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Change Management: Increased Provider Production Through EfficiencyDate: Thursday, May 2, 2019 Time: 2:30 – 3:45 PM
During this presentation we will have discussions of increased provider productivity through the use of tips and tricks to making patient flow more efficient. Through process improvement technics, data analytics, and coordinated care management clinical and administrative leaders come together for achieving efficient patient and work flows.
KYLE KELLUM – SAMARITAN HEALTHCL I N I C D I R EC TOR – K K ELLUM @ SA MAR ITAN HEALT HCAR E.COM
LARRY JURGENS – CLA (CLIFTONLARSONALLEN)DI R EC TOR , HEA LTH CA R E – LA R RY. JURGEN S@CLACON NEC T.COM
Approach – Background - ProcessIntegrated Care Model is a focused, hands-on, interactive, physician–team based approach to achieving improvements in patient access and office efficiencies. As such, it is not a simple assessment of physician style and practice profile, and/or a checklist of action items that could by implemented. Rather, it is a system in which the physician, office staff, and support staff actively engage in an organized process to achieve a common access and efficiency improvement goal.
The goal: The goal is to increase throughput, while simultaneously decreasing care delays and operating inefficiencies. Each of the three components of the goal has a set of measures through which changes are monitored. Each individual measure provides focus for the team, while the combined set of measures provides the balance necessary to achieve all the benefits of the system.
The process: The process takes place within each individual physician practice, utilizing a focused improvement model (rapid cycle testing), and simple data collection and feedback. The initial improvement priority is established by the goal. The process starts with identifying actions/changes to be made to improve access (the “bottleneck”). As the group engages in the process, it will identify office flow issues (“capacity constraint resources”) that will lead to efficiency improvements. Office flow improvements typically result in more access improvements (e.g. receiving timely referrals for same day appointments), and vise versa.
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Project Objectives
Restructure current clinical care model and delivery to:
◦ Enhance patient access,
◦ Improve patient satisfaction,
◦ Improve staff satisfaction,
◦ Improve provider efficiency,
◦ Reduce care variation, and
◦ Improve the financial performance of the clinics.
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Review of Phase MethodologyPhase I – Project Initiation◦ Introduction to project
◦ Data Gathering
◦ Stakeholder Information Gathering
Phase II – On-site Observations and Assessment◦ Conduct Stakeholder Interviews
◦ Clinic Observations and Workflow Analysis
◦ Data and Benchmark Analysis
Phase III – Report of Findings and Recommendation
Phase IV – Project Management and Implementation
Phase V – Ongoing Initiative Support
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Habit Key Elements
Represents possession of a compelling vision and strategy that are consistently communicated and periodically revisited.
Develop/Communicate a Compelling Vision and Strategy
Requires physicians to engage members in the key issues facing the group while preventing a vocal minority from holding the group hostage.
Build and Adapt Sustainable Physician Leadership and
Governance
Entails continuous operational assessment and improvement to ensure physician and patient satisfaction as well as improved population health at a lower cost.
Build Operational Effectiveness and Stability
Establish Performance Expectations
Involves collaboration in setting and understanding clinical, financial, and behavioral performance expectations.
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3
1
4
5
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Tie Rewards to Practice Goals and Strategies5
6Continuously Build
Economic Value
Build a Clinically Integrated Group
Represents aligning group goals and provider incentives with local economics. Given the volatility of the healthcare market, an ongoing review of a group’s compensation plan in comparison to the market is often required.Involves focusing energies on increasing the number of physicians, improving the revenue base (often through ancillaries), and enhancing contracted rates.
Represents taking steps to increase clinical integration, including utilization of large practice sites and clinical forums and facilitation of a socially interactive group.
Habits of Successful Medical Groups
Fundamentals for Primary Care Success
• Efficient patient flow and cycle time
•Access to care
• Patient assignment to Primary Care Providers
• Enhanced Care Teams
• Providers and staff working to top of credentials
•Optimization of Epic
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Review of Methodology and Approach
Care Transformation Guide
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Set Clear GoalsAssess Current
OperationsInitiative Planning
Orientation to Change
Management
Project InitiationEffective
CommunicationContinuous
Improvement
Culture, history and strategy are the major drivers of the organizational structure of medical groups.
Tight IntegrationLoose Integration
High
Low
Physician Autonomy
Opportunities for Infrastructure Economies of Scale
Management EffortHigh Low
Implementation EffortLow High
FullyIntegrated
Group
Independent Practices
Semi-Integrated
Group
SpecialtyPods
Practice Coordination – Range of OptionsThe organization of medical groups affects performance.
High
Low
Clinic Operational AssessmentSAMPLE RESULTS
Overview – Clinical Care Model and Delivery
• Lack of long term clinic vision and strategic plan
• Unclear organizational structure and lack of ownership to drive accountability
• Disjointed definition of roles and responsibilities resulting in an unorganized medical practice culture
• Current clinic operations not performing at “Leading Practice” standards
• Opportunities exist to improve patient experience/access/satisfaction
• Clinicians and care team members need to operate at the “top of their license” and begin thinking as teams to ease provider workload burden and burnout
Observations
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Clinical Care Model and Delivery - MA
• Develop clear guidelines and expectations for MA’s during the patient visit and hold team members accountable for completion.
• Height / weight / vital signs
• Chief Complaint
• Allergies
• Tobacco use
• Medication review (prescription and OTC)
• Verify and update pharmacy
• Review and input medical and surgical history, family and social history
• Etc.
Recommendations
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Clinical Care Model and Delivery - MA
• Begin migrating to a care team model which is focused on whole-person care coordination
• Develop clear guidelines and expectations related to consistent pre-visit planning prior to patient appointments consistent with whole-person care coordination vision
• Review preventive care needs to identify overdue services
• Annual exam
• Overdue shots
• Mammogram
• Colonoscopy
• Cancer screening
• Review registry systems to determine how patient is performing on quality measures
Recommendations
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Clinical Care Model and Delivery - Provider
• Develop clear guidelines and expectations on the following PROVIDER responsibilities during the patient visit and hold providers accountable for completion.
• Review information entered by MA
• Interview and examine patient
• Before exiting exam room
• Document visit diagnosis
• Update problem list
• Place orders for meds, tests, referrals, next visit
• Verbalize plan of care to patient
• Document level of service billing codes and enter charges
• Timely completion of documentation
Recommendations
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Clinical Care Model and Delivery - Provider
• Reduce practice style variation among providers to reduce rework:
• Medication refill intervals (1 mo/ 3 mo / 6 mo / 12 mo)
• Results notification
• Have labs done prior to visit when possible
Recommendations
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Samaritan Family Medicine Staff Survey Results
CLINIC OPERATIONS IMPROVEMENT
Engaged staff to select early priorities◦ Gain staff buy in to increase likelihood
of success
◦ Begin learning how to do change management and rapid cycle improvement within the team
(EFFORT VS. IMPACT)
0
1
2
3
4
5
6
7
8
0 1 2 3 4 5 6 7 8
IMPA
CT
LEVEL OF EFFORT
Pre-visit planning
Standardized rooming
Rx refillCall routing
Order processing
Provider visit documentationPrior authorization
Results reporting
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Message routing
Moving to Action ItemsIMPLEMENTATION OF CHANGES
Steps in Continuous Improvement
Continuous Improvement
1. Identify Problem
• What’s going on?
2. Gather Data
• What do we know?
3. Analyze Data
• What is the root causes?
4. Evaluate Solutions
• What could we do?
5. Choose Solution
• What’s the best thing to do?
6. Plan Roll-Out
• How do we change?
7. Implement & Test
• Problem solved?
8. Continue to Improve
• Can we improve on changes?
Focus on Service Excellence – Patient Have Choices
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Requirements:• Defined vision of success• Every Member of the Team• Every Customer• Every Day• Adoption of Culture of Excellence• Education & Training• Monitor and Manage
Understanding the four categories of features to Service Excellence.
Performance – Relationship between Functionality and
Satisfaction.
Must-be – Knowing simply what is expected.
Attractive – Delivery service causing a positive reaction.
Indifferent – service that may not change patient
experience.
Kano Model
Initial Focus Areas Phase IVImproving KPI and measurement monitoring
Enhance EPIC workflows◦ Test result processing, patient messages & call routing
Top of Scope work where possible◦ Engage Front Desk and Call Center staff for appropriate care team activities
Enhance MA staffing
◦ Improve clinic flow – patients roomed on time, standardized rooming
◦ Improve pre-visit planning; labs complete before visit, schedule overdue screening tests
Policies and procedure adoption
Enhance staff training
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Family Practice Flow Chart & Call Volumes
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Family PracticeCall Center
Reception
Automated Attendant
Inbound Calls
YESOption #1 ?
Incoming Call Process FlowOptions (8)
NO
Call Answered in 5 Rings?
Call Transferred to Call Center
YES
NO
Call Transferred to Reception
Call Answered in 5 Rings?
YES
NO
Count Percentage1555 Call Center Via 9770 8,108 20.2%9780 Family / Call Center 7,208 18.0%9783 Podiatry 2,688 6.7%9785 1 0.0%9786 PMC OB/GYN 6,515 16.3%9787 Sam Peds / Roll over to Call Center 4,242 10.6%9789 Ortho 3,213 8.0%9790 Urgent Care / Call Center 8,098 20.2%
Data Source Total 40,073 100%
Overall Call Volume for Period
Clinical Care Model and Delivery
Awareness of the business reasons for change. Awareness is the goal/outcome
of early communications
related to an organizational
change
Desire to engage and participate in the change. Desire
is the goal/outcome of sponsorship and
resistance management
Knowledge about how to change.
Knowledge is the goal/outcome of
training and coaching
Ability to realize or implement the change at the
required performance level.
Ability is the goal/outcome of
additional coaching, practice and time
Reinforcement to ensure change
sticks. Reinforcement is
the goal/outcome of adoption
measurement, corrective action
and recognition of successful change
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Create a formal change management process to help educate staff on transformation efforts. Recommend ADKAR model:
Employee Engagement Cycle
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Employee Engagement
Great Patient Service
Patient Loyalty
Strong Financial Results
Proud Employees
Investment in Employees
The bottom-up approach by investing in employees has a greater likelihood of long-term success than the typical top-down approach.
Access – 3rd Next Available
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Overview:Average length of time in days between the day a patients requests for an appointment with the provider. Third next available is used to reflect true appointment availability.
Based on data provided an overviewapproach was taken for benchmarking with Survey Median. Data for availability for new, established, preventative care and follow up appointments were aggregated.
Significant care delays exist with an opportunity to accommodate patientdemand.
High Target Low Target
Prov A Prov B Prov C Prov D Prov E Prov F Prov G Prov H
No Show – Family Practice
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Benchmarking and OpportunityOverall the Family Practice providers experienced an 10% higher rate of no shows compared to the Industry Family Practice Median. Providers variation from median by 0% up to 17%.
Financial Opportunity Reduction in No Show to MGMA Median
in 2017 equals $180,000 net revenue using Medicare fee schedule.
Industry Median
Family Practice Providers
Patient Check In – Family Practice
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Benchmarking and OpportunityThrough a measuring period from August 2017 – mid February 2018, overall the Family Practice experienced an 6 minute higher check in process compared to the Industry Family Practice Median.
OpportunityImpacting Patient Flow:
For 20 minute appointment the difference between median of 6 minutes is equal to 30%.For 30 minute appointment the difference between median of 6 minutes is equal to 20%. For 40 minute appointment the difference between median of 6 minutes is equal to 15%.
Assuming 20 patients per day the check in process is delaying patient flow by 120 minutes.
Initial Outcomes
Patient Satisfaction with Clinic Support of Pilot Pod
84.7
86.7
88.488.8
91.491.8
93.8 94.0
80
82
84
86
88
90
92
94
96
Jan-May 2018 June-Dec 2018
Sco
re
Ease of Accessing Clinic by Phone
Concern of Nurse/MA for yourProblem
Courtesy of Registration Staff
Staff Working Together
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Press Ganey Patient Survey Results of Pilot PodComparison Jan-May and June-Dec 2018
% PATIENTS SEEING PROVIDER WITHIN 15 MINUTES OF SCHEDULED VISIT
PATIENT SATISFACTION WITH CLINIC WAIT TIME
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86.5%
88.3%
85.5%
86.0%
86.5%
87.0%
87.5%
88.0%
88.5%
Jan-May 2018 June-Dec 2018
% Y
es A
nsw
ers
85.8
86.4
85.4
85.6
85.8
86
86.2
86.4
86.6
Jan-May 2018 June-Dec 2018
Sco
re
No Shows for Appointments
No shows have decreased to 7.1% - below the Industry mean of 7.65% for multi-specialty, hospital-owned practices
In May, Samaritan implemented a No Show policy requesting patient signature to acknowledge the importance of keeping appointments
This also reflects increased attention to reminder calls placed on Fridays for the following Mondays and the use of the Televox automated reminder system
Pre-visit planning serves as an additional appointment reminder when letters are sent to encourage patients to have lab tests performed prior to their visits
11.8%
7.1% 7.65%
0.0%
5.0%
10.0%
15.0%
% o
f Sc
hed
ule
d V
isit
s
No Shows for AppointmentsFamily Medicine Pilot PodTwo-period Comparison
(Jan-May vs. June-Dec 15, 2018)
Jan-May 2018 June-Dec 2018
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Industry mean based on 2017 Survey data for multi-specialty, hospital-owned
2018 Budgeted Encounters Compared to Actual Completed Encounters - Family Medicine Pilot Pod
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1296
2182 2308
1630
7416
1132
2700 2723
1305
7860
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
Provider 1 Provider 2 Provider 3 Provider 4 Total
# o
f En
cou
nte
rs
Budgeted Actual
Actual Encounters 6.0% greater than Budgeted
If annualized, encounters would
total 1740 or 11.9% increase overall
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Impact to Provider Productivity
Impact to Provider wRVUs
In comparing the two periods of January – May and June – December 2018, the Family Medicine pilot pod has increased their overall wRVUs 21%.
In addition, the pilot pod increased their proportion of the total Samaritan Family Medicine wRVUs from 40% to 44%.
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Dashboard Samples
Providers
Providers
Providers
Providers
Providers
Dashboard UpdateWeek of
2/4/-2/10/19Week of
2/11-2/17/19Week of
2/18-2/24/19Week of
2/25-3/3/19Week of 3/4-
3/10/19Week of
3/11-3/17/19Week of
3/18-3/24/19
No Shows 3.5% 8.9% 3.6% 8.2% 8.1% 7.2% 4.4%!
Cancels 68.0% 37.9% 25.0% 26.4% 32.4% 41% 29.8%
Appointment Cycle Time: Week of 2/4/-2/10/19
Week of 2/11-2/17/19
Week of 2/18-2/24/19
Week of 2/25-3/3/19
Week of 3/4-3/10/19
Week of 3/11-3/17/19
Week of 3/18-3/24/19
Check-in vs. Appointment Time
-14.2 -16.2 -14.7 -14.7 -12.5 -10.4 -15.1!
Wait to Room 11.3 11.5 12.0 9.6 9.3 9.8 10.8
Wait for Provider 16.4 18.5 12.2 11.3 13.6 14.1 10.2!
Time with Provider 10.0 10.0 8.7 10.9 13.6 11.2 9.8
Total Visit from Check-in 37.4 38.8 32.35 31.83 37.28 32.92 28.81
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Next StepsFOCUS AREAS FOR CONTINUED IMPROVEMENT
Barriers to Success
Epic improvements in system functionality and adoption of best practices are delayed until 2020 when Providence hosts the system
Design of current clinic space is suboptimal for supporting team interactions
Medical Assistants lack guidance without a nursing supervisor to focus on day-to-day clinic workflow
RNs should assume only work that requires RN licensure and is focused on goals of ACO and grant
Addition of pharmacy techs on the Care Team would bring expertise to prescription renewal and medication reconciliation processes
Limited resources to answer phones promptly to meet patient expectations
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Future Steps Toward Advanced Primary Care
ACCESS TO SERVICES
• Focused analysis of Telephone Performance
• Improve Approach to Patient Demand vs. Provider Supply of Appointments• Panel Management - PCP assignments
−% Patient Visits with PCP
−% Use of Urgent Care by Patients Assigned to PCPs
−% Patient Visits to Another Provider on Care Team
• Days to 3rd Next Available Appointment
•% of Schedule Availability
CARE COORDINATION
Streamline Front Office processes
Enhance Care Team◦ Ensure providers are doing provider work
◦ Care coordination/RN care management of complex patients
◦ Provide Rx refill and medication management support
◦ Behavioral Health integration
Optimize Use of Epic37
Road Map of Priority Improvement Areas for 2019
•Care Team Enhancements− Improve consistency of MA support to providers
−Continue to improve appointment cycle time
−Coordinate population health efforts (AWV, CCM, TCM)
−Establish pre-visit prep workflows by MAs
•Introduce Pharmacy Tech – coordinate prescription refills
•Improve Time of Service Collections (copays, payments on balances, payment plans)
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Road Map of Priority Improvement Areas for 2019
•Panel Management to support Population Health−Determine supply and demand for appointments
−Track distribution of patients across PCPs with new clinic
•Improve Access to Care−3rd Next Available Appointment by Visit Type
−% slots available within next 2 weeks
−Decrease No Show rates across departments (goal <7%)
•Establish Scheduling Guidelines−Criteria for extending 20-minute visits to 40-minutes
−Appointment type limits by session
−Patient contact hours per week
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OPEN DISCUSSION
Thank you!
KYLE KELLUM – SAMARITAN HEALTHCL I N I C D I R EC TOR – K K ELLUM @ SA MAR ITAN HEALT HCAR E.COM
LARRY JURGENS – CLA (CLIFTONLARSONALLEN)DI R EC TOR , HEA LTH CA R E – LA R RY. JURGEN S@CLACON NEC T.COM
