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Effective medical practice operations med chi_1-19-10

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Effective medical practice operations med chi_1-19-10

  1. 1. Effective Medical Practice Operations Bruce L. Golden, Ph.D. Robert H. Smith School of Business University of Maryland MedChi Course, Baltimore January 2010 © 2010 Robert H. Smith School of Business University of Maryland
  2. 2. Disclosures I, Bruce Golden, have no relevant relationships to disclose.I will not be discussing any “off-label” uses of products and/or devices. 2 © 2010 Robert H. Smith School of Business, University of Maryland
  3. 3. AcknowledgmentsMost of this presentation comes from theexcellent book Mastering Patient Flow byE.W. Woodcock, 3rd edition, MGMA, 2009Other sources include Value Stream Management for Lean Healthcare by Tapping, Kozlowski, Archbold, and Sperl, 2009 Value Stream Mapping for Healthcare Made Easy by Jimmerson, 2010 3 © 2010 Robert H. Smith School of Business, University of Maryland
  4. 4. Getting StartedSome key questions How can we improve patient flow in medical practices? How can we improve patient care? How can we ensure that all the processes in your practice are focused on your patients?Lean management can help 4 © 2010 Robert H. Smith School of Business, University of Maryland
  5. 5. Focus on the PatientIt used to be easierWhy? Demands by insurance companies and regulators More paperwork and administrative details More assertive, better informed patientsIf you focus too much on the details, thenyou are not focused on the patients 5 © 2010 Robert H. Smith School of Business, University of Maryland
  6. 6. Lean ManagementLean management was developed forToyota after World War II They re-engineered core processes and their culture They eliminated waste, improved quality, and became a market leader We will discuss how lean management can be applied to a medical practice 6 © 2010 Robert H. Smith School of Business, University of Maryland
  7. 7. How can Lean Management Help a Medical Practice? The translation from a manufacturing environment to medical practice operations will be one of our tasks A key goal is to eliminate waste With rising costs, declining reimbursements, and increased paperwork, physicians need to learn to do more with less Lean management shows how this might be done 7 © 2010 Robert H. Smith School of Business, University of Maryland
  8. 8. Examples of WasteTaking too much time to schedule appointmentsAdding unnecessary steps to a registrationprocessNot verifying a patient’s insurance coverage untilafter the service has been providedWaste exists in all medical practicesIn lean management, waste is referred to as“muda”Muda is the Japanese word for waste 8 © 2010 Robert H. Smith School of Business, University of Maryland
  9. 9. More on WasteWaste is the amount of time and othervaluable resources that are spent in a waythat prevents us from optimizing thepatient’s care A slow-speed scanner that adds three minutes to the patient registration process Losing a positive test result in a mountain of paperwork Last-minute cancellations and no-shows which reduce the daily capacity of the practice 9 © 2010 Robert H. Smith School of Business, University of Maryland
  10. 10. Referring a Patient to SpecialistPatients must describe theirsymptoms multiple timesThey must fill out forms at each stopThey may have to wait for weeksHow do the delays and repetitionsimpact the patient? Negatively! 10 © 2010 Robert H. Smith School of Business, University of Maryland
  11. 11. More on the Referral ProcessImagine a physician who has to help afriend, relative, or patient avoid a long wait(say, 3 months) or some other hurdle toobtain an appointment before others Acting as an insider, the physician makes a phone call or several This is a waste of his/her time A 3-month wait is an insult to the patient and it does not optimize a patient’s care 11 © 2010 Robert H. Smith School of Business, University of Maryland
  12. 12. Question the FamiliarSuppose a visitor asks a question aboutyour practiceYour answer is “that’s the way we’vealways done it”Then, it may be possible to improve yourpractice by doing things differentlyE.g., why have nurses take patients’ vitalsigns and medical histories, when medicalassistants can do it? 12 © 2010 Robert H. Smith School of Business, University of Maryland
  13. 13. Attack the FamiliarWhy do you have a front desk receptionarea?Typical answer: to greet patients andperform administrative functionsAlternative A sign-in list on a clipboard Pre-registration before the appointment (mail, internet, or a kiosk)Pre-registration allows you to verifyinsurance coverage and benefits andclarify copayment requirements 13 © 2010 Robert H. Smith School of Business, University of Maryland
  14. 14. Attack the FamiliarSuppose you counter that a fully-staffedfront desk facilities the collection of the co-paymentBut more practices are moving the patientcollection process to the end of thepatient’s visit to collect for all collectiblecharges Otherwise, they have to bill for additional charges and wait 30 to 60 days to collect 14 © 2010 Robert H. Smith School of Business, University of Maryland
  15. 15. Some ObservationsPatients would rather be greeted by a personwithout a wall or counter between themPatients would prefer to have already filled outregistration paperworkPatients would prefer to step into an exam roomASAPBy eliminating the reception area, physicianscould save thousands of dollars in space andfurnishingsPhysicians would no longer have to manage thefront desk turnover 15 © 2010 Robert H. Smith School of Business, University of Maryland
  16. 16. Challenging the NormDon’t look at individual processes inisolation Registration, scheduling, etc.Try to consider the entire flowFor example, in a general surgery practice,there may be a surgery schedulerThe process works roughly as follows Surgeon decides to schedule surgery Patient is told to see the scheduler 16 © 2010 Robert H. Smith School of Business, University of Maryland
  17. 17. The Surgery Scheduling Process The nurse completes forms specifying the surgeon’s requirements The nurse brings the patient and forms to the scheduler If the scheduler is not available, the patient is told to expect a phone call The scheduler schedules all aspects of the surgeryFrom the patient’s viewpoint, the processis suboptimal The patient wants to schedule his surgery and leave ASAP 17 © 2010 Robert H. Smith School of Business, University of Maryland
  18. 18. The Surgery Scheduling Process The nurse knows the patient’s situation Why can’t the nurse be cross-trained to schedule the surgery?The point here is not that a dedicatedsurgery scheduler is always a bad ideaThe point is that the value you provide topatients should be a driving force in yourpractice 18 © 2010 Robert H. Smith School of Business, University of Maryland
  19. 19. Assess the Value StreamWith lean management, everyone shouldthink about increasing value to patientsand reducing waste Rather than just following ordersThe entire process of patient care shouldbe analyzed and re-examined People, technology, information transfer Time expectations Every step in the process 19 © 2010 Robert H. Smith School of Business, University of Maryland
  20. 20. Map WorkflowHold an intensive work session to Evaluate and improve a processMap the current process flow Include every step Map the workflow, timing, individuals, etc. Then, question the processE.g., see Exhibit 1.1 in Mastering PatientFlow 20 © 2010 Robert H. Smith School of Business, University of Maryland
  21. 21. Map WorkflowExhibit 1.1 is a value stream map of ahypothetical scheduling process at anotolaryngology (ENT) practiceThe internal process time consumesbetween 55 and 85 minutesThe patient may wait as many as 21daysThe process study team went to work 21 © 2010 Robert H. Smith School of Business, University of Maryland
  22. 22. The Appointment Scheduling ProcessThe team found that 95% of patients wereapproved for scheduling when thephysician received the new patient folderResulting change: Instead of manuallyreviewing each request, the physiciansdeveloped written guidelinesAll patients were scheduled immediatelyHowever, a nurse practitioner reviewed thefolders and discussed the questionable 5%of appointments with the appropriatephysician 22 © 2010 Robert H. Smith School of Business, University of Maryland
  23. 23. The Appointment Scheduling ProcessSome of these appointments would becancelled And the patients referred elsewhereThe internal process time was reduced to 10minutes, on averageThe patient wait time was reduced to fivedays, on averageResistance to change can be strong Those employees directly impacted by the change should be invited to flesh out the details 23 © 2010 Robert H. Smith School of Business, University of Maryland
  24. 24. How to Propose Process ChangePDCA cycle: Plan-Do-Check-Act Plan: Come up with steps to achieve change Do: Implement the plan Check: Analyze the results using performance metrics Act: Standardize the change or repeat the PDCA cyclePut new ideas into practice rapidly, trythem out for a short time, and makeadjustments, if necessary 24 © 2010 Robert H. Smith School of Business, University of Maryland
  25. 25. Focus on PeopleTo eliminate waste and redesign flow,everyone must be involvedIn many medical practices, personnel havespecific tasks to perform They are expected to do as told No complaintsLean management teaches us otherwise Receptionists often have clever improvement ideas Physicians say “everything works just fine” 25 © 2010 Robert H. Smith School of Business, University of Maryland
  26. 26. Focus on PeopleIn a lean-thinking environment, managersbecome mentors and empower employees Employees become a key part of the redesign effortTo maintain high morale, you mightpromise no layoffs Job security will encourage creative ideas Jobs won’t disappear, but they may change 26 © 2010 Robert H. Smith School of Business, University of Maryland
  27. 27. Don’t ignore Waste, When you See itWhat is patient flow? The process of providing the best patient care in the shortest time without waste of resourcesAll employees should be on the alert forperformance improvement opportunitiesAfter observing an opportunity, take actionASAP A discussion is a good starting point 27 © 2010 Robert H. Smith School of Business, University of Maryland
  28. 28. Performance Improvement OpportunitiesMany practices encourage employees torecord waste when they spot itBuy-in from the physicians is critical Reminders Recognition Time set aside at meetings for discussion Prompt action TransparencySome examples of waste and a responsefollow 28 © 2010 Robert H. Smith School of Business, University of Maryland
  29. 29. Waste and a ResponseThe physician waits 3 to 5 minutes eachmorning for the exam room computer toboot-up From now on, the clinical assistant should start computers in the early morningThe receptionist realizes that nearby roadconstruction will delay patients for the nextseveral months Schedulers advise patients via telephone, the web, and mail to allow extra travel time 29 © 2010 Robert H. Smith School of Business, University of Maryland
  30. 30. Waste and a ResponseA clinical assistant observes that several timeseach month physicians can’t find and ask for theopthalmoscope The clinical assistant places an opthalmoscope in a special (and visible) container in each exam room Each day, each room is checked to ensure that the opthalmoscope is where it should beEach of these examples is a minor processchangeThe key is that once employees are empoweredto look for improvements, they will do so eagerly 30 © 2010 Robert H. Smith School of Business, University of Maryland
  31. 31. Clinical Workstation in a Medical PracticeIt houses the clinical assistants, nurses,communication to physicians and tools(forms, computers, and referencematerials)It is often the most visually chaotic area ofa medical practiceLean management would recommend thefollowing steps in order to fix adisorganized clinical workstation 31 © 2010 Robert H. Smith School of Business, University of Maryland
  32. 32. Recommended StepsSort the tasks and functions of theworkstation Remove unnecessary equipment, supplies, and resources Select the 8 to 10 most important (or most frequent) tasks performed here and create work spaces for eachDesignate and label Whether a physical location or an electronic file, label everything clearly 32 © 2010 Robert H. Smith School of Business, University of Maryland
  33. 33. Recommended StepsKeep the area clean and orderlyStandardize the layout Determine which supplies and how many are needed Determine where the supplies should goDetermine a consistent approach andprotocol For each function or task performed at the workstation 33 © 2010 Robert H. Smith School of Business, University of Maryland
  34. 34. Recommended StepsPool the staff’s collective knowledge To prevent piles of paper or build-up of inbound workBreak old habits Make good habits an expectationA clean and well-organized clinicalworkstation conveys professionalism topatients and other visitors See Exhibit 1.2 in Mastering Patient Flow 34 © 2010 Robert H. Smith School of Business, University of Maryland
  35. 35. Focus on the OrganizationMedical practices form operationaldepartments Reception Billing SchedulingDon’t try to optimize one without taking theother departments into accountTo master patient flow, focus on the bigpicture 35 © 2010 Robert H. Smith School of Business, University of Maryland
  36. 36. The Virtue of “Small” PracticesAs a medical practice grows, it becomes moredifficult to see the operations of the entirepracticeIf your practice is large, try to make it feel assmall as possible Build pods for a small number of physicians and their teams Do away with multiple-person front desks Decentralize Results: less noise, fewer distractions, better service 36 © 2010 Robert H. Smith School of Business, University of Maryland
  37. 37. Learn from OthersAsk a friend who works in another industry(e.g., manufacturing) to review yourpractice operations Start with a tour of your office Encourage questions Jointly generate new ideasAsk a physician from a different specialtywho lives nearby to review your practiceoperations Offer to reciprocate 37 © 2010 Robert H. Smith School of Business, University of Maryland
  38. 38. Terms from Lean ManagementContinuous flow: producing one product orservice at a time, in small batches Example: an internal medicine practice where lab draws are done in the exam room, rather than in a central labCycle time: length of time to complete aprocess Example: time from patient check-in to departure 38 © 2010 Robert H. Smith School of Business, University of Maryland
  39. 39. Terms from Lean ManagementKaizan: improving a system or processstep to create more value with less waste Example: eliminating the front desk and sign- in, escort patients directly to the exam roomKanban: a signal to pull work in exactlywhen a resource is needed Example: tasks marked for a clinical assistant to perform when rooming a patient 39 © 2010 Robert H. Smith School of Business, University of Maryland
  40. 40. Terms from Lean ManagementNon-value-added steps: process steps thatadd no value to the customer ororganization Typically introduced a long time ago Example: photocopying a patient’s insurance card multiple times for multiple parties (scan instead)Poka Yoke: mistake proofing a process Make human error more difficult Example: require a registration field for date of birth 40 © 2010 Robert H. Smith School of Business, University of Maryland
  41. 41. Terms from Lean ManagementTakt time: a measurement of productionbased on customer demand Example: determining the number of inbound phone calls per hour (this enables the practice to hire staff accordingly)Value stream: all processes required todeliver a product or service from start tofinish Example: listing all steps in the scheduling of an appointment 41 © 2010 Robert H. Smith School of Business, University of Maryland
  42. 42. The Practice’s Most Valuable AssetWho can bill for a service in your practice? a) Telephone operator b) Medical assistant c) Physician d) Biller e) Office managerPractice revenue is a function of how thephysician uses his/her time 42 © 2010 Robert H. Smith School of Business, University of Maryland
  43. 43. The Physician’s TimeInefficient use of a physician’s time →smaller patient panel → reduced revenueThe key is to leverage the physician’s timeThe physician’s time is the practice Time Typical Practice Ideal Practice Productive 75% 100% Wasted 5% 0% Delegatable 20% 0% 43 © 2010 Robert H. Smith School of Business, University of Maryland
  44. 44. The Physician’s TimeThe physician’s time is what patients wantThis is the asset that every other resourcein the practice must support to providemaximum value to patientsAs you consider steps to improve patientflow, consider whether they free up time forthe physicians to care for patientsRedesigning the patient flow process willfree up minutes here and minutes there,but these add up 44 © 2010 Robert H. Smith School of Business, University of Maryland
  45. 45. Examine the Physician’s Non-clinical TasksTo maximize the time the physician canspend with his/her patients, look for waysto reduce the amount of time he/shespends on non-clinical administrative tasks Tracking down test results Filling out forms Searching for a referring physician’s phone numberCan an office redesign save the physiciana few steps every hour? 45 © 2010 Robert H. Smith School of Business, University of Maryland
  46. 46. Saving Time for the PhysicianCheck with vendors to see if there areways to simplify the way physiciansinteract with electronic health recordsEasy-to-use electronic templates are goodoptions to explore Progress notes Electronic prescriptions Transmission of test orders Consult requests Referrals 46 © 2010 Robert H. Smith School of Business, University of Maryland
  47. 47. The Value of ObservationHave someone spend several hoursobserving your physicians as they interactwith staff before and after patient visits What tasks are performed? How long does each task take? How much walking is involved? Note times in minutes Look for ways to reduce non-productive time Use a pedometer to record daily mileage, before and after redesign 47 © 2010 Robert H. Smith School of Business, University of Maryland
  48. 48. The Role of Space in ProductivityThe bigger a medical practice gets, themore operationally inefficient it becomes Everyone must walk more in a bigger practiceA solo physician may have only 1,000square feet of office space A trip from one end to the other takes seconds An expansive suite of offices over multiple floors is likely to steal productive minutes from each physician each day 48 © 2010 Robert H. Smith School of Business, University of Maryland
  49. 49. Extra Steps Reduce Physician EfficiencySuppose a large practice has 10physiciansEach one wastes 30 minutes a daycarrying forms, running errands, andsocializing in the hallwayThe practice might have been able to see10 extra patients each dayOver the course of a year, this translatesinto a significant amount of additionalincome for the practice 49 © 2010 Robert H. Smith School of Business, University of Maryland
  50. 50. The Physician’s TimeThe most efficient physicians consider theirthree or so exam rooms to be their homebaseThey try to remain on or near home base alldayAnother idea is one of physical co-location Staff and physicians work together in workstations where they can easily interact Communication between team members is direct Messaging delays are reduced 50 © 2010 Robert H. Smith School of Business, University of Maryland
  51. 51. Co-locationWhen physicians and clinical staff caneasily interact, everyone knows wherethe patients are and what they needAn alternative is technology-based co-locationThe key point is that the physician’stime is better spent with patients thanin getting exercise 51 © 2010 Robert H. Smith School of Business, University of Maryland
  52. 52. Watch for WasteThere is no need for physicians to escortpatients to the exit after a visit Signs should direct the patient to the exitIf physicians often leave the exam room tolook for missing forms or supplies, there is aproblem Compile a list of everything that physicians use in the exam room Inspect and stock the rooms daily Each exam room should be set up in the same way 52 © 2010 Robert H. Smith School of Business, University of Maryland
  53. 53. Watch for WasteIf physicians leave the exam room becauseinformation on the patient is missing, there isa problem If test results, hospital discharge summaries, or consult notes are missing, implement a chart preview processSuppose physicians fall behind schedulebecause they go to their offices to do otherbusiness Instead of going to his/her office, a small workstation near the exam rooms should be used 53 © 2010 Robert H. Smith School of Business, University of Maryland
  54. 54. Case Study: The Impact of a Small Volume IncreaseDr. Smith wants $15,000 per month for physicianincome plus $15,000 per month to cover fixedcostsThe practice receives $80 per visit, but has topay $5 per visit to pay for variable expenses4,048 patients per year (22 patients per day, 4days per week, 46 weeks per year) satisfies Dr.Smith’s objectivesWhat would the impact of two additional patientsper day be? 54 © 2010 Robert H. Smith School of Business, University of Maryland
  55. 55. The Impact of a Small Volume Increase$75 x 2 (patients per day) x 4 (days perweek) x 46 (weeks per year) = $27,600(total revenue)The additional profit could pay forequipment improvements, facilitiesredesign, or staffingSo, the value of a physician’s time can becalculated 55 © 2010 Robert H. Smith School of Business, University of Maryland
  56. 56. Productive PhysiciansThe more time a physician spends withpatients, the more revenue he/she cangenerate A physician shouldn’t waste time trying to find a nurse A physician shouldn’t waste time searching for a referral formIt makes sense to allocate resources on thefixed cost side to free-up time for thephysician Staff, technology, etc. 56 © 2010 Robert H. Smith School of Business, University of Maryland
  57. 57. Productive PhysiciansThe few minutes it takes a clinical assistantto check blood pressure, weigh patients,etc. costs much less than a few minutes ofa physician’s timeWhen you consider a change, new hire, orprocess redesign ask the questions Would this improve the value my physician(s) can deliver to patients? How much will the change cost? How much revenue will the change generate? 57 © 2010 Robert H. Smith School of Business, University of Maryland
  58. 58. Strategic ConsiderationsRemember to consider long-term andintangible benefits E.g., better patient service → loyal patients → improved patient retentionManage time carefully Keep a realistic to-do list and indicate which tasks have been completed Maintain a calendar that displays a month at a time Put personal and professional commitments on the same calendar 58 © 2010 Robert H. Smith School of Business, University of Maryland
  59. 59. Strategic ConsiderationsManage time carefully Reserve time to work on critical tasks Keep important contact numbers in a single portable location (notepad or laptop) Maintain a clutter-free, organized, and functional workspace Eliminate technological disruptions (e.g., one voicemail box, one email address, no junk email) Teach support staff how to handle your messages (e.g., a medication renewal request) 59 © 2010 Robert H. Smith School of Business, University of Maryland
  60. 60. Strategic ConsiderationsManage time carefully Set ground rules for the handling of email and voicemail Learn to say no (money vs. stress)Estimate the average value of a customer(patient) When a patient leaves the office before seeing the physician, it is costly How costly is it? ARC = average revenue per customer AVC = average value of a customer 60 © 2010 Robert H. Smith School of Business, University of Maryland
  61. 61. Calculating ARC and AVC for a Neurosurgery Practice A Total gross charges $1,000,000 B Collections $600,000 C Patient panel 2,500 D ARC/year $240 B/C E Overhead 45% F AVC/year $132 D/(1-.45) That is, each patient the practice served during the year contributed an average of $132 to the income of the practice’s physicians 61 © 2010 Robert H. Smith School of Business, University of Maryland
  62. 62. Calculating ARC and AVC for a Neurosurgery Practice A Total gross charges $500,000 B Collections $300,000 C # of surgeries 550 D ARC/year $545 B/C E Overhead 15% F AVC/year $463 D/(1-.15) That is, each surgery the practice performed during the year contributed an average of $463 to the income of the practice’s physicians 62 © 2010 Robert H. Smith School of Business, University of Maryland
  63. 63. The Use of AVCIf a physician sees two fewer patients perweek because of long waits or otherwise,the impact would be approximately 2 (patients per week) x 46 (weeks per year) x $132 (AVC) = $12,144 If some of these patients would have needed surgery, the loss would be greaterAVC for a primary care physicianmeasures the “lifetime” value of thecustomer (patient) 63 © 2010 Robert H. Smith School of Business, University of Maryland
  64. 64. AVC for a Primary Care PhysicianAssumptions Each patient visits the practice three times per year for 15 years Acquisition costs per patient are $100 The practice spends $2 per visit to retain the patient (e.g., toothbrush and dental floss for dentists) 85% of patients remain with the practice from start to finish The practice makes $45 (after overhead) per visit 64 © 2010 Robert H. Smith School of Business, University of Maryland
  65. 65. AVC for a Primary Care PhysicianAVC is at least.85 x ($45 x 3 x 15) - $100 – ($2 x 3 x 15)= $1600The bottom line is that when you lose apatient, you lose incomeFocus practice operations on providingexcellent service to patientsNext, we turn our attention to telephones 65 © 2010 Robert H. Smith School of Business, University of Maryland
  66. 66. TelephonesBefore patients come in for appointments,they callThe practice should use this as an opportunityto provide good and efficient serviceAfter their appointment, patients call They call to clarify dosages or instructions They call about test resultsPatients don’t want to be put on hold or leavea messageThey want to talk to a person without delay 66 © 2010 Robert H. Smith School of Business, University of Maryland
  67. 67. Telephones in Your PracticeDo patients complain about busy signals orlong hold times?Do referring physicians complain that theycannot get through?Do staff members spend too much timesearching for answers to callers?If so, your telephone system needs to bereviewed 67 © 2010 Robert H. Smith School of Business, University of Maryland
  68. 68. Telephone DemandWhen telephone demands are high, there areseveral optionsFirst inclination: add more lines, buy newequipment, hire another telephone operatorAlternative: reduce telephone demand Maybe your practice is causing your telephone problemsReview your scheduling, prescription renewal,referral, and other processesSee Exhibit 3.1 in Mastering Patient Flow 68 © 2010 Robert H. Smith School of Business, University of Maryland
  69. 69. Inefficient Telephones Cost MoneyThe telephone is your practice’s main link to theoutside world Don’t put the wrong person in charge of answering the phoneInvesting time and money in this position makesgood business senseImprove working conditions for operators Hands-free headsets, ergonomic chairs, etc.Look for ways to redesign patient flow processesin order to reduce telephone demand 69 © 2010 Robert H. Smith School of Business, University of Maryland
  70. 70. Tracking Call VolumesMost automated telephone systems canproduce detailed reports Volume of calls per hour, day, week The number of rings before call answered Amount of time callers wait on hold Number of calls not processed per unit timeAsk your vendor how to obtain these reportsThese reports are the first place to look whentrying to address telephone-related issues 70 © 2010 Robert H. Smith School of Business, University of Maryland
  71. 71. Tracking Inbound Calls FirstSee Exhibit 3.2 in Mastering Patient FlowTrack the calls by category and note repeatcalls Prescriptions Scheduling Test results Billing/Referral Nurse/PhysicianIf repeat calls are a large percentage of totalcalls, there is obvious work to be done 71 © 2010 Robert H. Smith School of Business, University of Maryland
  72. 72. Tracking Inbound CallsMake sure you know why your patients arecalling and when they are callingSee Exhibit 3.3 in Mastering Patient FlowAreas in which there are a high percentageof repeat calls are ripe opportunities toimprove your practiceTarget those areas for improvement firstDiscuss the results of your incoming callanalysis with your staff 72 © 2010 Robert H. Smith School of Business, University of Maryland
  73. 73. Responding to the ResultsDon’t tell the patient to call for test resultson Monday, if they may not arrive until lateMonday or TuesdayIf patients call for directions, this can beavoided via email or written directions ordirections posted on a websiteIf patients call the practice for routine refillsinstead of the pharmacy, better instructionis required 73 © 2010 Robert H. Smith School of Business, University of Maryland
  74. 74. Responding to the ResultsDevelop action items, time frames, anddesignate a responsible employee for eachcategory of resultsMake one or two changes at a timeMonitor your progress and produce a newanalysis, as in Exhibit 3.3It shouldn’t take long for telephone demandto decrease 74 © 2010 Robert H. Smith School of Business, University of Maryland
  75. 75. An Informed Staff Reduces RiskStaff know basic medical terminologyThose answering the phone should be ableto spell correctly and write clearlyOtherwise, physicians waste time trying tofigure out the patient’s requestStaff should recognize patientemergencies and should know how torespond 75 © 2010 Robert H. Smith School of Business, University of Maryland
  76. 76. Analyze Outbound Calls AlsoAnalyze outbound calls using similarformsCompare inbound and outboundresults E.g., a high volume of inbound and outbound calls involving test results indicates that staff and patients may be playing phone tagNext, we discuss best practices 76 © 2010 Robert H. Smith School of Business, University of Maryland
  77. 77. Best PracticesIndustry standard: 4 to 5 inbound calls perpatient appointmentBest practices goal: one inbound call perappointment The initial call to schedule the appointment Reduce the need for calls Anticipate patients’ needs and contact them (e.g., dosage, delivery, duration, side effects, etc.)Bottom line: anticipate what the patient willneed and deliver it 77 © 2010 Robert H. Smith School of Business, University of Maryland
  78. 78. The Mystery Telephone Patient Survey To learn more about your practice’s telephone performance, try a mystery telephone patient survey See Exhibit 3.5 in Mastering Patient Flow Ask some friends to call your practice, each ask a basic question, and each complete a survey If possible, arrange for calls during each hour block These surveys, combined with anecdotal information may reveal what works and doesn’t work 78 © 2010 Robert H. Smith School of Business, University of Maryland
  79. 79. The Mystery Telephone Patient Survey in Action This survey can be part of a performance improvement initiative with goals Be more courteous Reduce waiting times Project a more professional image Run the survey for one month with at least 30 incoming calls As an alternative, consider getting feedback from patients directly 79 © 2010 Robert H. Smith School of Business, University of Maryland
  80. 80. Receive Feedback from Patients Directly Choose a small cohort of active patients Ask them to meet at your practice once a quarter Feed the group lunch Ask questions Listen carefully and take notes You will learn a lot from these patients and, at the same time, convey a commitment to improve to your community 80 © 2010 Robert H. Smith School of Business, University of Maryland
  81. 81. ResponsivenessHow long does it take businesses to answercalls? 19.3% : less than 5 seconds 28.1% : between 5 and 15 secondsHow long do businesses keep customers onhold? 26.3% : no hold at all 31.6% : on hold for less than a minute 35.1% : on hold between 1 and 2 minutesNext, we discuss ways to improve performance 81 © 2010 Robert H. Smith School of Business, University of Maryland
  82. 82. Don’t Play “Pass the Caller”The receptionist transfers a call to theschedulerThe scheduler transfers the call to the nurseThe nurse puts the patient on hold to consultthe physicianThe patient is transferred back to thescheduler An electronic health record (EHR) can help, since the patient’s information is easy to access 82 © 2010 Robert H. Smith School of Business, University of Maryland
  83. 83. Learn from the ExpertsAct upbeat on the phoneBe prepared Each operator should have a list of everyone’s location and agenda for that day Each operator should have a script with answers to common questionsGuide callers Ask “What can I help you with?” 83 © 2010 Robert H. Smith School of Business, University of Maryland
  84. 84. Good Habits for the TelephoneKeep a pad of paper near all phones Write down the caller’s nameUse a consistent greetingAvoid abbreviations Say “Surgical Oncology” rather than “Surg.Onc.”Watch out for negative non-verbalcommunication Sighs, moans, a negative tone 84 © 2010 Robert H. Smith School of Business, University of Maryland
  85. 85. Good Habits for the TelephoneMaintain a calm demeanor Especially when the caller is upsetPrepare for rough spots Response: I’m sorry that we didn’t meet your expectations Have the operator write down the caller’s comments and summarize them to the caller Convey to the caller that a complaint will be taken seriously 85 © 2010 Robert H. Smith School of Business, University of Maryland
  86. 86. Good Habits for the TelephoneConclude calls on a positive note Use the patient’s name Thank him/her for using your practiceIf you must return calls, do so within twohoursSet reasonable expectations and beatthem If you tell a patient to expect a test result in five days, try to deliver the result in three days.Exceeding expectations will createsatisfied customers 86 © 2010 Robert H. Smith School of Business, University of Maryland
  87. 87. Scheduling AppointmentsTrain your triage nurse to also schedulepatients The patient doesn’t want to deal with the telephone tree, finally reach the triage nurse, and then be put on hold until the scheduler picks upDon’t waste energy deflecting demand If a parent wants his/her child to be seen, schedule an appointmentTrain all physicians and staff to scheduleappointments for established patients For physicians this is the exception, rather than the rule (everyone should help you sell!) 87 © 2010 Robert H. Smith School of Business, University of Maryland
  88. 88. Post-visit ServicesA short discussion before the patientleaves regarding next steps or the nextappointment can eliminate wastefultelephone callsIdentify patients with appointments thatwere scheduled 90 days or more inadvance What percentage reschedule, cancel, or just don’t show up? What percentage do you have to bump due to schedule changes? If more than 10%, establish an electronic recall list 88 © 2010 Robert H. Smith School of Business, University of Maryland
  89. 89. Rescheduling AppointmentsIt is difficult to reach patients bytelephone and agree upon a new timePatients may be in the middle of acourse of treatment A delay of several weeks may create real hardshipPhysicians should limit reschedulingto emergencies 89 © 2010 Robert H. Smith School of Business, University of Maryland
  90. 90. Reminders can Reduce Telephone Demand Send out reminders to patients 4 to 5 days in advance of their appointment Or call patients 2 days in advance It may cost a small amount But, it will reduce incoming calls from patients who can’t remember It will also reduce no-shows and late arrivals Friendly, automated reminder telephone calls can also work well 90 © 2010 Robert H. Smith School of Business, University of Maryland
  91. 91. Appointments & PrescriptionsLet schedulers schedule They shouldn’t have to check with physiciansPrescriptions: most visits involve amedication An initial prescription, a change of medication, or a refill Steps should be taken to better handle prescriptions → reduce in-bound telephone calls 91 © 2010 Robert H. Smith School of Business, University of Maryland
  92. 92. Prescription Process ImprovementTransmit prescriptions to pharmacieselectronicallyWhen you fax or deliver a prescriptionmanually, write legiblyInstruct patients to call the pharmacydirectly for routine refillsRenew prescriptions while patient is inofficeCreate written guidelines for telephonerenewals and document all renewals 92 © 2010 Robert H. Smith School of Business, University of Maryland
  93. 93. Manage Message FlowManage the flow of messagescarefullyWhen patients ask to speak withphysicians Ask if there is something you can do to assist the patientAsk the patient for the information thephysicians and providers say isneeded Physicians must establish protocols for this 93 © 2010 Robert H. Smith School of Business, University of Maryland
  94. 94. Manage Message FlowTelephone messages should include Who took the message, when? Name of patient or caller Nature of call, degree of urgency Can response be handled by voicemail or email?Record patient’s account number withthe messageKeep message on active status Until the issue is resolved 94 © 2010 Robert H. Smith School of Business, University of Maryland
  95. 95. Follow-up CallsSurgical practices used to call theirpatients a day after discharge No longer common practice, but it still makes good senseMaking such a call can prevent amedical problem from getting worse Review instructions and medications, evaluate the patient’s improvement It is also a good marketing technique 95 © 2010 Robert H. Smith School of Business, University of Maryland
  96. 96. Managing Test Results“If you don’t hear anything from us,everything is okay.” This is not okay It is inconsiderate of the patientPatients want to know where theystand What is my cholesterol level? Has it improved since last year? What does the physician think? 96 © 2010 Robert H. Smith School of Business, University of Maryland
  97. 97. Reduce Unnecessary Clinical Calls Studies show that nearly 50% of the calls a medical practice receives about clinical matters come from patients who were just in the office Use the Incoming Clinical Calls Log (Exhibit 3.6 in Mastering Patient Flow) to track incoming clinical telephone calls for several weeks Review the results and seek simple solutions 97 © 2010 Robert H. Smith School of Business, University of Maryland
  98. 98. Some Simple SolutionsPlace the answers to frequently askedquestions on your practice web siteAsk patients at the end of theappointment if they have questions Write down answers for themProactively address side effects ofmedications, procedures, or treatment Better educated patients → your practice will operate more efficiently 98 © 2010 Robert H. Smith School of Business, University of Maryland
  99. 99. Telephone CallbacksWhen patients must speak withphysicians, schedule patients fortelephone callbackDesignate time each day that yourphysician will be available fortelephone consultation This avoids the wasteful game of phone tag 99 © 2010 Robert H. Smith School of Business, University of Maryland
  100. 100. Billing QuestionsYou want to reduce calls frompatients with billing questions First step: review your billing statements Revise statements to improve clarityGive your billing department its owntelephone number and emailaddress to improve access to yourbilling staff 100 © 2010 Robert H. Smith School of Business, University of Maryland
  101. 101. One Step BeyondIf you want to be proactive, you can useyour web site to deflect other types oftelephone calls Appointment scheduling Making registration and medical history forms available Appointment reminders Test results Prescription renewalsThe last three items above require asecure environment 101 © 2010 Robert H. Smith School of Business, University of Maryland
  102. 102. Inbound vs. Outbound CallsInbound calls are more difficult tomanage than outbound calls It is rare that the right person answers the phone Inbound calls cluster during busy times in the office The operator is not prepared for the inbound callIf we can turn an inbound call into anoutbound call, this can improve officeefficiency 102 © 2010 Robert H. Smith School of Business, University of Maryland
  103. 103. Inbound vs. Outbound CallsThe three challenges of the inboundcall are replaced by a single challenge Getting the patient on the lineCell phones make this easierBottom line: it is more efficient for youto call them In addition, patients would prefer that you call before they have to call you 103 © 2010 Robert H. Smith School of Business, University of Maryland
  104. 104. Voice MailIf you are considering adding voice mail,be careful Callers will expect a near-immediate responseYou may want to give billers voice mailboxes, but not your nurses (at least tostart)Select a voice mail system with goodreporting capabilities Number of messages recorded Total length of messages Average time before a message is deleted 104 © 2010 Robert H. Smith School of Business, University of Maryland
  105. 105. Voice MailIs the voice mail system’s size andcapacity adequate? How many messages can it hold? How long a message can a caller leave? What happens when the system is full?The system should be easy to use If your staff can’t learn it quickly, it is not a good match for your practice 105 © 2010 Robert H. Smith School of Business, University of Maryland
  106. 106. Voice Mail TipsUse voice mail to back up staffAlways offer a “live” operator optionCheck voice mail boxes frequentlyVoice mail is more appropriate forbilling, referral requests, andprescription renewalsDon’t use voice mail to triage clinicalcalls 106 © 2010 Robert H. Smith School of Business, University of Maryland
  107. 107. Staffing Your TelephonesHow many telephone operators doyou need?Rough benchmarks for an operator Telephones with messaging: 300-500 calls/day Telephones with routing (electronic system) only: 1000-1200 calls/day Telephone triage: 65-85 calls/day 107 © 2010 Robert H. Smith School of Business, University of Maryland
  108. 108. Staffing Your TelephonesMeasure the time it takes your staff tohandle each telephone call and applythat time to determine your practice’sideal workload rangeSome observations to keep in mind There may be more incoming calls on Mondays When the phones ring less frequently, staff may talk longer It might make sense to hire another operator on Mondays 108 © 2010 Robert H. Smith School of Business, University of Maryland
  109. 109. Look at the DataDay of week Operator time Phone volume Seconds per (mins) callMonday 1,149 1,200 57.5Tuesday 677 700 58.1Wednesday 512 650 47.3Thursday 479 620 46.4Friday 701 589 71.4 109 © 2010 Robert H. Smith School of Business, University of Maryland
  110. 110. BenchmarkingBenchmarking identifies specificreference points for your practice tomeasure performance, efficiency, andquality How do you stack up against your past performance? This is internal benchmarking How do you stack up against your peers? This is external benchmarkingBenchmarking is about identifyingwhere you currently stand and findingways in which you can do better 110 © 2010 Robert H. Smith School of Business, University of Maryland
  111. 111. Examples of Operational Benchmarking How many patients per month are you seeing? How many more procedures did you perform this quarter than last quarter? What is your patient retention rate? Where are the bottlenecks in office flow? How much overtime do you pay? How many employees do you have? What practice management software do you use? 111 © 2010 Robert H. Smith School of Business, University of Maryland
  112. 112. Information is CriticalBenchmarking allows you to set goals, butfirst you need the dataSome sources The Medical Group Management Association (MGMA) The American Health Information Management Association (AHIMA) Healthcare Billing and Management Association (HBMA) The National Association of Healthcare ConsultantsThe cost is typically no more than severalhundred dollars for a benchmarking reportin a practice specialty 112 © 2010 Robert H. Smith School of Business, University of Maryland
  113. 113. Lessons Learned So FarThere are good books to read on the topicof improving your medical practice andpatient flowLean management looks for ways toidentify and eliminate waste in yourpracticeThe key question to ask What do patients want from your practice?The value you provide to patients shouldbe the driving force behind your practiceCollect data: be as scientific about yourpractice as you are about medicine 113 © 2010 Robert H. Smith School of Business, University of Maryland
  114. 114. Lessons Learned So FarEmpower your staff to suggestimprovementsMany small changes can result in a bigimprovementUnderstand the lifetime value of a patientand treat patients accordinglyInstead of increasing your supply oftelephone operators, try to reduce thedemand for operatorsPay attention to practice benchmarks, bothinternal and external, and set goals basedon these 114 © 2010 Robert H. Smith School of Business, University of Maryland
  115. 115. Scheduling: The Key to Better Patient Flow A practice’s appointment scheduling process is critical Poor scheduling can cost your practice Fewer patients are seen The physician’s time is wasted Three general methods of scheduling Single intervals Multiple intervals Block (wave) intervals 115 © 2010 Robert H. Smith School of Business, University of Maryland
  116. 116. Appointment SchedulingSingle intervals Each patient is given 15 minutesMultiple intervals Patients are given 15 or 30 minutes depending on the type and number of complaintsBlock (wave) intervals A block (wave) of patients will be seen between 9 am and noon They are told to arrive at 9 am 116 © 2010 Robert H. Smith School of Business, University of Maryland
  117. 117. Introducing Your Practice to New Patients Ask patients who referred them Indicate how long an appointment should take Overestimate Get the patient’s contact information in case the physician must tend to an emergency Ask how the patient would prefer to be addressed Remind patients of required preparation for the visit E.g., fasting 117 © 2010 Robert H. Smith School of Business, University of Maryland
  118. 118. Introducing Your Practice to New Patients Describe your policy regarding patient payment at the time of service Direct patients to your web site for more information about the practice Thank patients for choosing your practice This introduction will help reduce misunderstandings and convey a commitment to customer service 118 © 2010 Robert H. Smith School of Business, University of Maryland
  119. 119. Keep the Scheduling System Simple Limit appointment types to a small number Short (for established patients) Long (for new patients and complex established patients) Procedures The modified wave approach A long or complicated patient visit is scheduled at the same time as a visit of shorter duration This approach helps when a practice has many no-shows 119 © 2010 Robert H. Smith School of Business, University of Maryland
  120. 120. The Modified Wave ApproachAs an example, four or five patientscould be scheduled at the top of eachhour (a mix of short and long visits)If one does not show up, thephysician’s productivity is not severelyimpacted The last patient would have to wait about 45 minutes This is a concern 120 © 2010 Robert H. Smith School of Business, University of Maryland
  121. 121. Treat Your Schedulers WellReview your schedulers’ workingconditions Do they work in a crowded space? Do they have to ask physicians for permission to make appointments? Do they struggle with unfriendly software? Are they treated with disrespect?A single “yes” answer signals a needfor improvement 121 © 2010 Robert H. Smith School of Business, University of Maryland
  122. 122. More on SchedulersThey are the sales representatives ofyour practice Pay them appropriately Treat them with respect Give them the tools to perform their jobs wellThey will stay with you, as a result 122 © 2010 Robert H. Smith School of Business, University of Maryland
  123. 123. ClusteringSome specialists supplement theirscheduling approach by clustering patientswith similar complaints or services A surgeon: post-operative clinics An obstetrician: prenatal patientsClustering promotes efficiency by using thesame processes, supplies, equipment, andmindset Make sure it doesn’t limit your availability 123 © 2010 Robert H. Smith School of Business, University of Maryland
  124. 124. Group VisitsOne way to boost both collections andpatient satisfaction is to try groupvisits (as an option)During group visits, physicians cansee 6 to 12 patients at once In just 60 to 90 minutes Typically, in evenings or over weekendsPay attention to patient privacy issues 124 © 2010 Robert H. Smith School of Business, University of Maryland
  125. 125. Group VisitsGroup visits are organized around acommon condition Asthma Diabetes ArthritisThe physician is joined by one or morenonphysician health professionals (e.g., adietician)You will need to discuss coding andreimbursement for group visits with theinsurance companies 125 © 2010 Robert H. Smith School of Business, University of Maryland
  126. 126. Final Thoughts on Group VisitsServing a light, healthy meal mightimprove attendance Charge a modest fee to cover expensesConsider a guest speakerTry out the idea and see if it worksfor your practice 126 © 2010 Robert H. Smith School of Business, University of Maryland
  127. 127. Extended HoursConsider opening your practicebeyond regular office hours Early AM, evenings, weekendsThis is of real value to patients whocould receive care without missingworkEarly or late hours may enablephysicians to reduce their commutetimes 127 © 2010 Robert H. Smith School of Business, University of Maryland
  128. 128. Extended HoursExtended hours may allow a full-timephysician or staff member to work 40hours per week, but have a half-dayor day off each weekExtended hours should reduce thenumber of non-emergency calls late atnight or on weekends It also increases revenue by transforming phone calls (usually not billable) into office visits 128 © 2010 Robert H. Smith School of Business, University of Maryland
  129. 129. Extended HoursExtended hours offer the opportunityto increase your per visit revenue It may be possible to bill an additional feeExtended hours aren’t just for primary carepracticesBe careful to match your practice’sphysician availability with your patientdemandYou will need to estimate your patientpopulation’s demand for extended hours 129 © 2010 Robert H. Smith School of Business, University of Maryland
  130. 130. Extended HoursSurvey your patients by mail, in theoffice, and via your web siteIt may take a month or two for theword to spread that you are open onMonday and Thursday evenings If the demand is higher than you estimated, you can expand hours or add physicians If it doesn’t work, you can return to normal hours 130 © 2010 Robert H. Smith School of Business, University of Maryland
  131. 131. Same-Day AppointmentsIt may make sense to keep open afew slots in each physician’s scheduleuntil the day before or the same dayto handle last-minute (acute) requestsfor appointmentsHow many appointment slots shouldbe held open?Use your practice’s own data See Exhibit 4.1 in Mastering Patient Flow 131 © 2010 Robert H. Smith School of Business, University of Maryland
  132. 132. Same-Day AppointmentsTrack the peak days of the week Many practices see a higher demand for acute visits on MondaysTrack requests by morning andafternoonRepeat the analysis at least once ayearThere may be seasonal trends E.g., flu season 132 © 2010 Robert H. Smith School of Business, University of Maryland
  133. 133. Same-Day AppointmentsIf the average demand for same-dayappointments on Monday is 5, then holdopen 80% or 4 slots during the dayCancellations and no-shows will oftencreate an additional open slotIf you are obligated by an insurancecompany to see some patients within 24hours of request, you may need to holdopen additional slots 133 © 2010 Robert H. Smith School of Business, University of Maryland
  134. 134. Advanced AccessAdvanced access is leaving your entireappointment schedule, except previouslyscheduled new patient and follow-up visits,open to patients who call with acute needsAdvanced access can Make your practice more accessible to patients Get new patients in faster Smooth the scheduling processAdvanced access is standard practice formany specialties 134 © 2010 Robert H. Smith School of Business, University of Maryland
  135. 135. Advanced AccessOncologists and trauma surgeons seepatients as soon as possibleAdvanced access means being able toaccommodate patients when they, or theirreferring physicians, desireAdvanced access represents a culturechange for many physicians Many practices become accustomed to a backlog Some practices take pride in their backlogs 135 © 2010 Robert H. Smith School of Business, University of Maryland
  136. 136. Advanced AccessSuppose the backlog is consistently sixweeks The laws of supply and demand → it is possible to eliminate the backlog Patient demand is not overwhelming physician availability, but there is a delay Patients will become frustrated and no-shows will increase The delay could be dangerous for some patients Evening hours, weekend hours, part-time or temporary help will reduce the backlog 136 © 2010 Robert H. Smith School of Business, University of Maryland
  137. 137. Advanced Access PrinciplesPatients need to see their regularphysicians The need for additional appointments decreases Patient satisfaction increasesSchedule appointments when patients call Don’t route their requests through channelsThere must be a reasonable balancebetween physician supply and patientdemand Otherwise, the practice should consider ways to reduce demand or increase supply 137 © 2010 Robert H. Smith School of Business, University of Maryland
  138. 138. Advanced AccessReferral-dependent practices(specialists) often need two to threedays to get authorization frominsurance companies If so, then advanced access means scheduling appointments for two or three days from nowNext, we discuss what needs to bedone to transition to advanced accessscheduling 138 © 2010 Robert H. Smith School of Business, University of Maryland
  139. 139. Integrating Advanced Access Scheduling Educate patients, physicians, and staff Physicians and staff will be anxious Patients will be pleasantly surprised Work through the backlog It may take a month or two Prepare for some variability Physicians and staff may have to stay late from time to time 139 © 2010 Robert H. Smith School of Business, University of Maryland
  140. 140. Integrating Advanced Access Scheduling Plan for contingencies What happens when patient demand exceeds physician capacity? You need a back-up plan Can one of your physicians work late? Can you call upon an outside physician for help? Track patient demand over time so that you are able to predict it reasonably well 140 © 2010 Robert H. Smith School of Business, University of Maryland
  141. 141. Integrating Advanced Access Scheduling Schedule patients with their chosen physicians Empower staff to meet patient needs (no hand- offs) Plan for the visit Find out the reason for the appointment What else can we take care of (e.g., medication renewals) Complete the visit Do some of the paperwork with the patient in the exam room Take care of the paperwork, referrals, prescriptions, etc. that day 141 © 2010 Robert H. Smith School of Business, University of Maryland
  142. 142. Integrating Advanced Access Scheduling Try to schedule follow-up visits on days other than Mondays Let the patient demand tell you how much physician availability you need If possible, grow the practice to meet demand Spread the word about your new scheduling policy There are many benefits that result from advanced access Better relationships with referring physicians, reduction in malpractice risks (no delays), etc. 142 © 2010 Robert H. Smith School of Business, University of Maryland
  143. 143. Other Advantages of Advanced Access No-show rates will decrease Patients will value seeing the physician sooner → they will keep coming back More new patients → more procedures → more relative value units (RVUs) → gross charges and collections should be higher → physician income should increase 143 © 2010 Robert H. Smith School of Business, University of Maryland
  144. 144. Primary Care Panels & Advanced Access Rough guidelines for primary care practices Between 0.75 and 1 percent of your patients will seek care each day If offered a same-day appointment, 75% of adults and 80% of children would accept For a panel of 2,500 active patients, approximately 20 to 25 will seek care each day (this includes those for whom a follow-up visit has already been scheduled). This can fluctuate due to the severity of your patient panel, the season, etc. 144 © 2010 Robert H. Smith School of Business, University of Maryland
  145. 145. Advanced AccessA review (assume 20 appointmentsper day) 15 appointments are reserved for all patients who arrive “today” Five appointments are reserved for “return” patients and those scheduled before “today” Advanced access is not easy to implement with success Despite its advantages, implementation of advanced access fails in more than half the cases 145 © 2010 Robert H. Smith School of Business, University of Maryland
  146. 146. The Carve-Out ApproachMany primary care offices dividepatients into “urgent” and “non-urgent”groupsThe carve-out approach is used to rationservice capacity between these groupsSuppose 20 appointments arescheduled per dayMaybe five are reserved for urgentpatients and 15 are left for non-urgentappointments 146 © 2010 Robert H. Smith School of Business, University of Maryland
  147. 147. Scheduling the PatientsDon’t force anyone scheduling a patientto request verbal permission to do so Keeps the patient on hold Wastes the time of physician, scheduler, and patientGive schedulers basic guidelinesincluding questions to ask andinformation to gather Train them Learn to trust them 147 © 2010 Robert H. Smith School of Business, University of Maryland
  148. 148. Emergency CallsIt is very important to train staff inschedulingSuppose a 50-year-old patient callswith sharp pain (first in jaw and thenupper back) and shortness of breathHow would your scheduler respond?Would he/she tell the patient to godirectly to an emergency room or dial911? 148 © 2010 Robert H. Smith School of Business, University of Maryland
  149. 149. Flexing Your WorkforceKeep records by day and hour of yourpatient workloadIt you consistently have 20% more workon Mondays, then it might make senseto deviate from constant staffing overthe days of the weekIn surgical practices where thescheduling of office visits is based onoperating room availability, this isespecially true 149 © 2010 Robert H. Smith School of Business, University of Maryland
  150. 150. Improve Staff SchedulingLet the work, not tradition, dictate how youstaffImplement a skeleton staff when you knowpatient volume will be light (e.g., Fridayafternoons)Consider putting staff on a slightly reducedworkweek (say 36 hours), with Fridayafternoons offHire part-timers (e.g., stay-at-home Moms) towork on the busiest days or half-days of theweek 150 © 2010 Robert H. Smith School of Business, University of Maryland
  151. 151. Scheduling for SeasonalityMost primary care practices expect flu seasonand back-to-school physicals to bringincreased volumeAll practices should record the number ofpatients seen by monthLet these numbers guide your staffingLeave open an extra appointment slot or twoper day during your practice’s busy periodsBe flexible: open 30 minutes early or stay lateseveral days a week during busy periods 151 © 2010 Robert H. Smith School of Business, University of Maryland
  152. 152. Better Scheduling to Contain Facility Cost The clinical areas of a practice facility are often in use less than 25% of the time Record your space utilization by hour If you have exam rooms to handle 6 patients per hour and see 5 patients per hour, your space utilization is 83%. See the table on the next slide for an illustration 152 © 2010 Robert H. Smith School of Business, University of Maryland
  153. 153. Facility Capacity Analysis Time (AM) Utilization Time (PM) Utilization 7-8 5% 12-1 20% 8-9 30% 1-2 60% 9-10 75% 2-3 95% 10-11 90% 3-4 80% 11-12 50% 4-5 30% 5-6 5%The facility is underutilized most of thetime 153 © 2010 Robert H. Smith School of Business, University of Maryland
  154. 154. Better Space UtilizationKey point: your practice may have moreuntapped space capacity than you realizeBetter scheduling may enable you to avoida move to a larger officeMost physicians spend between 5 and 10percent of their revenue stream on realestateThis space offers capacity 24 hours a day,seven days a week, so be flexible 154 © 2010 Robert H. Smith School of Business, University of Maryland
  155. 155. Better Space UtilizationFor surgeons, consider Saturday morningsas an alternative to weekday surgeries Patients like this option Your office can be used all weekTry starting early (7 am) or stay lateHave physicians stagger lunch hours, soyour exam rooms remain in use all dayTrain schedulers to tell patients what tobring and how long the appointment shouldtake 155 © 2010 Robert H. Smith School of Business, University of Maryland
  156. 156. Medical EmergenciesMedical emergencies can causescheduled patients to wait longer When this happens, a member of the clinical staff should tell waiting patients Give them a choice: wait or rescheduleThe receptionist should telephonescheduled patients who may beaffected by the delay Give them the opportunity to reschedule 156 © 2010 Robert H. Smith School of Business, University of Maryland
  157. 157. Medical EmergenciesDelayed physicians should alsoaddress patients When they arrive, they should step into the reception area, apologize for the delay, thank patients for waiting, and tell them that they will be as quick as possiblePatients really appreciate the courtesyand considerationNext, we consider the case wherepatients are late 157 © 2010 Robert H. Smith School of Business, University of Maryland
  158. 158. When Patients Create DelaysYou should expect some patients toshow up late for appointments Most practices consider a patient late once 15 minutes has passedSet expectations about promptnesswhen patients make appointmentsLet patients know about roadconstruction and limited parking inadvance 158 © 2010 Robert H. Smith School of Business, University of Maryland
  159. 159. When Patients Create DelaysIf a patient is late, give him/her the option ofrescheduling or waiting to be seen when thereis an opening (could be an hour or longer)Of course, if the physician is routinely late,then he/she shouldn’t expect patients to be ontimeIdentify those patients who are chronic latearrivers Try to change their behavior Don’t schedule these patients first or last Don’t fine them (it tends to cause bigger problems) 159 © 2010 Robert H. Smith School of Business, University of Maryland
  160. 160. No-showsNo-shows are a major source offrustration to physicians No one reimburses you for a no-showFor most practices, 5 to 7 percent ofall appointments are no-shows, butthe percentage can be higherHow can you prevent them fromdisrupting your day?How can you reduce their frequency? 160 © 2010 Robert H. Smith School of Business, University of Maryland
  161. 161. No-show Factors to ConsiderThe less loyal your patients are to yourpractice, the more no-shows you shouldexpectSome patients may not have reliabletransportation, dependable childcare, orworkplace flexibility They are more likely to be no-showsIf you schedule appointments too far inadvance, you should expect no-shows Some patients find other physicians and some simply forget 161 © 2010 Robert H. Smith School of Business, University of Maryland
  162. 162. Managing No-showsOne approach: schedule chronic no-shows for your lunch hour Either you’ll have a full hour for lunch or a shorter lunch and a little more moneySecond approach: overbook Suppose a no-show rate of 10% If you have slots to see 20 patients per day, schedule 22 slots 162 © 2010 Robert H. Smith School of Business, University of Maryland
  163. 163. Managing No-showsA stronger bond with patients will reducethe number of no-shows Send birthday cards to patientsAssign nurses to patients, especiallythose who make numerous visits to thepractice Print business cards for nurses to distributeAs mentioned before, identify no-showsand schedule them so as to avoidpatient flow disruption 163 © 2010 Robert H. Smith School of Business, University of Maryland
  164. 164. When a Patient Fails to ShowPatients who routinely fail to show up becomerisk management concerns for your practiceEstablish a dismissal policy, put it in writing,and ask new patients to read andacknowledge by signature (inform currentpatients also) After 3 or 5 missed appointments, the patient is dismissed You may still need to contact the patient if there are unfinished medical issues to resolve Review your policy with your malpractice carrier 164 © 2010 Robert H. Smith School of Business, University of Maryland
  165. 165. Managing No-showsAssign staff to remind chronic no-shows via telephone 2 days inadvance of their appointmentsFor procedures or visits that consumea lot of your time, ask the patient tocall and confirm at least 24 hours inadvance If they do not, schedule a patient or two from your waiting list for this time Make sure patients know about this policy 165 © 2010 Robert H. Smith School of Business, University of Maryland
  166. 166. Managing No-showsThe physician should close eachencounter with a patient with a review ofthe follow-up plan Emphasize the importance of showing up, especially, to the chronic no-showsShould you charge for no-shows? Many practices charge $15 to $25 for no- shows, but end up waiving some of these charges Check to see if the insurance companies will allow you to charge for no-shows 166 © 2010 Robert H. Smith School of Business, University of Maryland
  167. 167. Managing No-showsShould you charge for no-shows? Remember, some no-shows may actually be lucrative patients for your practice If you decide to charge for no-shows, communicate the policy in advance to all patients Bottom line: it is not clear that charging for no- shows is a good ideaThe goal is to reduce the rate of no-shows and manage the no-shows thatremain with the practice 167 © 2010 Robert H. Smith School of Business, University of Maryland
  168. 168. CancellationsCancellations are of two types Advance notice and little noticeTrack the latter as you would no-showsInform patients that cancellations mustbe made at least 24 hours in advanceKeep a list of patients who have askedfor earlier appointments and call them inresponse to last minute cancellations 168 © 2010 Robert H. Smith School of Business, University of Maryland
  169. 169. CancellationsWhen patients cancel and do notreschedule, it may mean that theyintend to leave your practice Your staff should call within a week, encourage them to reschedule, and gather feedback if they are dissatisfiedMake it easy for a patient to cancel inadvance E.g., a cancellation voice mail box or email address 169 © 2010 Robert H. Smith School of Business, University of Maryland
  170. 170. Analyze TrendsMonitor your appointment fill rate Suppose your practice had the capacity to see 60 patients last Thursday, but only saw 52 Your appointment fill rate was 87% Your goal is to have a fill rate of nearly 100% 170 © 2010 Robert H. Smith School of Business, University of Maryland
  171. 171. When Physicians Cancel Appointments Sometimes physicians cancel appointments at the last minute due to other functions or a desire for leisure time This is referred to as “bumping” an appointment Such behavior has a negative impact on practice productivity and customer service Bumps can also impact the loyalty of referring physicians See Exhibit 4.6 in Mastering Patient Flow 171 © 2010 Robert H. Smith School of Business, University of Maryland
  172. 172. Measure BumpsTrack the number of patientsbumped by your practice overseveral months Do this for each physician since it is important to identify any outliers Ask your scheduler to create a version of Exhibit 4.6 for your practice Add in the lost reimbursement as a cost of bumping 172 © 2010 Robert H. Smith School of Business, University of Maryland
  173. 173. Measure BumpsAsk your scheduler to write down anycomments of dissatisfaction whenhe/she speaks with the bumpedpatientsRecord whether the appointment isrescheduled or notThe goal here is to estimate the costof bumping to your practice 173 © 2010 Robert H. Smith School of Business, University of Maryland
  174. 174. Manage Physician BumpsPut the data, costs, and comments into areportShare it with the other physicians in yourpracticePoint out that the entire practice bears thecost of bumpingIf a physician is an obvious outlier, the reportalone is likely to change his/her behaviorIf one physician keeps bumpingappointments, ask him/her to reschedulethose appointments personally 174 © 2010 Robert H. Smith School of Business, University of Maryland
  175. 175. Manage Physician BumpsHow you handle bumps depends onyour practice’s cultureSet a goal of no physician bumpsBumps are very costly Over time they detract from your practice’s reputation with patients and referring physicians 175 © 2010 Robert H. Smith School of Business, University of Maryland
  176. 176. Patient Access IndicatorMeasure the following key indicators eachquarter to evaluate changes over timeAverage number of days to next availableappointment slot that can accommodate anestablished/new patientPercent of appointments for which patientsdo not show upPercent of appointments that the physiciancancels in which patients must be bumped 176 © 2010 Robert H. Smith School of Business, University of Maryland
  177. 177. Patient Access IndicatorRatio of new patient appointment slotsto total appointment slotsPercent of cancelled appointmentsthat are converted to an appointmentin which another patient is seen Typically, via a waiting listRatio of patients actually seen to totalappointment slots available (fill rate) 177 © 2010 Robert H. Smith School of Business, University of Maryland
  178. 178. Suppose Patient Demand is LowTarget established patients who youhave not seen in the last year Send them a postcard with your contact information Remind them that it makes sense to get a check-up once a yearOffer to speak at a school, seniorcitizens center, childcare center, etc.Offer to perform free screenings 178 © 2010 Robert H. Smith School of Business, University of Maryland
  179. 179. Other Marketing TipsVolunteer for community activitiesGet to know people who routinely meetnew arrivals (e.g., real estate agents)Thank established patients, referringphysicians, and staff who refer newpatients to youA professional-looking web site andlisting in the Yellow Pages will also help 179 © 2010 Robert H. Smith School of Business, University of Maryland
  180. 180. Supply vs. DemandIn a successful medical practice, patients cansee physicians without long delaysIf your practice has a problem, it stems from amismatch between supply and demandSupply is physician capacity How many patients can he/she see in a day?Suppose an allergist works 40 hours perweek and can see 32 patients per day andthe demand is 30 patients per day The allergist has enough supply to meet demand 180 © 2010 Robert H. Smith School of Business, University of Maryland
  181. 181. Suppose Demand is Too HighMost practices respond by increasingsupply—growing the practiceDecreasing demand is another optionDoes closing your practice to newpatients make sense? Probably not Revenue will drop Your ability to alter the payer mix will suffer 181 © 2010 Robert H. Smith School of Business, University of Maryland
  182. 182. Ways to Decrease DemandReview your contracts with payersConsider eliminating contracts withinsurance companies that pay you lessthan your costs or deny many of yourclaimsRe-negotiate the contract when it is up forrenewal You may get better terms If not, then seriously consider dropping the payer 182 © 2010 Robert H. Smith School of Business, University of Maryland
  183. 183. The Strategy of Dropping PayersOf course, dropping payers will not beapplauded by patientsHowever, it is the responsibility ofphysicians to determine whetherparticipation with a particular insurancecompany is cost-effective for their practiceParticipation implies a (two-way)relationship between two partiesSee Exhibit 5.1 in Mastering Patient Flow 183 © 2010 Robert H. Smith School of Business, University of Maryland

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