Recognizing implicit bias in decision making not only improves the quality of care for patients from historically marginalized groups, but helps doctors improve their diagnostic accuracy.

That was the message Denise Connor, MD, associate professor of clinical medicine at the University of California-San Francisco, delivered during the virtual session “Improving diagnostic reasoning: recognizing and addressing errors from implicit bias in patient care” on day one of the American College of Physicians Internal Medicine Meeting 2021.

“Implicit bias can affect our judgments and decision-making as clinicians, which can lead to disparities in health outcomes,” Connor said. “That’s especially true when we’re in realms that are complex, when we’re under time pressure and when we’re operating outside of established relationships,” she said.

Achieving better diagnostic accuracy depends to a great extent on communication skills, Connor added, because “99% of diagnosis is in the history, so our relationship and ability to communicate with them is critical to diagnosis accuracy.”

Moreover, patients often evaluate the overall quality of the care they receive based on their perception of communication quality, which in turn affects their level of engagement. In particular, Black patients being treated by White providers are more likely to respond positively to a collaborative communication style. “So communication becomes even more important when we’re communicating across differences,” Connor said.

Connor offered a variety of tools clinicians can use to improve diagnostic communication, starting with “cognitive reappraisal” the idea that reframing negative experiences in a positive way is better than trying to ignore or suppress them. 

“Reappraisal has been shown to increase positive emotions and benefit relationships, facilitate empathy and increase our ability to take in new information,” she said. In contrast, trying to suppress feelings caused by negative experiences can lead to problems with interpersonal relationships, reduce our ability to take in information, and even increase patients’ stress levels, she said.

Another helpful technique is to acknowledge feelings of fear or anxiety before treating a patient. “Just saying ‘I’m feeling anxious’ out loud before going into a patient’s room can be a positive thing,” she said. “To name it is to tame it.”

Engaging in mindfulness and stress reduction before potentially stressful patient encounters has been shown to reduce discriminatory behaviors and levels of bias, according to Connor. These can be as simple as engaging in moments of “’grounding gratitude’ for the trust patients are placing in you, or a mindful breath. Those quick actions can make a big difference in how the interaction goes,” she said.

Finally, empathy is a powerful tool in overcoming bias and improving communication, but it is “context-dependent,” Connor said. “We are more likely to feel empathy for someone we see as part of our own group versus someone we don’t identify with. So we have to ask ‘how can we reframe our relationship with a patient as a partnership so we feel like we’re both in the same group?’”

Connor noted that trying to overcome implicit bias and improve diagnostic communication has benefits that extend beyond patients from historically marginalized groups.“

Connor noted that doctors’ extensive training, specialized language and other attributes lead to communication challenges with all patients, regardless of their background. Consequently, “if we think about how to improve experiences for groups that historically have been marginalized in health care, those same interventions are going to benefit all our patients.”

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Recognizing implicit bias in decision making helps doctors improve their diagnostic accuracy.

The link between diagnostic reasoning and implicit bias in patient care

Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases (NIAID), says that addressing disparities in healthcare access disparities will likely take decades.

Fauci was taking part in a question-and-answer session during the opening plenary of the American College of Physicians (ACP) Internal Medicine Meeting 2021 along with Gregory Kane, MD, treasurer of ACP; and Darilyn Moyer, MD, executive vice president and CEO of ACP.

He said the pandemic has shown a bright light on the inequities of the healthcare system, particularly in the rates of hospitalization seen among racial and ethnic minorities. According to Fauci, these inequities are tied to social determinants of health which sees Black, Hispanic, and Native American citizens put into educational and economic situations which limit their ability to receive medical care.

“We have to start committing now to something that's going to take decades to change,” he says. “Because it took centuries to get here, it’s going to take decades to change. But if we don't make the commitment now to do it, we're never going to do it.”

When asked whether COVID-19 could be eradicated globally, Fauci seemed more confident that it will be eradicated in some countries and controlled in others, but the process will take years and vaccinating a large portion of the world’s population.

“We're going to be continually threatened by variants that will come from other countries, which tells us the obvious solution to that is to make sure that we get the entire world vaccinated against (COVID-19),” Fauci said. “Until we do that, I don't think we're going to eliminate this infection. I think it'll be there at a low level; we'll be protected. We may need to get boosted every once in a while, to keep the level of protection up. But we have to look at it as a global problem, otherwise, we're never going to truly eliminate it.”

Fauci said that early in the pandemic the U.S.’s response was hamstrung by the dismantling of the local health infrastructure, failure to mobilize the private sector early for diagnostics, and the rapidly evolving situation with little transparency from China.The transmission method of the virus also caught the world by surprise.

“We've never had any pathogen of any note of seriousness in which … 50 and 60 percent of the transmissions occur from a person who never will get symptomatic, or who was in the pre-symptomatic stage,” he said. “That broke all the paradigms of infectious disease because, prior to that, transmissions were always a little bit asymptomatic but dominated by the symptomatic person.”

As for the U.S.’s successes in responding to the pandemic, Fauci highlighted the Trump administration’s Operation Warp Speed which invested billions in vaccine development and pre-purchase as well as the Biden administration’s rollout of the vaccines.

The NIAID head said the COVID-19 pandemic has highlighted the need to address social determinants of health.

Fauci: Addressing healthcare access disparities will take decades

While the government has eased many restrictions on telehealth visits during the COVID-19 pandemic, practices still have to carefully plan their workflows in order to make the most of such visits.

That was the message from Reena Mehta, MD, a New Orleans-based allergist and immunologist and a presenter at a virtual session on telemedicine during the annual meeting of the American Academy of Allergy Asthma & Immunology.

“It’s got to be efficient, it’s got to work for your practice and it’s got to be streamlined so you can get patients in and out virtually and continue the flow of your practice,” Mehta said.

The first step is deciding if a visit is suited for telemedicine. “Basically, it’s a good fit for a patient that doesn’t want to come into the office and seems relatively uncomplicated. Not every visit requires a detailed physical exam,” she said. Conversely, visits that require significant procedures or that involve risk to the patient can’t and shouldn’t be done via telehealth.

Mehta has trained her staff to recognize when a patient is a good candidate for a telehealth rather than an in-person visit, and often uses pre-clinic huddles to get their input. She also provides a script for front office staff to screen patients calling for appointments as to their suitability for a telehealth visit.

Another workflow decision is whether to designate a block of time each day exclusively for telehealth visits, or to mix virtual visits with in-person. The latter route requires training staff to know when the doctor is most likely to have time in their schedule that can be filled by a telehealth visit.

“If your staff is well trained you should be able to crank these (telehealth) patient out and keep your workflow going smoothly,” she said.

When starting out with telehealth Mehta advises scheduling the same amount of time for a telehealth visit as an in-person visit, then adjusting visit lengths as needed. She cautioned that it’s important to have patients log on at least 15 minutes before the start of the appointment so staff members can address any technology issues, such as a patient with a bad internet connection or who’s unfamiliar with the technology.

Mehta said lab result reviews are the most common telehealth visits in her practice,since they don’t require face-to-face contact. Through screensharing, patients are also able to view the results with her simultaneously and ask questions about them.

As with in-person visits, proper documentation is key to getting paid for a telehealth visit, Mehta said. While verbal consent is all that’s been required during the pandemic, getting both verbal and written permission is considered best practice. Other documentation elements include:

The type of technology used, i.e. whether synchronous audio/video or audio alone

Where the patient is physically located and where the provider is located

Language specifying that the care was provided by telemedicine or telecommunication during the COVID-19 pandemic

The amount of time spent providing services

Mehta noted that under current law most of the changes to the rules governing telehealth visits would expire at the end of the public health emergency the nation is now under. “It remains to be seen if the changes in technology, regulation and reimbursement for telemedicine will be maintained long term,” she said.

AAAAI

Practices still have to carefully plan their workflows in order to make the most of such visits. 

AAAAI Annual Meeting: Making the most of a telehealth visit

As the COVID-19 coronavirus pandemic continues to rage, more and more practices have turned to telehealth to continue caring for patients.

Mike Tankersley, MD, MBA, of the University of Tennessee, gave some tips of how to prepare for a telehealth visit to cut down on confusion and stress for the patient and your staff as part of the session “Expanding Your Practice: Clinical, Administrative and Reimbursement Strategies for Success,” on Feb. 26 as part of the digital American Academy of Allergy Asthma & Immunology (AAAAI) Annual Meeting.

The ideal patient for a telehealth visit is returning patient, particularly for a follow up visit. For this patient, the physician should discuss with that patient at the end of their visit whether the follow up or next visit should be in-person or held using telehealth. Tankersley says he then lets the front office staff know and the next visit is booked as taking place over telehealth.

When it comes to using telehealth with a new patient, Tankersley notes that it’s best used when dealing with patients who are distant from the practice or if a patient would normally have to cancel their appointment due to unforeseen circumstances such as the severe weather that affected much of the country at the end of February.

“I'm in the city of Memphis, but if I want to set up a satellite clinic in Jackson, Tenn., an hour and 15 minutes away, I don't have to rent out space into a brick-and-mortar space,” he said. “I basically can set up a virtual satellite clinic and see patients who were there that don't have to drive the hour and 15 minutes to my office in Memphis.”

In preparation for upcoming telehealth visits, Tankersley says that every Friday at his practice they look over the next week’s schedule and send out templated emails to patients scheduled for telehealth visits which contain the time of the appointment and a link. He recommends the first or last appointment of the day for solo physicians.

Tankersly also has his staff collect any payment for the appointment beforehand. With patients he has already seen, he has them collect payment at the time they schedule the telehealth appointment, with new patients he has them call the patient the morning of the appointment to collect payment.

Another tip Tankersley gave was to create a mechanism so that the appointment starts on time in order to keep patients from being left staring at a computer screen waiting.

“Whether you set a timer, you got somebody in your office that's designated to kind of remind you, hey, Dr. Tankersley, your telemedicine’s in five minutes; just have some mechanism to remind yourself that that your telemedicine is live because the patient's not going to be in your clinic, letting everybody know that they’re there,” he said.

Mike Tankersley, MD, MBA, discusses workflow tips that can help practices in their use of telehealth visits.

AAAAI Annual Meeting: What to do before a telehealth appointment

As the U.S. general election swiftly approaches and the COVID-19 coronavirus pandemic wears on, MGMA Senior Vice President of Government Affairs Anders Gilberg gives an update on what’s happening in Washington and what that could mean for healthcare.

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MGMA Senior Vice President of Government Affairs Anders Gilberg gives a glimpse at what’s happening on the Hill

What’s happening in Washington D.C. with health care?

As tensions have risen with the onset of the COVID-19 pandemic, awareness of workplace violence in your practice is more important now than ever.

Rana McSpadden, FACMEP, CPC, CEMA is a Medical Practice Consultant with the Medical Practice Services Department at SVMIC. She provided some insight during her presentation at the MGMA 2020 practice excellence virtual conference on the best way to keep your practice safe.

 available from the United States Bureau of Labor Statistics were from 2018,” McSpadden said. “We have more violence attributed to our staff members in the workplace in general.”

All other industries surveyed in 2018 reported 5,500 violent actions, whereas the healthcare industry had over 15,000 incidents, according to the statistics. 

In order to decrease workplace violence, McSpadden outlined a 3-step process:

First, conduct a vulnerability assessment:

 Determine the specific risks associated with your practice. Questions for this step include inquiries about unmonitored entries and amount of security systems.

“I was out of practice not too long ago, and they had a police officer substation nearby and I recommended that they get to know those police officers more intimately because they were in a high crime area,” McSpadden said.

 You must create a plan where you practice can efficiently respond to a threat, whether it be an active shooter or an argumentative customer at the front desk that turns violent.

“Your staff members need to be aware of, 

at what point do I need to find somebody else, at what point do I need to bring in somebody else to help me with this individual

?” McSpadden said. “A lot of times, bringing in the physician or the provider actually will calm them down. They will act a-fool out in the lobby, but as soon as that provider walks in the door they’re perfect angels.”

 Organizations across the country use a variety of safety programs to educate their employees. Many colleges and universities use A.L.I.C.E training while the FBI uses ‘Run. Hide. Fight’.

“One of the things that you need to be training your staff on are warning signs for individuals that could potentially become violent,” McSpadden said. “If you address or recognize these warning signs, you may be able to squash anything that actually is going to come down the pike.”

“We have a general duty to keep a safe working environment for our staff members,” McSpadden added. “We have plans against fire. We have plans against tornadoes- have a plan against violence.”

Physicians need to prepare and take a stand against workplace violence


MGMA 2020: How to prevent workplace violence in your practice

Physicians may be focused on how patients are treated in their practices and the quality of care they receive, but they often overlook one of the biggest factors in 

 that also affects outcomes: patient finances. Steven Merahn, MD, FAAP, chief medical officer, Essen Health Ventures, and Jan Oldenburg, consumer health information strategist, Participatory Health Consulting, spoke about the importance of not overlooking money issues to increase patient satisfaction at the virtual MGMA 2020 conference.

“Patients see payment and billing as part of the total clinical experience even though doctors don’t,” says Oldenburg. Patients are seeing rising out-of-pocket costs and a push toward more health care consumerism, and patient expectations from doctors is changing.

Patient surveys show that only 12 percent said they had received information about out-of-pocket costs, while 67 percent said they have not discussed or do not plan to discuss their final bill with the hospital or provider.

Merahn says there are a lot of barriers to financial discussions: varying levels of financial and health literacy, unclear of complex information, social barriers or stigmas. “Despite the potential discomfort, it is critical to discuss the financial aspects of care,” Merahn says. “As a clinician, it’s not about them paying, but about committing to their care.”

Patients may be putting off care because of high deductibles or other financial reasons that doctors may misinterpret as them not wanting the treatments. “Helping people understand what care is recommended, and what can I pay for, when put together, changes things dramatically,” says Oldenburg. “Health care is implicated in 70 percent of bankruptcies, and it’s true that financial stress can have an impact on how someone recovers from an illness.”

Surveys show that patient behavior is influenced by money matters: 43 percent of patients said they changed their behavior regarding medical visits or procedures because of costs while 24 percent delayed prescriptions or never had them filled for the same reason.

Patients don’t always understand what they are paying for, so doctors need to help. “We haven’t done a good job of giving them tools to help them understand where costs from and what they can do to change them,” says Oldenburg. “We haven’t given consumers a way of figuring out whether this is a Gucci price because of the quality, or if it’s just a Gucci price for a knockoff product.”

Costs can also play a role in patients switching doctors, usually after a visit that generated an unexpectedly high bill. Of the patients surveyed, 65 percent said they would consider switching providers if they received a surprisingly high bill. “This is why you should make it easy to have a financial conversation way upstream of the bill,” says Oldenburg.

Merahn says that the foundation of a successful medical practice is the willingness to share the worries of another human being, and that includes their financial worries. He says practices need to embrace all the digital payment options and provide flexibility for patients to pay. “There are ways to pay that are convenient for them, not us,” he says. “Are there ways you can make things more efficient and more convenient for the people you are serving? Don’t forget about when actually caring about a patient’s time, that is a dimension of showing the organization is caring about them as a whole person; it’s not just getting money, but showing you care about their issues, including their time and convenience.”

Part of that convenience is translating goals into the real world. “An HbA1c level is our measure, not theirs,” says Oldenburg. “Their goal may be to dance at their daughter’s wedding. If we framed our goals in their terms, we will be more successful.”

A lack of money is also a social issue. “The financial education piece may not seem relevant, but as we are looking more at social determinants, it is a major one,” says Merahn. “Taking on some responsibility to help them with the basic science of financing is important. You aren’t balancing their checkbook, but helping them understand how it works both for and against them, and how to make educated decisions. And asking finance to set up a payment plan is not the same as providing assistance.”

He says that finances have to be considered part of the patient’s social history. “Get out of the idea you are prying into their personal lives. Part of medicine is professional intimacy; you understand their body and lives in many ways. In today’s society, it’s important to understand the circumstances of their life.”

Without looking at costs, a doctor is doing a disservice to the patient. “It doesn’t do anyone any good to charge forward and recommend an option they won’t act on because of cost, and if we don’t know that, then shame on us,” says Oldenburg.

The key to happy and healthy patients? Honest talk about finances.

MGMA 2020: How to improve patient engagement through financial information

The COVID-19 coronavirus pandemic has thoroughly derailed what was shaping up to be a good year for physician practices, but practice leaders should plan rather than prepare for what the financial implication will be in the post-COVID-19 world.

This was the topic of a seminar given by Fulcrum Strategies’ Chief Financial Officer and Strategic Planning Consultant Cynthia Nyberg as part of the Medical Group Management Association (MGMA) Medical Practice Excellence Conference 2020.

She said that prior to the coronavirus spreading across the U.S., unemployment was at 3.5 percent, wage growth was between 3.9 percent and 4 percent, the labor participation rate was 63.4 percent, and revenue and patient visits were up 16 percent.

Along with the pandemic came a raft of challenges for practices including limiting patient visits to essential services only, the implementation of telehealth seemingly overnight, furloughs of staff, attempts to secure paycheck protection program loans, and keeping patients and staff safe from infection through the purchase of personal protective equipment, Nyberg says.

While some in government say that the pandemic has passed, Nyberg says she doesn’t think the country is there yet especially with case numbers increasing in many states.

She says some of the challenges that will be facing practices post-COVID and beyond are:

changes in payers’ reimbursement strategies

the utilization implications of telehealth

Some financial strategies for the post-COVID world presented by Nyberg include:

Nyberg says she always has multiple plans, but it is wise think about whether one knows what their goal is, what are the challenges, what data is needed, where the data is coming from, and how results will be disseminated.

To formulate these quantifiable measures on how the practice or employees are meeting objectives practice leaders must have easy access to comparable data and the ability to change reporting time frames.

 It’s important to see what is going to happen, cash-wise, before it happens.

 It’s important to know how much a visit costs with the likely rise of capitation agreements post-COVID.

Patient policies for financial responsibility –

 As patient financial responsibility rises, practices must set clear financial and telehealth expectations.

 Whether it is a physical facility and telehealth, managing capacity will help financially.

 Whether it is used for telehealth, a dashboard for Key Performance Indicators, patient communications, patient payments, payment plans, or transparency and competition patients are thirsting for a more technological experience with their physician.

As the pandemic wreaks financial ruin on practices across the country, physician leaders need to begin to plan for their financial futures after the pandemic has passed.

MGMA 2020: Preparing financially for a post-COVID-19 world

Although risk-based care contracts have existed for many years, primary care doctors have been reluctant to embrace them. But with careful planning, these contracts can offer medical practices the flexibility and income they need to provide high-quality care, while maintaining their independence.

Representatives of practices using value-based payment contracts discussed their benefits during a session on the second day of the Medical Group Management Association’s 2020 Medical Practice Excellence conference.

“Why enter into these plans? First and foremost, it’s financial stability,” said Timothy Irvine, MD, a physician at IKP Family Medicine in The Woodlands, Tex, which has about 6,000 patients under capitated or pay-for-performance contracts. “The monthly capitation checks they provide are a dependable revenue stream that helps even out the ups and downs of the revenue cycle.”

The revenue stream proved especially important during the early months of the COVID-19 pandemic, when in-person patient visits all but dried up. “Our practice is in a much better position because of our participation in value-based contracts,” Irvine said.

Along with financial stability, being in value-based contracts has helped IKP improve its productivity and patient outcomes by offering a monthly, per-capita care management fee. The practice uses the funds to help cover the costs of care coordination managers. “These are the employees who tie everything together so when a patient comes in, it is the most productive visit we can have,” he said.

Joe Nicholson, DO, chief medical officer of CareAllies, a Cigna-owned consulting firm that helps practices transition to value-based care, said that process requires significant time and effort. “Those that succeed start small, and transition to a greater percentage of risk-based contracts over time, often focusing on areas they’ve already targeted for improvement.”

Nicholson advised practices to consider the following when deciding whether to enter into value-based contracts, and with which payer(s):

The payer mix: What mix of public and commercial contracts make the most sense for your practice?

The policies of the payer(s): Which payers have the best policies for treatment of chronic conditions, and invest in services that address the social determinants of health challenges in your community?

Reporting requirements: Look for payers that have similar quality reporting requirements so as to make it easier for your practice to test and scale risk-based arrangements

Flexibility in utilization management: Does the payer’s approach to utilization management allow your practice to manage and control service and treatment offerings for patients.

Nicholson also stressed the importance of collaboration and data-sharing with payers. “For every quality measure a practice is expected to report on, the payer should be willing to provide supporting clinical and cost data about its related patient populations, so the practice can assess where it needs to improve,” he said.

Practicing value-based medicine is what has enabled San Antonio, Tex.-based Gonzaba Medical Group to maintain its independence, according to William Gonzaba, MD, and Francisco Gonzaba, MHA, the practice’s medical director and executive director of business operations, respectively. After five years of struggling to succeed exclusively under the fee-for-service model, in 2005 the practice supplemented it with a full-risk capitated contract with a Medicare Advantage plan.

The key to success under such a contract, they said, is maximizing net revenue by focusing on factors such as performance on HEDIS metrics and reducing use of ineffective or duplicative services so as to reduce costs without harming the quality of care.

Throughout its experience, William said, the practice has been guided by the Institute for Healthcare Improvement’s “Triple Aim” of patient experience, population health and cost reduction, adding that the three parts are interlocking.

“If you really focus on delivering the right care at the right time, improving population health and patient satisfaction, you will invariably reduce the cost of care,” he said.

“The transition to a full-risk, value-based model of care is difficult, and it may not be the right fit for every practice, but it has allowed us to grow and remain independent,” Francisco said. “Ultimately, either you can manage the care, or it will manage you.”

Primary care doctors have been reluctant to embrace risk-based care contracts 

MGMA 2020: Transitioning to value-based care

A medical practice is often a busy place, with patients in the waiting area and physicians and nurses moving between exam rooms in narrow hallways. But have you ever stopped to think about why equipment is stored in one particular room versus another? Have you considered how doctors and 

 about the practice and if there is a better way that would save everyone time? Are you keeping excess supplies on hand because there are too many exam rooms?

These are all questions to ask when it comes to practice efficiency, says 

, MHA, FACHE, founder and CEO of Optimize Healthcare, who spoke at the MGMA 2020 virtual conference. She says that by applying steps from both Six Sigma and Lean Manufacturing processes, a practice can eliminate bottlenecks, reduce wait times for patients, and make more efficient use of equipment.

Lloyd says to use what’s known as a “5S” event: Sort, set in order, shine, standardize, and sustain. “This is an opportunity to get the entire team involved,” Lloyd adds, because each staffer’s workflow needs to be examined.

Start with a small area, such as an exam room and evaluate it. “Remove all the trash, move all unnecessary things to a holding area, then arrange everything based on how frequently it is used and label everything clearly,” Lloyd says. “Define the quantity of items you go through in a day and make sure you have enough stock for a few days or a week.”

A system should be created for alerting staff when an item is low. For example, divide supplies into two different colored bins. When the first bin is empty, reorder, while using items in the second bin. This type of system will also help rotate inventory and avoid expiration dates.

“Look at how much you’ve used over the last three to six months and calculate the average used by item type, and length of time to get reordered,” says Lloyd,

Collate needed items together, for example, putting all things needed for an IV in one place, and put a label on the outside of the drawer. For equipment, get rid of unnecessary items and layout stalls with labels on the storage room floor where each piece of equipment is parked when not in use.

Someone should be assigned at end of day to make sure everything is in place and to do a final wipe down of the equipment.

When all the rooms have been evaluated, create a checklist for the entire practice that assigns responsibilities at the beginning and end of the day to make sure items are in stock and that everything is where it is supposed to be.

“This is like restaurant prep where the morning crew double checks everything, but most of the work should have been done at the end of the day,” says Lloyd.

For the sustain step, audits should be done frequently to uncover any issues and take action to fix them. Assign an owner or champion to the system who is accountable for metrics and the regular review. This person can also monitor vendor utilization to look for bulk buying discount opportunities.

The poor flow of people and equipment through a practice can create bottlenecks and small inefficiencies that over time can cost a practice thousands of dollars in revenue, but Lloyd says a “spaghetti mapping” exercise can help identify trouble spots.

A spaghetti map exercise starts by taking a floorplan or blueprint of the practice and then drawing a line of how someone moves through the practice. Different colors are used for patients, staff, providers, paperwork, and lab specimens. By looking at where many lines intersect or where they double back on themselves, problem areas can be identified.

In one case, Lloyd saw a practice that had staffers going to a printer 40 times a day that was too far from their work area. This action took them enough time that it amounted to $6,000 in lost time costs, making it clear that buying a second printer and installing it in a different location was more than justified. The same mapping can be done within a room to create better flow within it and illustrating where supplies should be stored.

“Try to create one-way flows, evaluate the flow of each provider for each day of the week, and keep providers close to their resources,” says Lloyd. “Identify bottlenecks and change routes or room assignments to eliminate them.”

By making better use of your existing space, you can eliminate wait times, excess supplies, overcrowded rooms—and save money.

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