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