The Duke Outpatient Clinic (DOC) is an adult primary care clinic in Durham, NC serving over 5,000 unique patients and conducting over 22,000 provider visits per year. The DOC is the largest continuity clinic site for the Duke Internal Medicine Residency Program, with over 70 resident providers; two-thirds of the encounters in the clinic are performed by residents. More than 40 percent of patients seen at the DOC are on Medicaid and 10 percent uninsured, making the clinic the largest adult medicine safety net practice in the Duke University Health System (DUHS). Like many resident clinics, the DOC faced a number of challenges: resident providers' irregular availability; a large number of residents and attendings; resident and staff turnover; lower reimbursement rates; managing work outside of clinic visits; and the social and medical complexity of a relatively disadvantaged patient population, whose economic situation can impede adherence to medications and other medical advice; and dissatisfaction with the perceived difficulty of providing care in this setting. Beginning in 2012, the DOC underwent a year-long redesign for improved population health management and resident education.
The Six Sigma DMAIC approach (Define, Measure, Analyze, Implement, Control) was the basis for a process that sought input from stakeholder groups (including residents and patients), incorporated the results of pivotal pilots, and reviewed the internal and external landscape; culminating in the securing of the necessary resources from health system and community sources. Implementation began in 2013, and resulted in a reduction of 16% in ED visits and 17% reduction in the number of 30-day readmits. A ‘dashboard' of metrics was create to guide further refinements, improvements, and expansions of these interventions at the DOC going forward.
KeywordsPopulation Health, Urban, Public Health Sciences, Resident Clinic, Resident Experience, Cost-Effective, Underserved Population
Lynn Bowlby, MD, Duke University School of Medicine
Alex Cho, MD, MBA, Duke University School of Medicine
Lawrence Greenblatt, MD, Duke University School of Medicine
Daniella Zipkin, MD, Duke University School of Medicine
Natasha Cunningham, MD, Duke University School of Medicine
Adia Ross, MD, MHA, Duke University School of Medicine
Kevin Shah, MD, MBA, Duke University School of Medicine
Mark Dakkak, BS, Duke University School of Medicine
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