Mastering Patient Flow Elizabeth W. Woodcock, MBA, FACMPE, CPC
Speaker Background 2 Elizabeth W. Woodcock, MBA, FACMPE, CPC Speaker, Author, Trainer www.elizabethwoodcock.com MBA, Wharton School of Business, University of Pennsylvania BA, Duke University Fellow, American College of Medical Practice Executives Certified Professional Coder Author, 12 textbooks and more than 500 Articles Founder and Principal, Woodcock & Associates Former Consultant, Medical Group Management Association; Group Practice Services Administrator, University of Virginia Health Services Foundation; Former Senior Associate, Health Care Advisory Board
Call to Action 3 How many more incomprehensible signs can we post on the walls? How many more uncomfortable chairs can we cram in? How many more dusty, fake plants can we sit on the side tables? How many more old magazines that everyone on the staff has already taken home and read can we have? How much more awful artwork can we hang on the wall? How many more stains on the floor can we have?
Call to Action 4 4
Call to Action 5 Get voicemail. Get an automated phone attendant. Expand the parking lot. Hire some more staff. Install an EHR. Elizabeth, we could do our jobs really well if we just didn t have any patients 5
Agenda 6 Strategic considerations Five strategies to master patient flow Improve Communication Prepare Start and Stay on Time Make Sure They Show Up (More in Appendix) Manage the Oh by the Ways
Strategic Considerations 7 Your Physician s* Time is Your Practice s Most Precious Asset *or any billable provider www.corbis.com Defines Your Capacity!
Strategic Considerations 8 We re so full now, how can we possibly get patients in? Your office schedule can give you a false sense of busy. The schedule is full, but if X% of your patients never arrive, are you truly full? Fill rate is a retrospective review of patients actually seen. Now that s full!
Strategic Considerations 9 Fill Rate / Slot Utilization 120% A retrospective view of access Date Capacity Pts Seen Fill Rate Mon, 7/10 28 23 82.14% 100% Tues, 7/11 28 21 75.00% 80% Wed, 7/12 28 28 100.00% 60% 40% 20% 0% Mon, 7/10 Tues, 7/11 Wed, 7/12 Thurs, 7/13 Fri, 7/14 Mon, 7/17 Tues, 7/18 Wed, 7/19 Thurs, 7/20 Fri, 7/21 Thurs, 7/13 28 22 78.57% Fri, 7/14 28 25 89.29% Mon, 7/17 28 19 67.86% Tues, 7/18 28 16 57.14% Wed, 7/19 28 25 89.29% Thurs, 7/20 28 24 85.71% Fri, 7/21 28 20 71.43% define your capacity, and measure it against patients actually seen More Information in Appendix!!
Strategic Considerations 10 Productivity Versus Access 50 Work RVUs per Day 45 40 35 30 25 20 15 10 44% 94% 87% 98% A C B D 5 0 0 5 10 15 20 25 Calendar Days to Next Available Appointment The orthopaedic practice's internal goal of 10 calendar days to next available appointment Median work relative value of 34 per day, as formulated by median annual work RVU production for orthopaedic surgeons of 7,994 divided by 47 work weeks per year divided by a 5-day work week.* The bubble represents the orthopaedic surgeon s average daily fill rate (also known as percent of capacity filled) *Source: MGMA Physician Compensation and Production Report 2013 based on 2012 data.
Strategic Considerations 11 - Volume - - Time - There is a point of diminishing returns, where you have reached capacity... And productivity actually starts to drop because you are too full. Why? No-shows and cancellations reduce revenue, plus the burden of deflecting demand increases costs.
Strategic Considerations 12 Managing it means more work for everyone else involved!
Strategic Considerations 13 Don t celebrate when the patient doesn t show!
Strategic Considerations 14 Dashboard: Patient Flow KPIs Missed Appointment Rate (Scheduled but Not Arrived Rate) By Reason: No-show, Bump and Cancel New Patient Lag Time Established Patient Lag Time By Type New Patient Appointments as a Percentage of Total Appointments Cancellation Conversion Rate Inbound Telephone Calls per Appointment Repeat calls More Information in Appendix!!
Strategic Considerations 15 New Patients as a Percentage of Total 25.00% 20.00% 15.00% 14.50% 22.40% 19.80% 10.00% 9.20% 5.00% 0.00% All physicians Primary care Surgical specialties Medical specialties Source: National Center for Health Statistics of the Centers for Disease Control; Ambulatory Health Care Data: 2010 (Released1/13) ; http://www.cdc.gov/nchs/ahcd.htm
Strategic Considerations 16 37.00 22.12 14 No-Show 8.71% Cancel 25.08% Bump 3.86% Other 0.67% New Patient Lag Time (Days) Scheduled but Not Arrived (%) Source: Woodcock & Associates Patient Access Report 2013
17 Strategic Considerations Leakage To Care Percentage of Internal Referrals Fulfilled Date of Order/Referral to Date of Appointment
Strategic Considerations 18 Thank you for a full day! www.visualphotos.com
Strategic Considerations 19 Focus on hiring and retaining a care team www.medicalbillingandcodingsalary.net
Strategic Considerations 20 RN LPN NP/PA Physician CMA Social Worker, Pharmacist, Behavioral Health Specialist, Audiologist, Nutritionist, CDE, Physical/Occupational Therapist Balance the management of limited physicians time with the necessity of maintaining access to quality medical care
Strategic Considerations 21 Health Coach/Patient Navigator Care coordination Care team communication Disease registry Chart reviews Patient education Group visits Patient self-management support www.coachdawnwrites.com His/Her players = your patients
Strategies to Improve Patient Flow
Improve Communication 23 Telephones: Three goals 1. Provide the best service possible 2. Reduce the transaction time (often called the talk time ) 3. Reduce the demand for calls and still satisfy the caller!
Improve Communication 24 Establish Service Expectations for Telephones Measurement Abandonment rate Service level Average speed to answer Hours of operation On-hold time Expectation Three percent or less 80 percent within 30 seconds 24 seconds or less (maximum of six rings, if manually calculated) 30 minutes prior to office hours opening until 5 p.m. 30 seconds or less More Information in Appendix!! *automated call distributor
25 Improve Communication Short? Scheduling Long/Long? Long/Long /Long/Long? Short/Short /Short? Long? Short/Short? Long/Long /Long? Short/Short /Short/Short?
26 Improve Communication Challenge? Templates are so complex that... Schedulers can t schedule or cost of rework very high Productivity is actually constrained because slots go unfilled Scheduling
27 Improve Communication Scheduling Down to 3 or 4 types Don t let your template constrain your productivity! 8:45 Short 9:00 Long 9:15 Short 9:30 Short 9:45 Short 10:00 New 10:15 Short 10:30 Short 10:45 Short 11:00 Procedure 11:15 Procedure 11:30 Procedure 11:45 Short
28 Improve Communication Freeze and Thaw Hold appointment slots and then release them if they have not been filled. Strategic Overbooking Book two appointments at the same time one quick and one which requires significant pre-visit nurse intake time; at minimum, 10 am and 2 pm Modified Wave Book a wave of patients (2+) at top of the hour, then 2 at 15 after, then no more until the next hour; recommended for practices with non-compliant patients. Scheduling
29 Improve Communication Avoid Self-Generated Calls Give us a call to let us know how you re doing. Only drink clear liquids the morning of your procedure. Call us if you are still febrile. your sputum is still green. your cough is still productive. Clinical
30 Improve Communication Prevent the Call -- and Help the Patient Clinical Manage the Encounter: recognize the importance of communication [ Meaningful Use Requirement! ] Spell out medication instructions and side effects, even for OTC meds (Specialists) Detail instructions for surgeries, procedures, and tests Describe (if available) course of disease and follow-up Provide resources to patients -- outside of your practice
Improve Communication 31 Prescriptions Appointments Test results Referrals Use Technology to Engage Patients Medical records Bills
Improve Communication 32 Current State: 4-5 Inbound Calls per Visit 1 Scheduling Non- Scheduling Clinical New Visits Return Visits Procedures Test Results Prescription Refills / Renewals Others Goal: No of Calls 0-1 0-2 1 Speaker s personal research
Improve Communication 33 Messages Train staff on how to take a comprehensive message Get three (3) phone numbers Assign responsibility for callback within 3 hours Establish distribution protocols, ideally electronically Offer secure messaging, which reduces this operational burden Stage 2 MU Measure: A secure message was sent using the electronic messaging function...by more than five percent of unique patients... Source: CMS EHR Incentive Program
Improve Communication 34 First-call Resolution Respond to the caller s needs on the first call, thus avoiding any voicemail and telephone tag 1. Pick up the phone for goodness sake! 2. Ask the caller: Would you like to be seen? 3. Ask the caller: Is there anything that I can do to assist you? 34
Prepare 35 Prepare the Day Rooms clean? Computers on? Equipment in place? Room Standardization Enough supplies? Is there anything else that the physician needs in clinic?
Prepare 36 Source: UWisconsin Source: UCSD Determine product and quantity per exam, procedure, etc., room Label bins/containers within drawers Create inventory system for each supply with picture, room and place in supply closet Develop kits for common procedures If applicable (e.g., crash cart), record expiration on a master list
Prepare 37 Arrive at least 15 minutes before the first patient is due to arrive. Check the outside mailbox for mail. Unlock the door. Turn on front office and reception area lights. Inspect appearance of the reception area; straighten magazines, furniture, etc. Turn off call forwarding, check with answering service for messages. Record messages, routing them electronically or manually to the appropriate person. Review automated confirmation call report. Mark cancels on the schedule, putting a copy on the nurses station or electronically communicating with them to alert them of the newly opened appointment slots. Adjust heating/air conditioning thermostat. Review your inventory of supplies and forms for the day. Retrieve additional supplies if necessary. Unlock your cash drawer. Verify that the opening balance ($100) and cash log are present. Front Office Start-ofthe-Day Checklist Verify that all patient records are pulled for today s schedule. In the event of a missing chart, attempt to locate it. If it cannot be located, create a shadow chart to include printing any information electronically. Familiarize yourself with the past due account list. Greet patients who arrive early by name, with a smile and direct eye contact, making them feel welcome. Register and arrive patients as they present.
Prepare 38 Prepare the Session Preview the Chart/EHR Huddle with your Staff Daily Action Plan Standing Orders Exam Room Prepared Forms Prepared What was ordered? What is needed? planned care visit Health Maintenance! Who s on Deck whiteboard
Prepare 39 LEEP * ROOM 4 needed 1. Vitals stamp 2. Leep machine, foot pedal 3. Drape sheet, have patient undress waist down SET UP ON MAYO STAND Blue speculum, Long forceps (steel), Tenaculum, Sound 1. Monsels, Acetic acid in a cup have Lugol s out 2. Small, medium & large loop electrodes/ square electrode 3. 5mm cautery ball 4. 10cc control syringes (2) 1 with xylocaine, 1 with epinephrine 5. Biopsy bottles (3) 6. Scopettes 7. Q-Tips (4) 8.4X4 (2-3) 9. Grounding pad, to upper thigh 10. Bio-hazard bag 11. Pantiliner and pad out on counter 12. Nurse to assist Preference Card Courtesy of Somer Shields, CMPE, Administrator, Portland, OR
Start on Time 40 What does an 8:00 appointment with Dr. Jones mean to your patient? For that matter, what does it mean to you?
Start on Time 41 Don t resort to come 15 minutes early Give patients an arrival time or appointment with Dr. Jones care team Set appointments 15 to 20 minutes before clinic starts Stagger to reduce queues Afternoon clinic start time offers even greater opportunity
Stay on Time 42 Dr. Jones is on the phone for you Lighting system Vibrating pager Others? Remember: Two-way signal!!
Stay on Time 43
Stay on Time 44 Create a FLOWSTATION let the work come to you, and take care of it! 1 4 2 3 Lab results Phone messages Forms Prescription renewals
Stay on Time 45 Perform work in small batches throughout the day Prevent repeat phone calls Prevent late start to the day Avoid demoralizing staff When the day is done, so are you! Source: www.corbis.com; biomedme.com
Stay on Time 46 The Monday Mentality Elizabeth, if you d only been here on a Monday, you would have seen how hard we really work Do not schedule routine follow-up visits on a Monday
Stay On Time 47 Patient Volume 90 80 70 60 50 40 30 20 10 0 Leveling Monday Tuesday Wednesday Thursday Friday
Make Sure They Show Up 48 Confirm Target subset of patients based on analysis to supplement with warm confirmations Payer, type of appointment, timeframe appointment was scheduled, etc. drive the calls based on your analysis Consider asking patient to call back and confirm or even to come in! 30 days prior (optional, but great for over-scheduled physician) 36 hours (call) or 3 hours (text) prior
Make Sure They Show Up 49 Refine the return-to-office process At >30 to 150 days, recall don t appoint
Oh By the Ways 50 Prevention? At the beginning of the visit: Mr. Jones, I m going to summarize what you ve told me I ll be addressing those concerns today. Is there anything else you d like to discuss with me today? Get control of the list
Oh By the Ways 51 Reschedule? Mr. Jones, the issue that you are raising is so important that I d like to allow enough time to thoroughly discuss it with you Give him a follow-up appointment.
Oh By the Ways 52 Document, code and bill for it Bill appropriate level of the E/M If counseling or coordination of care with patient and/or family dominates the encounter, bill by time
Conclusion 53
Contact 54 Elizabeth W. Woodcock, MBA, FACMPE, CPC Woodcock & Associates Speaker, Trainer, Author Atlanta, Georgia 404.373.6195 elizabeth@elizabethwoodcock.com www.elizabethwoodcock.com These handouts may not be reproduced without the written consent of the speaker.