American College of Physicians Annual SessionPhiladelphia, Pennsylvania

April 6-8, 2006

Faculty

Workflow Design and Practice Efficiency: Saving Time and Money

While Enhancing Quality

Mary S. Applegate, MD, FACPDisclosure

No significant relationship to disclose.

©2006 American College of Physicians. All rights reserved. Reproduction of Annual Session presentations, or print or electronic material associated with presentations, is prohibited without written permission from the ACP.

Educational Disclaimer: The primary purpose of the Annual Session is educational. Information presented, as well as publications, technologies, products, and/or services discussed are intended to inform participants about the knowledge, techniques, and experiences of the faculty who are willing

to share such information with colleagues. A diversity of professional opinion exists, and the views of Annual Session faculty are their own and not those of the American College of Physicians. The ACP disclaims any and all liability for damages and claims which may result from the use of information, publications, technologies, products, and/or services presented at the Annual Session or distributed in association with the meeting.

March 20, 2006Posted Date:

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Work Flow Design &

Practice EfficiencySaving Time And Money While

Enhancing Quality

ACP Annual Session 4/06Mary Applegate, MD, FACP, FAAP

IntroductionI. INTRODUCTION

I. Pay for performanceII. PHYSICIAN PRODUCTIVITY

A. Clinical tasksB. Non-clinical tasksC. Good work habits

No batchingWork in the now

D. Happy healthinessIII. THE PATIENT ENCOUNTER

A. Difficult patientsB. 5 Fundamental steps of efficient visit

1. Opening the interview2. Establish expectations3. Elicit beliefs4. Collaborative decision-making5. Close the interview

IV. UTILIZING MIDLEVEL PROVIDERSV. OFFICE WORK SPACEVI. TELEPHONESVII. SCHEDULINGVIII. REGISTRATIONIX. WAITINGX. SUMMARY

IntroductionWhy Efficiency Matters?

Huge Financial Implications2 minutes / patient = 2 extra visits / day = $10,000 / year

Home earlierPay For Performance

Pay For Performance (P4P)Concept: Pay physicians (more) for high quality care!Goals: Improved:

patient outcomeschronic disease managementrate of errorsefficiency of delivery systemspatient safetyquality of carefinancial bottom line

ChallengesPhysician participation/costMeasuring and tracking dataFollowing proper mix of quality measuresNegative incentive to care for the complex or socioeconomically disadvantagedThreat to physician professionalism autonomy and job satisfaction

Efficiency is more important than ever

Take time to save timeHow?

Patient perspectivePhysician perspective

How do you spend your time?

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Productivity

Physician’s time falls into 3 categoriesProductive (maximize this!)

Wasted (eliminate this)

Delegated (hire staff for this)

ProductivityExamine all non-clinical physician tasks and delegate!

Clinical Tasks:Can any be done by a non-physician (with appropriate supervision)?

ProductivityNon-clinical tasks

Searching for charts and recordsStaff to find, pull, and print from computer in advance (day before?)

Searching for staffCross-train in staff routing slips

Searching for numbers and contact infoPDA, computer accessible

Searching for test resultsEasy computer access at work station

Filling out order formsSign only; use templates so staff can help

Looking up ICD-9 codesTop 20 cheat sheet, train front staff

Getting drug samplesDelegate

WalkingWork in the “field”

Socializing, family callsMonitor and manage appropriately.

Surfing the webDon’t

Waiting for results/patients/etcProblem-solve with staff

Driving between work sitesAdjust schedules

ProductivityClinical Tasks

Returning calls to patientsdelegate most

Returning calls to hospital/ECFMLPs,R.N.s may help

Returning calls to physiciansminimize interruptions by designating time, utilize pager system.Group related calls together.

Educating about basic health care, medication usage, disease statesdelegate to nursing staff, preprinted materials, email articles, give out websites

Clinical form fillingcreate RN Queen of Forms to help

Looking up informationPDA; computer resource

Retrieving test results/plansprotocols to prioritize urgency

Writing and Finishing notes/dictations (paperwork) “doctoring”only you can do

Productivity

Remember, the physician’s time isThe most valuable asset of a medical practiceThe primary financial driver of profitsThe main source of job satisfaction and quality health care

How much does your physician’s time cost?For 55 hours a week times 48 weeks a year$200,000 salary - 158,400 minutes a year =$1.26 a minute or $75.76 an hour

When the physician waits, it is time and money wasted.MGMA 2003

The Value Chain

MGMA 2003

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ProductivityHow to make the most of your “doctoring” time

Develop good work habitsBe prompt/early to prepare for the dayPaperman trumps PDAs for time managementKnow your approximate scheduleAvoid batchingWork in the “now”, real timePace yourself: do difficult job firstBuild in rewards

Stop all that “Batching”Batching = putting off work or organizing it to work on later.It can become an unhealthy addiction It is not efficient and compounds the inefficiencies

Productivity

End of day fatigue1 minute longer per patient to

remember the encounterLess accurate

documentation/dictation

Staff stays late to add forgotten labs/do forms

Physician leaves late with to-do stack

for Nursing

Delays patient getting ready for a.m.

appointment

Doctor starts lateBehind schedule

Batches more work

Doctor takes three minutes per patient to

apologize

Staffs time wasted by reorganizing calls and forms and staving off concerned patients

Staff batches their work

Day starts with work flow (& morale)

disrupted

Lower satisfaction

Patient leaves practice wasting time,

chart, and future revenue

FACT:It is more efficient not only for the physicians but for the entire staff to work on a real-time basis: NOW!

How to work in the NOW:1. Identify and evaluate the details of how work gets done

Review systems / processes / problemsNo work may get done as charts/to do starts are perpetually reorganized

Set priorities (e.g. stay on time)Assign specific hours for certain tasks

e.g. 7-8am check lab/test results; 12-1pm call backs

2. Develop a Specific PlanWho does which job when? This is the only way to limit interruptionsAll charts are pre-reviewed, tests done, results in (Nursing staff can do this if recorded in progress notes), rooms stockedAnticipate needs

Education, forms, scripts can avoid doing this during the busiest times of day!

3. Just Do ItDo not leave the exam room until doneStay focused

On maintaining momentum as time delay is a key component to patient, physician, and staff dissatisfaction

Guide ourselves and our staff into stopping after every 1-4 patients to finish any accumulated work: The virtual exam room.

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4. Be a team playerHuddle 3 minutes before AM and PM to establish game plan and avoid the surprise of disasterEmpower the staff to help you stay on timeControl the day before it controls you

5. Study successes and failures and act accordinglyGood Examples

1. Internal Medicine Associates 8-5pm but left at 7pmThey added 5 min/pt = 8-5:30pmThey all left at 5:30pm!

2. Standardized work sequencing(Pittenger & Diaz, Virginia Mason PCP Clinic, WA)Each doctor was asked to follow a pattern of tasks upon emerging from each patient room:

1. Fill out fee slip2. Document visit3. Respond to one “phone nurse” message4. Respond to one urgent message5. Read and respond to one routine mail6. Fill out one result report

Volume of calls down 30%; visits up 10%Increased qualityNote: Despite objections to following a “script” this process demonstrated that the best way to improve quality is to eliminate non-value added variations

3. MPC scales

6. Remember: a happy, healthy physician is a productive physician

Pay attention to work/life balanceDo work at a capacity reasonable to youThe drive to increase revenues creates much dysfunctional behaviorWorks harder long

hours

Personal needs not met

Less productive

(more batching)

The more hours needed to cover fixed expenses

Less efficient

Burnt out

Less money (bankrupt)

Happy Healthiness

Stephen Covey

The 7 Habits of Highly Effective People

The Patient EncounterDifficult patients = time consuming patients“By the way” syndrome

Characterized bylate divulgence of hidden agendaPositive ROSPatient perception that physician doesn’t listen

Irony: Physicians blame some patients for “wasting” their timeEtiology: Defective physician interview technique with failure to elicit agenda

Efficiency through effective communication

5 Fundamental steps of efficient office visit1. Opening the interview (most important)2. Establishing patient expectation3. Understanding patient beliefs4. Making decisions5. Closing the interview

The Patient Encounter

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1. Opening the InterviewPrepare for interviewOpen-ended questionsAsk “anything else”?Avoid interpretations Active listeningSummarizing the symptoms

The Patient Encounter2. Establishing patient expectations

Establish limitsEstablish patient priorities Negotiate the agenda

Fact: ~50% of patient symptoms and concerns are not addressedFact: ~50% of the time patient and physician reasons for the visit do not correlate, especially if psycho-social (only 6% agreement!)

(Stewart study in Annals Nov. 15, 2005)

The Patient Encounter

3. Elicit patient beliefs4. Collaborative Decision Making

Solicit patients ideasIdentify and address barriersList optionsAllow compromiseSolicit patient understanding

The Patient Encounter5. Close the interview

Anticipate problemsProvide written materialAsk patient to reiterate planRecommit patient to the plan

The Patient Encounter

The Patient EncounterSetting the agenda in advance facilitates redirecting patients and closing the interview

“It sounds like you enjoy gardening and I know you wanted to discuss which NSAID may help you most....”“I know it can be frustrating to have so many problems to discuss. Here is a summary of what our plan is until I see you next. We’ll work on the next most important ones then. Goodbye for now.”

Approach the frequent flier1. Take a breath, prepare self / patient (10% of patients, 90% of our time)2. Speak slowly, write down most important items3. Negotiate agenda. Keep it moving4. Share the care with MLP, Group visits (Loss of health is magnified by loss of

socialization)5. Give them active role6. Encourage patient to meet new goals7. Practice closure: “My nurse will be in to _______”

Quality of the visit (not quantity) is the keyMake eye contact

connect physician and patientSit with patient and be aware of body language

suggests no hurryReach out to briefly touch patient

smile, hand shakeChit chat

shows interestEnsure patient comfort

shows interest Listen first

it is faster and patients feel heardDo some work in front of patient including documentation

necessary, and improves patient retention of information – DX, RX, FLU, notesBe happy

set tone for staff, patients knowCommunicate in short, understandable information pieces

The Patient Encounter

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Research Shows Good Communications Improve patient outcomesImproves patient satisfactionImproves office efficiencyImprove physician satisfaction

Mid Level Providers (MLPs) can help! MLP = NP + PAs

“Value Added” OptionsNP/PA Sees low level visits, thus freeing physicians for more challenging casesNursing home visitsWalk-in or same day appointmentsExtended hoursSpecialized services/programs; emergency coverage

Increased time spentImproved patient education and satisfaction

The Patient EncounterThe larger the medical facility, the more inefficient as it takes time to get patients and staff in and out, especially with back tracking and the variety of physical ailments and associated appliances.

There is no CPT for accompanying the patient to check out. 60 seconds times 30 patients = 30 minutes.

Most efficient physicians consider their exam rooms (ideally 3 – 4) to be their “playing field”. They remain on the field to stay focused.

Office Work Space

How to know if your work space is efficient?Measure the time spent in or off your fieldWhere do go when outside the field?

IF THENLooking for help delegate/hire appropriatelyFetching drug samples arrange docs and staff into works

areas (pods)Retrieving test results two way radio, pager

routing sheets, EMRSearching for supplies/forms stock each room identically Looking up dosages, formularies PDAAccompanying patients Learn to say goodbye in room

better signageTalking on the phone email, pager, designated times

and attention to privacy

Office Work Space Office Work Space

Office Work SpaceGeneral Office Configuration

Cluster exam rooms to save stepsClose to reception area to save staff timeCentralized nursing station / telephonesConsider triage exam room for quick checksExam room layouts should be identical

Telephones

Friend or Foe? Handle them or they will handle you

Telephone demand is what you make it.The telephone is the barometer for efficiency of scheduling, billing, patient education and other office procedures.You know you have a problem when you have sudden walk-in volume

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Expect 100 – 200 calls/physician/day (75 – 125 if specialist)30% of calls to a practice are repeat calls!For efficiency, attend to telephone staff’s needs: hands-free sets, computer access etc.Basic medical terminology, recognition of patient emergencies ismandatory.Developing practice specific protocols is ideal.

TelephonesDo inbound and outbound topics match?(e.g. lab results) If so, there is too much phone tag.

Minimize time – wasting outbound callsStop playing “pass the caller”Avoid unnecessary repeat calls

set the expectation for call backAvoids the repeat callback and the patient anger

Decentralize scheduling (everyone can do this!)Don’t deflect demand

Triage nurse is necessary, but putting off patients eats huge resources. Instead, provide better access

Telephones

Reduce unnecessary inbound callsSchedule follow up visits at time of visitHave a 3 month schedule template, even with open access as people plan vacations, days off, transportationAsk physicians to stick to schedule to avoid rescheduling Automate appointment reminders and prescription refillsLet schedulers schedule without interrupting physician

Telephones TelephonesPrescription refill solutions

Ask patient to call pharmacy for refillAsk pharmacy to fax/e-mail requests for approval (Bonus – accurate documentation)Create voice mailbox for refill

(set up protocol for staff handling of requests)Ask patient at every visit if refills are neededLeave patient tablets in waiting rooms – “refill meds needed”Write legibly

Manage Patient to Doctor callsIf patient says “I only want to talk to my doctor” respond with “We work as a team. My medical assistant is an important member of my team”…etc.Consider printing business/team cardsMake follow-up calls to sickest patients after visitTake messages that stick

TelephonesManage Test Results

Reconsider “No news is good news” PhilosophyConsider automated test result retrieval program

Results are recorded in special voice mail set up or patient who receives a phone number and personal ID code

Forms/brochures explaining most common test resultsTell patient anticipated return of resultsEstablish preferred method of patient contact

(Need permission for e-mail / voice mail) Calling once, then letter is most efficient

All important results should be given in person at visit

Telephones

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Other ways to reduce unnecessary callsAnticipate and answer questions before patient leaves office

(50% of calls to practice are from patients seen in the last week)Improve written and verbal communication after visit action plan, hand outs, websiteBilling and referral calls go to dedicated number or billing @droffice.com - have clear billing statementsAsk hospital, ECF, colleagues to text page, email or faxReduce the rework – Do it right the first time (triage nurse…….)Utilize telephone technology (auto attendant with less than 5 options)Automated call distribution, call accounting, call forwarding, call hunt, call park, etc…

TelephonesMiscellaneous Telephone Notes

Consider blocking practice caller ID if services rendered are sensitive (psychiatry, infectious disease practices)Time expands to fill the task requirement

** staff talks 25% longer to patients on Friday because of lower volume compared to Monday

HIPAA requires “reasonable“ effort to protect patient privacy

Telephones

Managing No Shows“Overbook”: schedule 22 patients if you have 10% no shows and want to see 20 patientsImprove physician and patient relationship

create stronger nurse and patient relationshipProvide timely access, convenient hoursCall to confirm the appointment 48 hours priorDon’t schedule too far in advance Establish a no-show policyContinuous monitoring

Note – Physicians can be no shows too

Scheduling Scheduling“Manage the schedule rather than letting the schedule dictate your productivity”

Signs of trouble:Patients must speak to multiple staff to be scheduledPatient are often on hold or transferred Schedulers must interrupt physicians to resolve scheduling issuesNo shows are problematicPhysicians arbitrarily run on time some days and not othersSame day appointments are troublesome

Assess Access byTime to next available appointment for new patientTime to next available appointment for established patientsNo show rateBump rateNew patients / total patientsCancellation conversion rate

SchedulingTraditional Scheduling

Effective scheduling begins with setting target number of patient visitsBased on number of hours available on appointment scheduleDefine maximum number of patients a day, so you can manage No ShowsEstimate average same day walk-ins to determine daily targetsThen template to achieve revenue expectationMust consider time for quality work, new patients to avoid physician delays

Scheduling

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Scheduling

Woodcock 2003

Three General Methods of Scheduling1) Simple interval – all office visits are the same, new or established despite chief

complaint2) Multiple interval – based on chief complaints 3) Block/wave interval – all am patients come at 8 am

Allow for same day appointments: 20% left open or rotate “doc of day”All methods share “protecting the schedule” problem

Scheduling

If unable to do advanced access, at least free the template hostages:Institute sick bay, med expressFull templates often meet physician, not patient needsHave late patient policyShift staff during scheduling gaps

Consider advanced access or hybrid scheduling as more is processed on a real-time basis.

SchedulingBetter Scheduling Can Lower Fixed Costs

Adjust schedule for seasonal variationEvaluate current trends (Monday Madness)Analyze office use 8am – 6pmUse capacity analysis to make a difference

staff physician and staff lunches to keep rooms fullfirst appointment comes in 15 minutes early7am – 7pm 2 days a weekno catch up work during busiest times

Avoid delays: only one complicated patient per hour – balance sick and routine patients

Scheduling

Managing Running BehindHave schedulers prepare patient: bring x-ray, copay, insurance card forms and estimated time for appointmentGood communication smoothes schedule delay

Physicians notify office (nurse and receptionist)Give patients choice – wait or rescheduleCall patients yet to arrivePhysicians apologize, thank for waiting

SchedulingManaging No Shows

“Overbook”: schedule 22 patients if you have 10% no shows and want to see 20 patientsImprove physician and patient relationship

create stronger nurse and patient relationshipProvide timely access, convenient hoursCall to confirm the appointment 48 hours priorDon’t schedule too far in advance Establish a no-show policyContinuous monitoring

Note – Physicians can be no shows too

Scheduling

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RegistrationIf it takes 15 minutes to register new or established patients, that is more time than they spend with the physicianNational benchmark for registration = 5 – 8 minutes

(2 minutes if established, 14 minutes if new)Registration is a problem if front office staff is walking around

SolutionsPre-registration by phone (at the time of scheduling appointment)

by mail (with appointment reminders) by computer (patients can download the registration form) or by fax

Get Information Before the AppointmentVerify information at first and all subsequent visits Follow “error rate”

Registration formsKeep words to 7 letters (4th – 6th grade level)No abbreviationsColor code formsNecessary signaturesEliminate patient historyPhotograph patient licenseAsk patient how they would like to be addressedExam room registration

Registration

WaitingWe assume patients will wait for us. We even call it a waiting room. Patients are often not patient.

AMA: Average wait time is 19 minutes, varies with specialty. Average cycle time (patient in - patient out = 60 minutes

Measure it and track it so you know where to attack the wait time

WaitingIdeas for Medical Practice

Note pads that say “be sure to discuss with doc today”Patient education in waiting roomPatient paperwork is done ahead of timeSend statements by email, pay accounts on lineMaintain treatment plan log online, assess own care with clinical algorithmGuide patient to practice certain behaviors. E.G. remove socks and shoes if diabetic

Industry PerspectiveA. 5 Principles of Toyota Success

1. Standardized workEvery step is defined by best practice (EBM) and performed according to script

2. TimingThe rate a task must be completed to meet the customer’s demand is calculated

3. Workplace organizationEvery space must be neat and efficiently arranged to encourage self-discipline

4. Uneven customer demands are studied to create predictable output5. Signaling tools visually display what is needed to keep the process going

B. Applications1. Divide work into units2. Rotate hospital docs3. Routine yearly checkups in summer4. Avoid bottlenecks5. Stagger time off6. Mentoring

SummaryTop 10 Efficiency Tips for Physicians1. Commit to timeliness and empower the staff to help2. Develop good work habits

Be prompt. Do difficult work first3. Review your schedule in advance4. Huddle as a team BID5. Be prepared for patients6. Pull work into the day: delegate work in real time; no “batching”7. Establish the agenda, listen, prioritize, listen!8. Improve communication skills – closure

The words you choose make all the difference9. Work in the field, document during visit, delegate10. Embrace IT solutions (coding, billing, communication benefits)

Efficient Performance will pay off

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SummaryPhysician / Mid Level Provider time is critical to maximizing earningsReal-time work processing is more efficient than batch-work

Re-evaluate all batching

Eliminate non-value added processesDevelop systems that work for both patients and physiciansUtilize technologyStay focused on the patient

SummaryEfficiency tips for the physicians

Review the next day’s schedule by 4pmHuddleCommit to timeliness and empower staff to helpPull work into the day Be prompt and be preparedMatch young physicians with a mentorKeep team on same pageStay focusedDocument during visitSet priorities Work in the field

Resourceswww.acponline.orgwww.aafp.orgwww.memag.comwww.PhysiciansPractice.comBaker L, O’Connell D, Platt FC.

“What Else?” Setting the Agenda for the Clinical InterviewAnnals of Internal Medicine. 143(10):766-70, 2005 Nov.

Book Author: Woodcock, ElizabethTitle: Mastering Patient Flow2003 MGMA

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