Cover Story

What would make your day perfect?

A consultant asked the author and her colleagues that question—and took their responses seriously. This article shows how well a practice makeover can work when physicians are given their say.

By Mary Ann Bauman, MD
Internist/Oklahoma City

Just a few years ago, I questioned whether I wanted to keep practicing in this highly competitive managed care era where the hours and frustrations multiplied as my personal satisfaction level plummeted.

I work for an integrated health system group practice that was losing money—big time. We doctors were facing substantial salary cuts, and even that might not have been enough for the group to survive. I worried that our immersion into managed care would mean compromising on quality.

Rather than throw in the towel, we embarked on a long-term improvement initiative that gave greater autonomy to individual physicians. Now, two years later, I maintain a busier and more profitable practice, and I believe that quality has improved. Plus, I'm working fewer hours. With the extra time, I answer health questions on a local television news program twice daily, and speak to community groups and schools several times a month. More important, I have time to devote to my family, and am even able to run three or four times a week.

How did we achieve this turnaround? Instead of administrators issuing one-size-fits-all edicts, they challenged physicians to come up with our own ideas to solve our individual practice problems.

I wasn't the only skeptical physician in the room when a consultant we'd hired kicked off the process by asking us, "What would it take to make your day perfect?" I thought it rather idealistic, maybe even naive, like those bumper stickers telling us to "visualize world peace." What's more, the answer was so obvious that surely we'd all say the same thing.

I was wrong on both counts. Although wishing won't make things happen, having a vision is an important first step in improving the way we manage our practices. And the improvements that seemed so essential to me weren't the same as those cited by my colleagues.

My biggest concern was how to keep up with the paperwork without sacrificing quality of care. Another doctor wanted to get control over his appointment schedule so that patients wouldn't fume over long stints in the waiting room. A third wanted to see more patients and earn more income without having to work so late every night. A fourth was frustrated by our phone system, while another worried about staff morale.

So there was no single cause for our dissatisfaction any more than there was a single cure for it. That's the biggest lesson we learned from our consultant, International Council for Quality Care (ICQC), based in Boca Raton, FL. Drawing on its database of best practices, we were able to apply methods that gave each of us greater control over our own practices while meeting the challenge of declining reimbursement.*

We've dramatically increased productivity and efficiency, and made work fun and enriching again for both physicians and staffers. As a result, patient satisfaction is improving.

While our group, Integris Physicians Services, has about 60 employed doctors, we typically work in decentralized two-, four-, or six-physician offices in the Oklahoma City metropolitan area. I work in a four-doctor group. Here are several key strategies that have emerged from our experience. Some are simple to enact, some are complex. But each was important in helping us to differentiate our practices while remaining part of an integrated whole. They might work in your practice, as well.

Get control of your space

Redesigning your work space can be expensive and disruptive, but the right physical layout is essential. So when we began to reorganize, we also introduced a new approach to our office layout.

At that time, we were supported by four nurses, along with a centralized staff of receptionists, records clerks, and other administrative personnel to answer the phones, schedule appointments, maintain files, and handle payments and insurance matters. Now, we've formed four semiautonomous care delivery teams. Each team is composed of a physician, a nurse and a patient service coordinator, who serves as much more than a typical receptionist.

As much as possible, every function of the practice is carried out at the team level. There is a centralized "greeter" at the main entrance, but each team schedules its own appointments, handles its own payments and collections, maintains its own charts and records, and so forth.

To accomplish this radical change, our physical layout was redesigned into a series of separate "pods." Each pod has four exam rooms, clustered around a central work space where the care delivery team has its desks and patient files. The advantages:

• Charts are always close; there's no more waiting for them to be retrieved from some central archive.

• I can generally hear my nurse or receptionist when she talks on the phone, and I can immediately jump in if there's a problem. Sometimes, I've heard my receptionist struggling to explain something to a patient who might be upset. Now I can quickly intervene on the spot.

• The sense of teamwork is enhanced. For the most part, the staff reports to me alone; they don't have to try to remember several doctors' preferences. And they're trained to help each other.

• Patients react positively. There are fewer "gatekeepers" between them and the doctor. For example, each doctor has his own phone number. So my patients call my team directly, rather than go through a central clinic operator.

• Each receptionist handles the payment arrangements for her team. This includes credit card payments, since each pod has its own terminal. I am within earshot when the financial arrangements are settled, and patients are aware that I support the office policy on payment.

• Most important, this arrangement lets me control my workspace. I can organize my exam rooms exactly as I wish. For instance, I keep a copy of each major insurer's formulary in each exam room. It's a simple step, but a tremendous timesaver, and it helps patients avoid problems at the pharmacy.

We've also switched to handheld liquid nitrogen canisters with disposable tips, so we never have to go to a central tank to freeze a simple keratosis or wart. These canisters were a little more expensive, but they last a long time. Having one in each room eliminates wasted time tracking down equipment.

Above all, the workspace is deliberately kept small to reduce steps. In my exam rooms, almost everything I need is within arm's reach, and every item is located where I expect it to be. No more shuffling through drawers or cabinets for misplaced supplies.

Get control of your schedule

I've designated one of my exam rooms as my acute room, reserved strictly for work-ins and emergencies. Other physicians have different preferences, but I found myself frustrated when we placed patients in all four rooms. My personal rhythm simply works better with three.

Even more important, however, is the flexibility the acute room provides. My team members have the authority to work in any patient they need to, and to put him in the acute room. Work-ins are told, "The doctor has a full schedule. You may have to wait a bit, but she definitely will see you."

Obviously, you must have confidence in your staff for this to work, but the advantages are tremendous. Not only does it help avoid denial-of-care issues with managed care plans, but it also makes it easier for me to keep work-ins from throwing me off schedule.

When I'm with a patient in my acute room, I automatically know the patient is here for one specific problem only. If he raises other issues, I politely point out that we worked him in specifically for a particular problem, and suggest a regular appointment for his other concerns. Invariably, patients understand and are, in fact, grateful that I saw them right away to deal with their immediate concern.

Get control of the phones

When I asked my staff to name one change that had made their jobs easier, they immediately pointed to our fax machine. We now require that all pharmacy requests be faxed to us, rather than phoned in. It took only a short time to get all local pharmacies to cooperate.

When patients call us directly, we simply tell them it will be much quicker for them to ask the pharmacy to fax the request. This has proved to be a tremendous timesaver for us and our patients, and it cuts down on the potential for medication errors. In keeping with our decentralized approach, we installed a fax machine at each physician's pod.

Each physician decides for himself how to handle phone calls. Some of my colleagues prefer the menu system: Press 1 for new appointments, press 2 for questions about lab results, etc. While that works for doctors with a higher volume of patients, I don't favor it. My staff is able to handle our volume of calls, and patients prefer to get a live person on the phone. But because what works for me may not work for my colleague, each of us can do it his own way.

Get control of the paperwork

Here again, the pod concept is key. In addition to letting us keep all patient charts where we need them, each team can customize its filing system.

For example, at the suggestion of another physician in the group, we no longer file charts in strict alphabetical order. Instead, we use just the first two initials of the patient's last name, and the first initial of her first name. So John Doe's chart would be filed under "DO-J," along with Jane Doss and James Dolan. It's surprising how much time this saves since we no longer have to search for a very precise location for each chart. Instead, the staff simply groups any identical three-letter codes together, making refiling especially fast.

We also color-code chart folders to indicate the insurer. Obviously, every patient receives the same level of care regardless of insurer, but knowing which plan is in effect saves questions when it comes to prescription formularies, referrals, and other issues. We also color-code the charts of patients who are participating in trials or studies.

Some of the 60 doctors in our system now dictate chart notes in front of patients so that when the last patient leaves, they don't face a stack of unfinished files. One physician relies on an employee, who follows him into the room and takes notes on what he says. That note becomes his dictation, and helps meet the difficult documentation guidelines for Medicare. I always dictate my notes during or immediately after the visit, while the patient is getting dressed. When the patient leaves, the dictation is complete.

Streamline relentlessly

Little things mean a lot when it comes to creating a "perfect day." For example, I used to send a letter to each patient to report lab results. Patients liked this, but it took a lot of time—from dictation to transcription to signature to copying and finally to mailing.

When my staff and I learned that one of my partners was using a form in which he simply filled in the test results, we decided to build on this idea. We started using a two-part form, pre-punched to fit the chart. We ask the patient to fill in the top section (name, address, etc.) while she 's waiting in the exam room.

So now, instead of dictating a letter, I can just fill in the values for the test and jot a brief note at the bottom so patients know I've seen the results. Using a window envelope with the two-ply, pre-punched form eliminates three more steps (addressing, copying, and hole-punching the file copy). What's more, by having the patient fill in the information, we can check for any address changes.

We also automatically print a series of labels, with the patient's name, address, health plan information, phone numbers, etc. for each appointment. Then, any requisitions, correspondence, lab forms, or other documentation generated by the appointment don't have to be labeled by hand. Saving a few minutes with each patient adds up to significant time.

Make it a team effort

Each physician hires and evaluates her own staff and involves them in major decisions. For instance, when I hired a new patient service coordinator, I made sure my nurse had the opportunity to interview every candidate.

Coverage also works on a team basis. If I'm out of town, one of the other doctors is designated as on call and will see my patients in his own pod area. He'll then dictate a note, and I'll get a copy for my chart.

My staff doesn't take vacations at the same time I do. If I'm away, I want my team there to take calls, manage the office, and help out the other pods in our group.

This last point is important because one problem we have to guard against is "pod-itis," the territoriality that can come with working only for your own pod. Since a nurse works for me, she might feel that she doesn't have to help out Dr. Smith if he gets really busy. We let the staff know that we're still a joined practice and helping the other pods is essential. But this can be a challenge sometimes.

So far, we haven't had a staff member ask to leave one pod for another, but that could crop up, depending on convenience or compatibility. We'll deal with it when it occurs.

Our governance structure includes every member of the team and reinforces the idea that our pods are connected. We doctors meet once a week to review our managed care referrals and discuss clinical issues. The entire office staff—from all four pods—meets monthly to discuss our policies or clinical events, such as how to prepare for an upcoming accreditation survey. Each pod team meets monthly to work on some quality improvement procedure, such as scheduling or patient education.

Reward effort with bonuses

We're still tweaking our staff bonus system so that it's based on quantifiable events rather than subjective judgments. We're concerned that someone might think he's working hard, but his efforts aren't being noticed or rewarded. So we have criteria for the staff to qualify for bonuses.

One example is "no unexcused absences in a quarter." Of course, some absences are unavoidable, but they really throw off our schedule, and everyone else has to scramble. So consistent attendance at work should receive a bonus. Participation in our monthly pod meetings is another criterion. That sure helps attendance and keeps the lines of communication open. We also encourage staff members to come up with ideas for quality improvements.

Our group's administration handles much of the billing and collections, and we make sure these employees are included in the practice bonus plan. They're invited to our staff meetings and are considered a regular part of the practice, not just some ancillary service group.

Employees typically receive quarterly bonuses tied to physician productivity and profitability. The bonus formula is somewhat complicated, but the doctors with the most profitable practices get to distribute a greater share of bonuses to their employees. Still, employees of newer physicians whose practices aren't up to speed yet also work hard to qualify for bonuses. So far, the amounts have ranged from $200 to $1,700.

Never stop changing

As the saying goes, we can "change or be changed." Ultimately, change works better when we take charge of it, instead of waiting for it to be forced upon us.

For example, in advance of an upcoming JCAHO review, the physicians in our group recognized that we would all be required to use the same chart format. Each of us had worked for years to develop a chart we were comfortable with, but we had to change. By combining the best ideas from several chart formats, we ended up with one that actually works better than the old charts we were so proud of.

The next change for my practice will be the introduction of ICQC's precision scheduling—booking appointments in multiples of five minutes, rather than a standardized one-size-fits-all interval for every appointment. We may eventually decide we don't like it, but the important thing is to be willing to try something new.

Some physicians are farther along in patient education efforts than I am. So my pod will be working on that soon. We're gathering education materials and checking with others on how they do things. One of my partners just finished working on a system to reduce waiting times for patients. At our meetings, we'll discuss how it's working and see whether we can use it for our pod.

Find your own way

Some of these ideas will probably work in your practice, and some won't. Our way certainly isn't the only way. But the major changes we've made here prove that you can increase productivity while simultaneously improving patient care and employee morale.

Above all, we must overcome our feelings of victimization. When I first started seeing more patients under managed care, I resented having to spend a few hours every Saturday finishing up paperwork. Eventually, though, I realized that this was my own choice, in part because I don't like to have anything left over to finish the next week, and because I prefer to leave early some days to pick up my daughter at school. Once I determined that it was my choice to come in on Saturdays, I stopped being a victim and was happy with my decision.

That's the key, really—staying in control of your own destiny, in matters both large and small. To all of those doctors who have determined that medicine these days drives them crazy, I say you can diminish your level of frustration.

Once we instituted this new system, we physicians voluntarily took a salary cut of 15 percent. But the majority of us had greater income than the previous year because of bonuses from improved productivity. In 1997, Integris lost $9.7 million on our employed physician group. Losses for fiscal 2000 were less than $3 million. After next year, we expect the company to break even.

While no one has a "perfect day" all the time, I've learned that it's not unrealistic to strive for one, even within today's challenging environment. But you must begin right away, by taking a genuine step—even a small step—toward your goal.

*For more ideas on how doctors are re-engineering their practices, check our Web site (www.memag.com) under "Practice Management" in "The Medical Economics Library."

 

Mary Ann Bauman. What would make your day perfect?. Medical Economics 2001;2:104.