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American College of Physicians Annual Session

Philadelphia, Pennsylvania
April 6-8, 2006

Workflow Design and Practice

Efficiency: Saving Time and Money
While Enhancing Quality
Mary S. Applegate, MD, FACP

No significant relationship to disclose.

Posted Date: March 20, 2006

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Work Flow Design I.
Pay for performance
& A.
Clinical tasks
Non-clinical tasks
C. Good work habits

Practice Efficiency D.
No batching
Work in the now
Happy healthiness
Saving Time And Money While A. Difficult patients
B. 5 Fundamental steps of efficient visit
Enhancing Quality 1. Opening the interview
2. Establish expectations
3. Elicit beliefs
4. Collaborative decision-making
Close the interview
ACP Annual Session 4/06 5.



Introduction Pay For Performance (P4P)

™ Why Efficiency Matters? ™ Concept: Pay physicians (more) for high quality care!
™ Goals: Improved:
™ patient outcomes
™ chronic disease management
™ rate of errors
™ efficiency of delivery systems
™ patient safety
™ quality of care
™ financial bottom line
™ Challenges
™ Physician participation/cost
™ Measuring and tracking data
™ Huge Financial Implications
™ Following proper mix of quality measures
™ 2 minutes / patient = 2 extra visits / day = $10,000 / year
™ Negative incentive to care for the complex or socioeconomically
™ Home earlier disadvantaged
™ Pay For Performance ™ Threat to physician professionalism autonomy and job satisfaction

Efficiency is more important than ever

Take time to save time

How do you spend your time?
Patient perspective
Physician perspective

Productivity Productivity
™ Examine all non-clinical physician tasks and

™ Physician’s time falls into 3 categories ™ Clinical Tasks:

™ Productive (maximize this!) ™ Can any be done by a non-physician (with
appropriate supervision)?
™ Wasted (eliminate this)

™ Delegated (hire staff for this)

Productivity Productivity
™ Non-clinical tasks ™ Clinical Tasks
™ Searching for charts and records
™ Staff to find, pull, and print from computer in advance (day before?) ™ Returning calls to patients
™ Searching for staff ™ delegate most
™ Cross-train in staff routing slips
™ Searching for numbers and contact info
™ Returning calls to hospital/ECF
™ PDA, computer accessible ™ MLPs,R.N.s may help
™ Searching for test results
™ Easy computer access at work station
™ Returning calls to physicians
™ Filling out order forms ™ minimize interruptions by designating time, utilize pager system.
™ Sign only; use templates so staff can help ™ Group related calls together.
™ Looking up ICD-9 codes
™ Top 20 cheat sheet, train front staff ™ Educating about basic health care, medication usage, disease states
™ Getting drug samples ™ delegate to nursing staff, preprinted materials, email articles, give out websites
™ Delegate
™ Walking ™ Clinical form filling
™ Work in the “field” ™ create RN Queen of Forms to help
™ Socializing, family calls
™ Monitor and manage appropriately. ™ Looking up information
™ Surfing the web ™ PDA; computer resource
™ Don’t
™ Waiting for results/patients/etc
™ Retrieving test results/plans
™ Problem-solve with staff ™ protocols to prioritize urgency
™ Driving between work sites
™ Adjust schedules
™ Writing and Finishing notes/dictations (paperwork) “doctoring”
™ only you can do

Productivity The Value Chain

™ How much does your physician’s time cost?
™ Remember, the physician’s time is ™ For 55 hours a week times 48 weeks a year
™ The most valuable asset of a medical practice ™ $200,000 salary - 158,400 minutes a year =$1.26 a minute or
™ The primary financial driver of profits $75.76 an hour
™ The main source of job satisfaction and quality health care

MGMA 2003
™ When the physician waits, it is time and money wasted.
MGMA 2003

Productivity Productivity
™ How to make the most of your “doctoring” time ™ Stop all that “Batching”
™ Batching = putting off work or organizing it to work on later.
™ Develop good work habits ™ It can become an unhealthy addiction
™ Be prompt/early to prepare for the day
™ It is not efficient and compounds the inefficiencies
™ Paperman trumps PDAs for time management
™ Know your approximate schedule
™ Avoid batching
™ Work in the “now”, real time
™ Pace yourself: do difficult job first
™ Build in rewards

End of day fatigue

1 minute longer per patient to
remember the encounter ™ FACT:
Day starts with work Less accurate
flow (& morale) ™ It is more efficient not only for the physicians but for the entire staff to work
disrupted on a real-time basis: NOW!

Staff batches their Staff stays late to add

work Lower satisfaction forgotten labs/do forms ™ How to work in the NOW:
Staffs time wasted by 1. Identify and evaluate the details of how work gets done
reorganizing calls and Physician leaves ™ Review systems / processes / problems
forms and staving off late with to-do stack ™ No work may get done as charts/to do starts are perpetually reorganized
concerned patients for Nursing
Patient leaves
practice wasting time, Delays patient
Doctor takes three chart, and future
minutes per patient to getting ready for a.m.
revenue appointment

™ Set priorities (e.g. stay on time)

Batches more work Doctor starts late ™ Assign specific hours for certain tasks
Behind schedule ™ e.g. 7-8am check lab/test results; 12-1pm call backs

3. Just Do It
™ Do not leave the exam room until done
™ Stay focused
™ On maintaining momentum as time delay is a key component to patient,
physician, and staff dissatisfaction
™ Guide ourselves and our staff into stopping after every 1-4 patients to
finish any accumulated work: The virtual exam room.
2. Develop a Specific Plan
™ Who does which job when? This is the only way to limit interruptions
™ All charts are pre-reviewed, tests done, results in (Nursing staff can do
this if recorded in progress notes), rooms stocked
™ Anticipate needs
™ Education, forms, scripts can avoid doing this during the busiest times of

4. Be a team player 5. Study successes and failures and act accordingly
™ Huddle 3 minutes before AM and PM to establish game plan and avoid the ™ Good Examples
surprise of disaster 1. Internal Medicine Associates
™ Empower the staff to help you stay on time ™ 8-5pm but left at 7pm
™ They added 5 min/pt = 8-5:30pm
™ Control the day before it controls you
™ They all left at 5:30pm!
2. Standardized work sequencing
™ (Pittenger & Diaz, Virginia Mason PCP Clinic, WA)
™ Each doctor was asked to follow a pattern of tasks upon emerging from each patient room:
1. Fill out fee slip
2. Document visit
3. Respond to one “phone nurse” message
4. Respond to one urgent message
5. Read and respond to one routine mail
6. Fill out one result report
™ Volume of calls down 30%; visits up 10%
™ Increased quality
™ Note: Despite objections to following a “script” this process demonstrated that the best way
to improve quality is to eliminate non-value added variations
3. MPC scales

Happy Healthiness
6. Remember: a happy, healthy physician is a productive
™ Pay attention to work/life balance
™ Do work at a capacity reasonable to you
Works harder long
™ The drive to increase revenues creates much dysfunctional behavior

Less money Personal needs

(bankrupt) not met

Burnt out Less productive

(more batching) Stephen Covey
The 7 Habits of Highly Effective People

Less efficient The more hours needed to

cover fixed expenses

The Patient Encounter The Patient Encounter

™ Difficult patients = time consuming patients ™ Efficiency through effective communication
™ “By the way” syndrome
™ Characterized by ™ 5 Fundamental steps of efficient office visit
™ late divulgence of hidden agenda 1. Opening the interview (most important)
™ Positive ROS
2. Establishing patient expectation
™ Patient perception that physician doesn’t listen
3. Understanding patient beliefs
™ Irony: Physicians blame some patients for “wasting” their time 4. Making decisions
™ Etiology: Defective physician interview technique with failure to 5. Closing the interview
elicit agenda

The Patient Encounter The Patient Encounter
1. Opening the Interview 2. Establishing patient expectations
™ Prepare for interview ™ Establish limits
™ Open-ended questions ™ Establish patient priorities
™ Ask “anything else”? ™ Negotiate the agenda
™ Avoid interpretations
™ Active listening
™ Summarizing the symptoms

™ Fact: ~50% of patient symptoms and concerns are not addressed

™ Fact: ~50% of the time patient and physician reasons for the visit do
not correlate, especially if psycho-social (only 6% agreement!)
™ (Stewart study in Annals Nov. 15, 2005)

The Patient Encounter The Patient Encounter

3. Elicit patient beliefs 5. Close the interview
4. Collaborative Decision Making ™ Anticipate problems
™ Solicit patients ideas ™ Provide written material
™ Identify and address barriers ™ Ask patient to reiterate plan
™ List options ™ Recommit patient to the plan
™ Allow compromise
™ Solicit patient understanding

The Patient Encounter The Patient Encounter

™ Setting the agenda in advance facilitates redirecting patients and ™ Quality of the visit (not quantity) is the key
closing the interview ™ Make eye contact
™ “It sounds like you enjoy gardening and I know you wanted to discuss which ™ connect physician and patient
NSAID may help you most....” ™ Sit with patient and be aware of body language
™ “I know it can be frustrating to have so many problems to discuss. Here is a ™ suggests no hurry
summary of what our plan is until I see you next. We’ll work on the next most
™ Reach out to briefly touch patient
important ones then. Goodbye for now.”
™ smile, hand shake
™ Chit chat
™ Approach the frequent flier ™ shows interest
1. Take a breath, prepare self / patient (10% of patients, 90% of our time) ™ Ensure patient comfort
2. Speak slowly, write down most important items ™ shows interest
3. Negotiate agenda. Keep it moving ™ Listen first
4. Share the care with MLP, Group visits (Loss of health is magnified by loss of ™ it is faster and patients feel heard
socialization) ™ Do some work in front of patient including documentation
5. Give them active role ™ necessary, and improves patient retention of information – DX, RX, FLU, notes
6. Encourage patient to meet new goals ™ Be happy
7. Practice closure: “My nurse will be in to _______” ™ set tone for staff, patients know
™ Communicate in short, understandable information pieces

The Patient Encounter Office Work Space
™ Research Shows Good Communications ™ The larger the medical facility, the more inefficient as it takes time to get patients and staff
in and out, especially with back tracking and the variety of physical ailments and
™ Improve patient outcomes associated appliances.
™ Improves patient satisfaction
™ Improves office efficiency ™ There is no CPT for accompanying the patient to check out.
™ Improve physician satisfaction ™ 60 seconds times 30 patients = 30 minutes.
™ Mid Level Providers (MLPs) can help! MLP = NP + PAs
™ Most efficient physicians consider their exam rooms (ideally 3 – 4) to be their “playing
™ “Value Added” Options field”. They remain on the field to stay focused.
™ NP/PA Sees low level visits, thus freeing physicians for more challenging
™ Nursing home visits
™ Walk-in or same day appointments
™ Extended hours
™ Specialized services/programs; emergency coverage
™ Increased time spent
™ Improved patient education and satisfaction

Office Work Space Office Work Space

™ How to know if your work space is efficient?
™ Measure the time spent in or off your field
™ Where do go when outside the field?
™ Looking for help delegate/hire appropriately
™ Fetching drug samples arrange docs and staff into works
areas (pods)
™ Retrieving test results two way radio, pager
routing sheets, EMR
™ Searching for supplies/forms stock each room identically
™ Looking up dosages, formularies PDA
™ Accompanying patients Learn to say goodbye in room
™ better signage
™ Talking on the phone email, pager, designated times
and attention to privacy

Office Work Space Telephones

™ General Office Configuration
™ Cluster exam rooms to save steps ™ Friend or Foe?
™ Close to reception area to save staff time ™ Handle them or they will handle you
™ Centralized nursing station / telephones
™ Telephone demand is what you make it.
™ Consider triage exam room for quick checks
™ The telephone is the barometer for efficiency of scheduling, billing,
™ Exam room layouts should be identical
patient education and other office procedures.
™ You know you have a problem when you have sudden walk-in

Telephones Telephones
™ Expect 100 – 200 calls/physician/day (75 – 125 if specialist) ™ Do inbound and outbound topics match?
™ 30% of calls to a practice are repeat calls! ™ (e.g. lab results) If so, there is too much phone tag.
™ For efficiency, attend to telephone staff’s needs: hands-free sets,
computer access etc. ™ Minimize time – wasting outbound calls
™ Basic medical terminology, recognition of patient emergencies is ™ Stop playing “pass the caller”
mandatory. ™ Avoid unnecessary repeat calls
™ Developing practice specific protocols is ideal. ™ set the expectation for call back
™ Avoids the repeat callback and the patient anger
™ Decentralize scheduling (everyone can do this!)
™ Don’t deflect demand
™ Triage nurse is necessary, but putting off patients eats huge resources. Instead,
provide better access

Telephones Telephones
™ Reduce unnecessary inbound calls ™ Prescription refill solutions
™ Schedule follow up visits at time of visit ™ Ask patient to call pharmacy for refill
™ Have a 3 month schedule template, even with open access as people plan ™ Ask pharmacy to fax/e-mail requests for approval (Bonus – accurate documentation)
vacations, days off, transportation ™ Create voice mailbox for refill
™ (set up protocol for staff handling of requests)
™ Ask physicians to stick to schedule to avoid rescheduling
™ Ask patient at every visit if refills are needed
™ Automate appointment reminders and prescription refills ™ Leave patient tablets in waiting rooms – “refill meds needed”
™ Let schedulers schedule without interrupting physician ™ Write legibly

Telephones Telephones
™ Manage Patient to Doctor calls ™ Manage Test Results
™ If patient says “I only want to talk to my doctor” respond with “We work as a ™ Reconsider “No news is good news” Philosophy
team. My medical assistant is an important member of my team”…etc. ™ Consider automated test result retrieval program
™ Consider printing business/team cards ™ Results are recorded in special voice mail set up or patient who receives a phone
™ Make follow-up calls to sickest patients after visit number and personal ID code
™ Take messages that stick ™ Forms/brochures explaining most common test results
™ Tell patient anticipated return of results
™ Establish preferred method of patient contact
™ (Need permission for e-mail / voice mail) Calling once, then letter is most
™ All important results should be given in person at visit

Telephones Telephones
™ Other ways to reduce unnecessary calls ™ Miscellaneous Telephone Notes
™ Anticipate and answer questions before patient leaves office ™ Consider blocking practice caller ID if services rendered are sensitive
™ (50% of calls to practice are from patients seen in the last week) (psychiatry, infectious disease practices)
™ Improve written and verbal communication after visit action plan, hand outs, website ™ Time expands to fill the task requirement
™ Billing and referral calls go to dedicated number or billing - have ™ ** staff talks 25% longer to patients on Friday because of lower volume compared
clear billing statements to Monday
™ Ask hospital, ECF, colleagues to text page, email or fax ™ HIPAA requires “reasonable“ effort to protect patient privacy
™ Reduce the rework – Do it right the first time (triage nurse…….)
™ Utilize telephone technology (auto attendant with less than 5 options)
™ Automated call distribution, call accounting, call forwarding, call hunt, call park, etc…

Scheduling Scheduling
™ Managing No Shows ™ “Manage the schedule rather than letting the schedule dictate your
™ “Overbook”: schedule 22 patients if you have 10% no shows and want to see productivity”
20 patients
™ Improve physician and patient relationship
™ create stronger nurse and patient relationship
™ Provide timely access, convenient hours
™ Call to confirm the appointment 48 hours prior ™ Signs of trouble:
™ Don’t schedule too far in advance ™ Patients must speak to multiple staff to be scheduled
™ Establish a no-show policy ™ Patient are often on hold or transferred
™ Continuous monitoring ™ Schedulers must interrupt physicians to resolve scheduling issues
™ No shows are problematic
™ Note – Physicians can be no shows too ™ Physicians arbitrarily run on time some days and not others
™ Same day appointments are troublesome

Scheduling Scheduling
™ Assess Access by ™ Traditional Scheduling
™ Time to next available appointment for new patient ™ Effective scheduling begins with setting target number of patient visits
™ Time to next available appointment for established patients ™ Based on number of hours available on appointment schedule
™ No show rate ™ Define maximum number of patients a day, so you can manage No Shows
™ Bump rate ™ Estimate average same day walk-ins to determine daily targets
™ New patients / total patients ™ Then template to achieve revenue expectation
™ Cancellation conversion rate ™ Must consider time for quality work, new patients to avoid physician delays

Scheduling Scheduling
™ Three General Methods of Scheduling
1) Simple interval – all office visits are the same, new or established despite chief
2) Multiple interval – based on chief complaints
3) Block/wave interval – all am patients come at 8 am
™ Allow for same day appointments: 20% left open or rotate “doc
of day”
™ All methods share “protecting the schedule” problem

Woodcock 2003

Scheduling Scheduling
™ If unable to do advanced access, at least free the template hostages: ™ Better Scheduling Can Lower Fixed Costs
™ Institute sick bay, med express ™ Adjust schedule for seasonal variation
™ Full templates often meet physician, not patient needs ™ Evaluate current trends (Monday Madness)
™ Have late patient policy ™ Analyze office use 8am – 6pm
™ Shift staff during scheduling gaps
™ Use capacity analysis to make a difference
™ Consider advanced access or hybrid scheduling as more is processed ™ staff physician and staff lunches to keep rooms full
on a real-time basis. ™ first appointment comes in 15 minutes early
™ 7am – 7pm 2 days a week
™ no catch up work during busiest times
™ Avoid delays: only one complicated patient per hour – balance sick and
routine patients

Scheduling Scheduling
™ Managing No Shows
™ “Overbook”: schedule 22 patients if you have 10% no shows and want to see
20 patients
™ Managing Running Behind ™ Improve physician and patient relationship
™ Have schedulers prepare patient: bring x-ray, copay, insurance card forms and ™ create stronger nurse and patient relationship
estimated time for appointment ™ Provide timely access, convenient hours
™ Good communication smoothes schedule delay ™ Call to confirm the appointment 48 hours prior
™ Physicians notify office (nurse and receptionist) ™ Don’t schedule too far in advance
™ Give patients choice – wait or reschedule ™ Establish a no-show policy
™ Call patients yet to arrive ™ Continuous monitoring
™ Physicians apologize, thank for waiting
™ Note – Physicians can be no shows too

Registration Registration
™ If it takes 15 minutes to register new or established patients, that is more time than they ™ Registration forms
spend with the physician
™ Keep words to 7 letters (4th – 6th grade level)
™ National benchmark for registration = 5 – 8 minutes
™ (2 minutes if established, 14 minutes if new) ™ No abbreviations
™ Registration is a problem if front office staff is walking around ™ Color code forms
™ Necessary signatures
™ Solutions ™ Eliminate patient history
™ Pre-registration by phone (at the time of scheduling appointment) ™ Photograph patient license
™ by mail (with appointment reminders) ™ Ask patient how they would like to be addressed
™ by computer (patients can download the registration form) or by fax
™ Exam room registration
™ Get Information Before the Appointment
™ Verify information at first and all subsequent visits
™ Follow “error rate”

Waiting Waiting
™ We assume patients will wait for us. We even call it a waiting ™ Ideas for Medical Practice
room. Patients are often not patient. ™ Note pads that say “be sure to discuss with doc today”
™ Patient education in waiting room
™ AMA: Average wait time is 19 minutes, varies with specialty. ™ Patient paperwork is done ahead of time
Average cycle time (patient in - patient out = 60 minutes ™ Send statements by email, pay accounts on line
™ Maintain treatment plan log online, assess own care with clinical algorithm
™ Guide patient to practice certain behaviors. E.G. remove socks and shoes if

™ Measure it and track it so you know where to attack the wait time

™ Industry Perspective ™ Top 10 Efficiency Tips for Physicians
A. 5 Principles of Toyota Success 1. Commit to timeliness and empower the staff to help
1. Standardized work 2. Develop good work habits
™ Every step is defined by best practice (EBM) and performed according to script ™ Be prompt. Do difficult work first
2. Timing 3. Review your schedule in advance
™ The rate a task must be completed to meet the customer’s demand is calculated
4. Huddle as a team BID
3. Workplace organization
™ Every space must be neat and efficiently arranged to encourage self-discipline 5. Be prepared for patients
4. Uneven customer demands are studied to create predictable output 6. Pull work into the day: delegate work in real time; no “batching”
5. Signaling tools visually display what is needed to keep the process going 7. Establish the agenda, listen, prioritize, listen!
B. Applications 8. Improve communication skills – closure
1. Divide work into units ™ The words you choose make all the difference
2. Rotate hospital docs 9. Work in the field, document during visit, delegate
3. Routine yearly checkups in summer 10. Embrace IT solutions (coding, billing, communication benefits)
4. Avoid bottlenecks
™ Efficient Performance will pay off
5. Stagger time off
6. Mentoring

Summary Summary
™ Physician / Mid Level Provider time is critical to maximizing ™ Efficiency tips for the physicians
earnings ™ Review the next day’s schedule by 4pm
™ Real-time work processing is more efficient than batch-work ™ Huddle
™ Re-evaluate all batching ™ Commit to timeliness and empower staff to help
™ Pull work into the day
™ Eliminate non-value added processes
™ Be prompt and be prepared
™ Develop systems that work for both patients and physicians
™ Match young physicians with a mentor
™ Utilize technology ™ Keep team on same page
™ Stay focused on the patient ™ Stay focused
™ Document during visit
™ Set priorities
™ Work in the field

™ Baker L, O’Connell D, Platt FC.
™ “What Else?” Setting the Agenda for the Clinical Interview
™ Annals of Internal Medicine. 143(10):766-70, 2005 Nov.
™ Book Author: Woodcock, Elizabeth
™ Title: Mastering Patient Flow
™ 2003 MGMA

Bibliography Bibliography
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