REMOVING OBSTACLES TO

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MISSISSIPPI PRIMARY HEALTH CARE ASSOCIATION
REMOVING OBSTACLES TO ORGANIZATIONAL PRODUCTIVITY
Presented by Michael R. Taylor, Precision
Resources, Inc. MRTPRI_at_aol.com
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SESSION GOALS

• Discuss how operational issues affect health
  center financial performance in general and
  provider productivity specifically.
• Review primary systems flows to identify
  potential trouble spots.
• Identify system approaches and methodologies to
  help alleviate trouble spots.

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FACTORS AFFECTING PROVIDER PRODUCTIVITY

• Staff knowledge of and will to meet production
  standards
• Sufficient service/provider demand
• Provider supply and availability that reasonably
  match demand
• Operating infrastructure (e.g., staff, practice
  management system) and processes that facilitate
  moving patients efficiently through the system

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STAFF KNOWLEDGE OF AND WILL TO MEET PRODUCITIVY
STANDARDS

• Determine and communicate standards at least
  sufficient to cover organizational overhead and
  make a reasonable profit
• Define and communicate each staff members
  role(s) in achieving defined standards
• Identify and neutralize/remove impediments to
  achievement
• Incorporate achievement into staff employment
  agreements/performance evaluation criteria
• Consider financial incentives for performance
  above established standards

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UNDERSTAND OPERATIONS

• Perform detailed, systemic analyses to understand
  how operations affect productivity and
  performance.
• Anecdotal information, assumptions, or the way
  weve always done things, will give a misleading
  picture of how a health center functions and what
  needs to change to improve performance.
• Various tools can be employed to measure
  operating performance in each health center
  department.
• Once management understands operations, it can
  begin to develop effective solutions for
  improvement.

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SIMPLIFIED VISIT-TO-CASH FLOW CHART(THE BIG
PICTURE)
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UNDERSTAND THE MAJOR PROCESSES (THE BIG PICTURE)

• Some steps on the preceding diagram represent a
  complex series of actions and decisions.
• Every action step and decision point raises a
  potential bottleneck or pitfall.
• Avoiding pitfalls and bottlenecks is what makes
  health center operations run smoothly.
• Management must collect the right data to
  identify deficiencies and then conclude how to
  correct them in order to improve performance.
• More detailed flow charts depict what can/should
  be measured.

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UNDERSTAND THE MAJOR PROCESSES (THE COMPONENTS)

• APPOINTMENT SCHEDULING

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APPOINTMENT SCHEDULING

• Appointment scheduling has a major impact on
  operations, efficiency and collections.
• The scheduling template is key to provider
  productivity. Templates that are thoughtfully
  developed, and then used and managed properly can
  virtually guarantee that providers have an
  adequate supply of patients to see and, thus, are
  productive.
• Provider productivity can be expressed as an
  equation
• Productivity S X
  
• Management CAN influence the outcome of this
  equation.

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COMPONENTS OF APPOINTMENT SCHEDULING

• Objective - To realistically schedule the maximum
  number of patient appointments for the available
  providers
• Incoming Phone Calls - Front office staff
  (usually Schedulers, Unit Clerks) take incoming
  calls from persons seeking an appointment. In
  general, they
• Determine the underlying reason(s) for the
  requested visit (e.g., physical, follow-up, etc.)
• Request then note the callers demographic
  information in the scheduling module
• Inquire if the caller has insurance
• Ascertain if the caller will be a new or is an
  established patient

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COMPONENTS OF APPOINTMENT SCHEDULING

• Incoming Phone Calls Schedulers should
• Inquire as to the reason for the requested
  appointment, the callers preferred date, time
  and provider preference
• Search the scheduling module for appointment
  options that meet caller-specified
  preferences/parameters
• Conclude and reiterate the selected appointment
  date/time
• Note then instruct the caller to bring
  identification, insurance card (if insured),
  proof of income (if uninsured) and visit
  co-payment
• Check the account of established patients for any
  outstanding balance and remind them that payment
  is past due, required and will be requested
  during registration
• Remind caller that they are expected to call to
  cancel if they cant keep appointment and will
  forfeit if they are late

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COMPONENTS OF APPOINTMENT SCHEDULING

• Reminder Phone Calls - Front office staff call
  appointed patients one or two days beforehand to
  confirm appointment dates/times, and to determine
  the patients intent to either keep, cancel or
  reschedule.
• Follow-up Appointments - Front office staff
  (usually Discharge or Unit Clerks) or clinical
  support staff schedule subsequent patient
  appointments per provider orders.
• Documentation and Notification of No-Shows -
  Front desk staff note patients who missed their
  appointment and place follow-up phone calls to
  those patients to schedule a new appointment.

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SCHEDULING IMPACT ON PROVIDER PRODUCTIVITY

• Management should
• Ensure a steady flow of patients for providers
• Providers see the patients who are presented to
  them
• Consider provider-specific no-show and walk-in
  rates to estimate the number of daily appointment
  slots that should be double or triple-booked for
  each provider
• Conclude provider schedules (i.e., availability)
  and scheduling templates (i.e., standard time
  slots by clinical specialty for each appointment
  type) as policy
• Deviation from this policy should require the
  Chief Medical Officers approval
• Dont put Schedulers in the unenviable position
  of debating scheduling issues with providers

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SCHEDULING IMPACT ON PROVIDER PRODUCTIVITY

• Management should
• Determine how walk-ins will be treated (e.g.,
  designated urgent care provider(s), designated
  appointment slots, worked in between scheduled
  patients, etc.)
• Monitor each providers patient throughput to
  determine if walk-ins routinely cause
  unreasonable delays for appointed patients
• Determine the distribution of new, established,
  appointed and walk-in patient visits over the
  course of a typical day in order to match
  provider availability

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SCHEDULING IMPACT ON PROVIDER PRODUCTIVITY

• Scheduling staff should make every attempt to
  schedule the next available appointment that
  meets patient specifications.
• Practice management system should have an built
  in algorithm that facilitates the identification
  of next available slots.
• On a regular basis, the front office manager
  and/or business manager should
• Review and monitor the scheduling of patient
  visits
• Check that appointments are being
  double/triple-booked, as appropriate and
• Review the impact of special requests on
  appointment scheduling (e.g., unanticipated
  provider schedule changes).
• Schedulers should fill the full days schedule.
• Dont stop scheduling appointments early.
• Use same-day appointment to fill open and
  cancelled appointment slots.

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SELECT PERFORMANCE MEASURES FOR SCHEDULING

• Average Number of Rings Before Calls Are
  Answered/Call Drop Rate/Rate of Calls Placed on
  Hold/Average Hold Time - Measured at Peak and
  Non-Peak Times
• Percentage of Successful Reminder Phone Calls
  (i.e., where contact is made and language enabled
  communication)/Postcards (number/percentage
  mailed/returned)
• No-Show Rates By Provider (new and established
  patients separately)
• Wait Time from Arrival to Exam Room (appointments
  and walk-ins separately)
• Number/Percentage of Walk-Ins an Same-Day
  Appointments
• Appointment Lead Times (Urgent, Routine/Well and
  Non-Urgent Sick Visits)
• Number/percentage of unfilled appointment slots

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UNDERSTAND THE MAJOR PROCESSES (THE COMPONENTS)

• PATIENT REGISTRATION

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PATIENT REGISTRATION DETAIL
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REGISTRATION IMPACT ON PROVIDER PRODUCTIVITY

• Objective - To quickly and accurately register
  the maximum number of patients who present for
  care
• Ineffective registration processes cause
  throughput bottlenecks and provider downtime.
• Waits to register, for insurance
  verification/eligibility determinations, for
  medical record, for clinical staff notification
  and patient retrieval
• Effective processes enable staff to perform key
  tasks easily, quickly and accurately
• Accurate and complete patient paperwork
• Collect/verify patient identification,
  demographic information and insurance coverage
• Ensure collected information is consistent with
  that in practice management system and in payers
  database
• Retrieve record, notify clinical staff and
  collect co-payment

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POTENTIAL BOTTLENECKS IN REGISTRATION

• Overabundance of walk-in versus appointed
  patients
• Majority of patients who require demographic
  information updates
• Insurance verification methods that are not
  automated (dependent on telephone calls)
• High number of patients whose insurance coverage
  is determined to be inactive
• ___________________________________________
• What are the root causes and impacts of these
  bottlenecks?
• ___________________________________________
• What is the impact, in number of patients who
  could be seen, if bottlenecks were eliminated?

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REGISTRATION IMPACT ON PROVIDER PRODUCTIVITY

• Training, monitoring and feedback are essential.
• High turnover of front desk staff is common.
• New staff frequently have limited, if any,
  relevant experience.
• Existing staff adopt bad habits (e.g., shortcuts,
  omitting key tasks).
• Curriculum should be based operating policies and
  procedures
• Include common scenarios They might not
  encompass every situation a Registrar encounters
  but they can establish expectations and
  parameters.
• Proper completion of the Registration Form is
  crucial
• Make the form self-explanatory or routine to
  minimize misunderstanding and personal
  interpretation.
• Inform staff that they are responsible to ensure
  proper completion
• Ensure that the correct patient is being recorded
  in the system
• Insurance coverage verification
• Use an on-line systems, whenever available
• Aggressively screen uninsured patients for
  coverage eligibility

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SELECT PRODUCTIVITY MEASURES FOR REGISTRATION

• Average Number of Patients Registered Per Hour
  Per Provider
• Average Time(s) to Complete Patient Intake (for
  new, established, appointed and walk-in patients)
• Average Wait Time in Registration
• Error rate(s)
• Practice management system should be configured
  and used so that it accumulates the right
  information by user. When this is so, management
  can analyze each users performance.

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HEALTH RECORDSARE THEY AVAILABLE AND COMPLETE
FOR APPOINTED PATIENTS
UNDERSTAND THE MAJOR PROCESSES (THE COMPONENTS)

• PATIENT SERVICE

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PATIENT SERVICE DETAIL
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POTENTIAL BOTTLENECKS IN PATIENT SERVICE

• Charts not available or incorrect charts
  delivered to clinical area
• Exam rooms not turned over timely
• Exam room inventory not replenished
• Provider running behind not ready for the
  patient
• High number of patients found ineligible for
  their coverage
• ___________________________________
• What are the root causes and impacts of these
  bottlenecks?
• ___________________________________
• What is the impact in number of visits that could
  have been completed if bottlenecks were
  eliminated?

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CLINICAL SUPPORT STAFFS ROLE IN
CAUSING/ELIMINATING BOTTLENECKS

• Objective - To prepare facilities and patients
  for a productive visit with a provider as quickly
  as possible
• Clinical support staff (e.g. nurses, medical
  assistants) impact patient flow and provider
  productivity. They should
• Understand and perform their job functions (e.g.,
  retrieve and prepare patients in a timely manner,
  prepare exam rooms, maintain exam room supply
  inventory)
• Have supervision who monitors performance and
  resolves issues that negatively influence
  performance
• Be organized in a workable staffing model (i.e.,
  nurses versus MAs) that has a sufficient
  complement.
• There is not a right staffing model instead
  health centers tend to equalize the cost of these
  staff by the skill level mix (i.e. CHCs with a
  nurse staffing model tend to have less clinical
  support staff per provider).

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PROVIDERS ROLE IN INCREASING THEIR PRODUCTIVITY

• Objective - To provide the highest possible
  quality of care to the maximum number of patients
• Providers should
• Direct questions/comments/requests regarding
  appointment scheduling to the appropriate
  manager, not the staff person who performs the
  function.
• Discuss schedule changes with the Chief Medical
  Officer as soon as possible (and secure approval,
  as appropriate).
• Arrive at work at least 15 minutes before their
  first appointment each day (everyone needs prep
  time).
• Avoid working in walk-in patients when it causes
  unreasonable delays for those with an
  appointment.
• Resist the natural tendency to treat all the
  conditions of medically complex patients who have
  been noncompliant (e.g., repeat no-shows) during
  a single visit.
• Establish a protocol to identify and then
  reschedule noncompliant patients.

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PROVIDERS ROLE IN INCREASING THEIR PRODUCTIVITY

• Providers should
• Minimize time devoted to non-patient care
  activities
• Occasions requiring long travel times (e.g.,
  between care sites) during the middle of the day
• Administrative time
• Time off during peak volume cycles
• Organize records so that basic patient facts
  (e.g., diagnoses, medications, treatment plans)
  can be easily identified.
• Consistently document care, at least sufficiently
  to support selected diagnostic and procedure
  codes, before each patient is discharged.
• Maintain an ongoing dialogue with support staff
  regarding ways to increase the teams collective
  productivity.
• Share impediments to increased productivity with
  management and jointly conclude ways to eliminate
  them.

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UNDERSTAND THE MAJOR PROCESSES(THE COMPONENTS)

• MANAGEMENT

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MANAGEMENTS ROLE IN INCREASING PROVIDER
PRODUCTIVITY

• Management will be most effective when they
  enable, not dictate, increased provider
  productivity.
• Incentive compensation
• Will encourage increased provider productivity
• Will not remove operational impediments that
  suppress it
• Operating processes that are clearly defined,
  thoroughly understood and consistently carried
  out are key

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MANAGEMENTS ROLE IN INCREASING PROVIDER
PRODUCTIVITY

• Monitoring staff conformity with defined
  processes is required to ensure continued
  compliance.
• Measure process time
• Measure cycle time
• Identify bottlenecks
• Review exam room utilization
• Review patient satisfaction surveys
• Directly observe patient flow
• Identify space needs of operations
• Review health center space layout
• Review provider schedules and appointment
  scheduling
• Create a continuous feedback loop that informs
  ALL parties.
• Oftentimes the best forum for communication is
  facilitated peer-to-peer interaction.

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RESULTS

• Efficiency gains (cycle time reductions) will
  yield greater productivity for all staff,
  improved patient satisfaction AND improved
  financial performance.

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QUESTIONS