Re-engineering Your Practice

Pick the team, and write the game plan

Here's how to take the first steps toward boosting productivity and patient access.

By Neil Chesanow
Senior Editor

To meet evolving health care needs, more and more primary care physicians are re-engineering practice systems and structures. Sooner or later, you'll have to join them if you want to remain competitive.

But redesigning your office systems isn't something you should undertake lightly. While it should raise productivity and patient satisfaction, it will also radically change the way you and your staff work. So before you start, you should know what you're doing and why.

If you've had experience with continuous quality improvement and felt frustrated by its complexity and slowness to deliver results, you may be hesitant to embrace another fancy-sounding problem-solving method from the corporate world. "I did CQI both at the hospital and the office," says pediatrician Ronald E. Miller of Magic Health Partners, a 15-doctor family medicine and pediatric group in Twin Falls, ID. "It's not a method for making rapid, measurable change. CQI projects could take years. We want projects that take weeks, maybe days! We want quick successes that people can immediately see."

By rapidly testing specific innovations, Magic Health Partners successfully tackled one re-engineering project after another during a year-long period. The practice went to open-access scheduling, slashed chart dictation turnaround time, repositioned staff to maximize productivity, redesigned its waiting room, and made other improvements that have patients, staffers, and doctors "falling out of their chairs," according to Miller, the group's office im-provement leader. (See "Re-engineer your practice—starting today," Jan. 24, 2000.) Throughout this intensive, often challenging process, the group's physicians continued carrying their full patient load.

How do you start such an ambitious undertaking? How do you organize your staff to help? How do you find out where changes are needed? And how do you make them without upsetting your office routine too much? Here are some answers.

First, make sure you're committed to change

Being asked to give up old ways can be upsetting. Doctors and staff may resist change without strong leadership from above. "We tell the CEO or physician leader that he's accountable for selecting the redesign team," says Roger Coleman, a Pegram, TN-based consultant who helps re-engineer primary care practices. "He's the only manager in the practice responsible for all or most departments. So the team must report to him, not to someone lower in the organization who can be ignored. He must kick off re-engineering by announcing to the organization, 'I insist we do this!' Without genuine commitment at the top, nothing happens."

Expect the ripples of change to extend to everyone in your practice—including you. Coleman recalls one client, the lead physician of a multispecialty group, who was all for re-engineering his clinic—until he found out that the new system called on him to arrive punctually for work each morning. Change not openly embraced by the leader will be ignored by the troops.

The biggest hurdle for soloists and doctors in small groups is giving up some physician control and shifting decision-making responsibility to the staff. But this is a must for re-engineering to succeed. Recognizing this fact, Charles S. Burger, a solo internist in Bangor, ME, sent his staff to a local technical college to attend seminars in quality improvement. Several staff members were trained to facilitate redesign meetings. Says Burger: "We look at our staff as investments rather than costs." To make the most of a redesigned practice, you'll need to, as well.

Choose a redesign team of your best and brightest

In a small practice, you might dragoon the entire staff to plot practice redesign. Burger has divided his 17 full-time and part-time staff members (including his two NPs) into two teams. One focuses on improving patient care, the other on improving service. Some employees are on both teams.

Coleman recommends that a team be composed of four to six people, including at least one physician. Larger teams tend to bog down meetings and slow decision-making.

Whom you choose to be on the team is vital. "Give us your best and brightest," Coleman tells clients, which include primary care practices of two to 50 doctors. "We're looking for people with certain key traits." If you have the luxury of choice, he suggests asking yourself these questions:

• Does the staff respect this person's judgment?

• Is she a team player?

• Will her area of expertise make for a varied team?

• Is she an excellent listener?

• Is she an excellent verbal communicator?

• Is she a proven problem solver?

• Is she frustrated with current systems and processes?

• Is she demonstrably open to change and new technology?

Politics and deference to a candidate's rank aren't criteria for team selection. "A large practice might suggest a nursing supervisor, because they can't get anything done without her cooperation," Coleman explains. "We say, 'That's no reason to put someone on a team.' The team will create a redesign that works well for patients and staff and boosts productivity. If you let one person stand in the way, then you have a management problem that needs to be dealt with individually."

NP Pat Pickering, a re-engineering coach at Coleman's firm, says, "Ideally, your team should include a doctor, a nurse, a front-office person, and a financial person." It's also wise, says Pickering, to seek people with these complementary personalities:

• A visionary who isn't rooted in the status quo and who sees how things could be.

• A detail person to remind the team's innovative thinkers what they decided last time they met.

• An informal leader—not necessarily a manager or supervisor, but someone whom the masses follow. When it's time to enact changes, this person can smooth the way.

• An outsider. She may be from another department or site, or a new hire. As someone who isn't yet immersed in the practice culture, she has the objectivity to ask, "Why do things that way? It doesn't make sense."

• An in-your-face person—someone you'd normally slip out the back door to avoid. If she's willing to stand up to you for legitimate reasons, says Pickering, she'll withstand pressure to agree with the team simply for the sake of group harmony.

Train the team to collaborate effectively

Unfortunately, you can't cram staff members into a room, clap your hands, and announce, "Let's fix things." First, you have to enlist their help.

That's what internist Allyn Norman of Buffalo, NY, did, with good results. His initial re-engineering project was to move to open-access scheduling, so that patients could get appointments the same day or the next day. Working down his backlog of appointments required the soloist and his staff to put in longer days for about three months.

"It was tough breaking the news to them, but they knew me well enough to say, 'We'll try it for a while,'" Norman recalls. "They were very specific about going along for a limited time, though." That's another reason why quick results are vital.

Team members—be they doctors, nurses, medical assistants, clerks, or receptionists—should know that they're all equal, at least while wearing their re-engineering hats. In meetings, they should address each other by first names to reinforce the leveling of rank. This helps nonphysicians overcome their natural tendency to defer to physicians, which hinders collaboration. For the same reason, avoid putting a subordinate and her superior on the same team. Although the team needs to choose an informal leader to facilitate meetings and share progress with the practice leader, Coleman stresses that the role is merely first among equals. Success hinges on the team hierarchy's remaining flat.

Your staff may need to learn new communication skills to collaborate effectively as a team. "We follow fairly formal rules for how we interact in groups," says Charles Burger. "The meeting facilitator's job is to ensure that those rules are followed. We don't, for example, want people jumping up at the same time and trying to speak. They should raise their hands, wait to be acknowledged by the facilitator, and be respectful." Team members are taught how to avoid personal attacks and present contentious issues objectively rather than emotionally.

If your staff needs training, local colleges can help. Courses in assertiveness training, effective communication, negotiation, and/or conflict resolution should impart the necessary skills.

Give the team time to meet without adding to their load

Small practices, in which the entire staff may serve as a team, tend to meet before or after work or during lunch, commonly for an hour. Initially, they might convene several times a week. Once re-engineering is under way, weekly meetings seem to be the rule.

That's not what Roger Coleman recommends to his clients, however. In Coleman's system, a team initially assembles each week, preferably off-site to eliminate interruptions, for one to two meetings lasting four hours each. If meetings are less than two hours long, "creativity and breakthrough thinking don't have time to occur," Coleman maintains. When meetings last over four hours, "people just waste the time."

Staff downtime may be re-engineering's greatest expense. Some groups hire temps to fill in for team members or ask co-workers to share a colleague's workload while she's at a meeting or conducting a test. Other clinics remain open with a skeleton crew while some staff members are off-site.

The time spent on re-engineering should be considered real work, Coleman asserts—not something people are asked to do in addition to their normal workloads. He also urges that meetings be scheduled during business hours, not before or after work, although smaller practices may have no choice. Being on a re-engineering team is stressful, Coleman points out. Deadlines are tight. All eyes are on the team. Not being forced to work overtime helps to keep team members from burning out.

Analyze office processes to spot the bottlenecks

Once your redesign team has been assembled and trained, it's time to analyze your office processes. Have the team split up into pairs to track and map patient visits. One member of each pair accompanies a patient from the time he enters the office until he leaves. She sits with the patient in the waiting room (for an hour, if necessary), joins him at the front desk, and may even accompany him into the exam room, if she's a clinician.

The other person observes the processes that the patient doesn't see, Pickering explains. "Has the front desk done its thing, and is the chart posted? Why isn't the medical assistant escorting the patient to the back? Where's the provider? Is there a bottleneck at the front desk? Is the receptionist getting 15 phone calls? Is she losing paperwork? Is it taking forever to get a form in? Why isn't the back office reacting to the front office? So the team doesn't track paperwork, the physician, and the patient separately. It tracks them together, because they intertwine."

Each pair of team members maps two patient visits from start to finish, using a simple flow chart. On the chart, they note the time when each step began and ended. So a six-person re-engineering team will produce 12 patient maps—sufficient to convey an accurate, real-time snapshot of how the practice functions and where the bottlenecks are.

The findings are invariably a revelation to team members. "Everyone gasps, 'I had no idea!' " says Pickering. "People are often appalled at the way patients are treated in their office. We make the CEO and staff do a walk-through, because it's such an eye-opener."

Patient and staff surveys can also help you avoid mistakes when you redesign your office. Before switching to open-access scheduling, for example, in-ternist Allyn Norman wanted to ensure that daily patient demand in his Buffalo, NY, practice would be sufficient. Over four weeks, his staff surveyed each patient who phoned. They tracked the total number of calls, the reasons for the calls, and how many patients would accept a same-day appointment, if offered. A significant number of patients said they would.

Pick projects with a quick payoff

Avoid broad, abstract agendas, like: "Let's redesign the entire practice." To achieve quick results, keep goals specific. Magic Health Partners was able to zero in on a specific goal after it surveyed its patients. The practice is the result of a recent merger between a family medicine group and a pediatric group, and patients complained that they no longer knew whom they were talking to when they phoned the practice. Patients also said they wanted to see their own doctors, not whoever was available.

The practice responded by repositioning staff. "Instead of having schedulers in the front of the office, we moved them to the back with the doctors," says pediatrician Ron Miller. So if Miller's scheduler wants to know if he can see a patient that day, she just asks him, because he's usually within earshot. "She no longer has to tell patients, 'I don't know which doctors are in the office right now, where they are, or how many patients they have,' " says Miller. "And patients get to know my scheduler on a first-name basis."

HealthNet Community Health Centers in Indianapolis had no choice but to take a step-by-step approach to re-engineering at its Southeast Health Center, where three physicians care for 20,000 patients. "The center was frantically trying to get through the day, because patient flow was so chaotic," observes Pat Pickering, who coached Southeast's redesign effort. "We just wanted to clean up the flow so that the providers could say, 'Gosh, this is really better.' Then we could think about other things—like improving chronic disease management."

Among Southeast's innovations: Medical assistants were trained to take notes for doctors, which made charting more efficient. Triage was moved from the back of the office to the front, which slashed waiting times for patients with minor injuries or those who sought mainly prescription refills. Doctors were assigned their own nurse/medical assistant teams for more effective and consistent support. Receptionists in front of the clinic were equipped with two-way radios to communicate with doctors in back. Walkie-talkies, the team found, worked better than light boards, chart racks, or phone calls in getting a doctor's attention and keeping him aware of his patient load at any given time.

Do trial runs before making changes

After conducting research and identifying specific problem areas, the team next has to take a crack at some solutions. Soloists and small groups may choose to pack providers and staff into one room where people throw out ideas. At other practices, teams split up so that members can work on a problem individually. They then reconvene to trade notes and collectively choose the best ideas to try first.

A team's ideas may look good on paper, but each must be tested to see if it really works. Plan to test in stages to minimize disruption to practice operations. Pickering suggests setting up a temporary operation in the least trafficked wing of the clinic, or running a test on a Friday night or a Saturday for 3 to 4 hours, starting with just one team and one provider. If that works, you can expand the test incrementally.

"As the new plan progresses and gets smoother during subsequent tests, add more variables—more patients, more staff," Pickering advises. "Keep challenging the new system to see what it can do. Perfect it through testing. You may need six tests; you may need 12. But conclude them in 8 to 12 weeks. Then, put the redesign into place full time in the affected area for a full-blown trial run, with the whole staff involved."

Re-engineering is an ongoing process. There will probably always be something in your office that needs reinvention to improve productivity, patient satisfaction, or the quality of care. Internist Allyn Norman, for example, is creating registries of all his patient populations, so that when, say, a woman over 40 who's diabetic and hypertensive appears for a breast exam, all her problems will receive attention in a single visit.

Magic Health Partners is pondering how to improve access to patient charts. Ron Miller is also toying with the idea of eliminating the group's waiting room. "We don't want patients to wait at all," he says.

Maine internist Charles Burger is investigating whether his young, healthy patients need a two-part physical spread over two appointments. One of Burger's two NPs kept records of how long it took her to conduct a physical. Many patients required only 30 minutes, half the time allotted.

Burger's other NP has now been asked to present her own data during a team meeting. If it mirrors her colleague's, the conduct and scheduling of physicals will be redesigned, at least for some patients. A disparity in the data would also be investigated by the team. It might be that one NP works slower than another, but that's not necessarily a sin. The faster NP might be rushing patients through their exams. Burger's challenge: to fine-tune each system just enough without sacrificing patient satisfaction to efficiency.

How to learn more about re-engineering

Some of the practices mentioned in the accompanying article are participating in a national re-engineering project. The program is sponsored by the Idealized Design of Clinical Office Practices project of the Institute for Healthcare Improvement in Boston (617-754-4800, www.ihi.org). A cooperative of some 40 physician groups, IDCOP offers a trove of information about what works and what doesn't in practice redesign. (See "Re-engineer your practice—starting today," Jan. 24, 2000.)

You might also consider a re-engineering consultant. At the moment, most of the ones working in health care focus on hospital redesign, although that's expected to change. One firm that does specialize in primary care practices is Coleman Associates (4517 Scenic Drive, Pegram, TN 37143; 615-646-9519; fax: 615-662-0548; e-mail: rcole9519@aol.com). Coleman's fee—$4,500 per practice—covers phone counseling, an on-site visit, and a three-day retreat with a coach.

The Reengineering Revolution: A Handbook, by Michael Hammer and Steven A. Stanton (HarperBusiness, 1995, $15), is one of the books that sparked the current re-engineering trend. Hammer enumerates the principles of re-engineering and shows how to put theory to pragmatic use. While the book's examples are all from the business world, it's easy to see how they relate to medical practices.

This is the second article in a monthly series on re-engineering office-based practices. Next up: how to make the transition to same-day scheduling of patient visits. Other installments in the series will cover such topics as care teams; redesign of office space; phone systems; how to make the most of each visit; telephone treatment and other nonvisit care; measurement of how changes improve care, efficiency, and satisfaction; and the financial implications of re-engineering.

Ken Terry, ed. . Pick the team, and write the game plan.

Medical Economics

2000;4:74.