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Organizational and Operational Efficiencies in Michigan’s Health Care
Safety NetPeter D. Jacobson, JD, MPH
Valerie Myers, PhDJudith Calhoun, PhD
Presented to the CHRT Safety Net Symposium29 October 2010
Overview
• Study of Michigan’s health care safety net organizations
• Focus on efficiencies• Context of health care reform
Methods
• Qualitative interviews• Components of an efficient clinic• Strengths/challenges• Strategies for improving efficiencies• How organized
• Data collection
Sample – Clinic types
**Interviewed at each site
N=29 SitesFQHC 52
Free Clinic 34
Hybrid 10
FQHC -14Free Clinic -12Hybrid - 3
N= 96 Interviews
Interviews by Clinic Type
• CEO/Executive**• Medical Director/Clinic Director**• Nurses/Direct Worker• Clerical/Reception• Various Volunteers
5
Sample (N=96) - Position Types
Clinic Director; 25
Executive Director, 23Medical Director;
22
Receptionist; 13
Other; 13
Interviews by Position Type
Components of an Efficient Clinic
• Staff• Leadership• Transparency
• Open communication• Clear expectations
• Requisite education and training• Reliability and dedication
Components of an Efficient Clinic
• Aligned vision • Clinic mission is consistent throughout staff
• Partnerships• With local hospitals, physicians for referrals
• Processes• Appointment scheduling• Patient flow• Established policies/procedures
• Quality of care
Administrative Efficiency Domains
People
• HR/ Staff/ Volunteers (Free Clinics)
• Management • Training
Processes
• Patient flow• Appointment
Scheduling
Technology
• Health IT• EHR
ENVIRONMENTAL MODIFIERS- Physical space, insurance coverage, $$, health care system
Clinical Efficiency Domains
Quality of patient care
•Medical and non-medical staff•Availability of services (in-house or by referrals)•Case management
Continuity of care
•Coordination of services•Referral networks
ENVIRONMENTAL MODIFIERS- Physical space, insurance coverage, $$, health care system
Enabling Services Efficiency Domains
Ability to leverage resources
•Non-medical care services•Transportation•Translation services•Administrative support•Community outreach
ENVIRONMENTAL MODIFIERS- Physical space, insurance coverage, $$, health care system
Key Context for our Findings
• Measurement is limited—numbers not robust• Variation
• Lots of variation across clinics, but not a lot across clinic type
• Efficiency and inefficiency share vocabulary
Efficiency or Inefficiency?
Common terms or examples used for efficiency/ inefficiency
Efficiency Inefficiency
Appointment scheduling ✓ ✓
Patient flow ✓ ✓
Coordination/ Continuity of care
✓ ✓
Referrals ✓ ✓Patient wait time ✓ ✓Information systems ✓ ✓Case management ✓ ✓Patient education ✓ ✓
How are Efficiencies Measured?
Measure Do not measure
Formal QI methodsMostly FQHCs or other clinics with measurement tied to funding
Six SigmaBalanced scorecardsBenchmarks# patient visits, length of visit, no show rates, volunteer hours
N/A
Informal QI methods Monthly meetings Many clinics do not formally measure efficiency“Mental comparison” to other clinics
How are Efficiencies Measured?
• As specific as • Volume/productivity• Time-related (patient wait time, appointment length)• Clinical quality (Joint Commission/HRSA
requirements)• Patient satisfaction
• As vague as• The basics—immunizations, patient wait times
• As honest as • I really don’t know
A Closer Look at Administrative Efficiencies
• People• Leadership
• Processes• Patient flow
• Technology• Health IT/EHR
What Contributes to Efficiencies?
Administratiion 54
Human Re-sources 102
IOM Aims 16
Patient & Community
Factors 23
Process 68
Structure 12
Culture 3
CliniciansCommitted StaffStaff KnowledgeStaff TrainingLeadershipTeamworkVolunteers
Leadership Contributes to Efficiency
Leader
Fundraising
Building referral networks
Teamwork
Supporting and promoting missionInstitutional memory
Communication
Transparency
Clear expectations
More efficient clinics had more than one person in this role
Change brings short-term inefficiency
Efficient Patient Flow Systems
• Flexible• “Everyone has a different style so we try to balance [staff] out
so they get a breather from a really demanding doctor” (FQHC talking about patient flow)
• Adaptive • Creativity (e.g., “color-coded pods”) to fit the needs of the clinic
• Measured• Well staffed• Well implemented• Not crowded – manageable patient loads
Examples of Patient Flow Strategies
• Color-coded pods for patient flow• Team assigned to color-coded pod• Functions like a mini-doctor’s office
• Express Care—acute walk-ins for colds, sore throats, sprained ankles.
• Patients stay in room—staff come to them • Patients rotate in a circle to see all professionals• Sign-in and complete simple form• “Huddling” (pre-visit planning)
Specific Challenges
• Staffing• Volunteers• HR
• Communication• Plant/Structural
• Inadequate space• Organizational capacity• Funding
• Continuity/coordination of care/referrals
Technology
No IT New IT Established IT
Both efficient and inefficient Inefficient Mostly efficient/Unknown
Known systems that people know how to use efficiency
Inefficiencies of paper-based systems (retrieval times, data reports)
Change brings inefficiency in the short term
Interoperability issues
Many reported increase in efficiency with IT after adjustment period
Hope that IT will bring efficiency
Unknown resolution of interoperability issues
Unknown long-term sustainability of new systems
22
Computer System Inefficiencies
• Insufficient data collected/provided• Interoperability lacking• Slows processes• Decreases patient flow
23
Computer System Inefficiencies
• Accessing patient information difficult• Within the clinic• Across multiple clinic sites• With clinic partners
• Support for patient referral • Follow-up especially problematic• Efficient manual follow-up when staff value/take
ownership of referral process
24
Computer System Efficiencies
• Tracking and monitoring of patient data across care episode, affiliated sites, referrals• Overall practice management processes• Reporting/tracking financial data• For few Free Clinics with computer access, positive benefits in quality of patient care and related processes
• “Quite a change for us in every aspect of process management”
• Short-term inefficiencies, significant long-term benefits
25
Areas for Improving Computer System
• Overcome staff resistance/adjustment - Complete transition processes to newer systems
- Restructure/reorganize for staffing alignment
- Provide adequate staff training
• Integrate systems/interoperability• Improve software• Free/Hybrid clinics lack adequate funding• FQHCs report adequate funding, split on use
Study Conclusions
• More challenges mentioned than efficiencies• Structural/HR challenges predominant• FQHCs more adept with HIT and HR than Free
Clinics• Substantial variation in efficiencies (i.e., patient
scheduling works well for some, but nightmare for others)
• Lack of sharing best practices
Study Conclusions
• No clear organizational model as best practice – models evolve
• Consider hybrid as a strong model• Concept of medical home in safety net
organizations is tenuous
Study Implications
• Measurement needs to be improved and integrated into funding mechanisms
• Highly committed leaders drive change• Leadership development • Leadership team
Study Implications
• Unknown impact of health reform on safety net organizations
• Affordable Care Act invests heavily in FQHCs• Free Clinics could become irrelevant—patients further
marginalized• Invest in Free Clinics/Hybrids?
Study Implications
• Need to invest in knowledge transfer (i.e., guidelines, best practices)
• Difficult to meet HITECH/“meaningful use” rules• Environment a driver of variation, not clinic type• Money matters, but not the biggest problem
Policy Recommendations
• Include measurement as contingency for funding• Federal/state funding essential for
• Investment in HIT/data• Free Clinics to survive
• Access/continuity of care jeopardized• Disparities continue for uninsured populations
Policy Recommendations
• Expand public health nursing to staff clinics• Expand telemedicine capabilities• Explore regional strategies• Encourage alternative delivery models and
workforce requirements
Practice Recommendations
• Invest in information systems/data analysis• Develop administrative/clinical best practices• Process improvements
• Appointment scheduling• Patient flow• Transportation
Practice Recommendations
• Human resources• Recruit providers• Access to specialists• Provide adequate Staff training• Educate patients (health literacy)• Improve staff communications
Future Research
• Understand characteristics of those clinics measuring efficiency
• Measure quality of clinical care• Specify/measure return on investment (ROI)• Comparative ROI analyses across clinic types