Teams

Operational, Clinical, and Teamwork Overview

Mike Davies, MD FACPMark Murray and Associates

Burning Questions

• How many support staff are needed in our practice?– How many will improve production?– How many will improve outcomes?– How many do other practices have?

• If we decide to hire, what professional types of person is best?– RN/LPN/MA/Other?– Social worker, case manager, other?

• Other burning questions?

Related Questions

• What is our current team number and composition?

• Are we clear about our mission and goals?• Are we working together as smoothly and

efficiently as we could?• Are we providing the right care for our

patients?• Is working with this team any fun?• Do we get the job done well?

Let’s get to the burning questions..

• What kind? (Who ARE support staff?)

• How many?

• US Government (excellent data)

• US Military (excellent data)

• US Private Practice (survey data – fair data)

• US HMO (excellent data)

Who are Support Staff?

• Medical Clerks• RN’s • LPN’s • Medical Assistants • Health Technicians

• Pharmacists (including PharmD’s)?

• Case Managers?• Social Workers?• Billing• Others?

What are Support Staff Duties?

• Check in/out patients & Schedule• Example Nursing Duties

– VS; Prevention & Chronic Disease screening, information, care

– Nursing evaluations; injections; office procedures

• Independent Follow-up clinics– BP; DM; Cholesterol; Anticoagulation

• Telephone calls

Are These Support Staff Duties?

• Phlebotomy

• Billing (and other business office functions)

• Support for specialty or mental health clinics

• Other professionals not working directly with providers – i.e. dieticians, social workers

• Pharmacy prescription filling duties

Team Composition and NumberLarge Govt. Healthcare US

• Adult Primary Care Tending toward Geriatric Practice

• 1100 Sites of Care• ~4300 Providers

– 2864 MD– 1393 Non-MD Providers (NP, PA)

• ~8,200 Support Staff FTEE• Pro-Rated to time spent in clinic managing the

panel of assigned patients

Bottom Line Average US Govt. Healthcare

RN/Provider 0.6

LPN/Provider 0.5

Clerk/Provider 0.6

MA/Provider 0.2

Pharm/Provider 0.15

Support/Provider 2.1

US Military

• US Military Primary Care = 2.7-2.8 support staff/provider FTEE– 0.5 RN

– 1.8 LPN

– 0.5 Clerk

FTEE MGMA Safety NetProvider** 1 1**

RN 0.51 0.3

LVN 0.63 0

MA 0.53 1

Med. Receptioinist

0.85 1

Case Manager 0 0.3

Clinical Support Staff/FTEE Pro.

1.67 1.6

Medical Record 0.4 0.3

Gen. Admin 0.25 0.17

2.52/Provider FTEE

2.6/ProviderFTEE

MGMA

Specialty RN LPN NA Clerk Total Ratio

Multi-Specialty 0.4 0.6 0.9 0.4 2.3

Medicine Single Specialty 0.6 0.5 0.9 0.4 2.4

Surgery Single Specialty 0.4 0.6 0.9 0.4 2.3

Cardiology 0.4 0.4 0.6 0.6 2

OB/GYN 0.5 0.9 0.9 0.7 3

Psychiatry 0 0 1 0.2 1.2

HMO Team Composition

FTEE Team Role

6 Physician

2.5 Nurse Practitioner

11.5 Medical Assistant/Support Staff

3 RN/Extended Role LVN

0.5 Exempt Manager

1.0 Behavior Health Med Specialist

1.0 Health Educator

0.5 Physical Therapist

2.8/FTEEOverall

Team Composition and Number Summary

• Large Govt. US = 2.1 staff/PCP– (RN, LPN, Clerk, Pharmacist)

• MGMA = 2.52– (RN, LVN, MA, Receptionist)

• Safety Net = 2.6– (RN, MA, Receptionist, Case Mgr.)

• US Military = 2.7-2.8– (RN, LPN, Clerk)

• US HMO = 2.8 staff/PCP– (RN, LVN, MA)

Pro

du

ctiv

ity

# On Team

What Is the Right Number?

Advanced Access

Support Staff per Provider

4

3

2

1

Nov 1998 Jan 2000

Wisconsin F.P. Group

3.18 baseline

2.69

Who?

RN Team Member

Fee for Service Capitated

Workload (Burnout)

Less Less

Doc Visit # Less Less

Intensity of Doc Visit

Less Less

Net Revenue Less (Unless replaced)

More

Clinical Care Better Better

LPN Team Member

Fee for Service Capitated

Workload (Burnout)

Less Less

Doc Visit # No Change No Change

Intensity of Visit Same or Less Same or Less

Net Revenue Same Same or Slightly more

Clinical Care Better Better

RN/LPN Comparison

RN Fee for Service

Capitated

Workload (Burnout)

Less Less

Doc Visit #

Less Less

Intensity of Doc Visit

Less Less

Net Revenue

Less (Unless replaced)

More

Clinical Care

Better Better

LVN Fee for Service

Capitated

Workload (Burnout)

Less Less

Doc Visit # No Change No Change

Intensity of Visit

Same or Less

Same or Less

Net Revenue

Same Same or Slightly more

Clinical Care

Better Better

Why Choose RN Based Team?

• If you are:– Thinking of moving to Alternative Pay– Have so much work you can’t possibly do it– Want to improve clinical care

Now let’s step back….

What is the big picture here?

What is a Care Team?An integrated group of professional and

clerical staff whose processes and skills enable them to care for the needs of a patient population over time.

What is a Care Team?

• Cares for a defined population of patients• Measures process and outcomes for feed-

forward and feedback• Matches the activities to customer

demand (uses the data to improve individual and population care)

Batalden, Nelson, et al. Continually improving the health and value of health care for a population of patients; the panel management process. Quality Management in Health Care, 1997, 5 (3). 41-51

Population

Provider initiated returns (Internal

Demand)

Daily walk-ins (External Demand)

Seasonal Variation

Rx refill habits

High Utilizers

Self Care

Pt. Psychosocial and Cultural needs

Top 10 Diagnosis

Patient Demographics

Daily Phone Calls

Total number of patients

NurseReception

Team (2.5X FTEE)

Provider

NurseReception

Team (2.5x FTEE)

Provider

360 Patients are Over 65

60 Patients had more than 10 Office

Visits Last Year

130 are Clinically Depressed

228 have Hypertension

160 have Heart Disease

248 have Arthritis

113 have Asthma

66 have Diabetes

Panel Size 2000

39% of Capacity is Physician Time39% of Capacity is MA Time22% of Capacity is RN Time

Demand Capacity

Basic Team Duties• Clinical – WHAT to do

– What are the main population needs?– What protocols and guidelines do we need?– What is the work?

• Operational – HOW to do it.– Process mapping and redesign– Space/staff use and redesign– Who will do the work?

• How “good” is the overall teamwork?– Putting it all together

Operational and Clinical TeamsC

linic

al T

eam

s: W

hat

to

do

?

Operational Teams: How to do it?

Close to Agreement

Far from agreement on HOW to do it (how to

implement guidelines, how to support provider’s

efficiency)

XX

XX

Far from agreement on WHAT to do (what

prevention and chronic disease guidelines to

implement)

Operational Teams

This is about efficiency, reliability, and safety

Flow Through the Office

Check-in to Nurse

Nurse to Room

Dr. in to Dr. out

Check-out to leave

Synchronization Point

System

How Processes Support Flow

1

P r o c es s

1

P r o c es s

1

P r o c es s

Check-in to Nurse

Nurse to Room

Dr. in to Dr. out

Check-out to leave

1

P r o c es s

1

P r o c es s

1

P r o c es s

1

P r o c es s

1

P r o c es s

1

P r o c es s

Process

What are Some Clinic Processes?

documentation medication refills lab review messages referrals forms management

How Tasks Support Processes

Physician ordersconsult

Clerk calls tomake appointment

Clerk gives appointmentreminder and directions

to patient

4 minutes

5 minutes

Check-in to Nurse

Nurse to Room

Dr. in to Dr. out

Check-out to leave

Task

TasksMake Appointment

Give Directions

Specialist Referral Process

Physician ordersconsult

Clerk calls tomake appointment

Clerk gives appointmentreminder and directions

to patient

4 minutes

5 minutes

Task

How Tasks Support ProcessesSpecialist Referral Process:

Task: Call to make appointment

Task: Give directionsfor specialist

Provider Roles (continuum)…

• MD with non-consistent nurse and clerical staffing

• MD with consistent nurse staffing, but inconsistent clerical staff

• MD with consistent nurse and clerical staffing

• Group of providers with consistent RN, MA, and clerical staff

Better!

Clerical Staff Roles: (continuum)

• Scheduler at front desk or in central area

• Schedules and takes messages for many

• Scheduler accountable to a group of providers

• Scheduler actually co-located with the providers and patients they support

Better!

Nursing Roles: (Continuum)

• Phone calls, rooming, paperwork, triage, scheduling

• Nurse offers advice over the phone or through e-mail

• Nurse manages populations of patients

Better!

What are the attributes of a Care Team?

• Proactive vs. reactive

• Communicative vs. isolated

• Accountable to each other, and to the patient

• Uses measures for feedback

• Delivers high quality chronic, acute, and preventive care

Attributes continued…….• Cross-trained versus territorial

• Integrated versus separated

• Continuous flow versus flow based on urgency

• All staff work to highest level of training, experience, and licensure

Flow Through the Office

Clinical Teams

This is about doing the right thing right!

Clinical Teams

• Refers to the “what” we provide for our patients

• Depends on disease burden and evidence

• Good clinical teams use every team member to the greatest extent of their license

360 Patients are Over 65

60 Patients had more than 10 Office

Visits Last Year

130 are Clinically Depressed

228 have Hypertension

160 have Heart Disease

248 have Arthritis

113 have Asthma

66 have Diabetes

Panel Size 2000

ICD 9 Diagnosis401 Essential Hypertension

250 Diabetes Mellitus

272 Disorders of Lipid Metabolism

465 Upper Resp. Infection….

V70 General Medical Exam

780 General Symptoms

473 Chronic Sinusitis

724 ….Back Disorders…

462 Acute Pharyngitis

477 Allergic Rhinitis

Chronic Dz Clinical Goals

Diagnosis Protocol? Our Outcomes BenchmarkHTN

DM Hgb A1c

DM Foot

DM Eye

DM Lipids

CVD Lipids

MDD New Meds

CHF Weight

CAP - Culture

Chronic Dz Clinical Goals

Diagnosis Protocol? Our Outcomes BenchmarkHTN 75%<140/90

DM Hgb A1c <12% > 9DM Foot 85%DM Eye 80%DM Lipids >80% LDL<120

CVD Lipids <20% LDL>100

MDD New Meds >77% CHF Weight >95%CAP - Culture 92%

Prevention Clinical Goals

Prevention Protocol? Results Benchmark

Flu shot

Colon Ca

Breast Ca

Cervical Ca

Pneumo. V.

MDD Screen

SUD Screen

Tob. Counsel

Prevention Clinical Goals

Prevention Protocol? Results Benchmark

Flu shot >90%

Colon Ca >75%

Breast Ca >90%

Cervical Ca >90%

Pneumo. V. >87%

MDD Screen >95%

SUD Screen >95%

Tob. Counsel >93%

Firm A Medical Outcomes: Baseline Through February '03

0%

10%

20%

30%

40%

50%

60%

70%

80%

Month

% A

t G

oal

A1c < 7.5

LDL cholesterol <100

BP < 140/90

All Outcomesp < .01

Clinical Quality IndicatorsPrimary Care Dx Management

58% 57%

47%

61% 60%

54%

63% 64%

52%

66%

72%

58%

69%66%

59%

74%70%

66%

74%

69%65%

77%

71% 70%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

% LDL < 100 % HgbA1c < 7.5 % BP< 140/90

Oct to Mar FY 02 Ap to Sept FY 02 Oct to Mar FY 03 Ap to Sept FY 03 Oct to Mar FY 04 Ap to Sept FY 04 Oct to Mar FY 05 Ap to Sept FY 05

Oct 01 to Sept 05

Results:Improvement in CRC screening

0%

20%

40%

60%

80%

100%

2003-2005 CRC Screening

% c

ompl

ete

Stage IV CRC from Charleston VAMC Tumor Registry

through April 1, 2005

0

1

2

3

4

5

6

7

2003 2004 2005

Stage IV

Teamwork

It matters! A lot!

Home Team

Operational Improvement Clinical

Team

Teamwork!

Airplane Accidents

• In an analysis of 35,000 reports of incidents over 7.5 years, almost 50% resulted from a flight crew error, and an additional 35% were attributed to air traffic controller error

• Communication was a significant factor in about ½ of the human errors.

How Hazardous Is Health Care?(Leape)

1

10

100

1,000

10,000

100,000

1 10 100 1,000 10,000 100,000 1,000,000 10,000,000

Number of encounters for each fatality

To

tal

liv

es

lo

st

pe

r y

ea

r

REGULATEDDANGEROUS(>1/1000)

ULTRA-SAFE(<1/100K)

HealthCare

Mountain Climbing

Bungee Jumping

Driving

Chemical Manufacturing

Chartered Flights

Scheduled Airlines

European Railroads

Nuclear Power

Errors

• JCAHO Data of 2034 Sentinel Events – Majority resulted in death– Communication root cause in 60%

• VA Data of 10,000 near misses– Communication root cause in 55%

It’s all about communication…..………in a certain way

Communication Example

• Canadians:– Please divert your course 15 degrees to

the south to avoid a collision.

• Americans:– Recommend you divert your course 15

degrees to the north to avoid a collision.

An Actual Radio Conversation between US Naval Ship & Canadian Authorities off the Newfoundland Coast October 1995

• Canadians:– Negative, you will have to divert your course 15 degrees

south to avoid a collision.

• Americans:– This is the Captain of a US Navy ship.

I say again, divert your course.

• Canadians:– No, I say again, you divert YOUR course.

• Americans:– This is the Aircraft Carrier USS Lincoln, the 2nd largest

ship in the Atlantic Fleet. We are accompanied by 3 destroyers, 3 cruisers, and numerous support vessels. I DEMAND that you change your course 15 degrees north, I say again, that’s one-five degrees north, or counter-measures will be undertaken to ensure the safety of this ship.

• Canadians:

– This is a lighthouse. Your call.

An Actual Radio Conversation between US Naval Ship & Canadian Authorities off the Newfoundland Coast October 1995

Engagement

• Challenge• Authority• Autonomy• Stimulation• Access to information• Growth opportunities

• 20% highly engaged• 40% moderately• 20% unengaged

• Sr. Mgr 53% engaged• Directors 25%• Supervisors 18%• Non mgt 12 to 14%

• Higher in nonprofit sector

28

56

16

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Q.27 Cooperation and teamwork

% Favorable % Neutral % Unfavorable

Cooperation and Teamwork

Results are shown from most to least favorable

Most Important Reasons People Leave

• 1. Lack of Respect

• 2. Not listened to

• 3. Not involved

• 4. No opportunity to increase responsibility

• 5. Can’t make an impact

• 6. Pay

Do patients notice good teams?

From John H. Wasson MD - Dartmouth

Perfect Care (Patient Perspective) Correlated with Teamwork (Clinical Staff Perspective) for Ten Office

Practices

0

10

20

30

40

50

60

70

80

90

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5

Rating of Teamwork In Office Practices (5 is Best)

% R

ati

ng o

f P

erf

ect

Care

by P

ati

ents

U

sin

g T

hese O

ffice P

racti

ces

R=.77; p=.01

From John Wasson

Surgery Service Story

Young, et al. Best Practices For Managing Surgery Services: The Role of Coordination.Health Care Management Review 22 (4), p 72 – 81.

Surgery Service O:E Ratio

00.20.40.60.8

11.21.41.61.8

1 2 3

Best-Middle-Worst of 44 ServicesMorbidity Mortality

Well Functioning Teams Have:

• Leadership and direction

• Common aim

• Population of patients identified

• Shared work and process

• Shared information

• Flexibility   

Team Performance Curve

Pe

rform

an

ce

E ffectiveness

Work Group

Pseudo-T eam

PotentialT eam

RealT eam

High-perform ing T eam

Source: “The Wisdom of Teams” Katzenbach/Smith

Defining an Ideal Place to Work!

E m p lo yee

M anagem ent

J o b O ther Em p lo yees

Trust the people you work for

Be proud of what you do Enjoy the people you work with

Staff Turnover 2002-2003

0.00%5.00%

10.00%15.00%20.00%25.00%30.00%35.00%40.00%

J -02 F-02 M-02 A-02 M-02 J -02 J -02 A-02 S-02 O-02 N-02 D-02 J -03 F-03 M-03 A-03 M-03 J -03 J -03 A-03 S-03 O-03 N-03 D-03

13 M

onth

Rol

ling

Aver

age

Voluntary Involuntary

Summary

• We know typical support staff numbers

• We know typical support staff composition

• We can probably markedly improve efficiency

• We can discover population needs

• We know a key difference between good and great teams is teamwork!

Next 18 months…

• Improve operational teams (LS 3)– Through “office efficiency” change ideas– Flow mapping & Task analysis– Measure lead time and cycle time

• Improve clinical teams (LS 4)– Identify and improve chronic disease care– Identify and improve prevention care

• Improve teamwork (Throughout)– Improve individual and team functioning

Homework

• Measure lead time (operational)

• Discover top 10 diagnosis (clinical)

• Talley chronic disease and prevention protocols (clinical)

• “Take the test” page 3-11. Record answers on page 16 (teamwork)

• Read championship teams introduction

• DO module 1 and 2 in the book