Transcript Introduction to Operational Teams

Introduction to Operational
Teams
“Rounding out” the major aspects
of operational teams
Mike Davies, MD FACP
Mark Murray and Associates
Operational and Clinical Teams
Clinical Teams: What to do?
Far from agreement on
WHAT to do (what
prevention and chronic
disease guidelines to
implement)
XX
Far from agreement on
HOW to do it (how to
implement guidelines, how
to support provider’s
efficiency)
Close to Agreement
Operational Teams: How to do it?
XX
Why Operational Teams?
Capacity
Demand
Panel Size 2000
66 have Diabetes
360 Patients are
Over 65
Team (2.59 FTEE)
113 have Asthma
60 Patients had
more than 10 Office
Visits Last Year
Reception
Nurse
Provider
248 have Arthritis
130 are Clinically
Depressed
228 have
Hypertension
160 have Heart
Disease
39% of Capacity is Physician Time
39% of Capacity is MA Time
22% of Capacity is RN Time
Reimbursement (Demand)
Limits
•No-shows
•More resources needed
(staff, rooms, etc)
•Quality?
•New patients meet mission
Gross
Revenue
Visits
Expenses (Capacity)
Total
Cost
Or
Expense
Fixed
Visits
Net Revenue
Limits
Staff
burnout
Net
Revenue
No
Shows
(pt. burnout)
New patients
needed to
serve
mission
Visits
More staff
and space
needed
Value
• Does net revenue reflect true value to the
patient?
• What do patients value?
– Access
– “Good” Doctors and Clinics
•
•
•
•
Listening, understanding and emotional support
Detection of disease
Prevention of disease
Continuous relationship (continuity)
Support Staff all Related to
Productivity
• Classic study
• “nursing, administrative, clerical, and aids
all independently related to productivity
measured by both visits and billings”
• Reinhardt, U., The Review of Economics and Statistics, Feb 1972,
pp 55-66.
• Thurston, NK et al. “A Production Function for Physician Services
Revisited,” Review of Economics and Statistics, February 2002, Vol
84, (1): 184 – 191.
Support Staff and Productivity
Correlated
• “Strong positive correlation between
number of support staff and productivity as
measured by visits per week.
• Held true for secretaries, RN’s, LPN’s, and
medical technicians.
• Data from 1976 HCFA surveys of 3,482
physicians
• Brown, DM., “Do Physicians Underutilize Aids,” Journal of Human
Resources, Summer 1988, Vol. 25 (40): 342-355
Admin and Medical Support Staff
Increase Revenue
• Strong relationship between both
administrative support staff and medical
support staff and physician productivity (as
measured by revenue per physician).
• Revenue is visits and procedures
• HCFA 1988
• Pope, GC., “Economies of Scale in Physician Practice,” Medical
Care Research and Review, December 1996, vol 53 (4): 417-440.
Clerks are Important
• DeFelice, analyzing the AMA’s Physician’s
Practice Cost and Income Survey from
1984-85 found + relationship between
weekly hours of clerks per MD and the
number of MD visits
• No association between hours of nursing
time and number of visits
•
DeFelice, LC., “The Impact of Financial Incentives on Physician Productivity
in Medical Groups,” Health Services Research, August 2002, Vol. 37 (4):
885-906.
Operational Team Challenge
•
•
•
•
•
•
•
Create Access
Provide quality
Maintain financial viability of the clinic
Optimize capacity of team for visits
Maximize number and value of visits
Minimize inefficiency
Optimize team dynamics and function (morale,
engagement, personal mission, turnover)
Teamwork!
Operational
Improvement
Team
Home Team
Clinical
Major Aspects of Operational
Teams
• The Work Organization
– What is the goal?
– What is the process?
• The Worker
– Enthusiasm, Talents, Style, Profession
• The Work Content
– What is the work and who does it?
Major Aspects of Operational
Teams
• The Work Organization
– What is the goal?
– What is the process?
• The Worker
– Enthusiasm, Talents, Style, Profession
– Work assignment?
• The Work Content
– What is the work?
What is the work and who does it?
Flow Through the Office
Check-in to Nurse
Dr. in to Dr. out
Nurse to Room
Check-out to leave
Synchronization
Point
System
How Processes Support Flow
1
1
1
1
Process
Process
Process
Process
Check-in to Nurse
Dr. in to Dr. out
Check-out to leave
Nurse to Room
1
1
Process
Process
1
1
1
Process
Process
Process
Process
What are Some Clinic
Processes?
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




documentation
medication refills
lab review
messages
referrals
forms management
How Tasks Support Processes
Specialist Referral Process
Physician orders
consult
4 minutes
Tasks
Make Appointment
Clerk calls to
make appointment
5 minutes
Clerk gives appointment
reminder and directions
to patient
Check-in to Nurse
Dr. in to Dr. out
Nurse to Room
Check-out to leave
Task
How Tasks Support Processes
Specialist Referral Process:
Physician orders
consult
Task: Call to make
appointment
4 minutes
Clerk calls to
make appointment
Task: Give directions
for specialist
5 minutes
Clerk gives appointment
reminder and directions
to patient
Task
Tasks in the clinic – What is the
work? What do we know?
Job Analysis
• Survey of 7 practices
• Extensive interview of provider, nurse,
pharmacist, clerk (1-2 days)
• Standardized description of tasks
• 243 Tasks identified
Task Categories
• Administrative
– Scheduling, phones,
• Prevention
– Education, treatment
• Treatment
– Medication, procedures
• Diagnosis
– History, Physical, ordering & interpretation of tests
• Relationship
– Primary Care Provider
Administrative
Prevention
Treatment
Diagnosis
Relationship
Administrative
Prevention
Treatment
Diagnosis
Relationship
Administrative
Prevention
Treatment
Diagnosis
Relationship
Administrative
Prevention
Treatment
Diagnosis
Relationship
% Tasks Endorsed
MD
58.02%
NP/PA
55.14%
RN
71.19%
LVN
54.73%
MASPSA 18.11%
HlthTech 19.75%
Provider
Nurse
Clerk
Task Overlap
MD
MD
NP/PA
90.30%
RN
LVN
MASPSA
HlthTech
63.01% 63.91%
45.45%
68.75%
65.90% 65.41%
40.91%
64.58%
96.99%
93.18%
95.83%
77.27%
87.50%
NP/PA
85.82%
RN
77.30% 85.07%
LVN
60.28% 64.93%
74.57%
MASPSA
14.18% 13.43%
23.70% 25.56%
HlthTech
23.40% 23.13%
26.59% 31.58%
50.00%
54.55%
Who COULD Do Task?
Doc
Nurse
Clerk
Administrative
Y
Y
Y
Prevention
Y
Y
P
Treatment
Y
P
N
Diagnosis
Y
P
N
Relationship
Y
P
N
Who Should Do Task?
Doc
Nurse
Clerk
Administrative
N
N
Y
Prevention
P
Y
P
Treatment
P
P
N
Diagnosis
Y
P
N
Relationship
Y
P
N
Example Task 1: Summon Pt
• Call patient from waiting room, direct
patient to office or exam room, explain
next steps and procedures to patient (e.g.
vital signs), open patient information in
computer, verifying accuracy of patient
information (e.g., patient identity, SSN,
DOB), in order to prepare patient for
measurement of vitals.
Example Task 239: Pt. Call
• Receive patient phone call for symptom-related
concerns, test results, scheduling questions, or
medications, review patient’s medical history
and plan of care, ask patient questions about
symptoms, listening to patient responses,
determine urgency of request, discuss options
with patient or refer to another source, notify
provider if urgent action is required, in order to
address patient concerns or requests received
on clinic phone line.
Financial Impact of Task
Reassignment
MD
RN Clerk Total 20% $ Red. Wk Svs Yr Svs
Task 1
Freq
Cost
7
$10
87
$226
31
$9
126
$245
$196
$49
$2,548
$120
$6,240
Task 239
Freq
31
26
Cost $380 $166
20
$154
77
$601
$481
Error/Complexity
Human Error Risk
Task 1
Task 239
2
4
Work Complexity
2
3
Impact of Task Reassignment
• Positive Considerations • Negative Considerations
– Increase capacity of
expensive resource
– Save $
– Clarify roles in team
– Pain of change
– Match of job with
individual preferences and
talents ??
Task Reassignment: The 4 T’s
• Task – what is the work and who could do
it under ideal conditions?
• Team – who is on our team and could do
the work (actual conditions)?
• Timing – does the timing of the task lend
itself to reallocation?
• Terrain – is the task member in the right
place to do the task?
Task Reassignment Examples
• Assistance with undressing for exam
– Could be done by LPN or MA if available
– Sometimes done by MD due to timing
• Vital Signs
– Often done by RN
– Could be done by MA if 4 T’s apply
• Phone answering
– Often done by RN or LPN
– Could be done by MA or Clerk if 4 T’s work
Task Reassignment Examples
• Common Medical Problems
– Often addressed by MD in a visit
– Could be done by RN with MD assistance if
protocols were in place
• Prevention
– Often not done
– Could be done by LPN/RN/MD team if
organized well
What is the work…who is/should be
doing it?
Task
Clerical MA
Registration
Rooming
Refills
Advice
Order Entry
Med. monitoring
Teaching
RN
Provider