Organizational and Operational Efficiencies in Michigan’s Health Care

Safety NetPeter D. Jacobson, JD, MPH

Valerie Myers, PhDJudith Calhoun, PhD

Presented to the CHRT Safety Net Symposium29 October 2010

Overview

• Study of Michigan’s health care safety net organizations

• Focus on efficiencies• Context of health care reform

Methods

• Qualitative interviews• Components of an efficient clinic• Strengths/challenges• Strategies for improving efficiencies• How organized

• Data collection

Sample – Clinic types

**Interviewed at each site

N=29 SitesFQHC 52

Free Clinic 34

Hybrid 10

FQHC -14Free Clinic -12Hybrid - 3

N= 96 Interviews

Interviews by Clinic Type

• CEO/Executive**• Medical Director/Clinic Director**• Nurses/Direct Worker• Clerical/Reception• Various Volunteers

5

Sample (N=96) - Position Types

Clinic Director; 25

Executive Director, 23Medical Director;

22

Receptionist; 13

Other; 13

Interviews by Position Type

Components of an Efficient Clinic

• Staff• Leadership• Transparency

• Open communication• Clear expectations

• Requisite education and training• Reliability and dedication

Components of an Efficient Clinic

• Aligned vision • Clinic mission is consistent throughout staff

• Partnerships• With local hospitals, physicians for referrals

• Processes• Appointment scheduling• Patient flow• Established policies/procedures

• Quality of care

Administrative Efficiency Domains

People

• HR/ Staff/ Volunteers (Free Clinics)

• Management • Training

Processes

• Patient flow• Appointment

Scheduling

Technology

• Health IT• EHR

ENVIRONMENTAL MODIFIERS- Physical space, insurance coverage, $$, health care system

Clinical Efficiency Domains

Quality of patient care

•Medical and non-medical staff•Availability of services (in-house or by referrals)•Case management

Continuity of care

•Coordination of services•Referral networks

ENVIRONMENTAL MODIFIERS- Physical space, insurance coverage, $$, health care system

Enabling Services Efficiency Domains

Ability to leverage resources

•Non-medical care services•Transportation•Translation services•Administrative support•Community outreach

ENVIRONMENTAL MODIFIERS- Physical space, insurance coverage, $$, health care system

Key Context for our Findings

• Measurement is limited—numbers not robust• Variation

• Lots of variation across clinics, but not a lot across clinic type

• Efficiency and inefficiency share vocabulary

Efficiency or Inefficiency?

Common terms or examples used for efficiency/ inefficiency

Efficiency Inefficiency

Appointment scheduling ✓ ✓

Patient flow ✓ ✓

Coordination/ Continuity of care

✓ ✓

Referrals ✓ ✓Patient wait time ✓ ✓Information systems ✓ ✓Case management ✓ ✓Patient education ✓ ✓

How are Efficiencies Measured?

Measure Do not measure

Formal QI methodsMostly FQHCs or other clinics with measurement tied to funding

Six SigmaBalanced scorecardsBenchmarks# patient visits, length of visit, no show rates, volunteer hours

N/A

Informal QI methods Monthly meetings Many clinics do not formally measure efficiency“Mental comparison” to other clinics

How are Efficiencies Measured?

• As specific as • Volume/productivity• Time-related (patient wait time, appointment length)• Clinical quality (Joint Commission/HRSA

requirements)• Patient satisfaction

• As vague as• The basics—immunizations, patient wait times

• As honest as • I really don’t know

A Closer Look at Administrative Efficiencies

• People• Leadership

• Processes• Patient flow

• Technology• Health IT/EHR

What Contributes to Efficiencies?

Administratiion 54

Human Re-sources 102

IOM Aims 16

Patient & Community

Factors 23

Process 68

Structure 12

Culture 3

CliniciansCommitted StaffStaff KnowledgeStaff TrainingLeadershipTeamworkVolunteers

Leadership Contributes to Efficiency

Leader

Fundraising

Building referral networks

Teamwork

Supporting and promoting missionInstitutional memory

Communication

Transparency

Clear expectations

More efficient clinics had more than one person in this role

Change brings short-term inefficiency

Efficient Patient Flow Systems

• Flexible• “Everyone has a different style so we try to balance [staff] out

so they get a breather from a really demanding doctor” (FQHC talking about patient flow)

• Adaptive • Creativity (e.g., “color-coded pods”) to fit the needs of the clinic

• Measured• Well staffed• Well implemented• Not crowded – manageable patient loads

Examples of Patient Flow Strategies

• Color-coded pods for patient flow• Team assigned to color-coded pod• Functions like a mini-doctor’s office

• Express Care—acute walk-ins for colds, sore throats, sprained ankles.

• Patients stay in room—staff come to them • Patients rotate in a circle to see all professionals• Sign-in and complete simple form• “Huddling” (pre-visit planning)

Specific Challenges

• Staffing• Volunteers• HR

• Communication• Plant/Structural

• Inadequate space• Organizational capacity• Funding

• Continuity/coordination of care/referrals

Technology

No IT New IT Established IT

Both efficient and inefficient Inefficient Mostly efficient/Unknown

Known systems that people know how to use efficiency

Inefficiencies of paper-based systems (retrieval times, data reports)

Change brings inefficiency in the short term

Interoperability issues

Many reported increase in efficiency with IT after adjustment period

Hope that IT will bring efficiency

Unknown resolution of interoperability issues

Unknown long-term sustainability of new systems

22

Computer System Inefficiencies

• Insufficient data collected/provided• Interoperability lacking• Slows processes• Decreases patient flow

23

Computer System Inefficiencies

• Accessing patient information difficult• Within the clinic• Across multiple clinic sites• With clinic partners

• Support for patient referral • Follow-up especially problematic• Efficient manual follow-up when staff value/take

ownership of referral process

24

Computer System Efficiencies

• Tracking and monitoring of patient data across care episode, affiliated sites, referrals• Overall practice management processes• Reporting/tracking financial data• For few Free Clinics with computer access, positive benefits in quality of patient care and related processes

• “Quite a change for us in every aspect of process management”

• Short-term inefficiencies, significant long-term benefits

25

Areas for Improving Computer System

• Overcome staff resistance/adjustment - Complete transition processes to newer systems

- Restructure/reorganize for staffing alignment

- Provide adequate staff training

• Integrate systems/interoperability• Improve software• Free/Hybrid clinics lack adequate funding• FQHCs report adequate funding, split on use

Study Conclusions

• More challenges mentioned than efficiencies• Structural/HR challenges predominant• FQHCs more adept with HIT and HR than Free

Clinics• Substantial variation in efficiencies (i.e., patient

scheduling works well for some, but nightmare for others)

• Lack of sharing best practices

Study Conclusions

• No clear organizational model as best practice – models evolve

• Consider hybrid as a strong model• Concept of medical home in safety net

organizations is tenuous

Study Implications

• Measurement needs to be improved and integrated into funding mechanisms

• Highly committed leaders drive change• Leadership development • Leadership team

Study Implications

• Unknown impact of health reform on safety net organizations

• Affordable Care Act invests heavily in FQHCs• Free Clinics could become irrelevant—patients further

marginalized• Invest in Free Clinics/Hybrids?

Study Implications

• Need to invest in knowledge transfer (i.e., guidelines, best practices)

• Difficult to meet HITECH/“meaningful use” rules• Environment a driver of variation, not clinic type• Money matters, but not the biggest problem

Policy Recommendations

• Include measurement as contingency for funding• Federal/state funding essential for

• Investment in HIT/data• Free Clinics to survive

• Access/continuity of care jeopardized• Disparities continue for uninsured populations

Policy Recommendations

• Expand public health nursing to staff clinics• Expand telemedicine capabilities• Explore regional strategies• Encourage alternative delivery models and

workforce requirements

Practice Recommendations

• Invest in information systems/data analysis• Develop administrative/clinical best practices• Process improvements

• Appointment scheduling• Patient flow• Transportation

Practice Recommendations

• Human resources• Recruit providers• Access to specialists• Provide adequate Staff training• Educate patients (health literacy)• Improve staff communications

Future Research

• Understand characteristics of those clinics measuring efficiency

• Measure quality of clinical care• Specify/measure return on investment (ROI)• Comparative ROI analyses across clinic types