Make the most of your staff

Re-engineering Your Practice

Make the most of your staff

"Care teams" will improve your office's efficiency, delighting patients—and easing your workload.

By Deborah Grandinetti
Senior Editor

Imagine working in a practice that runs like clockwork. Charts, X-rays, and lab results are at hand when you need them. Your crackerjack staff is continually figuring out better ways to streamline operations. Because all your employees are pulling their weight, the day's load seems lighter. You even find yourself leaving work earlier in the evening with fewer worries about office-related problems. Best of all, patients seem very satisfied.

Sounds like a dream?

Practices that are re-engineering their operations are beginning to realize some of these goals. One of the ways they're delighting patients is by opening up the appointment calendar so patients can get in the day they call. (See "You mean I can see the doctor today?" March 20, 2000.) And patients don't have to wait long for the doctor once they arrive.

Of course, it isn't possible to maintain a mostly open appointment calendar unless the office is operating efficiently. And that requires staff to be doing the right work at the right time, so that operations are seamless.

A number of practices across the country are experimenting with "care teams" to promote continuous workflow and improve staff flexibility. Staff members work together on a team to provide care for a defined group of patients. In addition to physicians, the team may include nurse practitioners, physician assistants, registered and licensed practical nurses, certified medical assistants, and other clinicians. In a small practice, all clinical staffers might belong to the same care team. Larger groups break down their clinicians into units of manageable size.

In a five-physician, two-NP family practice group at ThedaCare health system in Appleton, WI, for example, each FP has his or her own care team. The team includes a "patient service representative" (aka scheduler), an RN, and a CMA. When a patient arrives at the office, she's welcomed by a "patient greeter," who obtains demographic information and verifies insurance. Then the greeter hands the patient off to a medical assistant or a nurse, who brings the patient into the examining room.

Because the greeter takes care of the front desk, the patient service representative can work closely with the physician in the back office. As a result, she gets to know the patients' needs and can schedule them more appropriately. This staff member also handles managed care-related tasks, such as referral paperwork. That frees the nurses to do more hands-on patient care, such as histories and vital signs, medication refills, and assisting with disease management efforts. That, in turn, makes the physicians more efficient, because they can delegate duties that don't require their expertise.

"We've redefined some of the jobs with the intention of providing seamless patient care," says practice administrator Anne VanEpern. The increased efficiency has enabled three of the group's five physicians to take on new patients—which means more revenue for the practice.

Some practices cross-train care team members so they can cover for each other when someone is out, or lend a hand when one aspect of the work is unusually heavy. At a nine-doctor primary care practice in Eugene, OR, nurses are trained in scheduling, and schedulers are taught how to handle refills, using protocols developed for that purpose. "This has been very positive for keeping the flow going," says internist Frank H. Littell, who belongs to one of three care teams in the practice. (The others include FPs and pediatricians.) The practice has created even more flexibility by "floating" care-team members from one physician to another on days when one of the doctors is not in the office.

How to create care teams that meet patient demand

Care teams don't just spring into being by themselves. They require careful thought and planning. First, you have to analyze the demand for services in your office, and then see how that work meshes with your existing staff.

The Boston-based Institute for Healthcare Improvement, which has launched a national re-engineering program for physicians, emphasizes the importance of matching the team with the work. (See "Re-engineer your practice—starting today," Jan. 24, 2000.) Failure to do this is a prime reason why, in many practices, the phone is always ringing off the hook, paperwork seems never-ending, the staff is always frantic, and the waiting room is jammed, says internist Charles M. Kilo, vice president and director of IHI's Idealized Design of Clinical Offices Practices initiative.

Let's say that 10 percent of the demand in a pediatrician's office is for pre-school and camp wellness forms, but the staff devotes only 2 percent of its efforts to these exams. No wonder wellness forms always pile up and never get out on time.

"You need to take a hard look at demand and track it on a regular basis," says Kilo. "Not many practices do. But out of that effort comes a much different understanding of how to put together a care team."

Since the right configuration is different for every practice and for different groups of patients, you'll need to measure your own patients' demands rather than rely exclusively on what other practices do.

To get a handle on demand, Kilo recommends measuring:

• Patients' most common diagnoses. Then consider what specific work is needed to care for those conditions.

• The age and sex distribution of patients.

• The needs of patients and what staff must do to meet those needs.

• The volume and content of phone calls.

• The paper flow—how much and for what purpose?

A more detailed breakdown might include tasks related to visit interactions, nonvisit interactions, and other activities such as prescription refills, test result reporting, and hospital rounds. By plotting the frequency of the most important duties against the types and numbers of clinicians available to perform them, you can devise daily and weekly planning schedules.

When you track practice demand and who performs the services, you'll inevitably see areas of mismatch, says Kilo. In most cases, you'll find that physicians are doing work that lower-paid clinicians could accomplish. "The point is not to put doctors out of business, but to free them to do higher-level work they can bill more for, and to build as big a patient base as they can handle," he says.

You'll also find that the work is predictable from week to week, says Kilo. "One of the myths of office management is that demand is not predictable. But that's not true. And that predictability allows a much more exact management of resources," he says. "Understanding the patient population allows the care team to plan its work beforehand."

Stretching the limits of nonphysician clinicians

One physician who has been very successful at getting the most out of his nonphysician clinicians is Bangor, ME, internist Charles S. Burger. A soloist, Burger cares for 4,500 patients. Despite that relatively large number, the office can usually accommodate patients on the day they call.

How does Burger do it? To begin with, he has an unusually large clinical staff for a soloist—two NPs, an RN, and a CMA with advanced training. (Altogether, he has 17 staffers, many of them part-timers.) Linda E. Turner, the practice's operations coordinator, says that hiring a medical assistant to work with the nurse practitioners three days a week has brought a "dramatic improvement" in work flow.

Another, admittedly radical, strategy of Burger's is to assign all routine physical and wellness exams to the RN and the CMA. That's legal under Maine's scope-of-practice laws, so long as the exams involve no assessment or diagnosis, notes Turner. The nurses are trained to follow Burger's protocols to the letter. They are aided by "Problem-Knowledge Coupler" software that asks for information such as blood pressure or cholesterol level, and prompts the clinicians to ask the appropriate questions. They even take Pap smear samples—but are not permitted to do them alone until their trainer certifies that they've done 50 correctly.

Since Burger's patients request as many as 37 physicals or wellness exams every week, delegating the work to lower-level personnel frees a lot of time for the doctor and his two NPs, says Turner. The RN and the CMA spend about half their time doing the exams, and the rest assisting Burger or the NPs.

Patient calls are handled just as efficiently. Patient representatives—some of whom are CMAs—triage every call that involves a request for an appointment. The "Problem-Knowledge Coupler" program helps them determine what level of priority to give a caller. The customized program prompts reps so they know how much time to set aside for the appointment, whether to ask the patient to come in early to complete paperwork, and whether to have the doctor order lab tests or X-rays prior to the appointment.

"We've invested heavily in employee training since 1995," says Turner. "Every employee has attended a 15-week total quality management course at the local college."

Involving the team in the re-engineering effort

Finding ways to help employees work to the best of their abilities is a common theme among practices experimenting with care teams. These offices also expect the staff to supply them with a steady stream of ideas about how to improve the workflow.

Change isn't imposed from the top down; rather, ideas are solicited from those staff members most familiar with particular aspects of the practice. At ThedaCare's family practice group in Appleton, WI, for instance, physicians and staff meet on a weekly basis to talk about what's working, what's not, and what fixes to make, says practice administrator Anne VanEpern. Even staff members who have the day off come in for the meeting.

"Everyone is involved in the decision-making," she says. "As a result, staff members realize that the day-to-day operation is ours to design." They know that the doctors and administrators aren't creating policies behind closed doors, because decisions are made out in the open. She admits, however, that it took time to convince the staffers that they could play a meaningful role.

The switch to this collaborative style of practice management can make life easier for physicians, even as it empowers staff, says Marjorie M. Godfrey, director of clinical improvement at Dartmouth-Hitchcock Medical Center in Hanover, NH. "When physicians let go of control, they no longer have to run interference or play 'Mom' when staff members disagree with one another."

But this democratic approach can take some getting used to. Buffalo, NY, internist Allyn M. Norman says he had to put his ego aside as he made the transition from a very traditional solo practice to one where "we don't have an office manager, but operate as a collaborative." When he and his staff meet informally every few hours to talk about how the day is shaping up, "they tell me what I should be doing. They're not afraid to say, 'Allyn, you don't think you need to do this, but you do.' "

Not everyone will love the process of change

Not all physicians are able to tolerate these changes. Norman was able to do it more easily because he's his own boss. But the situation can be stickier when the physicians feel they don't have any control. When one of Dartmouth-Hitchcock's internal medicine practices launched its re-engineering effort in 1998, nine of the 12 doctors quit in protest. What upset them most, says Godfrey, was senior management's talk about new performance measurements and targets.

Despite this setback, the internal medicine practice is making a strong comeback. Job satisfaction, "which was in the gutter before the doctors left," has increased dramatically, says Godfrey. Surveys show that employee loyalty is greater, and stress levels are down. Meanwhile, patient satisfaction ratings at the clinic are the highest of any internal medicine department in the system, while the no-show rate is the lowest. Best of all, patients who had left the practice along with their disgruntled physicians are returning, to the tune of about 100 each month.

Internist Frank Littell of PeaceHealth has also seen increased patient and staff satisfaction since his office introduced care teams. Equally gratifying, the combination of open access and care teams has improved the practice's operating margin. Care teams have been introduced in three of PeaceHealth's other practice sites, Littell adds.

Many doctors still oppose the use of nonphysician practitioners. Nevertheless, a growing number of doctors view the care-team approach as a logical response to the increased demands and lower reimbursements of managed care. While not every patient will be happy to have a nurse conduct his physical, patients do like same-day scheduling, brief or no office waits, and a relaxed, efficient atmosphere—all of which depend on close collaboration among clinical staffers.

Where to get help setting up care teams

Consider visiting a practice in your area that is engaged in re-engineering. To find one, contact the American Academy of Family Physicians or the American Academy of Pediatrics.

You can also contact internist Charles M. Kilo or his assistant, Sharon Tippo, at the Institute for Healthcare Improvement (617-754-4824 or www.ihi.org) for information and resource materials. The institute has worksheets that can help you map your office's workflow and rethink the way you use your clinical staff. Kilo says the institute may create a collaborative project for practices interested in or already using care teams.

Help your employees stretch their skills

"There are a lot of rote operational clinical tasks that don't require four years of medical school," says Buffalo, NY, internist Allyn M. Norman. Certain things are better done by his nurses, he says, "such as irrigating ears or changing dressings. And the nurse or NP can spend more time talking to the patient about medication or diet than I can. This allows everybody to have a little more time."

Broadening their duties also makes the job more interesting for his staff, says Norman. "People like to work to their maximum level." Of course, when you hire staff, you have to look for individuals who want to be challenged, he adds.

The way to get staff functioning at the upper range of their capacity, says Norman, is to give each staffer a little more responsibility to see what she can handle. "Sometimes you have to push a little. If someone is at the border, you may need to spend a little more time training her, so next time she can do it herself."

He cites a nurse who was initially reluctant to do a soft debridement on a patient with a leg ulcer but eventually learned to do it. "While that task is normally left to physicians, the nurses who work in the intensive care units in hospitals are trained to do it," he says.

When you're considering whether to increase the responsibilities of a particular staffer, however, "make sure you know what the state regulations are," cautions Linda Turner, operations coordinator for internist Charles S. Burger in Bangor, ME. Be careful not to ask your employees to take on something that falls outside the lawful scope of duty for their discipline, she stresses.

This is the fourth article in a monthly series on re-engineering office-based practices. Next up: how to measure how changes improve care, efficiency, and satisfaction. Later installments in the series will cover such topics as redesign of office space, phone systems, how to make the most of each visit, telephone treatment and other nonvisit care, and the financial implications of re-engineering.

 

Carol Pincus,Ken Terry, ed. Deborah Grandinetti. Make the most of your staff. Medical Economics 2000;8:56.