1. Introduction to Operational Teams “Rounding out” the major aspects of operational teams Mike Davies, MD FACP Mark Murray and Associates

2. Operational and Clinical Teams

3. Why Operational Teams?

4. 39% of Capacity is Physician Time 39% of Capacity is MA Time 22% of Capacity is RN Time Demand Capacity

5. Reimbursement (Demand) Gross Revenue Visits Limits No-shows More resources needed (staff, rooms, etc) Quality? New patients meet mission

6. Expenses (Capacity) Cost Or Expense Visits Variable Fixed Total

7. Net Revenue Net Revenue Visits No Shows (pt. burnout) More staff and space needed Staff burnout Limits New patients needed to serve mission

8. Value Does net revenue reflect true value to the patient? What do patients value? –Access –“Good” Doctors and Clinics Listening, understanding and emotional support Detection of disease Prevention of disease Continuous relationship (continuity)

9. Support Staff all Related to Productivity Classic study “nursing, administrative, clerical, and aids all independently related to productivity measured by both visits and billings” Reinhardt, U., The Review of Economics and Statistics, Feb 1972, pp 55-66. Thurston, NK et al. “A Production Function for Physician Services Revisited,” Review of Economics and Statistics, February 2002, Vol 84, (1): 184 – 191.

10. Support Staff and Productivity Correlated “Strong positive correlation between number of support staff and productivity as measured by visits per week. Held true for secretaries, RN’s, LPN’s, and medical technicians. Data from 1976 HCFA surveys of 3,482 physicians Brown, DM., “Do Physicians Underutilize Aids,” Journal of Human Resources, Summer 1988, Vol. 25 (40): 342-355

11. Admin and Medical Support Staff Increase Revenue Strong relationship between both administrative support staff and medical support staff and physician productivity (as measured by revenue per physician). Revenue is visits and procedures HCFA 1988 Pope, GC., “Economies of Scale in Physician Practice,” Medical Care Research and Review, December 1996, vol 53 (4): 417-440.

12. Clerks are Important DeFelice, analyzing the AMA’s Physician’s Practice Cost and Income Survey from 1984-85 found + relationship between weekly hours of clerks per MD and the number of MD visits No association between hours of nursing time and number of visits DeFelice, LC., “The Impact of Financial Incentives on Physician Productivity in Medical Groups,” Health Services Research, August 2002, Vol. 37 (4): 885-906.

13. Operational Team Challenge Create Access Provide quality Maintain financial viability of the clinic Optimize capacity of team for visits Maximize number and value of visits Minimize inefficiency Optimize team dynamics and function (morale, engagement, personal mission, turnover)

16. Teamwork!

17. Major Aspects of Operational Teams The Work Organization –What is the goal? –What is the process? The Worker –Enthusiasm, Talents, Style, Profession The Work Content –What is the work and who does it?

18. Major Aspects of Operational Teams The Work Organization –What is the goal? –What is the process? The Worker –Enthusiasm, Talents, Style, Profession –Work assignment? The Work Content –What is the work?

19. What is the work and who does it?

20. Flow Through the Office Check-in to Nurse Nurse to Room Dr. in to Dr. out Check-out to leave Synchronization Point System

21. How Processes Support Flow Check-in to Nurse Nurse to Room Dr. in to Dr. out Check-out to leave Process

22. What are Some Clinic Processes?  documentation  medication refills  lab review  messages  referrals  forms management

23. How Tasks Support Processes Check-in to Nurse Nurse to Room Dr. in to Dr. out Check-out to leave Task Tasks Make Appointment Give Directions Specialist Referral Process

24. Task How Tasks Support Processes Specialist Referral Process: Task: Call to make appointment Task: Give directions for specialist

25. Tasks in the clinic – What is the work? What do we know?

26. Job Analysis Survey of 7 practices Extensive interview of provider, nurse, pharmacist, clerk (1-2 days) Standardized description of tasks 243 Tasks identified

27. Task Categories Administrative –Scheduling, phones, Prevention –Education, treatment Treatment –Medication, procedures Diagnosis –History, Physical, ordering & interpretation of tests Relationship –Primary Care Provider

28. Relationship Diagnosis Treatment Prevention Administrative

29. Relationship Diagnosis Treatment Prevention Administrative

30. Relationship Diagnosis Treatment Prevention Administrative

31. Relationship Diagnosis Treatment Prevention Administrative

32. % Tasks Endorsed MD58.02% NP/PA55.14% RN71.19% LVN54.73% MASPSA18.11% HlthTech19.75% Provider Nurse Clerk

33. Task Overlap MDNP/PARNLVNMASPSAHlthTech MD90.30%63.01%63.91%45.45%68.75% NP/PA85.82%65.90%65.41%40.91%64.58% RN77.30%85.07%96.99%93.18%95.83% LVN60.28%64.93%74.57%77.27%87.50% MASPSA14.18%13.43%23.70%25.56%50.00% HlthTech23.40%23.13%26.59%31.58%54.55%

34. Who COULD Do Task? DocNurseClerk AdministrativeYYY PreventionYYP TreatmentYPN DiagnosisYPN RelationshipYPN

35. Who Should Do Task? DocNurseClerk Administrative NNY PreventionPYP TreatmentPPN DiagnosisYPN RelationshipYPN

36. Example Task 1: Summon Pt Call patient from waiting room, direct patient to office or exam room, explain next steps and procedures to patient (e.g. vital signs), open patient information in computer, verifying accuracy of patient information (e.g., patient identity, SSN, DOB), in order to prepare patient for measurement of vitals.

37. Example Task 239: Pt. Call Receive patient phone call for symptom-related concerns, test results, scheduling questions, or medications, review patient’s medical history and plan of care, ask patient questions about symptoms, listening to patient responses, determine urgency of request, discuss options with patient or refer to another source, notify provider if urgent action is required, in order to address patient concerns or requests received on clinic phone line.

38. Financial Impact of Task Reassignment

39. Error/Complexity

40. Impact of Task Reassignment Positive Considerations –Increase capacity of expensive resource –Save $ –Clarify roles in team Negative Considerations –Pain of change –Match of job with individual preferences and talents ??

41. Task Reassignment: The 4 T’s Task – what is the work and who could do it under ideal conditions? Team – who is on our team and could do the work (actual conditions)? Timing – does the timing of the task lend itself to reallocation? Terrain – is the task member in the right place to do the task?

42. Task Reassignment Examples Assistance with undressing for exam –Could be done by LPN or MA if available –Sometimes done by MD due to timing Vital Signs –Often done by RN –Could be done by MA if 4 T’s apply Phone answering –Often done by RN or LPN –Could be done by MA or Clerk if 4 T’s work

43. Task Reassignment Examples Common Medical Problems –Often addressed by MD in a visit –Could be done by RN with MD assistance if protocols were in place Prevention –Often not done –Could be done by LPN/RN/MD team if organized well

44. What is the work…who is/should be doing it?