Col. Gale S. Pollock, FACHE, commander, Martin Army Community Hospital, Fort Benning, Georgia

ORGANIZATIONAL INFORMATION

The military medical treatment facility (MMTF) consists of primary care family practice, obstetric, orthopedic, and urgent care clinics (but no hospitalization or true emergency care) at a remote military installation. The MMTF serves a patient population of 28,000 that is composed of mostly active-duty military personnel and their family members but includes retired military personnel as well. The Department of Defense funds the MMTF as part of the military medical health system. This MMTF has been in operation since 1986.

The MMTF is located in a medically underserved rural area. A local civilian community offers hospitalization and limited specialty care. Most specialty care is only available at the nearest metropolitan area, more than 75 miles from the base and its local community. The MMTF is the only military healthcare facility in a 250-mile radius.

As the MMTF commander, I serve as the CEO. The executive committee consists of the CEO and three senior commissioned officers: chief physician, chief nurse, and chief administrator. The organization employs 431 personnel.

BRIEF STATEMENT OF THE PROBLEM

The MMTF was allocating too many resources to operate its urgent care clinic (UCC) 24 hours a day. Nighttime utilization of the UCC was low, and most visits were not urgent. On the other hand, daytime demand for primary care greatly exceeded capacity at our family practice clinic such that we consistently failed to achieve timely access standards. I solved these problems by eliminating the night shift at the UCC. I then reallocated those resources to the family practice clinic, extending its operating hours into early evening and Saturday mornings.

DESCRIPTION OF THE PROBLEM

Background
Military healthcare underwent a major transformation in recent years. Formerly, military healthcare was performed solely by military providers and in military facilities. Over several years the military shifted to a TRICARE (all military services) healthcare benefit that has tiers of service for beneficiaries and relies on civilian providers for much of the benefit. There was significant initial resistance to this change from a military cradle-to-grave care process to a health maintenance organization-type benefit. However, as the transition ended, beneficiaries had become more comfortable with getting their healthcare through the TRICARE local civilian providers. One vestige of the old system was continued operation of a 24-hour UCC at the MMTF.

Problems with UCC Night Shift
Soon after assuming command of the MMTF I became concerned that the UCC night shift was consuming too many resources for the few patients it served. This potential misallocation of assets was a major problem for the MMTF because I had already determined that we were not adequately meeting demand for primary care during the day. Thus, I undertook an analysis of historical demand to determine the cost and benefit of operating the UCC throughout the night.

Analysis of two years of data indicated that only 86 patients had come into the UCC at night for truly urgent care; the remainder of patients could have done self-care or been appointed to the family practice clinic the next day. Obviously, maintaining the night shift seven days a week for less than one urgent nighttime patient a week was a severe misallocation of scarce resources.

Not only was the UCC underutilized for urgent care, it was also misused for primary care. The vast bulk of patients presenting at the UCC during the 12-hour night shift came early in the evening and were simply seeking primary care at that time because they either could not get a daytime appointment soon enough (hence urgent) or could not get to a daytime appointment because of their own work schedules. Thus, clearly the bulk of our UCC patients just needed better access to routine care appointments. However, because I had already ensured maximum utilization of existing exam rooms for normal daytime appointments, I needed to consider expanding primary care clinic hours into the evenings and weekends.

Other problems with the UCC night shift existed besides underutilization and its misuse. First, maintaining a high quality of care was becoming increasingly difficult. The physician care provided was through a contract agency and had not been reliable. These contract providers would often call in sick and not report for their assigned shifts. As a result I had to respond with backup providers. We had to rely on physician assistants to fulfill these unprogrammed requirements as all physicians had a full schedule of daily appointments. However, our physician assistants were not trained or credentialed to work alone while providing pediatric care, which was the typical, though infrequent, nighttime demand. These physician assistants did a service by determining whether we had to call in a physician, but their judgment had not always been correct.

Furthermore, physician providers began to report problems and concerns about the clinical competency of the nursing personnel who had gravitated to the night shift. These nurses were considered the weakest staff members by the nursing supervisor, and performance improvement plans had not succeeded. Understandably, the day and evening nursing supervisors were reluctant to address substandard performance for these individuals; that is, because little patient care was needed during the night shift, allowing these nurses to work nights was more convenient than attempting an elimination action. Normally, these weak performers generated enough energy to not get fired but not enough to provide quality care.

Second, keeping the UCC open at night was hindering our attempt to provide continuity of primary care through the family practice clinic. Many of our beneficiaries are young soldiers beginning families (intentionally or not), away from home for the first time, and without easy access to their extended families. They are often frightened when a young child is irritable or feverish and unsure of how to care for them. Bringing the child to the UCC for nonurgent care even at night was fairly convenient. However, this propensity to seek episodic care in the UCC prevented primary care providers from optimally monitoring their patients' health. I was extremely pleased to discover that the majority of the family practice physicians were willing to stagger their shifts to extend clinic hours, ensure that board-certified family practice physicians were always available to our physician extenders, and maximize continuity of care. Again, extended hours for family practice was emerging as a real potential solution.

Third, the night UCC increased the risk of providing care to ineligible or nonenrolled patients. For example, patients coming to the UCC at night were able to circumvent the daytime TRICARE healthcare benefit screening and enrollment requirement. Furthermore, we had several instances of ineligible patients coming to the night UCC in an attempt to get medication refills or physician orders for laboratory tests.

Other Persons and Groups Involved
The installation commander was very sensitive to any modification in service that could be construed as a decrement in those services by the beneficiaries. He resisted any change in clinic hours unless patients clearly perceived it to be an improvement in healthcare. He and I agreed that any change had to be clearly and widely communicated as in the best interest of the troops and families. He was also sensitive to the vague concerns he had heard from union representatives.

Union officials were concerned that their employees who worked the night shift would not have emergency services available. In addition, their members were emphatic that a change in hours would reduce their compensation because they would no longer receive night differential pay. This was a major disconnect. The MMTF does not exist to fund federal employees; rather the opposite, I fund federal employees to provide care to soldiers and families, not to sit in an almost empty clinic all night.

ADMINISTRATIVE DECISIONS

I decided to close the UCC at night and shift those physician or physician assistant hours to extending the family practice clinic into evening and Saturday morning appointments. This increased our available appointments by 500 appointments per month. Naturally, we also shifted requisite nursing and support staff resources to the evening and Saturday shifts. To address the truly urgent nighttime care needs we created a 24-hour 1-800 nurse advice line to assist patients in making a decision to arrange a next-day urgent appointment or go directly to an emergency room.

These one-a-week or so urgent nighttime care patients could easily get emergency-level care at a local hospital. The TRICARE benefit covers emergency room visits for either emergency or urgent needs. Beneficiaries incurred no out-of-pocket expenses for using the civilian facility for these episodes of care. In fact, seeking urgent care at civilian facilities was the norm for the majority of our beneficiaries as most of the military families lived in contract or rental housing too far from the installation to get urgent care from our UCC. Furthermore, emergency room care was not available at the MMTF. All true emergency patients had to go to a local hospital for care. Thus, I concluded that I would rather have the urgent care patients get more expensive (to the reimbursement budget) emergency services than continue to allow patients to use the UCC for mostly routine care.

Alternatives
I considered two alternatives to the above decision. First, I could have continued with the status quo; neither the union nor nighttime nursing employees supported any change. However, our need to provide more primary care appointments and ensure high quality of care compelled me to fight installation inertia to improve healthcare services.

Second, I could have staffed the night UCC with only ancillary nursing personnel to direct patients to an emergency room or a next-day urgent appointment. The night nursing personnel saw this as a means to make their lives even easier as it would decrease the utilization of the UCC even further. I was very concerned that this would render marginally competent personnel incapable of responding to a truly urgent need.

Obstacles
I negotiated our proposal with the union first because I had to have that done prior to seeking approval for the change from the installation commander. I agreed with the union's request that employees would not be required to work other than normal daytime hours unless the evening clinic was at least as busy as the daytime clinic. I assumed some risk in this restriction but anticipated that evenings would be as busy as daytime.

I briefed the installation commander and received his support because of the significant increase in primary care appointments and the extended hours for the family practice clinic. His only concerns were (1) ensuring a marketing campaign that emphasized the expansion of primary care clinic hours rather than focusing on our closing the UCC night shift and (2) educating the on-base patients about proper access to urgent care during night hours. We had already developed a marketing and education plan to accomplish both of these legitimate objectives. I also briefed him on the above arrangement I had forged with the union.

A final potential obstacle came as a surprise. When taking my proposed change up to the medical command, they informed me that congressional approval was also required. We adopted a two-tier strategy. The installation commander and I presented the proposal to our local congressman. The medical command's congressional liaisons (in Washington, DC) presented it to our two senators and other representatives for our state. All agreed that we were improving access, not decreasing it, and approved our change.

RESULTS

Closing the UCC night shift and extending our family practice clinic hours was a great success. We significantly increased appointment availability, improved continuity of primary care, substantially improved patient satisfaction, provided more than adequate access to urgent care at the local hospital, and improved skills of weaker nursing personnel.

First, we increased our available appointments by 500 appointments per month. Time would soon show that patients filled these extended-hour appointments at a higher rate than normal daytime appointments! That is, our internal auditor reviewed appointment utilization in the family practice clinic for six months following implementation and showed that utilization rates were slightly higher for the evening clinics than in the daytime. Thus, I could continue requiring union employees to work into evening hours. Furthermore, the auditor analyzed no-show rates in the family practice clinic. The daytime rate was about 20 percent, whereas the evening and weekend rate was less than 5 percent. This was a significant reduction of wasted provider time.

Second, our continuity of primary care improved as almost no patients opted for episodic care when routine care from their assigned physicians was reasonably available. Job satisfaction of our family practice physicians also improved as they were able to stabilize their practices, seeing their own panels of patients. Furthermore, because we had eliminated solo night providers, we eliminated the problem of unsupervised physician assistants providing pediatric care for which they were not trained.

Third, our patient satisfaction, as reflected in monthly Department of Defense surveys, began a steady improvement. Clearly, the patient population was pleased with the extended hours, increased appointments, and continuity of care.

Fourth, we had no negative outcomes from sending urgent care patients (about one per week) to the local emergency room. Because I served as a nonvoting member of the board of directors, I knew the quality of care at the hospital's emergency room and was completely comfortable with sending our patients there. I had assessed that care earlier as a commander when true emergency patients needed to be sent there. I accepted the small increase in reimbursement to that facility as a small price to pay for the vastly improved efficiency of the family practice and urgent care clinics.

Fifth, the chief nurse instituted a renewed competency assessment program. As a result she formally enrolled several of the former night nursing personnel into performance improvement plans to address their identified weaknesses. This enhanced oversight of weaker nurses improved the morale in the department as some of the other nursing personnel had articulated that they were fearful to work with these weaker employees. It also enabled me to begin formal documentation of the few truly irresponsible nursing personnel for future elimination actions.

The Test of Time
The need to reallocate scarce assets from the UCC night shift to an expanded family practice clinic became obvious to me fairly soon after my arrival as commander. Overcoming the institutional resistance to closing the night shift had become possible as the TRICARE system of using civilian providers had become an acceptable practice. Implementing this major change took more than a year. The improvements to our clinic were substantial and quantifiable.

I am convinced that any future effort to cut back the evening family practice clinic hours will be met with serious resistance from the patient population. Saturday-morning operations may be more difficult to sustain. Future installation commanders, often extremely averse to relying on external agencies, may try to reopen the UCC at night. Future MMTF commanders must resist this degradation of the MMTF's primary care mission.

Sources

Sources for this report include an evaluation of appointment utilization in the family practice clinic, a report by the internal auditor of MMTF (Spring 2001), Composite Health Care System ad hoc reports on clinic workload for both the urgent care clinic and the family practice clinic, and monthly data (June 1999 through June 2001). Primary sources of information used in the preparation of this case report were my direct participation in this process, first-hand observation, and personal knowledge.

Note: The views presented are those of the author and do not necessarily represent the views of Department of Defense or its components.