Office Organization and Management
Strategies to Enhance Family-Centered Care in Primary Care Practices
Interesting Reading
Office Accessibility
Strategies to Enhance Family-Centered Care in Primary Care Practices
For your families and CSHCN
Help families prepare for their visit with you and for after the visit
Provide families with information about signs and symptoms which require immediate attention; make sure they have a plan to connect with health care services 24 hours a day, 52 weeks a year.
Examine your practice for ease of accessibility for patients with disabilities
Give the child a method to communicate preferences and health care choices
Provide parents with tools to organize health information, optimize a medical office visit, and optimize communication with other providers in the community
Anticipate and prepare for transitions in health care, especially adolescent to adult
Create linkages to connect families with local resources and with other families
Link families to information about their child’s condition
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For Your Practice
Use Medical Home Tools to guide office practices and visit format for families of CSHCN
- Medical Home Family Index
- Family Needs Assessment
- Culturally Effective care assessment
Obtain feedback (positive and negative, suggestions for change) about the practice from families
- Feedback questionnaires
- Focus groups
- Parent Advisory group (see below)
- Parent participation in Quality Improvement team
Connect and follow-up with consultants, sub-specialists, and other community providers involved in the care of the child.
- Obtain feedback from the family about services received from the consultants and community providers.
Consider an Electronic Medical Record – as the formatting for Pediatric populations improves, the EMR has the potential to streamline record-keeping, care plan development, medication management, determination of patient problem prevalence for practice management and billing, and accessibility of the medical record between offices.
- Some EMRs have ability to make referrals electronically (Pointshare system) by automatically faxing information to the provider. (‘Families don’t call and say, ‘The specialist didn’t get your referral,’ any more!)
- Meditech computer system in the Spokane hospitals allows electronic access to patient record from hospital visits – e.g. if they were in the ER the night before you can access that information.
- Ability to sign medical record electronically is labor-saving!
Consider ways to provide case management/care coordination services in your practice setting.
Practices that do a better job in care coordination have: 1) Electronic Medical Records, and 2) Care coordination personnel on staff
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Interesting Reading
Managing the 'NO SHOW' patient
http://www.aafp.org/fpm/20050200/65mana.html
Language Interpreters
Using Bilingual Staff as Interpreters
http://www.aafp.org/fpm/20040700/34usin.pdf
Getting the most from language interpreters
http://www.aafp.org/fpm/20040600/37gett.pdf
Electronic Medical Records
"How to Select an Electronic Medical Record System"
by Kenneth Adler, MD, MMM (Masters in Medical Management)
http://www.aafp.org/fpm/20050200/55howt.pdf
Creative Solutions to Specific Problems
Serving the Uninsured Patient
http://www.aafp.org/fpm/20040900/51insu.pdf
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Office Accessibility
From: Making our offices universally accessible: guidelines for physicians. Karen E. Jones, BSc, MD; Itamar E. Tamari, MD CMAJ 1997;156:647-56.
Getting to and entering a medical facility
- Offices should ideally be located as close as possible to public transportation routes, including subway stops and bus shelters. They should also be close to accessible laboratory facilities, which should include technicians with relevant training and experience in working with persons with disabilities (expert opinion).
- There should be curb cuts in the blocks around the building for ease of use by persons using wheelchairs or scooters.
- Adequate exterior passenger loading zones should be provided directly in front of the building entrance. An access aisle not less than 1500 mm wide and 6000 mm long, adjacent and parallel to the vehicle pull-up space, should also be provided. Canopies and marquees above the vehicle's path of travel should provide a height clearance of at least 2750 mm.
- Designated parking spaces should be reserved for persons with disabilities; these should be located close to the building entrance and properly marked. Spaces should be 3900 mm wide, allowing adequate room for transfer from wheelchair to vehicle. At least 1 such space should be provided for every 20 parking spaces and 1 for any remaining parking spaces less than 20.
- Buildings should be clearly marked, in nonglare, contrasting colours with sufficiently large, legible signage, so that reading the signs does not pose a problem for persons with visual disabilities; the use of symbols as well as written labels should be considered.
- Signage should be immediately visible upon entering the building and should indicate the locations of elevators, rest rooms, offices and other services.
- Barrier-free facilities (e.g., accessible entrances, rest rooms, elevators and parking spaces) should be identified by a sign with the international symbol of accessibility for persons with disabilities.
- Wherever the path of travel involves a change of level to reach a destination inside or outside the building, ramps, elevators or other facilities should be provided to enable a person to reach the other level without having to use stairs or escalators (expert opinion); the grade should be 1:20 (ratio of rise to run) and should not exceed 1:12 (for short ramps). Ramps and stairs should not intersect.
- Bilateral handrails 865 to 965 mm high should extend at least 300 mm beyond the top and the bottom of a ramp; the ramp width should be sufficient to accommodate all wheelchairs (at least 870 mm between handrails).
- Building entrances should have electric, automatic hinged or sliding doors unless existing wide revolving doors are designed to allow the passage of wheelchairs (expert opinion). Doors should allow easy clearance for wheelchairs (at least 800 mm) when opened 90°. Doors should close in no less than 3 seconds.
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Entering offices and waiting rooms
- Flooring should be smooth and slip-resistant, consisting of tile or carpet with a pile less than 13 mm high.
- Corridors should be well lit, unobstructed, and at least 1500 mm wide.
- Elevators should be equipped with both audible and visible hallway signals for available cars. Labels inside and outside cars should be raised, indented or in Braille. Control buttons should be operable with 1 hand, located less than 1220 mm above the floor and arranged horizontally. Elevator cars should be wide enough to accommodate scooters and all wheelchairs, including electric wheelchairs (which are usually wider). Mirrored back walls may assist persons using wheelchairs to back out of elevators (expert opinion).
- Waiting rooms should accommodate a variety of seating arrangements and individual variations in size, shape and height to accommodate the various needs of persons wearing braces or having back problems; some chairs should be equipped with armrests. Furthermore, at least 2 spaces should be designated for persons using wheelchairs.
- If waiting-room space allows, a small, high table (the level of a reception counter, as described later) with knee clearance, accessible to persons using wheelchairs, may provide a surface for reading, placing cups, etc. (expert opinion).
- Reception counters should accommodate persons using wheelchairs and thus be no more than 860 mm high and no less than 765 mm wide, with suitable knee space below (685 mm high and 485 mm deep). If reception areas are separate from waiting rooms, chairs should be provided for waiting patients in the reception area (expert opinion).
- There should be a visual (e.g., hand-held chalkboard) as well as audible method for calling patients in for consultation (expert opinion); secretarial staff should be aware of patients' needs.
- Staff awareness of individual patients' needs for accommodation may be facilitated by appropriate chart-coding techniques (expert opinion).
Rest rooms
- Rest room doors should be automatic (expert opinion).
- If the rest room has stalls, at least one should be wheelchair accessible; single-person rest rooms should be accessible.
- Accessible stalls should have wide doors (at least 800 mm wide when open 90°) that open outward; doors should be equipped with graspable latch locking mechanisms. A turning space of 1500 mm in diameter should be provided inside the stall.
- Horizontal grab bars should be placed on the side wall of the stall closest to the toilet. In the absence of a tank, an additional grab bar should be placed on the wall behind the toilet. There should be space (wider than 1050 mm) between the side of the toilet and the far wall to allow side transfers (to a wheelchair or scooter). Grab bars should be 840 to 920 mm above the floor and 30 to 40 mm in diameter; they should have a clearance of 35 to 45 mm from the wall.
- Grab bars on both sides of the toilet are useful for ambulatory persons with disabilities but may impede transfer for persons using wheelchairs; it should be possible to swing such grab bars in and out of place easily so that they can be used only when required. Toilet seats should be 400 to 460 mm above the floor.
- There should be a coat hook within the stall, which should be no more than 1400 mm above the floor, so that it can be reached by persons using wheelchairs.
- At least one sink should be accessible to persons using wheelchairs. It should allow sufficient clearance (at least 735 mm) beneath the counter and have faucets and a basin at an accessible height. The sink should be no more than 865 mm high and should be equipped with blade or lever handles. Pipes to and from the sink should run to the back of the sink and be insulated so that they do not come into contact with the legs of persons using wheelchairs.
- Soap or towel dispensers should be no more than 1200 mm above the floor in order to be accessible to persons using wheelchairs.
- A mirror should be provided; its bottom edge should be no more than 965 mm above the floor.
- An emergency call bell should be available (expert opinion) and should be connected to the nurse's or physician's office. The bell should be mounted no more than 1375 mm above the floor.
Examination rooms
- Walls, door jambs, doors and baseboards should be distinctly different colors or shades to facilitate visual orientation and balance.
- There should be adequate turning room (1500 mm in diameter).
- Examination tables should be wide and adjustable in height, obviating the need to climb on and off the table and allowing ease of transfer and examination.
- A horizontal grab bar appropriately placed on the wall above the examination table would assist patients to change position and transfer to a wheelchair, scooter or other assistive device (expert opinion).
- The transfer of a person with a disability to the examination table varies with each person; the patient should be asked how he or she is accustomed to accomplishing such transfers. The physician should never assume that similar disabilities translate into similar transfer techniques.
- Portable examination equipment (such as ophthalmoscopes, otoscopes and sphygmomanometers) are a useful addition (expert opinion).
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Miscellaneous building features
- All doors should be equipped with lever handles or be designed in a way that does not necessitate tight grasping and twisting of the wrist to open them.
- Drinking fountains should be a maximum of 915 mm high; they should protrude from the wall with sufficient knee space underneath for persons using wheelchairs.
- Lighting levels should be at least 50 lx (5 foot candles).
- A stripe at eye level throughout the office, and especially in small rooms, would be helpful for ambulatory persons with visual disabilities (expert opinion).
- Counters provided for public telephones should be easily accessible (see recommendations for reception counters), and at least one wall-mounted telephone should have a number pad, receiver and coin slot no more than 1375 mm above the floor and a telephone cord more than 735 mm long; at least one telephone should have a volume control. An accessible telephone should be placed near the building entrance and exit for use by people awaiting transportation (expert opinion).
- Escape routes for emergency departures should have both visible and tactile wall markings; alarms should be visible as well as audible.
- Placement of handrails along hallways should be considered (expert opinion); chairs should be strategically placed en route (expert opinion), ensuring that there is adequate room for someone in a wheelchair to pass by unobstructed.
Other miscellaneous issues
- Attendant services should be made available (expert opinion). Office staff with knowledge of various aspects of care of persons with disabilities (such as transfers, dressing and undressing) should be available when needed. Local organizations concerned with disability can be contacted to educate staff or provide recommendations.
- Information specifically relevant to persons with disabilities as well as general patient information should be made available in a variety of formats (e.g., audiotape, Braille and large print) and be written in plain language.
- Alternative methods of communication with persons who are deaf, hearing impaired or nonverbal should be considered; these include the use of sign-language interpreters, computer terminals and Teletype (TTY) technology for patient bookings and inquiries.
- Accommodation should be made in scheduling persons with disabilities to take into account extra time needed (because of variable arrival times of public transportation for persons with disabilities or transfers and clothing changes, for example). Appointments must be started and finished on time, because people traveling by public transportation (for persons with disabilities) must leave the office on time. These services are often the only means of transportation for persons with disabilities, and the drivers will not wait.
- Service dogs (including guide dogs) must be permitted on the premises.
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