10 Steps to Clinical Efficiency

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• 10 Steps to Clinical Efficiency

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Overview

• Problem Statement
• Getting Buy-in
• Identifying the problem and communicate to key
  personnel
• Cooperation from all parties vital for success
• How to Implement
• The 10 Steps
• Where they came from
• What they are
• Results
• Data
• Testimonial
• Way Ahead

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Problem Statement

• Indicators point toward a need for improvement
• Poor historical coding timeliness performance
• Low RVU/ Encounter
• Access grumblings
• Process Improvement Teams (PIT Crew) developed
  and implemented FY04
• Successful in clinics with strong leadership
• Turnover in the clinics degraded performance over
  time
• Unsustained improvement due to leadership
  turnover
• A Permanent solution required a multi-faceted
  approach
• Goal Improve everything about how the clinics
  work, make it easy for the clinics to perform

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Getting Buy-in

• Previously, problems were addressed independently
• Leadership frustrated, tendency exists to fix
  symptoms
• Solution build a framework that logically
  stepped through all business aspects of clinic
  operations
• Sold to facility leadership as depot
  maintenance for clinics
• Gave all support agencies a chance to work
  together
• Clinics allowed independent voice (no cookie
  cutter approach)
• Must instill ownership
• Identify a clinical rep and an admin rep for each
  clinic who own the results and are responsible
  to leadership
• Engaged leadership

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How to Implement

• Build a Small Core Team
• Leader someone with experience with clinic
  administration, data quality, and business
  planning
• Direct support senior coding auditor, data
  quality manager
• Role Keep project on track, report to leadership
• Build expert specialty support teams
• CHCS knowledge of file and tables, clinic
  design, keys, etc.
• Documentation AHLTA application expertise,
  paired with coders
• Others Manpower, coders, MEPRS, etc.
• Create a shared place to share information
• Responsibility, Documentation, Progress, Results

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Rules of Engagement

• Meetings scheduled weekly (except holiday weeks)
• Consistent attendance from clinic leadership
  essential
• Meetings last 1.5 hours and focus on agenda items
• Some meetings will result in homework for clinic
  staff
• Assist if needed, always review performance at
  each step
• Senior leadership briefed at the conclusion of
  the project
• All participants meet together to share
  experiences and learn from one another
• Focus on 5 clinical areas at a time and realized
  great cross-feed amongst group

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Identifying the 10 Steps

• There is no one best way to run a clinic
• There are certain things all clinics must
  accomplish to be successful
• Each clinical environment has its own challenges
• Clinic leadership must know WHAT must be done
• As well as HOW to do it within their constraints
• Objective Find the minimum necessary (process
  steps and execution detail) to ensure maximum
  production potential can be achieved
• Ensure clinics know WHAT to do and then help them
  figure out HOW to do it without wasting time and
  effort

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The 10 Steps
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The Ten Steps to Clinical Business Efficiency

• Staffing
• Clinic Walk Through
• MEPRS
• CHCS Profiles
• CHCS Templates and Schedules
• Consult Process
• AHLTA Use
• Front Desk Process
• Coding and Third Party Collection
• Business Plan

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Staffing

• Goal Let the clinic know what they earn and
  get feedback on how they utilize manpower
• Invite Manpower personnel
• Explain the manning documents
• Clinic specific manpower documents are passed out
  in meeting so participants are familiar with
  contents
• Discuss authorized versus assigned FTEs/ planned
  vs. reality
• Explain proper procedures on how to correct
  disconnects (Authorized Change Request)
• Share Whats New in Manpower
• Outcome Reconcile manning documents, identify
  shortfalls for action (training, gap fill,
  contracts, rotations)

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Clinic Walk Through

• Goal Fix easy inefficiencies on the spot,
  identify clinic-specific barriers to success, and
  identify best practices
• The core team visits each respective clinical
  area to review current business processes
• Schedule visit during normal duty hours to
  observe clinic operations
• Front desk check-in, flow of medical records if
  used, learn nuances of clinic, observe best
  practices to share with other clinics and take
  note of areas needing improvement
• Visits should include NCOIC and Clinic Chief, no
  more than 2 hours
• Outcome Clinic identifies with core team core
  team witnesses the real barriers

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MEPRS

• Goal Train clinic staff on impact and importance
  of MEPRS
• Invite MEPRS personnel to meeting
• Review roles and expectations of MEPRS monitors
  or designees in clinics
• Define MEPRS (personnel time, workload, expenses)
• Inpatient, Outpatient, Ancillary, Dental, Special
  Codes (External workload)
• Review templates or procedures for accurate time
  reporting for clinical areas
• Provide last personnel time submission to each
  specific clinical area during brief
• Highlight common concerns such as annotating time
  for readiness and other special codes
• Outcome MEPRS templates corrected, invigorate
  staff

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CHCS Profiles

• Goal Ensure maximum utility of CHCS PAS Menus
• Review current profiles (Clinic Profile-CPRO,
  Provider Profile-PPRO)
• Explain the purpose of each field (i.e. address
  and phone number fields are used by DMDC on
  enrollment letters for primary care locations)
• Discuss importance of maintaining accurate
  settings in both CPRO and PPRO
• Appointment detail codes, workload type (COUNT
  vs. NON-COUNT is very important in PPRO),
  durations, auto-reconfiguration
• Inactivate providers that are no longer working
  in clinic
• CHCS email bulletin is sent to SDSMGR mail group
  for other cleanup activities (NED groups,
  Provider and User files)
• Outcome all clinic CPRO and PPRO fields
  corrected

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CHCS Templates/Schedules

• Goal Ensure maximum schedule transparency and
  flexibility with minimum maintenance
• Discuss the importance of schedule optimization
• Review appointment demand in clinics to ensure
  enough appointments are offered to meet the
  access standards
• Total duration of offered appointments should be
  compared to Clinical Available time in MEPRS
• Remove old templates to eliminate inappropriate
  schedules
• Utilize Auto-Reconfiguration to maximize access
• Ensure at least 30-45 days of the clinic schedule
  is open
• Outcome Reconfigured templates and schedules
  with a minimum of 30 days of appointments open

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Consult Management

• Goal Educate clinic on consult routing process
  (ordering, appointing, and resulting)
• Invite representation from Consult Appointing and
  Management Office (CAMO) and Referral Management
  Center (MTF)
• Overview of current process
• Discuss review statuses and routing procedures
• Review current consult resulting metrics
• Outcome Update electronic SOPs

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AHLTA

• Goal Integrate coding/ documentation/ clinic
  flow
• Invite AHLTA trainers and Clinical Staff
• Review updates since initial training
• Recent software updates
• Tips Tricks
• SG Memorandum regarding compliance (utilization
  and appropriate use)
• Discuss issues in each clinic
• If they cannot be resolved in meeting, schedule
  follow-up meeting with staff
• Outcome Increased AHLTA utilization, RVU per
  Encounter, Encounter per day

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Front Desk Functions

• Goal Identify all the must dos at the front
  desk
• Customer service
• Friendly, welcoming
• Review primary duties of front desk personnel
• DEERS eligibility checks
• End of Day reconciliation between AHLTA and CHCS
• Medical Records
• Notice of Privacy, DD2569 etc.
• Outcome Speedy front desk that gets all required
  information

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Clinical Coding

• Goal Optimize documentation practice
• Review coding practices
• Measure coding timeliness (i.e. BDQAS)
• Review recent coding audits
• Address accuracy concerns, common errors
• Review sample of record documentation (AHLTA and
  SF600)
• Identify deficiencies
• Recommend additions to AHLTA templates
• Explain supervising provider vs. co-signer vs.
  transfer
• Outcome Improved documentation practice

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Third Party Collections (TPC)

• Goal Educate clinic on how TPC can help the
  facility, improve collection rate
• Invite TPC personnel
• Provide an overview of TPC program
• Discuss mandate to collect DD2569
• Discuss local procedures for optimization (i.e.
  Use of scanners to review OHI in CHCS)
• Present clinic specific data for Billed vs.
  Collected
• QA with clinic staff
• Outcome Streamlined 2569 collection process
  within the clinic operation

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Business Plan

• Goal Educate staff on how all the previous steps
  lead to productivity as measured by the business
  plan
• Explain business plan
• Provider productivity, RVUs, Prospective Payment
  System
• Educate the Staff
• Reading the outcomes graphs
• How to plan for future targets
• Identifying areas for improvement from the raw
  performance data
• Outcome Trained staff who can sustain
  performance with limited interaction and an
  increased business output

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Results
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A Quick Note on Data

• This endeavor begins and ends with data
• Consistency of reporting tools is essential
• We used three essential products
• M2, BDQAS, and CHCS Ad-Hocs
• We used an analysis cell that consolidated all
  the data into the reports you will see here then
  distributed them via SharePoint
• While you dont need an analysis cell or
  SharePoint it makes the project much more
  manageable

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Results (Quad View)

• RVU/Encounter 0.8 to 1.1 (38 increase)
• RVU 17,229 to 20,630 (20 increase) monthly
  1,435 to 1,765
• Encounters 22,819 to 21,433 (6 decrease)

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Results (Quad View)

• RVU/Encounter 1.07 to 1.50 (40 increase)
• RVU 22,661 to 30,729 (36 increase) monthly
  1,631 to 1,941
• Encounters 21,164 to 21,803 (3 increase)

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Results (AHLTA Utilization)
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Results (AHLTA Utilization)
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Results (Testimonial)

• It was challenging but being a new element leader
  I learned a lot about how my clinic should be
  running to be successful. I am very thankful
  (even though it was painful at times) for what I
  came away with and am still using those same
  processes today.
• - Capt Foster, GYN Element Leader

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Conclusion

• It just works
• The best outcome is business savvy leaders
• The second best outcome is teamwork between admin
  and clinical staff
• Way ahead/ lessons learned
• Develop tools to better measure demand and access
  supply close to real time (i.e. David Grant
  Appointment HUD)
• The unit of production is the appointment RVUs
  are only a consequence of this production
• Although touched on in templates and schedules,
  there could be much more work done to really
  boost production