Time is money: 4 ways to manage practice productivity, organize staff

Time is the physician’s most important resource. Although healthcare is moving toward fee-for-outcome-based payment models, most physician income still depends largely on effective time use based on the number and intensity of services provided. Because reimbursements do not seem to be keeping pace with escalating costs, physicians need to focus on efficiency. 

Harnessing time by creating workflows and processes can boost physician and staff productivity, increase revenue and improve patient care. But physicians face regulatory and administrative burdens on a daily basis that threaten their ability to use time most effectively. There are strategies doctors can embrace to improve productivity, and reduce these daily hassles.

It starts with putting detailed processes in place that physicians and employees can turn to when navigating challenges, allowing each practice member to do the work they are trained to do, and freeing up the physician to do what he or she does best: treat patients.

“This is about taking decision-making out of a doctor’s hands, and placing it in the hands of a protocol,” says Frederick Turton, MD, MBA, MACP, medical director of general internal medicine at Emory University Hospital Midtown in Atlanta.

1. Mapping workflow

It’s often hard to identify tasks that could be performed capably by another employee or done in a more efficient manner because activities just become part of the everyday workflow with no real rhyme or reason. This is why a workflow analysis is a crucial step to improving efficiencies and productivity.

Performing a workflow analysis can be a lengthy process. It involves looking at every process and mapping out each step and who performs it. Because there are dozens, if not hundreds, of processes to choose from, practices should start with obvious pain points, says Jeff Hummel, MD, MPH, medical director for healthcare informatics at Qualis Health, a Seattle-based nonprofit healthcare quality improvement and consulting organization.

Physician practices looking to start mapping processes should focus on three key areas that can provide the most benefit, says Frank Cohen, MPA, a practice management consultant in Clearwater, Florida and Medical Economics editorial consultant.

The key areas to map include:

• the patient visit (from check-in to check-out),

• the billing cycle (from patient check-out, through the reimbursement process, to payment posting), and

• the clinical event

Each of these process areas can be broken down into more distinct processes. For example, in the clinical event area, the practice could analyze the turn-around time for imaging or lab results, charting every step along the way from the patient encounter when the test was ordered, through the referral or performance of the test, and ending with patient notification of the test results and next steps.

Next: The five C's of process mapping

For each workflow mapping project, every employee who touches that process must be identified and involved, says Peggy Evans, PhD, CPHIT, consulting director with Qualis Health in Seattle. Employees then meet and, literally, draw a map using a large white board or paper easels that shows each step of a
process.

Writing out the process in incremental steps is vital, Cohen says. “Most practice managers and administrators are virtually clueless as to how each of the processes work, which steps are involved and the data that surround those steps,” he says. “The process map details each step. It helps to identify steps that are not necessary, that don’t benefit the practice or the patient.”

The key to making sure the new process works is by mapping the old, or existing, process. To do that, practices must collect baseline data to define the baseline for whatever problem it is attacking and set goals for improvements. One of the first steps after identifying the process to be mapped is to figure out how to collect data to measure that, Cohen says.

Hertz says the practice should look at each step and ask, “Why are we doing this?” The steps most hazardous to a practice’s health are those for which the answer is, “because this is the way we’ve always done it.” There must be a value associated with each step. If that step does not provide some type of value, it should be considered waste.

The next step is defining the desired improvements and re-designing the workflow to achieve that outcome. Once a new process is put in place, the data should be run again a month later and compared to the baseline data to see if the changes are working, says Evans. If things are not improving, the workflow may need more tweaking. This is why the baseline data are important, and why workflow redesign can often take a year or more to complete.

Hummel says efficiencies can be realized with a workflow that includes daily morning huddles. He explains that in most settings, the day starts with the medical assistant (MA) preparing the exam room and the doctor seeing the first patient.

But if the MA spends a few minutes with the doctor at the start of the day going over the patient list, it will help the MA know what to prep for each patient. If the MA knows the patient at 11:15 is coming in to go over a report, she can have that report ready. If the MA knows the 1:30 appointment is getting a PAP test, she can have the set-up ready to go.

The front desk can also help make the examinations go more smoothly by giving the patients their medication lists to review in the waiting room, crossing off old medications and adding new ones. Because the patient is already thinking about the medications before he or she enters the exam room, time will be saved, Hummel says.

Workflows also can be crucial for dealing with staff turnover and training new employees, because new employees will have defined steps and procedures to follow and refer to, Cohen says. He says training a new front-desk receptionist will go much more smoothly if that person has a map on the wall that details every step in the patient check-in process, including how to address difficult issues such as collecting payment in advance, declined insurance, or complicated changes in patient data.

“It will shorten the training process, and more important, everyone is on the same page resolving challenges the same way,” Cohen says.

Next: Working at the top of your license 

2. Working at the top of your license

Kenneth Hertz, CMPE, principal with the MGMA Health Care Consulting Group, once worked with a physician who liked to give patients brochures and handouts. He had an original copy of each one and every time he wanted to give one to a patient, he left the exam room to make a trip to the copier.

It was a nice gesture, recalls Hertz, but there were plenty of people in that practice qualified to make copies besides the highest-credentialed member of the staff.

Physicians are often the busiest people in a practice because they feel they can do everything better than anyone else, Turton says. And while that may be true, there’s no reason for physicians to perform work that can be performed by a lower-salaried worker. Turton says it’s about “allowing the least trained-but still qualified-person do the work.”

If physicians focused on the things only they were qualified to do while delegating the remaining tasks to others, they will gain more time in a day. When this concept trickles down to every member of the staff, no employee will be performing work they are overqualified to do and tasks will be assigned appropriately.

But delegating must be a standardized process based on protocols, says Turton. The way to do this is to create protocols for various functions, from scheduling patients to conducting wellness exams.

For example, Turton says practices should create a prescription refill protocol that allows refill inquiries to be routed to a certified staff member so that most refills can be authorized without the physician. The times when a refill needs to be brought to the physician’s attention should be outlined in the protocol.

Many practices are turning to non-physician providers (NPPs) such as nurse practitioners and physician assistants to help improve practice productivity. While they aren’t able to provide all of the same services as a physician, NPPs can perform a large number of services such as routine well visits or diagnosing and treating minor acute problems. According to the MGMA, practices that employ NPPs perform better financially.

Effective delegation to NPPs can also improve outcomes. Turton says that his practice improved adherence to diabetes markers by creating a protocol that called for having medical assistants conduct the basic interview with patients and perform A1c tests and foot exams, based on protocols designed by the physician.

A practice must decide exactly how the NPP will fit into the workflow. The NPP’s job description should include work that he or she is credentialed to perform and for which the doctor is over-qualified. A practice can achieve ultimate efficiencies when it continues this exercise for each staff member: if there is work an NPP is doing that an RN is qualified to do, or work an RN is doing that a medical assistant (MA) is qualified to do,  changes to the practice’s workflow may be required.

Next: Patient portals

3. Patient portal

For James Morrow, MD, installing a patient portal presented an opportunity to improve communication with his patients without the use of other employees’ time.

From anywhere, at any time, patients can send a message. Patients can also access their lab results, request prescription refills, or schedule an appointment without the time-draining routine of calling, leaving a message with the front desk staff, waiting for the message to be relayed to the appropriate person, then waiting for that person to respond.

Because he is able to message the patient back directly whenever he has a free moment, the patient gets a much quicker and satisfactory response, says Morrow, chief executive officer of Morrow Family Medicine, a primary care practice in Cumming, Georgia. “It just makes everything about the communication better, in my opinion,” he says.

Few comprehensive studies have looked at both the financial and administrative benefits of patient portals, according to a May 2011 literature review conducted by the California HealthCare Foundation. But numerous studies have shown the potential for patient portals to lower costs and improve practice productivity. A 2005 study in the Journal of Healthcare Information Management, for example, found physicians that using secure messaging had a 10% increase in productivity.

“Everyone is trying to do more with less and trying to save where they can, and [secure messaging] is a tremendous place where you can save. It’s remarkable the monetary savings that can come from that,” says Morrow.

While no practice will ever have 100% participation in its portal, it’s possible to get close to 90%, Morrow says.

The best way to do that is to tell patients that this is the way you are doing it now, instead of saying, “Well, if you’d like to, you can get online,” explains Morrow. By explaining the benefits to patients, most will be eager to sign up, even the older patients, he says.

Creating a process for staff members to inform patients about the availability and  features of the portal is key. One option is to have staff members assist patients with registering on the portal while in the office. Overcoming the registration barrier will introduce more patients to the portal.

A 2011 case study by the Office of the National Coordinator for Health Information Technology illustrated how medical practices can best implement patient portals and reap their benefits. The Primary Health Medical Group, an Idaho-based independent practice with 11 clinics, uses a coordinated strategy to inform patients about its portal that includes distributing fliers and posting materials at the clinics, and providing talking points for staff to encourage patient registration.

The practice developed a flow for patient messages, including a determination of whether messages should go directly to the physician or to another provider. They built templates for common messages such as delivery of lab results. The messages were monitored and reviewed to ensure they were succinct and patient-friendly.

The result? Secure messaging to provide patients with lab results resulted in five to 10 fewer phone calls to the practice each day. In addition, patients responded to portal messages at a much higher rate than to phone calls. The portal helped financially, too, cutting down on the practice’s expenses by reducing the amount of overtime staff members had to work.

Next: Motivating employees

4. Motivating employees

No initiative will be successful without buy-in from employees. Employees must be willing to accept that they might not be as efficient in their jobs as they could be, and they must be open to change. How to get them in this mindset can sometimes be tricky.

 Building a motivated team starts with hiring, Hertz says. In the interview process, practice leaders need to share their vision and culture and determine whether that candidate shares the same commitments.

But employees still like to be recognized for a job well done. While financial incentives may seem like the most effective form of motivation, it is possible to motivate employees without the promise of a hefty bonus at the end of the year, something that most physicians cannot afford to offer.

The staffing and human resources consulting firm Adecco has a set of recommendations for rewarding and recognizing employees. Among them is to involve employees when developing a recognition program. The reward doesn’t have to cost a lot of money; it can simply be a token of appreciation. When employees help to decide what that token will be, it becomes more meaningful and motivating to them to work harder to obtain the reward.

Adecco also recommends giving a reward to all who meet the set goals instead of holding contests. If the entire staff accomplished the task given to them but only one person receives recognition, there will likely be one person feeling appreciated and a handful of others who feel resentful.

Many of Adecco’s recommendations come down to building an appreciative culture inside the practice: saying ‘thank you’ often, nurturing self-esteem and recognizing behaviors, not just outcomes.

Little gestures also can go a long way. Hertz says a great example he once saw was a physician who sent a handwritten note to three employees each month, recognizing something special they did. Another possibility is to hold fundraisers for community causes and allow employees to take turns deciding which causes will be supported.

Practice leaders who treat employees as respected members of their team instead of subordinates will find a higher level of motivation. Employees must feel respected and valued, says Hertz.

“None of that costs any money,” he says. “Give them good direction and good training. Treat them like human beings with respect and let them know how they fit in.”

Valuing the opinion of employees can do more than just make them feel good. It can also help empower them to drive positive changes in the practice. They know their jobs better than anyone else, so when the practices is looking for ways to improve efficiencies, those employees will likely have the best ideas.  

Next: Improve time management by avoiding 'batching'

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