Scott Decker, quality manager for ThedaCare, remembers the first day he and several physicians and staff members were introduced to the IDCOP concept. Forty-five minutes into the presentation, Decker recalls, he saw the two physicians' eyes light up. "They knew what they were operating was 'broken,' and couldn't be fixed as it was," says Decker. "They knew there was no guarantee, but they were willing to try something different."

In the months before his clinics became prototype sites for IDCOP in 1998, Decker recalls, morale had hit rock bottom. "Some of the staff members were ready to walk. They were working until 7:30 at night, and still couldn't catch up." So the group started by embracing the IDCOP principle that nonphysician personnel are capable of performing a number of tasks typically handled by physicians — history taking, certain patient exams, and procedures such as Pap tests, for example.

"This is a very touchy topic for physicians, but too often, you realize that physicians are doing a lot of work that other people could very competently do" with appropriate supervision, Kilo says. The concept has become a happy reality at ThedaCare.

"Now, they're loving their jobs," says Decker, "and the doctors are seeing about 25 patients a day instead of 35."

As each new innovation or process change takes hold, clinic staff members come up with new ideas for improvements, making the redesign a staff-led, dynamic process.

"We coined the phrase that 'it's our job to slay the sacred cows,' and embraced the idea of figuring out what we can do differently right now," Decker says. "Three years later these clinics continue to challenge the sacred cows."

As word of the clinics' successes and improved working conditions gets around, staff working in other parts of the system are seeking spots there, according to Kathryn Correia, senior vice president of physician services.

"I get a lot of requests from people who want to work in our division because they've heard about this," she says. "It's what I call the 'wow factor.' One of the most important things about redesign is that the real meat is the behind-the-scenes improvements."

'How we do business'

Other practices are realizing similar successes, albeit with different focuses on the four IDCOP themes. For Luther Midelfort Mayo Health System, a Rochester, N.Y.-based behavioral health clinic, a key to its redesign was the IDCOP principle of population-based care — namely, improved management of patients with depression, who account for 40 percent of its patient panel.

Its new Depression Care Track involves a more structured patient intake process and brings nonphysician personnel into symptom reporting and history taking. It also makes extensive use of "problem knowledge couplers" — a data-driven, evidence-based system of using symptoms, patient history, and patient data entry to devise more standardized care.

Approximately 25 percent of patients with depression participate in group therapy sessions, which have brought treatment response rates above national benchmarks. In addition, the advanced-access scheduling system, now two years in operation, ensures that most patients are seen within 24 hours of requesting service; patient education and empowerment are intrinsic elements of their care. The group also began combining the medical and psychotherapy treatment aspects into a single visit, where feasible, ultimately reducing the number of patient visits without compromising revenues.

"Patients were very positive about it, and highly endorse the process," says Robert Peck, MD. The Depression Track program's success garnered Luther Midelfort an award from the American Group Management Association, and Peck, as part of IDCOP's train-the-trainer methodology, is consulting with other regional practices looking to implement the IDCOP principles.

In changing its system, Luther Midelfort got even more out of the bargain than expected. Efficiencies gained by using nonphysician personnel and patients themselves in information gathering and patient tracking, for example, contributed to a reduced need for transcription services and streamlined use of front-office and nursing resources - eventually, through attrition, reducing the number of full-time equivalent (FTE) personnel by 6.5.

The redesign process taught Peck two important lessons: "For one, I never fully realized how many people were involved in supporting my practice. And I also know that if you want to make substantial gains in improving the care of patients and populations, you have to work in a new way. You can't make the old system do more."