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AS SEEN IN
Medical Group Management
JOURNAL
For patients and providers,
it's all about access
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Abstract
Key words: Health services accessibility, scheduling, patient satisfaction
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Increasingly, immediate patient service-whether scheduling an appointment orseeing a physician - is a realistic expectation. Smoothing patient access and hitting service targets takes sophisticated planning and a true scientific approach. The department of medicine at Boston's Children's Hospital has taken a new approach to visit management, using a model that could be applied to any practice in any setting. Staff have set up categories
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of care and guidelines for scheduling, realigning tasks in order to make abetter use of provider resources and expertise and restructuring associated supporting operations.
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immediate access to their money anywhere and anytime through automated teller machines - health care will become increasingly consumer-driven. Those delivery systems that can clear roadblocks to access, by providing superior customer service as part of high-quality care, will corner market share and wallet share, and will soar above the competition. Better managed practices already offer same-day access for urgent care visits and schedule both routine and new patient visits within two days. Return visits are scheduled as needed, or within one week.
Increasingly, immediate service is a realistic expectation. That goes for wait time in the practice, too. Once patients arrive, the best practices shoot for under 20 minutes of total wait time, including thumb-twiddling in the exam room. The industry is moving toward prompt, efficient service by staff members who know exactly how long patients have been waiting and connect them with providers in record time.
Providing immediate service becomes even more challenging as organizations expand (see Figure 1). One-third of practices
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Timely access to quality care is a hot issue. Politicians are campaigning on it. Consumers are up in arms about it. And health care delivery systems are scrambling to provide it more efficiently and cost-effectively than the next guy. The stakes are high. Recently, for instance, Kaiser Permanente announced a settlement with one of its physicians and several health plan enrollees who sued over the practice of scheduling multiple patients for the same appointment times at after-hours, urgent-care clinics.
Patient access is the brass ring on the carousel of health care-what providers and patients alike shoot for, but often have trouble achieving. A majority of
patients base their entire perception of clinical quality around access issues: Can they get an appointment with the provider of their choice, and, if they
can, how long must they wait before they are seen?
Like the banking service industry - which now offers people
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Figure 2
Applying the lessons
While the department of medicine is an academic teaching and research organization where physicians have multiple responsibilities for research, teaching and clinical care, its new approach to visit management could be applied to any practice in any setting.
Becoming a more patient-responsive organization requires sophisticated volume planning. It means realigning expectations about physician roles and commitments to delivering ambulatory clinical care. And it involves restructuring associated supporting operations.
Follow these basic steps:
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Start by developing your own categories of care. Challenge your underlying assumptions of how much time is required in the exam room because each patient's needs are different. Chronic, complex and episodic may not actually describe your patient panel, but develop your categories that will. Understand and quantify the types of patients that you serve and the type of care that you deliver. Categories of care provide the framework for assembling the right operational and staffing support, by patient type, to ensure a smooth visit and to maximize provider productivity.
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Next, work out a visit map. Have all providers in your practice, from physicians to nutritionists, roughly estimate what it takes to see each of the patients in the categories you have developed. You want to know where patients are going at all times, and how long they will be there. A map is the key to effective pre-visit planning and a smooth office experience once the patient arrives. Remember to keep the physicians' time pure, so that when doctors are with patients, they are providing care and treatment and not tasks that support staff could easily handle.
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Finally, set up protocols for patient calls. Clearly delineate how patients who call in for appointments will be handled. The process differs for each
category. For example, the complex patient requires a nurse's prior assessment over the telephone to determine how much time to set aside in the schedule. She or he also decides what other resources and interventions might be necessary and creates the care plan.
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today have more than 100 physicians; only 15 percent of practices have fewer than five doctors. As practices balloon in size, so does the potential for
commotion and disorder around patient access issues.
Luckily, smoothing patient access and hitting service targets isn't happenstance or magic; it takes sophisticated planning and a scientific approach for management to achieve these goals. In many cases, it requires dramatic changes in the very way practices and health care organizations are
organized to do business.
As you read about lessons learned at Children's Hospital, apply the basic steps to your organization (Figure 2).
Case in point: Children's Hospital
Even the best and the brightest struggle with access challenges, including Children's Hospital in Boston, one of the world's premier children's health
care organizations, and selected by U.S. News and World Report for nine years running as the top children's hospital in the country.
The department of medicine at Children's Hospital is a large, multispeciality academic pediatric department with more than 250 full-time faculty, 100
clinical fellows in subspecialty training, and 120 pediatric interns and residents.
Part of an academic center, development of medicine was not unique in the challenges it faced. Institutional and departmental structures, information systems and overhead all contributed to slightly ineffective and inefficient operations. Scheduling one patient for one hour in one exam room generated
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a perceived lack of clinical space. Suboptimal staffing resulted in clinicians spending approximately 40 percent of their time in activities that alternative
providers or administrative staff could accomplish far more cost effectively. Tracking down a medical record or lab test, cleaning a room or escorting a
patient does not require physician-level skill. And, perhaps most importantly, optimal use of physician time is crucial to ensure that only necessary
recruitment of new physicians take place.
These operational issues take their toll on customer service and patient satisfaction. Patients may wait for long periods of time to complete a multi-faceted visit. Complex testing in multiple areas of the hospital may not be arranged effectively in advance. And physicians, in their struggle to meet
the competing demands of quality patient care and teaching, may sacrifice a bit of each to the benefit of the other.
Department administrators sought an opportunity for ambulatory operations to become even more patient-responsive. Working together, administrators and clinicians developed an Ambulatory Patient Care Delivery Model designed to ensure the delivery of quality care effectively, efficiently and profitably.
The goals are to ensure daily patient access and to increase volume by 30 percent over three years. Meeting these highly ambitious targets requires a
cultural and organizational shift and redesign of how patients are managed throughout the process.
Volume Planning
In the process of assessing the situation, the department of medicine set out to provide optimal allocation of visit time, combined with appropriate
pre-visit and on-site preparation and
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staff support, as a key to reaching volume and patient access goals. Initially, three categories of care were created, specific to the types of patients seen
in the department of medicine's specialty care programs:
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Chronic - Children whose underlying or multiple disease state is monitored over time. For example, a child with Crohn's disease.
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Complex - Children with multiple diagnoses, those who are from out-of-town or another country, or children who require a second opinion in a condensed period of time. For example, a child who is a candidate for liver transplantation.
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Episodic - Well children requiring an episodic intervention; for example, a child needing an endocrinology work-up. While episodic visits do not always
result in a long-term relationship with the patient, patients may be reclassified as their needs or care plans change.
With categories of care, the department now has a framework for organizing, in a more predictable way, the staffing, scheduling and resources needed for each visit, even as patients' needs differ in intensity and complexity. Patients who require more time should get it - enhancing the overall quality of care delivered. Equally important, the physicians have endorsed the concept. They have estimated how much time should be allotted to render quality care for children in each category, distinguishing between patients for each group, and they were involved in discussions about staffing support. They understood that a change in scheduling ultimately could result in an increase in productivity, and a subsequent boost in clinical revenue, in an unforeseen way if the discussions had centered solely on how they, as physicians, could see more patients in a day.
The categories of care framework also dispels some myths surrounding how much physician time actually is required to treat a patient. For instance, in one division, physicians initially believed most patients were complex and needed more than one hour in the exam room. In fact, when physician-provided data was analyzed (see Figure 4), the physicians were surprised to learn that only 10 percent of their patients were complex. Sixty percent of their patients were chronic, requiring only 30 minutes of their time. Physicians immediately, therefore, demonstrated how to increase current productivity from one patient per hour to 1.68 patients per hour.
The beauty of this model is that staff are working smarter, not harder, by clearly defining who should do what for each category of care. More efficient use of provider resource has a trickle-down effect - reallocating the 40 percent of their time spent in non-provider tasks ensures that staff are more appropriately utilized and patient visit time is condensed. Managers do a grave disservice to the industry when they think that productivity boils down to having physicians work faster. Our goal as administrators is to keep the physicians' time pure - providing quality care and treatment, not tracking down medical records or calling for laboratory results.
Pre-Visit Planning
The establishment of categories of care and time guidelines for
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Figure 3 Preventing administrative creep
When physicians assume lower level administrative and clinical tasks, profitability and productivity are compromised and the amount of time allocated
to the visit lengthens. The top 12 tasks that inappropriately slip into the physician's job description, but are more expeditiously managed prior to the
visit by support staff, are:
- escorting patients;
- fetching medical records;
- tidying the exam room;
- tracking down ancillary test results;
- backtracking to provide care, i.e., patient presents with fever, but no temperature taken;
- updating medical record that does not contain notes from last visit;
- backtracking to update care when record does not reflect visits to the emergency department or to specialists;
- managing flow and coordinating visit - for instance, finding a nurse practitioner and transitioning a patient to be educated about asthma;
- dealing with managed care companies for referrals;
- advocating for patient to receive care, such as a fast X-ray;
- coordinating services - for instance, determining who will initiate a discussion/education about birth control; and
- fetching supplies (forms, equipment).
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scheduling gives staff tools for pre-planning the visit, ensuring that all needed resources are identified, gathered and in place when the patient
arrives. Staffing is reconfigured and responsibilities and tasks realigned in order to pre-plan more effectively. For example, for all complex patients, a
nurse conducts a phone assessment of patient needs before the visit to determine a care plan, scheduling requirements, length of visit, and other
interventions or resources that may be necessary, such as translation services. Also, staff are assigned as needed to retrieve medical records or other
supporting documentation.
For episodic patients, a triage nurse handles the call to determine the urgency of the visit, whether the patient needs to be seen and when, what the care plan should be and what resources to assemble. On the other hand, most chronic patients are scheduled in the office by setting follow-up appoinments before check-out.
Under these new categories of care, staff will be responsible for:
- ensuring that all necessary internal and external medical records, X-rays, and lab results are collected prior to, and are present at, the visit;
- pre-planning who needs to see patients, determining what steps or stops are necessary, and plotting the visit out with time intervals;
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Figure 4
Categories
of
care mix |
Percent total |
Physician time allocation |
Patients/hour |
| Chronic |
60 |
30 |
2.00 |
| Complex |
10 |
75 |
0.80 |
| Episodic |
21 |
25 |
2.40 |
| Episodic new |
9 |
55 |
1.09 |
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| Average patients per hour |
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1.68 |
weighted average calculated from the mix, physician time estimate and time allocation by patient type
Source: The Croes Oliva Group
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- increased patient volume 30 percent in 36 months, and recognizes the potential for more growth in the future;
- reconfigures utilization of available resources so that increased volume can be managed;
- allows for better identification of areas where recruitment of clinical physicians is necessary;
- ensures that sufficient exam room capacity exists to accommodate session needs and increased volume, with no major facility increase; and
- builds a foundation for future additional growth.
Perhaps, most importantly, all of the above are being accomplished through the buy-in and commitment of physician leadership who have participated in the process since inception and developed their own categories of care time allocations. Also, the department of medicine now has stated goals from which progress will be measured. A year from now, the department will be able to assess its achievements of these ambitious goals.
Improving the patient visit is a carefully orchestrated process that involves thoughtful planning and a commitment to change. Do it well and your organization will succeed on a number of fronts: by anticipating your patients' needs, and accurately scheduling their visits by allocating appropriate time and support staff by using your facility and exam rooms more efficiently. This ensures physicians' support with the tools and resources they need to render quality care and by setting and communicating realistic patient service guarantees.
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- developing scheduling templates for each operating unit that incorporates category of care and provider capacity allocations and room time allocations as determined in advance; and
- educating patients as to what to expect on the visit day.
Task Redefinition
There are a number of important underlying assumptions to the staffing plan, such as:
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- ensuring that triage, phone screening, discharge planning, patient education and assessment functions are staffed by nurses who have the patient care insight to best manage these processes;
- assigning support staff to patient flow tasks to ensure that patient wait time is minimized, and provider time maximized, by anticipating patient needs and visit steps to ensure flow and productivity. Office staff are asked to manage patient wait times by ensuring that all parties - physicians, staff and, most importantly, patients-understand the expected duration of the visit, and keep others informed if delays arise. This communication is essential since "not giving reason for delayed appointment" was the No. 1 customer service issue identified in patient questionnaires; and
- development of the role of 'floor manager': an administrative leadership position charged with responsibility for ensuring customer satisfaction in a quality care experience.
Results
The Ambulatory Patient Care Delivery Model, though still in its initial implementation phase, is making a significant impact in workflow, employee
moral and patient satisfaction. The model:
- encourages patient access every day of the week for participating divisions, with appointments available every day;
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Figure 5
Performance Targets
While the reengineering of the department of medicine will be a long-term endeavor, 12-month goals include:
- same-day appointment availability;
- no-show rate reduction of 10 percent;
- room utilization increase of 20 percent; and
- management of 10 percent more volume.
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Debi Croes is a principal with The Croes Oliva Group in Burlington, Mass., a team of practice management professionals working to put business into practice and service physicians and organizations throughout New England.
Sally Andrews is vice chair, administration and strategic planning and chief administrative officer of the department of medicine at Children's Hospital,
Boston and Department of Pediatrics (CH) at Harvard Medical School.
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