facilitating teamlet partnership and communication skills
are also important for team-based care. Co-location of residents to sit right next to their medical assistants during clinic
is very helpful for facilitating minute-to-minute communication. Creative use of space may be needed if the existing
space is not designed for co-location, such as by repurposing
alternative spaces, or by having some team members work
from mobile laptops. FMCs with co-located workspaces
should be cognizant of not placing precepting space too far
away from the co-location spaces, as residents may end up
spending most of their time working in the precepting space
while waiting to precept.
Intermittent observations of how residents communicate
with medical assistants can be helpful for coaching teamlets
on communication. Team members and residents can be
trained in effective huddle skills using huddle checklists,
which can be used in both larger team huddles and in minihuddles in teamlets. Teamlet huddles allow the teamlet to
review the patient schedule for the clinic session together
and plan specic patient care tasks and clinic ow, such as
what can be done if running behind, which patients may need
extra support, how to adjust if a patient arrives late, etc. It is
also helpful to empower medical assistants to teach or coach
residents in improving their clinic ow. At the Tufts
University Family Medicine Residency Program at
Cambridge Health Alliance, residents and medical assistants
are coached by faculty to do a quick check-in every clinic
session about their teamwork, where the medical assistant
and resident each identify one positive aspect of their work
together that day, and one thing to try improving in future
sessions. Teamlets also receive dedicated time together outside of clinic for relationship-building discussions and activities. Providing time and tools to develop the working
relationship can have extremely benecial impacts on teamlets’ working relationships, and engage both medical assistants and residents to think critically about how they function
in clinic.
Residents should also have opportunities to learn about
different team member roles, and have faculty guidance on
the best ways to work with each team member to optimize
care for their patient panel. Team members ideally are
engaged as teachers of residents from the perspectives and
skill sets of their unique roles. Some programs have built
opportunities for residents to shadow and learn about team
member roles in introductory clinic curricula, and it can be
helpful to prime clinic staff with teaching points ahead of
time. Team members are also an important source of feedback on residents’ clinic skills, and collection of regular
feedback from various clinic team members helps better
assess resident strengths and improvement needs in their
clinic performance. Residents should also be incorporated
into clinic team meetings, which requires their schedules to
be built to allow residents to consistently attend team
meetings.
Fostering a culture of empowering team members to share
the care and responsibility for patients [21], rather than a
feeling of merely being delegated to, makes the work of primary care more sustainable with less exhaustion for both clinicians and team members [22]. This involves investing in
educating team members on the value of tasks they are asked
to take responsibility for and the direct impact on patients.
Setting ground rules for teamwork, and developing standing
orders and standardized workows with training and skills
checks are also instrumental in expanding care team member
roles [9]. While there are no standardized stafng ratios or
care team models for FMCs, the ability of individual clinicians to care for a patient panel is greatly expanded by having robust teamlet ratios and extended care teams. For
example, if the stafng level does not support at least one-toone teamlets in clinic consistently, it is difcult to have medical assistants take on signicant roles beyond rooming and
taking vitals, such as proactively managing preventive and
chronic care tasks for patients.
University of Colorado’s AF Williams Family Medicine
Clinic [23, 24] has invested in an advanced teamlet model
with a 2 medical assistant per clinician teamlet. This allows
each medical assistant to ask patients advanced intake questions using EHR history-taking templates, scribe and pend
orders while the clinician is in the room, and review care
plans with the patient during discharge to a much more
advanced degree. Advocating for expanding care team models often involves negotiations with health system leaders
and should factor in and translate health system priorities
and patient care benets into a compelling business case [4].
FMCs can be opportune settings to incorporate interdisciplinary team members and their learners in the actual care of
patients, which provides experiential learning in interdisciplinary care, rather than theoretical. In some programs, residents work alongside RN care managers, social workers,
clinical pharmacists, behavioral health, and their trainees
[25]. As residents see patients, interprofessional team members are used for co-consults with the patient, warm hand-
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offs, and precepting discussions. These interactions provide
residents additional training in patient care management and
in working with interdisciplinary team members, and provide patients with more comprehensive care. Seeking out
opportunities to partner with nearby training institutions in
various disciplines may yield creative ways to expand the
primary care team.
Population Management
In addition to didactic training on population health, consider incorporating resident education in population management into actual panel management in the FMC as much as
possible. Make individual residents’ panel data on various
preventive and chronic care quality metrics easily accessible,
and create different opportunities for residents to review
these with a constructive improvement lens. This can be
done while promoting team-based care. Teamlets can be
instructed to review panel data together and discuss ways to
improve, perhaps during designated panel management time
during team meetings.
Care gaps (where patients are overdue on recommended
preventive or chronic care tasks) may be addressed through
inreach (when patients present to clinic for care) or through
outreach (contacting patients who are not present in clinic).
Inreach is often a good area for teamlets to address through
improving standardized workows for medical assistants to
proactively offer or pend orders for care gaps. Outreach may
happen through team-based staff for their empaneled
patients, or through designated population health staff for the
whole clinic. Residents can be taught to review their panel
data and registry lists to strategically identify patients for
outreach, and consider PDSA cycles for workows to
improve inreach or outreach efforts.
In addition to various registries that can be created for
certain clinical conditions or complex care/high risk patients,
population management is important to consider with an
equity lens. As much as possible, important metrics should
be stratied by race/ethnicity, sexual orientation/gender
identity, and additional demographics to identify inequities.
Teaching residents to analyze their own panel data to identify
inequities and discuss potential causes and solutions can be a
powerful way to translate health equity lessons into practice
[26].
Continuity ofCare
Continuity is associated with improved preventive and
chronic care, higher patient and clinician satisfaction, lower
costs, and is the basis for the patient–clinician relationship
[27]. However, it is particularly challenging in the FMC due
to the complexity of having many part-time clinicians.
There are various formulas for continuity, but the most
commonly used metrics mainly measure continuity from two
perspectives, the patient perspective and the clinician perspective [15]. The basic denition of patient-centered continuity is the number of patient visits with the patient’s
empaneled PCC, divided by the total number of patient visits. Thus, if a panel of 1000 patients has a total of 3000 visits
in a year, and 2000 of these visits are with the PCC, continuity is 2000/3000, or 67%. A 2018 review of continuity in
residency clinics reported a median patient-centered continuity rate of 56%, with a range from 43% to 75% [28]. Some
high-performing teaching clinics achieve rates of 70% or
higher [29].
The basic denition for clinician-centered continuity is
the number of clinician visits with patients on their panel
divided by the total number of clinician visits. If a clinician
has 200 visits in a month, and 120 of these are with patients
on their panel, continuity is 120/200, or 60%. A reported
median for clinician-centered continuity in residency clinics
was 55%, ranging from 37% to 63% [28].
Some clinics also calculate team-based continuity from
the patient’s perspective, meaning how many of the patients’
visits are with a clinician on their assigned team. If a team
has more than three clinicians, this does not translate to a
signicant experience of continuity for the patient. Continuity
with a small team, or clinician pair, is more meaningful.
As with other key data, continuity metrics should be calculated consistently, drilled down to individual clinician levels, tracked regularly, and widely shared and discussed with
everyone in the clinic. Prominently featuring and discussing
continuity data contributes to a culture of continuity in the
clinic, where everyone recognizes continuity as a priority
and regularly considers ways to improve it. This also extends
to patient messaging and education on continuity and why it
contributes to their care. Patients should also be clearly messaged who their empaneled PCC and team are through visuals in the clinic and patient-facing materials.
Specic workows to improve continuity rely heavily on
training staff at the front desk, and/or call center, where
appointments are made. Continuity-promoting scheduling
algorithms should be made that prioritize the patient seeing
the PCC and offers those appointments as the rst option
[30]. If the PCC is not available within the timeframe needed
by the patient, additional layers of continuity could be
offered based on teams. For example, the patient may be
offered to see a different clinician on the same team as the
next best option, and only offered other team clinicians if
those options still are not feasible. Patient-friendly scripts
that offer patients the choice of prioritizing continuity
upfront can be written to aid schedulers. Past the point when
appointments are scheduled, some corrections for continuity
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can still be made if there is a process for reviewing patient
schedules ahead of time, or even during huddle, and switching patients to their PCC when possible.
As mentioned previously, resident scheduling plays an
important part in allowing continuity. Resident clinic sessions should be scheduled frequently, with short intervals
between times of signicant clinic presence. The schedules
should be predictable and made far enough in advance to
allow the clinic to schedule patients with their resident PCCs.
Increasing overall clinic time throughout residency makes
residents overall more available for continuity patients, and
helps improve patient-centered continuity [19, 31].
Another approach to improving continuity is to utilize
team-based strategies. With complex resident schedules, it is
inevitable that resident PCCs will be at times unavailable for
their continuity patients. Assigning residents with complementing clinic schedules as practice partners may help provide patients continuity between a pair of clinicians. Some
clinics have opted to assign a faculty clinician, nurse practitioner, or physician assistant to a team to act as a continuity
anchor—instead of carrying their own panel, their clinic
appointments are used to see their team’s patients when the
resident PCC is not available. Oftentimes clinical staff, such
as medical assistants or nurses, may have more longevity
than residents at the clinic. If patients are seen consistently
on their assigned teams, the team’s clinical staff can also provide continuity relationships for patients, which give patients
some stability through resident transitions.
It is helpful to note that not all strategies affect patientversus resident-centered continuity in the same way, and
some changes move them in opposite directions. For example, if resident clinic time is increased, patient-centered continuity may increase while clinician-centered continuity may
decrease with the resident having increased availability in
clinic [28]. A combination of approaches is needed to optimize both patient- and resident-centered continuity.
Prompt Access toCare
Timely and appropriate access is another area of particular
difculty in the FMC.Access exists in various formats: inperson visits, phone visits, video visits, portal communication, or non-visit phone communication for things like care
coordination, rells, forms, and more. The focus in most
clinics tends to be on access for visits, which may differ
between new patients and follow-up patients.
A common access metric is the third-next available
appointment (TNAA), which refers to the number of days
until the third next open appointment for a clinician or clinic.
The third next appointment is used, rather than the earliest
next appointment, to account for the logistic realities that a
patient may not be able to be scheduled into that appoint-
ment quickly enough (e.g., a last-minute cancellation), or
may not be able to make it during that particular time.
Additional metrics can provide a fuller assessment of the
state of a clinic’s access. The percentage of same-day
appointments (the number of appointments scheduled today
or yesterday divided by overall number of scheduled appointments) gives an idea of how easily a patient can get urgent
access. Open capacity (number of open slots divided by total
number of appointments in a given timeframe) indicates
whether there are sufcient available appointments in the
near future.
For good access, demand and capacity for appointments
need to be balanced. By revisiting the ideal panel size equation discussed earlier, we can identify relevant factors
impacting access [32]. Demand is impacted by panel size,
return intervals, seasonal factors, and patient population
needs. Capacity is affected by clinician time in the clinic,
number of appointments per clinic, lengths of appointments
and whether appointments are restricted by type, and whether
other services are available for patient care (e.g., registered
nurse visits for chronic care management, behavioral health,
etc.) [33].
To reduce visit demand, panel size could be reduced,
intervals at which patients are asked to return for follow-up
could be increased, and requests not requiring visits could be
handled via inbox messages or the patient portal (though
time for clinicians to address these will need to be considered). To increase capacity, the clinic could include more
visits per session, have clinicians in clinic more sessions per
year, or have team members add capacity to care for patients.
For example, if a number of visits per year could be independently done by a registered nurse, pharmacist, or physical
therapist for concerns like routine diabetes or hypertension
care, or uncomplicated low back, knee or shoulder pain, this
directly augments the capacity of the clinic and frees up the
PCC for other visits. Another way to increase capacity is to
reduce no-shows, which strategically timed reminder calls
can help achieve [34]. Since no-show rate increases with the
number of days between when a patient makes the appointment and the date of the appointment [35], some clinics open
appointment slots for patient scheduling only 1–2weeks in
advance of the appointment. This automatically makes
TNAA no more than 1–2 weeks, and no-show rate is
minimal.
Other access strategies do not increase overall capacity,
but rearranges capacity to provide some sooner availability
at the cost of future availability [36]. Some clinics do this by
having one clinician per session assigned to providing sameday/next-day access, with appointments slots that only open
the day of the appointments; this often comes with the price
of lower continuity. Other clinics reserve a subset of slots on
appointment templates to be unavailable until a certain
amount of time before the appointment, such as 1week or