Written Assignment-Seacoast Family Practice/Core Physicians-Exeter,NH For this assignment, please read the Core Physicians: Meeting Patient Needs with Empa

Written Assignment-Seacoast Family Practice/Core Physicians-Exeter,NH For this assignment, please read the Core Physicians: Meeting Patient Needs with Empathy and Excellence case study found in this week’s supporting materials section.  In 1 1/2 to 2 pages highlight and discuss from a organizational/management perspective the key reasons for this endeavors success.  Provide specific examples to support your analysis.  Please submit your completed assignment as a WORD document double spaced using 12 point-type face. Organizations Profiled

Seacoast Family Practice, Exeter, New Hampshire
Core General Surgery, Exeter, New Hampshire

Jessica Boccelli, Director of Service Excellence, Core Physicians
Caron Callahan, Practice Manager, Seacoast Family Practice

Beth Fletcher, Medical Office Coordinator II, Core General Surgery
Marc Fournier, CMPE, Director of Human Resources, Core Physicians

Nicholas D. Garcia, M.D., Vascular Surgeon and Chief Physician Executive,
Exeter Health Resources

Jason Howe, D.O., Primary Care Family Practitioner, Core Physicians
Jana Jacobs, Senior Practice Administrator, Core General Surgery

Roderick S. McKee, M.D., FACS, General Surgeon, Core Physicians
Diane P. Palladino, M.D., General Surgeon, Core Physicians

Jay W. Swett, M.D., FACS, Chief of Surgery and Interim CMO, Core Physicians

Core Physicians:
Meeting Patient Needs
with Empathy and Excellence
By Elaine Zablocki, Staff Writer, Picker Institute

october 2015

pat i e n t- c e n t e r e d c a r e c a s e s t u d y
A Picker Institute Series

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Toll Free (800) 388-4264 • Fax (402) 475-9061

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toll free at (800) 388-4264.

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ii Core Physicians: Meeting Patient Needs with Empathy and Excellence Call Toll Free (800) 388-4264

Organization Profile

Seacoast Family Practice and Core General
Surgery are divisions of Core Physicians, a
community-based, multi-specialty group
practice affiliated with Exeter Health Re-
sources. Core Physicians includes over 160
providers in 28 locations, providing com-
prehensive primary, specialty, and pediat-
ric dental care throughout New Hampshire’s
Seacoast Region. Core Physicians is an af-
filiate of Exeter Hospital, a 100-bed, com-
munity-based hospital serving the Seacoast
Region. Exeter Hospital is a Magnet-recog-
nized healthcare organization.

Seacoast Family Practice includes two
family practice physicians, a part-time
physician’s assistant, a registered nurse,
a licensed practical nurse, and a medical
assistant. Core General Surgery includes
five general surgeons, a nurse practitio-
ner and registered nurse, and three medi-
cal assistants. Core Physicians and Exeter
Hospital are both operating affiliates of
Exeter Health Resources, which also in-
cludes the Rockingham Visiting Nurse As-
sociation.

Statement of Interest
Medical groups today strive to meet patient
needs on many levels. The Clinician and
Group Consumer Assessment of Healthcare
Providers and Systems (CG-CAHPS) survey
documents medical group performance in
five areas of patient-centered care:
• Patients’ rating of the provider (doctor,

nurse practitioner, and physician assis-
tant)

• Getting timely appointments, care, and in-
formation

• How well providers (doctors, nurse prac-
titioners, and physician assistants) com-
municate with patients

• Helpful, courteous, and respectful office
staff

• Follow-up on test results

In each of these areas, certain medical
groups are excellent performers, with con-
sistent high scores on specific CG-CAHPS
measures. Picker Institute case studies ex-
plore the ways medical groups achieve these
outstanding results, and share examples of
best practices.

This case study profiles Seacoast Family
Practice and Core General Surgery, which
the Picker Institute has identified as high
performers in delivering patient-centered
care based on their exemplary performance
in CG-CAHPS publicly reported data. Both
organizations have top ratings for “How well
providers communicate with patients.” In
addition, Core General Surgery has top rat-
ings for “Getting timely appointments, care,
and information.”

Core Physicians: Meeting
Patient Needs with
Empathy and Excellence
Core Physicians defines its mission in terms
of “Triple Aim Plus One.” The Triple Aim is
a framework developed by the Institute for
Healthcare Improvement that describes an
approach to optimizing health system per-
formance by pursuing three dimensions si-
multaneously:
• Improve the patient’s experience of care

(including quality and satisfaction)
• Improve the health of populations
• Reduce the per capita cost of healthcare

Core Physicians adds “Plus One,” an empha-
sis on sustainability, because so many orga-
nizations have found that it’s not enough to
just make improvements; it is equally as im-
portant to develop ways to sustain those im-
provements, and to hardwire a system that
sustains improvements.

Core Physicians relies on Lean methodol-
ogy for process improvement and to sustain
its improvements. “Lean is one of the tools
we use constantly to re-examine our pro-
cesses so we can be more efficient, improve
workflow, and see more patients,” said Jes-
sica Boccelli, Director of Service Excellence
for the organization. “On every improvement
project we conduct a Lean analysis and we
use Lean tools. Key stakeholders at Exeter
review our processes to determine which
improvement projects should be our high-
est priorities.”

Based on these aims and methods, it’s
not surprising that Seacoast Family Prac-
tice and Core General Surgery receive top
ratings for “How well providers communi-
cate with patients,” and that Core General
Surgery has top ratings for “Getting timely

How Well Providers Communicate with Patients

The survey asks patients how often their providers explained things clearly and lis-
tened carefully to them. The specific questions are:
• Provider explained things in a way that was easy to understand
• Provider listened carefully to patient
• Provider gave easy-to-understand information about health questions or concerns
• Provider knew important information about patient’s medical history
• Provider showed respect for what patient had to say
• Provider spent enough time with patient

Possible responses for these questions include “Never,” “Sometimes,” “Usually,” and
“Always.”

Getting Timely Appointments, Care, and Information

The survey asks patients how often they got appointments for care as soon as needed
and timely answers to questions when they called the office. The specific questions are:
• Patient got appointment for urgent care as soon as needed
• Patient got appointment for non-urgent care as soon as needed
• Patient got answer to medical question the same day he/she phoned provider’s
office

• Patient got answer to medical question as soon as he/she needed when phoned
provider’s office after hours

• Patient saw provider within 15 minutes of appointment time

Possible responses for these questions include “Never,” “Sometimes,” “Usually,” and
“Always.”

1Core Physicians: Meeting Patient Needs with Empathy and Excellence Call Toll Free (800) 388-4264

appointments, care, and information.” All
of the staff at these clinics makes a special
effort to listen to patients, tune in to their
feelings, and treat them with care and re-
spect. Core Physicians processes for hiring
and evaluating physicians, nurses, and other
staff emphasize qualities such as empathy,
creativity, initiative, and optimism.

We asked some physicians at these orga-
nizations exactly what they do that assures
their patients that they are listening care-
fully, showing them respect, and explaining
things clearly. Not surprisingly, one of the
most important things they do is take time
to listen.

Patients can face anxiety when questions
arise in addition to uncertainty about what
to do after a surgical procedure. Taking a per-
sonalized approach is standard practice for
Jay W. Swett, M.D., FACS, Chief of Surgery and
Interim Chief Medical Officer, who calls all
of his patients. “If there are any issues that
arise, I want to speak to them directly,” he
said. “Patients like receiving a call from their
surgeon and it saves the on-call physician
from getting a call.” This best practice has
created streamlined efficiencies in addition
to increased patient satisfaction scores.

Jason Howe, D.O., Primary Care Family
Physician at Seacoast Family Practice, be-
lieves that when your patients talk with-
out interruption, it can be extremely useful.
“When you let them speak without interrup-
tion, nine times out of 10 they’re going to tell
you what’s wrong,” he said. “If you don’t lis-
ten, they’re not able to tell you what is really
happening with them.”

Dr. Howe likes to begin patient encoun-
ters by making a personal connection with
his patients. He might ask them about a re-
cent trip, or how they’ve felt over the past few
months; he doesn’t necessarily start with the
current chief complaint. Once he has estab-
lished a personal connection, he moves for-
ward. “The biggest thing in being empathic
is listening,” he said. “When you’re seeing 20
or 25 patients a day, sometimes that can be
stressful, but I think in the end it saves time.
I ask someone what they think is wrong, and
many times that’s a great time-saver because
you can allay their fears rather quickly. In the
end, it’s not me driving the visit, it’s more the
patient driving the visit.”

When a patient is coping with a complex
issue, too much to cover in 15 minutes, Dr.
Howe often encourages them to make an-
other appointment. “You explain that to fully

address this problem we need to get you
back in,” he said. “It’s a matter of time man-
agement. If we’re not giving you enough time
to really figure out this problem, it’s not fair
to you or me or the next patient who is wait-
ing for me—they understand that.”

“The biggest thing in being
empathic is listening. I ask
someone what they think is
wrong, and many times that’s
a great time-saver because
you can allay their fears rather
quickly. In the end, it’s not me
driving the visit, it’s more the
patient driving the visit.”

—Jason Howe, D.O., Primary Care
Family Practitioner, Core Physicians

Diane Palladino, M.D., is primarily a general
surgeon, but she felt her technical training
hadn’t prepared her to help people cope with
the mental, spiritual, and emotional effects
of serious illness. Through a brief intensive
course at Dartmouth-Hitchcock, plus in-
formal training through the Exeter Hospi-
tal hospice and palliative care service, she
became board certified in hospice and pal-
liative medicine. “I was always more inter-
ested in the human side of healthcare,” she
reflected. “I felt that the technical side was
relatively easy to learn, but human touch was
more difficult and equally as important.”

Through hospice and palliative care train-
ing, she learned specific methods, such as
always sitting down at the patient’s level, in-
stead of standing up and looking down at
them. It’s also important to make eye con-
tact and ask questions, so the patient ends
up doing most of the talking. “You say, ‘Tell
me a bit more about that.’ You try to get is-
sues that are in the closet out on the table,”
Dr. Palladino said. “This helps you build a re-
lationship of trust with the patient. It leads
them to feel that you’re interested in them
for who they are, not just for their diagnosis.”

Her hospice training also emphasized
shared decision making, describing possi-
ble options, and offering patients choices.
“With every treatment option, we need to
discuss the benefits and risks of those op-
tions with the patient, always focusing on
quality of life,” she said. “This means we need

to take the time to understand and listen to
where the patient is coming from—what
their most important goals and desires are.”
At the end of each visit, she asks patients
whether they have any questions. Sometimes
she asks them to summarize their under-
standing of the conversation, since this is a
way to double check how much the patient
has understood, and whether there are any
gaps in their understanding.

All of the staff at these practices under-
stands that listening carefully to patients is
an important aspect of their role. Recently a
medical office coordinator at Core General
Surgery helped a patient who was extremely
upset. She encouraged this patient to take
her time, listened to her concerns, and
helped her find solutions. A few days later
the coordinator found a package on her desk.
When she opened it, she saw a small vase
made of shells, plus a handwritten note say-
ing, “Your kindness and help is appreciated.”

In addition to emphasizing communica-
tion with patients, physicians at Seacoast
Family Practice and Core General Surgery
also emphasize effective communications
with other physicians. Their EMR makes it
easy to send questions to specialists, or refer
a patient for specialty care, and also be aware
of what the specialist has done. “Having spe-
cialist notes available has been very useful,”
Dr. Howe said. “For example, when the spe-
cialist changes medications, I’m aware of
those changes, and this increases our pa-
tients’ confidence in us.” The practice has
two-way communications between primary
care physicians and specialists. “Specialists
often refer people back to me for issues re-
lated to primary care, such as acid reflux,”

2 Core Physicians: Meeting Patient Needs with Empathy and Excellence Call Toll Free (800) 388-4264

Dr. Howe said. “In those situations, I forward
the note to my nurse and ask her to bring the
patient in for an appointment. We close the
loop, and our patients appreciate it.”

At the end of each visit, the electronic
health record generates an end-of-visit sum-
mary, also called a patient plan, which sum-
marizes the reasons for the visit, chronic
conditions, medication list, the discussion
during the visit, and next steps needed. Gen-
erally this customized patient plan is com-
pleted during the visit, so patients leave with
a description of their entire visit, plus the
next steps needed for the most effective care.

“With every treatment option,
we need to discuss the benefits
and risks of those options with
the patient, always focusing on
quality of life. This means we need
to take the time to understand
and listen to where the patient is
coming from—what their most
important goals and desires are.”

—Diane P. Palladino, M.D.,
General Surgeon, Core Physicians

Practitioners and Staff
Listen to Each Other to
Improve Patient Care
For Seacoast Family Practice and Core Gen-
eral Surgery to function effectively, it’s essen-
tial to have open communications between
physicians, nurses, and all the staff about ev-
erything that affects the patients. “The phy-
sicians are always open to ideas that lead to
better patient care or improved workflow,”
said Caron Callahan, Practice Manager at
Seacoast Family Practice. “Recently the clin-
ical staff at Seacoast Family Practice devel-
oped new ideas for improved workflow for
prescriptions to be picked up at the office.
They presented a proposal, and the physi-
cians accepted it.”

“In our healthcare environment, it is es-
sential for staff members to be able to clar-
ify what a physician says, to ensure there are
no errors,” said Jana Jacobs, Senior Practice
Administrator for Core General Surgery. She
recalls one person who was obviously intim-
idated when she first arrived at the prac-
tice. “I walked with her to the provider and

encouraged her to ask her question. That
broke down the initial barrier and set some
communication parameters for them, and
their mutual communication strengthened.”

Since 2014, Core Physicians has been
using tiered huddles, which help to create
a culture of communication throughout all
levels of the organization. A huddle is a short
face-to-face stand-up meeting, usually last-
ing about five minutes. One definition calls
the huddle “a planning session to re-estab-
lish situation awareness, reinforce plans al-
ready in place, and assess the need to adjust
the plan.”

Core Physicians uses a brief template for
topics to be covered at the huddle: Who is
working today, providers and staff ? Who is
available for backup, if needed? Are there
open appointments? Are there any quality
or safety concerns?

One of the basic principles at Core Physi-
cians is that everyone is encouraged to step
forward and facilitate communications.
Boccelli recalls one day when both manag-
ers were out, so the medical assistant imme-
diately stepped forward and led the huddle.
“Communication is everybody’s responsibil-
ity,” she said. “The huddle is usually led by a
manager, but the reality is that they could
be anywhere, so everyone should be able to
pick it up and lead the team.”

After each practice has its daily huddle,
all the practice managers get together on the
phone with the Core Physicians vice pres-
idents and directors and the president for
a tier-two huddle. This huddle reviews any-
thing that came up at the tier-one huddle,
plus some additional categories. Fifteen
minutes later, the Core Physicians adminis-
tration and hospital get on the phone for a
tier-three huddle.

One of the basic principles of Lean meth-
odology is that work should flow smoothly.
About two months ago Core Physicians
added workflow to the huddle list, and asked
managers to notice anything that interrupts
flow and makes life difficult, and bring those
issues to the tier-two level. The tier-two level
sets a deadline for fixing the issue or brings
it to tier three if needed. The basic princi-
ple here is that these issues will be fully re-
searched and resolved within a very short
timeframe.

It seems to be working. When Boccelli
rounds, she makes a point of asking whether
there are process issues or flow busters to

review. At one high-volume express care site,
the front desk staff said that printing same-
day medication reconciliation sheets in ad-
vance for each patient added up to an hour
of work each day, and took them “out of flow.”
The clinical staff always reviews medications
with each patient during the intake process.
After looking closely at the issue, the tier-
two office decided that this preliminary step,
printing out the medication list, wasn’t re-
ally necessary.

Callahan agrees that the new focus on
flow busters is extremely valuable. “When
it was my turn to present a flow buster, we
talked about medication prior authoriza-
tions, which are very time-consuming and
take a substantial amount of time away from
patient care. Deb Cresta, President of Core
Physicians, happened to be on that call. She
was the first one to say, ‘We’ve to do some-
thing about this right away. Let’s get this
centralized so one person can deal with the
authorizations, while the practices continue
focusing on patient care.’ When you see ac-
tion being taken at that level, so quickly, you
really feel validated.”

The Environment Supports
a Culture of Care
Many aspects of the physical and social en-
vironment at Core Physicians support a
culture of patient-centered care. This is espe-
cially noticeable at Seacoast Family Practice,
where the space is organized so each physi-
cian sits right next to their principal assis-
tant, with materials and files for the day filed
nearby. The clinical support person juggles
priorities and organizes workflow to make
the best use of the physician’s time.

This close environment supports team-
work between physicians and other pro-
fessionals. “There is a great deal of trust
between the provider and clinical staff, and
they will take the time to stop and take care
of essential functions in between patients,”
Callahan said. “I’ve also noticed that in this
situation many things are handled verbally,
so it’s very quick and efficient.”

Dr. Howe relies on his nurse to interrupt
him between patients when something
needs to be addressed quickly. Clinical and
administrative staff is trained to prioritize
messages. “Low priorities can wait for the
next 24 or 48 hours before I need to look at
them,” Dr. Howe said. “We try to deal with
high priorities within 10 to 15 minutes, and

3Core Physicians: Meeting Patient Needs with Empathy and Excellence Call Toll Free (800) 388-4264

then middle-of-the-road issues are dealt
with by the end of the day.”

Core Physicians’ patient portal plays an
important role in responding quickly and
efficiently to patient requests. It was first
set up four years ago, and at present about
38 percent (28,000) of patients have regis-
tered to use it. It is a confidential, secure
Web site that patients can use to commu-
nicate directly with medical and adminis-
trative staff, request appointments, send
messages, request prescription refills, or re-
view their health history. When a physician
responds, patients receive an email saying
there’s a message waiting on the portal, and
they sign in using a password.

The portal is particularly effective for
routine lab results and appointments. “It’s
a great avenue to support communication
between the doctor and the patient because
it addresses so many mundane things that
can be accomplished easily with this type of
communication,” Dr. Howe said. “It’s a two-
way street, so patients can contact me with
questions about a recent appointment or a
question about a medication, and we can ad-
dress those questions rapidly without tying
up resources.” His nurse reviews patient por-
tal messages and prioritizes them before he
sees them. “Often there are issues she can
address directly, so she’s working at the high-
est level of her licensing. She’s very good at

triaging messages so I see the most impor-
tant issues in a timely way,” he said. Dr. Howe
responds to portal messages throughout the
day, and estimates this takes about 45 min-
utes per day.

“The patient portal is a
great avenue to support
communication between
the doctor and the patient
because it addresses so many
mundane things that can be
accomplished easily with this type
of communication. It’s a two-way
street, so patients can contact
me with questions about a recent
appointment or a question
about a medication, and we can
address those questions rapidly
without tying up resources.”

—Jason Howe, D.O., Primary Care
Family Practitioner, Core Physicians

When someone learns they need surgery,
they naturally want to see the surgeon as
soon as possible. Core General Surgery
makes a special point of adjusting sched-
ules in order to get them into the office. Even
when the schedule seems to be full, it is still
possible to make adjustments. “We’ve made
it very clear to staff that we do want to get
patients in as soon as possible,” said Nich-
olas D. Garcia, M.D., Vascular Surgeon and
Chief Physician Executive, Exeter Health Re-
sources. “We build in flexibility, and make
special allowances for people who need to
be seen, even when the schedule is already
crowded.”

To support proactive responses to patient
needs, Core Physicians has developed clear
standards for phone calls, with model scripts
for typical calls. For example, when calling
a patient, staff always asks whether this is a
good time for a call. When taking a message
for a practitioner, staff assures patients they
will get a call back by the end of the day. At
the end of each call, they always say, “Thank
you for calling.”

Core General Surgery has one receptionist
who answers 90 percent of incoming calls,
and then sends them on to the appropriate
clinical or administrative person. Since pro-
viders don’t have answering machines, all

their messages flow through the staff or the
patient portal. This means physicians have
more time available for actually seeing pa-
tients.

At the same time, they all try to return
calls promptly. Dr. Palladino responds to
calls whenever she has time between pa-
tients; she doesn’t wait until the end of the
day. Her nurse calls patients who have be-
nign results, but she personally calls each
person who needs further testing or who
has negative results.

Similarly, Dr. Garcia asks his assistant to
bring him notes about needed phone calls
throughout the day, and responds as soon
as possible. This pattern of timely responses
to incoming phone calls promotes an even
workflow. It also supports patient-centered
care, reducing patients’ anxiety since they
don’t have to wait till the end of the day for
a call back. “We’ve had positive results from
this,” Dr. Garcia said. “The model is basically
you’re always doing the work as it’s coming
in. As we do more of this sort of work, we
think we’ll get better and faster.”

Core General Surgery has developed pro-
tocols for typical appointments, so now most
staffers can schedule appointments based on
their own knowledge of patient needs. “Be-
fore we streamlined our processes, some ap-
pointments had to be reviewed in advance
by the provider,” said Beth Fletcher, Medical
Office Coordinator II for Core General Sur-
gery. “Often that was quite difficult, since the
physician was in the OR or the cath lab—we
ended up playing phone tag. Now we just put
the patient on the schedule, and let the pro-
vider know afterwards.

Hiring and Training
Staff for Service
Core Physicians has developed a patient-
centered culture, and one factor that
supports this culture is its emphasis on
finding and hiring appropriate people. It
seeks people with warm, caring personal-
ities, people who want to offer excellent
patient care. When Jacobs interviews po-
tential employees, she sometimes asks
them to describe a particularly difficult
patient in the past, how they dealt with
that situation, and its outcome. “As a man-
ager you can hear a lot in that story,” she
said. “ You’re looking for someone who can
focus, because this is always a busy envi-
ronment. We can teach people the prac-
tical skills they need; we are looking for

4 Core Physicians: Meeting Patient Needs with Empathy and Excellence Call Toll Free (800) 388-4264

someone who can consistently, sincerely
deliver excellent patient service.”

About four years ago, Core Physicians em-
barked on a customer service training pro-
gram for all employees, called “Taking the
HEAT.” HEAT stands for four important prin-
ciples:
• Hear. Listen to the patient.
• Empathize. Put yourself in the other per-

son’s place, tune in to their feelings, de-
sires, and needs.

• Apologize. Simply say, “I’m so sorry that
this happened.”

• Take responsibility for action. Take ap-
propriate steps to meet the patient’s ex-
pressed needs.

When this program was introduced, every
employee went through several four-hour
training modules, which combined an intro-
ductory talk with educational videos. Each
module included breakout sessions, with op-
portunities for role-playing, so the training
sessions were lively and interactive. People
learned more effectively because they were
involved in the process. In addition, each ses-
sion used a variety of materials, to suit peo-
ple who often learn in different ways.

All the physicians participated in a short-
ened version of the HEAT training, lasting
about two-and-a-half hours, so they were
able to absorb similar concepts …

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