Introduction to Operational Teams
“Rounding out” the major aspects of operational teams
Mike Davies, MD FACPMark Murray and Associates
Operational and Clinical TeamsC
linic
al T
eam
s: W
hat
to
do
?
Operational Teams: How to do it?
Close to Agreement
Far from agreement on HOW to do it (how to
implement guidelines, how to support provider’s
efficiency)
XX
XX
Far from agreement on WHAT to do (what
prevention and chronic disease guidelines to
implement)
Why Operational Teams?
NurseReception
Team (2.59 FTEE)
Provider
360 Patients are Over 65
60 Patients had more than 10 Office
Visits Last Year
130 are Clinically Depressed
228 have Hypertension
160 have Heart Disease
248 have Arthritis
113 have Asthma
66 have Diabetes
Panel Size 2000
39% of Capacity is Physician Time39% of Capacity is MA Time22% of Capacity is RN Time
Demand Capacity
Reimbursement (Demand)
GrossRevenue
Visits
Limits•No-shows•More resources needed (staff, rooms, etc)•Quality?•New patients meet mission
Expenses (Capacity)
Cost Or
Expense
Visits
Variable
Fixed
Total
Net Revenue
NetRevenue
Visits
NoShows
(pt. burnout)
More staff and space
needed
Staffburnout
Limits
New patientsneeded to serve mission
Value
• Does net revenue reflect true value to the patient?
• What do patients value?– Access– “Good” Doctors and Clinics
• Listening, understanding and emotional support• Detection of disease• Prevention of disease• Continuous relationship (continuity)
Support Staff all Related to Productivity
• Classic study
• “nursing, administrative, clerical, and aids all independently related to productivity measured by both visits and billings”
• Reinhardt, U., The Review of Economics and Statistics, Feb 1972, pp 55-66.
• Thurston, NK et al. “A Production Function for Physician Services Revisited,” Review of Economics and Statistics, February 2002, Vol 84, (1): 184 – 191.
Support Staff and Productivity Correlated
• “Strong positive correlation between number of support staff and productivity as measured by visits per week.
• Held true for secretaries, RN’s, LPN’s, and medical technicians.
• Data from 1976 HCFA surveys of 3,482 physicians
• Brown, DM., “Do Physicians Underutilize Aids,” Journal of Human Resources, Summer 1988, Vol. 25 (40): 342-355
Admin and Medical Support Staff Increase Revenue
• Strong relationship between both administrative support staff and medical support staff and physician productivity (as measured by revenue per physician).
• Revenue is visits and procedures
• HCFA 1988
• Pope, GC., “Economies of Scale in Physician Practice,” Medical Care Research and Review, December 1996, vol 53 (4): 417-440.
Clerks are Important
• DeFelice, analyzing the AMA’s Physician’s Practice Cost and Income Survey from 1984-85 found + relationship between weekly hours of clerks per MD and the number of MD visits
• No association between hours of nursing time and number of visits
• DeFelice, LC., “The Impact of Financial Incentives on Physician Productivity in Medical Groups,” Health Services Research, August 2002, Vol. 37 (4): 885-906.
Operational Team Challenge
• Create Access• Provide quality• Maintain financial viability of the clinic• Optimize capacity of team for visits• Maximize number and value of visits• Minimize inefficiency• Optimize team dynamics and function (morale,
engagement, personal mission, turnover)
Home Team
Operational Improvement Clinical
Team
Teamwork!
Major Aspects of Operational Teams
• The Work Organization– What is the goal?– What is the process?
• The Worker– Enthusiasm, Talents, Style, Profession
• The Work Content– What is the work and who does it?
Major Aspects of Operational Teams
• The Work Organization– What is the goal?– What is the process?
• The Worker– Enthusiasm, Talents, Style, Profession– Work assignment?
• The Work Content– What is the work?
What is the work and who does it?
Flow Through the Office
Check-in to Nurse
Nurse to Room
Dr. in to Dr. out
Check-out to leave
Synchronization Point
System
How Processes Support Flow
1
P r o c es s
1
P r o c es s
1
P r o c es s
Check-in to Nurse
Nurse to Room
Dr. in to Dr. out
Check-out to leave
1
P r o c es s
1
P r o c es s
1
P r o c es s
1
P r o c es s
1
P r o c es s
1
P r o c es s
Process
What are Some Clinic Processes?
documentation medication refills lab review messages referrals forms management
How Tasks Support Processes
Physician ordersconsult
Clerk calls tomake appointment
Clerk gives appointmentreminder and directions
to patient
4 minutes
5 minutes
Check-in to Nurse
Nurse to Room
Dr. in to Dr. out
Check-out to leave
Task
TasksMake Appointment
Give Directions
Specialist Referral Process
Physician ordersconsult
Clerk calls tomake appointment
Clerk gives appointmentreminder and directions
to patient
4 minutes
5 minutes
Task
How Tasks Support ProcessesSpecialist Referral Process:
Task: Call to make appointment
Task: Give directionsfor specialist
Tasks in the clinic – What is the work? What do we know?
Job Analysis
• Survey of 7 practices
• Extensive interview of provider, nurse, pharmacist, clerk (1-2 days)
• Standardized description of tasks
• 243 Tasks identified
Task Categories
• Administrative– Scheduling, phones,
• Prevention– Education, treatment
• Treatment– Medication, procedures
• Diagnosis– History, Physical, ordering & interpretation of tests
• Relationship– Primary Care Provider
Relationship
Diagnosis
TreatmentPrevention
Administrative
Relationship
Diagnosis
TreatmentPrevention
Administrative
Relationship
Diagnosis
TreatmentPrevention
Administrative
Relationship
Diagnosis
TreatmentPrevention
Administrative
% Tasks Endorsed
MD 58.02%
NP/PA 55.14%
RN 71.19%
LVN 54.73%
MASPSA 18.11%
HlthTech 19.75%
Provider
Nurse
Clerk
Task Overlap
MD NP/PA RN LVN MASPSA HlthTech
MD 90.30% 63.01% 63.91% 45.45% 68.75%
NP/PA 85.82% 65.90% 65.41% 40.91% 64.58%
RN 77.30% 85.07% 96.99% 93.18% 95.83%
LVN 60.28% 64.93% 74.57% 77.27% 87.50%
MASPSA 14.18% 13.43% 23.70% 25.56% 50.00%
HlthTech 23.40% 23.13% 26.59% 31.58% 54.55%
Who COULD Do Task?
Doc Nurse Clerk
Administrative Y Y Y
Prevention Y Y P
Treatment Y P N
Diagnosis Y P N
Relationship Y P N
Who Should Do Task?
Doc Nurse Clerk
Administrative N N Y
Prevention P Y P
Treatment P P N
Diagnosis Y P N
Relationship Y P N
Example Task 1: Summon Pt
• Call patient from waiting room, direct patient to office or exam room, explain next steps and procedures to patient (e.g. vital signs), open patient information in computer, verifying accuracy of patient information (e.g., patient identity, SSN, DOB), in order to prepare patient for measurement of vitals.
Example Task 239: Pt. Call
• Receive patient phone call for symptom-related concerns, test results, scheduling questions, or medications, review patient’s medical history and plan of care, ask patient questions about symptoms, listening to patient responses, determine urgency of request, discuss options with patient or refer to another source, notify provider if urgent action is required, in order to address patient concerns or requests received on clinic phone line.
Financial Impact of Task Reassignment
MD RN Clerk Total 20% $ Red. Wk Svs Yr Svs
Freq 7 87 31 126Cost $10 $226 $9 $245 $196 $49 $2,548
Freq 31 26 20 77Cost $380 $166 $154 $601 $481 $120 $6,240
Task 1
Task 239
Error/Complexity
Human Error Risk Work Complexity
Task 1 2 2Task 239 4 3
Impact of Task Reassignment
• Positive Considerations– Increase capacity of
expensive resource– Save $– Clarify roles in team
• Negative Considerations– Pain of change– Match of job with
individual preferences and talents ??
Task Reassignment: The 4 T’s
• Task – what is the work and who could do it under ideal conditions?
• Team – who is on our team and could do the work (actual conditions)?
• Timing – does the timing of the task lend itself to reallocation?
• Terrain – is the task member in the right place to do the task?
Task Reassignment Examples
• Assistance with undressing for exam– Could be done by LPN or MA if available– Sometimes done by MD due to timing
• Vital Signs– Often done by RN– Could be done by MA if 4 T’s apply
• Phone answering– Often done by RN or LPN– Could be done by MA or Clerk if 4 T’s work
Task Reassignment Examples
• Common Medical Problems– Often addressed by MD in a visit– Could be done by RN with MD assistance if
protocols were in place
• Prevention– Often not done– Could be done by LPN/RN/MD team if
organized well
What is the work…who is/should be doing it?
Task Clerical MA RN ProviderRegistrationRoomingRefillsAdviceOrder EntryMed. monitoringTeaching