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Michelle Wier, CMPEDebra Wiggs, FACMPE

Building Blocks for Effective and Efficient Practice Management

…the seminal difference between successful companies and mediocre or unsuccessful ones has little to do with what they know or how smart they are; it has everything to do with how healthy they are.

Patrick Lencioni

The Advantage

What Will This Program Do For Me?

•Lead

•Professionalism

•Communication

•Critical Thinking

What Will This Program Do For Me?

•Manage

•Assess

•Implement

•Monitor

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This Program Will Not…

•Provide a “how to” list

•Solve my management challenges

•Reduce my workload

•Replace on-the-job experience

•Short cut the process of becoming a professional

Leadership

“The art of influencing people to

make progress toward a goal*.”

*“Worthy”

Management vs. Leadership?

A manager focuses only on getting a

task done, whereas a leader focuses on

getting it done in a way that gives

employees a feeling of accomplishment

and willingness to follow the leader

again.

- Paul B. Malone, III, PHD.

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Technical vs. Managerial Responsibilities

Employee Supervisor Manager

Director

Executive

“4

0” H

ou

r W

ork

We

ek

Technical Responsibilities

Managerial Responsibilities

Source: Success Oriented Supervision (USDA)

Leadership Styles – Power Bases

• Legal Power: Official authority & position

• Punitive Power: Impose penalties

• Reward Power: Give or withhold incentives

• Expert Power: Knowledge, ability, information

• Reverent Power: Respect, personality, charisma

Leadership Style & Authority

Authority Retained by the Manager

Area of Freedom for Employees

Tell Persuade Discuss Consult Join

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Characteristics of a Successful Leader

Integrity (must be trusted)

Sense of responsibility

Self confidence

High energy level

Empathy

Internal locus of control

Sense of humor...

Morale:

THE DISCIPLINE, CONFIDENCE, AND ENTHUSIASM, OF A PERSON

OR GROUP AT A PARTICULAR TIME.

ENTHUSIASM

CONFIDENCE

DISCIPLINE

Healthy Skills

•Communication

•Difficult People

•Motivation

•Change Management

•Delegation

•Coaching

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“ The Interaction Between People

for the Purpose of Creating

a Mutual Understanding”

Communication

COMMUNICATION

Barriers to Communication“Intent” Versus “Content”

“I know you believe you understand what you think I said, but I’m not sure you realize that what you heard

is not what I meant!”

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The Communications Process

1) Identify

Desired

Results 2) Consider

Influencing

Factors

3) Select

Approach

4) Select

Medium

5) Implement

6) Observe

Reactions

7) Listen for

Understanding

8) Respond &

Clarify

9) Monitor

Performance

10) Provide

Coaching

Being Heard Communication Assessment Tool

Temperaments and tendencies are

hardwired, leaders learn to manage to

strengths and how to mitigate the

shadow side.

Color Your World

Identifying communication styles for clearer conversations

This tool is excerpted and adapted with permission from and is used as part of the Star Achievement Series developed by the HR Department at The Children’s Hospital of Philadelphia.

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Your Personal Communication Style is Important!

To Communicate:

Convey, Disclose, Declare, Enlighten, Impart, Express, Inform, Relate…That’s what you are doing when you communicate. Convey concepts. Disclose information. Declare yourself. Enlighten others to a new idea. Impart a philosophy or process upon others. Express your ideas or thoughts. Inform co-workers of important news or give them data. Relate your manager’s or customer’s comment or request.

But how do you know if you are being heard?

Your Personal Communication Style is Important!

To Communicate: Convey, Disclose, Declare, Enlighten, Impart, Express, Inform, Relate…That’s what you are doing when you communicate. Convey concepts. Disclose information. Declare yourself. Enlighten others to a new idea. Impart a philosophy or process upon others. Expressyour ideas or thoughts. Inform co-workers of important news or give them data. Relate your manager’s or customer’s comment or request.

But how do you know if you are being heard?

Successful individuals work to effectively

communicate with others. They strive to speak in a way that the other person can hear them. They realize one way to meet this challenge is to tap into another person’s preferred communication style.

IF you want to give the best internal (colleagues & staff) & external customer (patients, clients, business partners) service, or persuade, negotiate, & get support from others, you will want to learn about the various styles of communication.

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Excercise

But they all have to learn to live

in the same box.

We can learn a lot from crayons: some are

sharp, some are pretty, some are dull, some

have weird names, & all are different

colors…

Listening

“Seek First to Understand, Then to Be Understood”

Stephen Covey

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Barriers to Communication Five Common “Filters”

•Automatic Reactions

•Preconceptions (Expectations)

•Selective Attention

•Defensiveness

•Premature Conclusions

•Just Breathe (reflect/pray)

•Monitor & Adjust (walk the talk)

•Let Go, Be Free (learn)

Be Present

Between stimulus and response there is a space.

In that space is our power to choose our response.

In our response lies our growth and our freedom.Viktor E. Frankel

Dealing with Difficult People

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Characteristics of the Difficult Person……

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__________

__________

__________

__________

__________

__________

__________

__________

__________

__________

__________

__________

__________

__________

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10 Unwanted Behaviors

1. The Tank

2. The Sniper

3. The Grenade

4. The Know-It-All

5. The Think-They-Know-It-All

6. The Yes Person

7. The Maybe Person

8. The Nothing Person

9. The No Person

10. The Whiner

Mighty Manager: Dealing with Difficult People

– Dr. Rick Brinkman and Dr. Rick Kirschner

Consider Your Dominate Style

•Competing

•Collaborating

•Compromising

•Avoiding

•Accommodating

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Five Steps to Negotiating with difficult people

1. Control your own behavior

2. Disarm them by stepping to their side.

3. Reframe the dispute in terms of interests.

4. Build a Golden Bridge. Make it easy to say “yes”.

5. Make it hard to say “No”.

Getting Past NO: Negotiating in Difficult Situations

- William Ury

“Remember not only to say the right things in the right place, but far more difficult still, to leave unsaid the wrong thing at the

tempting moment.”

--Benjamin Franklin

Step One: Control Yourself

Essential Communication Skills

• Positive Attitude.

• Take an inventory of yourself.

• Listen. Listen. Listen.

• Be mindful of body language.

• Conflict Management – maintaining control.

• Assertiveness (depending on the type of difficult person).

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Step One: Control Yourself

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• Listen actively.

• Ask clarifying questions.

• Paraphrase their statements.

• Acknowledge their points and feelings.

• Express sympathy if needed.

• Use the word “Yes” when possible, instead of “But”.

• Make “I” statements as opposed to “you”.

Step Two: Disarm Them

• Rephrase in terms of interests rather than positions.

• Ask open ended questions.

• Ask problem-solving questions.

• Ask “why not” about alternatives.

• Ask “what if” to introduce new options.

• When positional tactics are used simply ignore them.

• Restate personal attacks as expressions of concern.

• If problematic behavior persists – identify it and negotiate the acceptable tactics.

Step Three: Reframe

Step Four: Build a Bridge

• Make it easy to say yes by removing common obstacles for both sides.

• Avoid telling them what the solution is.

• Offer choices.

• Focus on their logic and perspective.

• Look for the intangible interests that might be holding them back.

• Consider seeking third party recommendations. (Save face)

• Give them credit where possible.

• Go to the balcony.

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How can we resolve this?

What can we do to move forward?

Which of these options works for you?

Focus on solutions,

not excuses :

Step five: Make It Hard To Say No

• Avoid power tactics to force agreement.

• Use power to bring them to their senses.

• Identify why agreement is in their best interest.

• Ask reality-testing questions.

• Build a coalition.

• Weigh the benefits of concession.

• Be ready to walk.

Bonus Step: Accept “No” For An Answer

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Your Crucial Conversations Script

1. Explain the reason for the meeting

2. This concerns me because….

3. Confirm their understanding of the issue

4. Make clear coaching recommendation

5. Confirm recommendation & repeat it back

6. Set up review time

7. Clarify you have confidence in the person

Excerpt from “ What Exceptional Leaders Know” T. Spears

Expectations

•Be Clear

•Communicate – Sandwich Technique

•Follow Up

Leadership to Management

The leader asks what and why;

The manager asks how and when.

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Motivation

“Creating an Environment And/Or

Providing “Incentive” for People to

Behave in a Particular Way.”

Motivation — JOHARI WINDOW

Training

1I Can

I Will 2

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I Can’t

I Would

I Can

I Won’t

I Can’t

I Won’t

Mo

tivate

High

W

i

l

l

i

n

g

n

e

s

s

Ability

Low

Homework Assignment —1. Write the first name of each of your employee’s in the appropriate quadrant.2. Using the motivational techniques discussed, identify strategies to move employees in quadrant 4

(I can’t, I won’t) to quadrant 1 (I can, I will)

I Can

I Will

I Can’t

I Would

I Can

I Won’t

I Can’t

I Won’t

W

i

l

l

i

n

g

n

e

s

s

Low

High LowAbility

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The Anatomy of Organizational Change

S

O

U

R

C

E

S

Sources of Change

• Management Initiatives

• Physician Preferences

• “Customers”

• Payers

• Hospitals

• Staff Changes

• Process Improvement

• External Sources

• Others...

The only place most of us want to see change is from a vending machine.

Expectations

•Change is desired, planned, and controlled by me

•Change is anticipated, but not controlled by me

•Change is not anticipated or controlled by me

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Initial Response

•Desired/Controlled = Positive

•Anticipated/Not Controlled = Positive or Negative

•Not Anticipated or Controlled = Negative

The Norm

•Familiar and Comfortable

•Discomfort

•Accommodation

•Habit (“A Rut is a Coffin with the Ends Kicked Out”)

•Cultural Norm

•Familiar and Comfortable

Implementation

• Reality Hits

• Personal Implications Become Clearer

• Implications for Work Group Become Clearer

• Implications for Our Culture Become Clearer

• Missteps and Barriers Guaranteed

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“Grieving” Process*

Stability

Immobilization

Denial

Anger

Bargaining

Depression

Testing

Acceptance

*Moving at the Speed of Change by Daryl Conner

DELEGATION

How many monkeys

are you carrying?

What is a monkey?

Monkeys are issues/actions that people bring to you to solve.

Issues may be problems, tasks, or other items at work that you need to resolve.

They can come from just about anywhere and you need to learn to manage them.

THOSE THAT DON’T DELEGATE

AREN’T ALLOWING OTHERS TO GROW

SARAH J. HOLT PHD, FACMPE

HOLT MEDICAL PRACTICE SOLUTIONS

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COMPLEX vs complicated

• We live in a complex world, always have, always will.

• We do not need to live complicated lives

Delegation Is...

• An investment in your staff and in your future

• An opportunity to provide training and development with their motivational benefits

• An opportunity to better tap and allocate the resources under your control to achieve the organization’s goals

• A way to ensure assignment of both responsibility and authority to other

• A method for establishing accountability with the “delegates”

• A risk

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Delegation Is Not…

• Abdication of Responsibility;

• Laziness on the Part of the Manager;

• “Dumping” on Subordinates;

• Loss of Control;

• Decision Avoidance;

• An “Ego Trip”;

• Easy to Start;

• Always Successful;

• A Reduction of Your Productivity

Coaching

• Know the game!

• Select the talent (staffing)

• Develop the talent (staff development -skills, knowledge, experience) through practice

• Teach teamwork

Effective Coaching

• During the game

• Keep cool & objective

• Deal with the hand that is dealt!

• Facilitate answers

• Teach

• Encourage

• Overcome failure

• Post game evaluation

• Team performance

• Individual performance

• Coaching

• System performance

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Practical Applications

•Planning

•Finance

•Measurement

If you’re not headed anywhere in particular...

You’re bound to get there!!

Why Plan?

• Determine the who, what, when, where, why and how of a venture

• Understand factors impacting success or failure (systems approach)

• Build ownership (unity) of Mission, Vision, Values and Strategies among constituents

• Distinguish between opportunities & “temptations”

(“He who chases two rabbits…”)

• More efficiently use limited resources (people, money, equipment, time, etc.)

• Standard against which to measure performance

• Keep bookshelves occupied!

Failure to Plan is Planning to Fail

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Plan: Begin with the End in Mind

• When to take action…

• How to take action

• Why take action…

Planning Tools

• Lean

• Six Sigma

• Form, Storm, Norm, Perform, Reform

• Recommend, Agree, Perform, Input, Decide

• Plan Do Study Act

A Plan Perspective

• Be a Positive Deviant*

• Ask an unscripted question

• Don’t complain

• Count something

• Write something

• Change

* Adapted from “Better” by Atul Gawande, MD

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A Healthcare Business Conundrum

Insanity:

Doing the same thing over and over again expecting

different results. Einstein

What is benchmarking?

The exercise used by management to evaluate various aspects of a process in

relation to “best practices” using internal or external resources as a reference.

Benchmarking

•Why is it important to benchmark?

•Tools to gather

•Where to focus

•Setting your goals

•Sample Reporting Tool

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Benchmarking…..(it’s advantages)

•Overcomes “paradigm blindness”

•A 20/20 visual of past performance

•Passport to opportunity for success

•Provides tools for accountability

•Snapshot of industry trends

Benchmarking…..(it’s disadvantages)

• Takes time … which you already feel short of

• Indicates opportunities but it doesn’t define how to achieve them

• Can lead to more questions than answers

• Not a substitute for professional judgment

Where do we start?

• Select items to benchmark based on your organizations strategic initiatives.

• Identify targets that are meaningful to your practice & that are measurable.

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What we can track…….

ACCOUNTS RECEIVABLE

INDICATORS

PRODUCTIVITY

INDICATORS

FINANCIAL

INDICATORS

DAYS IN ACCOUNTS

RECEIVABLE

DAILY & MONTHLY VISIT

STATISTICS

CONTRACTUAL

ALLOWANCES

COLLECTION RATIOS NO SHOWS

BUILDING OCCUPANCY

COST RATIO

POINT OF SERVICE

COLLECTIONS GROSS CHARGES

CLINICAL SUPPLY COST

RATIOS

PAYER MIX CODING HISTOGRAMS STAFFING COST RATIOS

What Do You Need?

• Monthly financial reports.

• Monthly account receivable reports.

• Monthly productivity reports.

• Scheduling reports.

• Benchmarking resources

• MGMA Survey Data

• AMGA Survey Data

• CMS Data & Payer Data Think Outside the Bowl

What is your Plan?

Identify the intent of the benchmarking effort:

Financial Management

Accountability

One time Snap Shot

Compliance Analysis

Make your plan accordingly!

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DOWNTIMEType of Waste Description Where it shows up

Defects Time spent doing something incorrectly, inspecting for errors, or fixing errors

Patient registration processes with data entry errors or information: impact patient perceptions, clinical care (pre-authorizations), revenue cycle errors

Over Production Doing more than what is needed by the “customer” or doing it sooner than needed

Duplication of tests; talking “at” patients instead of “with” patients, doing someone else’s work

Waiting Waiting for the next event to occur or next work activity

Any space called “waiting”, pre-authorizations, staff work waiting for MD response, re-testiing

Non-UtilizedTalent

Waste and loss by not engaging team members who touch the process, listening, supporting

Reduced motivation to work at top of license, CYA behaviors

Transportation Unnecessary movement of “product” (patient, specimen, documents, materials)

Patient arrival > registration > waiting room > vital signs > waiting room > exam room > waiting for clinical support > discharge > imaging/lab > discharge

Inventory Excessive cost through storage, movement, waste and spoilage

Non-standardized rooms, stocking procedures, thinking about where something is

Motion Unnecessary movement by the team through the system

Searching (ECG, pulse ox, thermometer, meds,)

Extra Processing Doing work not valued by the customer or caused by definitions of quality no aligned with patient needs

Collecting information with no review, no data, no expected outcomes

*Modified from Graban, M. (2011) Lean Hospitals: Improving quality, patient safety, and employee engagement, 2nd edition. CRC Press Boca Raton

The Fiscal Note:

Item Cost per occurrence/event

Tossing scalpel $751 per occurrence

Untimely completion of patient record (EMR or paper)

$120 per chart per day

MD late arrival $190 (30 min/day/MD)

Referrals for prospective care orRx management

$15/occurrence

Meetings $50-75/hr pp /s MD$125-250/hr pp /c MD

The Business of Care Alphabet (a small sample)

•ACA: Affordable Care Act (Obamacare)•HIPAA: Health Insurance Portability and Accountability Act

http://www.hhs.gov/blog/categories/hipaa

•RBRVS: Resource Based Relative Value Schedule•RVU: Relative Value Unit•CPT: Current Procedure Terminology•ICD-10: International Classification of Diseases 10th Edition•ACO: Accountably Care Organization•CIN: Clinically Integrated Network

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The Medicare Access and CHIP Reauthorization Act of 2015:

Next steps toward value-based payment in Medicare

MACRA

Practices will have choices under MACRA

• Statutory updates

• Consolidated reporting

• Reduced penalty risk

Fee-for-Service under a “Merit-based Incentive

Payment System” (MIPS)

• Higher updates

• Exempt from MIPS

• Preferred treatment for medical homes

• Specialty models encouraged

Alternative Payment Models

MACRA milestones

2016

• Likely last performance year for PQRS, meaningful use, and VBPM

• Proposed rule outlining MIPS and APM criteria expected in the spring

2017• Likely first performance measurement year for MIPS

• APM criteria set, proposals accepted for review on an ongoing basis

2018

• Likely first performance measurement year for APMs and second for MIPS

• Separate PQRS, meaningful use, and VBPM programs / penalties sunset on Dec. 31

2019

• First MIPS payment adjustments applied, maximum +4% (phases up to + 9% in 2022)

• First APM performance assessed, 5% bonus payments made to qualifying participants

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Prior Law 2019

adjustments

PQRS -2%

MU -5%

VBPM -4% or more*

Total penalty risk -11% or more*

Bonus potential (VBPM

only)

Unknown (budget

neutral)*

MIPS factors 2019 scoring

Quality measurement 50% of score

MU 25% of score

Resource use 10% of score

Clinical improvement

activities

15% of score

Total penalty risk Max of -4%

Bonus potential Max of 4%, plus

potential 10% for high

performers

*VBPM was in effect for 3 years before MACRA passed, and penalty risk

was increased in each of these years; there were no ceilings or floors on

penalties and bonuses, only a budget neutrality requirement.

2019 (first year) penalty risks compared

APMs

• APM is a generic term describing a payment model in which

providers take responsibility for cost and quality performance

and receive payments to support the services and activities

designed to achieve high value

• According to MACRA, APMs include:

− Medicare Shared Savings Program ACOs

− Patient-centered medical homes

− CMS Innovation Center Models

− Other federal demonstrations

Positioning practices for the future

• Fee for service payment methods are blurring and morphing into new payment models

• Increasing focus on accountability for total cost of care, while maintaining quality

• Growing emphasis on care coordination, health IT and patient satisfaction

• Practices with a sophisticated understanding of financial and clinical analytics will be best positioned for evolving payment models

• Stay ahead of the curve and thoughtfully consider if certain voluntary programs are right for your practice

• Be aware of the changing landscape by engaging with MGMA

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What physician practices can do now

Expect MACRA implementation to proceed

−Elections estimated to have limited impact

oMACRA passed House 392-37; passed Senate 92-8

Assess your performance under current programs

−How did your group perform in PQRS and MU?

−Have you downloaded your 2014 Quality and Resource Use Report?

Engage in ongoing learning about MACRA

−Visit mgma.com/MACRA for more information and resources

−Subscribe to the Washington Connection for updates about MACRA implementation

Consider participating in a public or private value-based payment initiative

Debra Wiggs, FACMPE dwiggs@v2vms.com

Thank You For Your Time