“Fix the problem, not the blame” is a well-known Japanese proverb. It sounds like common sense – isn’t fixing problems what we all ultimately want? But when mistakes happen, the search for culprits instinctively begins – and with it often comes demoralization and tension. Worse, the search for a scapegoat usually won’t keep problems from recurring. Bad systems create more problems than bad employees. When workflow is faulty, the mistakes are built into the process. Figuring out who was working the process when it failed does nothing to prevent failure in the future. As organizations grow and silos (i.e., departments) form, so do opportunities for workflow inefficiencies to masquerade as staff incompetence. We’ve worked with medical practices that have grown so fast, they haven’t noticed their processes aren’t keeping up. But even more than growth, market evolution has put new tasks on everyone’s plate. These tasks may not fit well with jobs as originally configured – and that may mean more errors. Here’s a common example. Insurance has become increasingly complex for patients and staff alike. Higher deductibles have also made front desk collections a priority, but it’s a new priority added on top of everything else. Are front desk employees already trying to answer phones, check patients in, answer questions, collect demographic information, and verify insurance? When patients are seen and it turns out they weren’t covered or aware they owe a deductible, it may seem “obvious” that the front desk staff is to blame – especially to your billers, who must deal with the errors. But more likely, front desk employees are simply juggling too much. As jobs evolve, mistakes may increase. Resentments can fester between departments. But the answer isn’t to find someone to blame – it’s to find out where the process breaks down. In the case of the front desk, a better response would be to reconfigure roles, to let staff focus on the tasks in front of them, without multitasking. As work gets more complex, making people feel embarrassed and afraid won’t help them do their jobs better – retraining staff and refining their
Personalized, customized service has become the norm in our lives as consumers. We've come to expect even everyday items like coffee and sandwiches to made to our specific preferences. But when we're talking about the administrative side of the patient experience, customizing can seem like a much bigger deal. With so many other demands on our medical practice processes, is the idea of personalizing beyond our reach ... or even a little nuts? It may seem that way, but it doesn't have to be. The wonderful thing about offering more choices in how to do business with your practice is that so many of the options patients seek can be cost-saving for you. For example, studies have shown that consumers prefer to pay bills electronically over sending checks. The trend towards paying online, on-the-go, at any hour of the day has become so pervasive, many people don't keep stamps or even checks on hand. If you're not allowing your patients to exercise this preference, instead hoping they'll mail a check (or only taking credit card payments by phone or in person at the office), you're making it harder for patients to pay. That probably means you're getting paid more slowly -- and at higher cost to your practice. But what happens if you do offer patients the ability to receive statements electronically and make payments that way, too? When patients can pay electronically, it's easy for them to do it immediately -- even if they receive your bill at 10:00PM. They avoid the unpleasant feeling of being behind on their bills, and your staff avoids the more unpleasant task of calling them to collect. And you'll get paid faster -- at less expense, since staff won't have to spend time on the phone with the patient or stuff an envelope with a statement. Best of all, when you implement an option like a payment portal or automatic debit, your patients will thank you for it, even as they're paying you more promptly and reliably. Electronic patient payments are just one of several examples of technology-enabled services that conserve staff resources
Technology for the medical practice front office has many benefits. It can speed up processes, keep critical data safe from fire and flood, allow practice staff to tap resources from other organizations via the Internet, and so on. The list is long and growing. But my favorite front office technology benefit by far is the ability to eliminate duplicate effort, especially duplicate data entry. The reason is simple: eliminating duplicate effort is like money in the bank! When you cut down on duplicate data entry, you don't just eliminate the cost of repeating steps; you also reduce errors, which can be even more costly to find and fix. Some errors -- like mistakes in patient demographics or coding -- cause a direct hit to the bottom line, since they affect billing and reimbursement. Get those demographics right the first time, and your likelihood of getting paid promptly just went up -- and the effort required to make it happen just went down. There are many technology tools that medical front offices can use to reduce duplicate effort. Here are just a few that most practices should explore, if you're not taking advantage of them already. EHR/PMS integration. When a practice moves from separate billing and EHR systems, or from paper charts to an EHR that integrates with the billing/practice management system, the gain in billing efficiency is profound. An integrated EHR/PMS set-up allows physicians and other clinicians to transmit superbills electronically from the EHR into the PMS. This means no data entry of CPT and diagnosis codes from paper tickets -- a huge time savings. But even more important, the data that's transferred over to the billing system is exactly what the physician or non-physician provider intended -- not what the biller guessed at based on a handwritten superbill. And if there are any doubts about the services provided or diagnosis codes, the chart note is right there in the system to provide clarification. EHR/PMS integration means faster, more accurate billing -- for faster, more reliable reimbursement. Fewer delays to clarify what's supposed to be billed, and no risk that
Looks better than mine, even w/o butter.* I observed something this morning when making toast. I don't make toast often, but when I do, I tend to let it go for a few minutes before heading back into the kitchen to check on it, hovering outside the toaster oven to make sure I grab it when it's "just right." Now, like you (I suspect), I tend to be a little annoyed by wasted time. Standing next to the toaster oven, tapping my foot impatiently, that's definitely wasted time. So I have developed a habit of "prepping" for the toast by scooping up the butter I'll use on it and putting it on my plate. But today it finally dawned on me that this prep routine (which I've done for years) really saves no time at all. It's no quicker to pick the butter up off plate and put it on my toast than it would be to just take the butter out of its own container and spread it; the step of transferring it to the plate in advance is meaningless. (In fact, when I do this the entire process usually ends up taking longer, since I rarely get just the right amount of butter on my plate -- a mistake I wouldn't make when just buttering the bread from the tub.) Of course, I do get a personal payoff from this little activity: I am less bored while I wait for my toast. But even though I feel like I'm doing something, it actually makes me no more (and usually a bit less) productive. Naturally, when I realized this, my mind immediately jumped to practice workflow, and how easy it is to be deceived by activities that feel like progress but actually have no effect -- or even slow things down. My favorite one of these, a subject that we wind up discussing with almost every practice we work with, is the central vitals station. Transferring patients from the reception area to the vitals station, then from the vitals station to the exam room, is one of
Are some jobs at your medical practice just too urgent or important to assign to specific people? That's the argument some practice managers and physicians make, e.g: "Phones need to be answered by the first available person, whatever their job" "Everyone should keep an eye on the fax machine, and deliver faxes they see piling up" "Let's all keep an eye on the reception area, to make sure no one's waiting too long" "It's the entire team's job to make sure the patient bathrooms are clean and stocked" When the entire team is engaged on these important, urgent tasks, the theory usually goes, there will always be someone available to do them, right when the need arises. Everyone will have an equal stake in making sure they'll get done -- right? Alas, no. Have you ever heard the amusing little story about four people named Everybody, Somebody, Anybody and Nobody? It goes like this: There was an important job to be done and Everybody was sure that Somebody would do it. Anybody could have done it, but Nobody did it. Somebody got angry about that, because it was Everybody's job. Everybody thought Anybody could do it, but Nobody realized that Everybody wouldn't do it. It ended up that Everybody blamed Somebody when Nobody did what Anybody could have done.* There is a lot of organizational insight packed into that little verse. When something is everybody's job, it's effectively nobody's job. Nobody is actually accountable to do the work, and everybody can rationalize that they thought someone else would do it. When everyone has other work to do that they believe is important, they'll be more likely to assume someone else will take care of the group responsibility. We have worked with several practices that have applied this "everyone's job" idea and been very unhappy with the results. Laurie, they say, why aren't the staff answering the phones? We tell them over and over that everyone has to answer the phones! Instead, our messages are piling up, patients and other doctors are complaining, and nobody's getting the help they need when they call.
Employees who are not always busy working are frequently a source of consternation to physicians. Sometimes, practices attempt to remedy the situation by restructuring staff jobs -- not always with good results. Consider the front desk, for example. In almost any practice, front desk workload will ebb and flow. Depending on variables like patient punctuality, the mix of appointment types, and the number of new patients, the front desk might be swamped or slow on any given day or during any clinic session. Sometimes, front desk receptionists may have no one needing their help or attention at all. Physicians and managers may be tempted to rectify the situation by, say, having the phones ring first at the front desk. For a typical, busy practice, that's a foolproof way to increase staff busyness! But does it improve productivity? In my view, usually not. One reason people appear busier when you ask them to switch back and forth between tasks -- or do multiple jobs at once -- is that it's harder to do any of them properly. They're more active, but not necessarily more productive. This makes intuitive sense, no? But we don't need to rely on intuition, thankfully. With multitasking so prevalent in modern offices, researchers have good reason to study it -- and the results suggest that multitasking is even more of a productivity drain than your gut would tell you. One study found that people lose as much as 40% of their productive capacity when trying to constantly do multiple tasks at once. When front desk staff are required to answer phones while also helping the patients that are standing in front of them, service suffers. Either the patient on the phone or the patient at the desk feels like they're in second place. And switching back and forth means the employee has to mentally regroup -- adding to the length of time it takes to complete each task. More effort is required to do the same tasks -- yet the patients staff deal with will perceive less effort made on their behalf. Lose-lose for both of the two patients being
How many times do you walk down the hall and see empty exam rooms or alternatively, how often are they filled but you still have patients waiting to be roomed and the doctors are running behind? If nothing is going on in the exam rooms there is a financial cost to the practice; whether the room is empty or is occupied by a patient that is kept waiting. Ideally, if you have three rooms for each provider, this results in the physician in one room, the nurse rooming another or giving post visit patient instructions and a third room in transition by patient getting undressed or dressed and nurse preparing room for the next patient. It takes efficient and consistent facilities and processes, and optimizing the clinical staff’s time to make this happen. Depending on the specialty it may also require additional triage space or diagnostic space for pre-visit care such as cast removal, x-ray or blood work. The first step to finding out how efficient you are with your exam rooms requires taking a critical look of the use and function of space and human resources. Most EMRs now have the capability to track a patient through their visit from the time of check-in, when roomed and when the provider enters and leaves the room and when the patient is checked out. Use this information to analyze the variables and establish reasonable standards for the patient flow process that addresses how much time is needed for: Rooming a patient and preparing them for the visit; Clinical time each provider needs to spend with the patient; and Post-visit instructions and documentation Going through this assessment offers the practice an opportunity to identify which processes are efficient and standardized, and which ones have little or no value and can be eliminated or automated. It also allows you to explore how well you are using your resources and how to optimize them. For example, do you have the nurses doing everything their skill level permits to support the provider and is the provider consistently delegating processes to the staff that don’t require
I've previously recommended Dr. Christian Terwiesch's introductory MBA-level operations management course on Coursera -- and, great news, it's being offered again this fall. UPenn/Wharton have expanded their selection on Coursera to include four "MBA foundation" courses in operations, marketing, finance and accounting -- an incredible opportunity for physicians and practice managers alike to explore these first-year courses (and maybe learn if further MBA training is right for them). I can vouch for Dr. Terwiesch's operations management course -- I took it to get a refresher on my own MBA training in operations, and was delighted to find that many of his excellent examples were actually drawn from healthcare. The course will provide you with some new insights for evaluating your own practice workflow. Best of all, it's presented in digestible online sessions of 15-20 minutes -- perfect for busy professionals. To learn more about the ops course and the entire MBA Foundation Series, visit this link -- or to see more about Penn's other offerings on Coursera, or the program in general, visit coursera.org.
It might be the toughest message a practice management consultant has to deliver to a physician client: you're just not working hard enough. When doctors bring us in to analyze their practices' profitability problems, they usually expect us to find they're over-staffed, or that their building expenses are too high, or that their billing service is inadequate. And, to be sure, we do often find those problems. But, it's just as often the case that we find that the physicians are seeing many fewer patients than they thought. And, when we show the doctors data comparing their visit volume against other practices in their specialty, we'll hear, "but we're so busy!" How is it possible that we can walk into a practice and see underutilized exam space and know immediately that visit volume is an issue, while the physicians simultaneously feel -- truly believe -- that they're operating at capacity? This is the phenomenon I like to call 'faux busyness.' The physicians feel busy -- fully occupied -- but the real number of patients they're seeing tells a different story. The sad thing about faux busyness is that it's just as tiring as the real thing, but a lot less profitable. What are some of the causes of faux busyness? Here are a few: Provider calendars with gaping holes -- so that the physician is in the office all day, but not seeing patients much of the time Providers scheduled in multiple places for partial days -- adding transit time and scheduling hassles to every day Layout issues, inconsistently prepped exam rooms, and other issues that require physicians to be moving around the office too much -- cutting into possible visit time Is faux busyness cutting into your practice's profitability? There's only one way to find out: start digging into data. Analyze your scheduling processes to determine if they include unnecessary complexity. Make sure your staff understand the importance of booking next-available appointments. And look to benchmarks to reality test your patient volume against comparable practices.
I recently heard about a classic book from the eighties that apparently was all the rage among business students and aficionados back in the day, but that somehow slipped by me. Since it was about operations management, and presented in an unusual format -- a novel -- I felt compelled to check it out. Now that I have, I think medical practice managers should, too. It's called The Goal, by Eli Goldratt, and it tells the story of a plant manager named Alex Rogo who must turn around abysmal performance in his manufacturing plant. Despite achieving 'efficiencies' in many steps of production, the plant's productivity overall has deteriorated to the point where orders are backed up for weeks, and the company's salespeople can't reliably forecast when orders can be delivered (and so can't really sell any new orders, either). If Alex can't fix the plant, it will be shut down. Alex is mentored in the book by a professor named Jonah, who guides him in the process of understanding the plant's constraints -- bottlenecks -- and how to increase their throughput. By analyzing what really drives (or holds back) production in his plant, Alex learns that many of his most relied-upon assumptions aren't correct -- and develops a better way to improve his plant's productivity. I happened to be reading this book while working with a medical practice that was having workflow problems, and the parallels were striking. This practice was proud of its wonderful system for triaging patients -- but, the system was so efficient, patients were waiting for ages in exam rooms for their providers. The practice had over-optimized in triage, creating huge bottlenecks down the line at the exam rooms -- and, no benefit whatsoever to patients and no improvement at all in the number of patients seen! They needed to look at their "plant" with fresh eyes, just like Alex did, to see that overall process efficiency is dependent on the performance of the slowest link in the chain.