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EFFECTIVE UTILIZATION OF SUPPORT STAFF TO INCREASE PROVIDER PRODUCTIVITY. COMMUNITY HEALTH OF SOUTH FLORIDA, INC Mae K. Goins, Vice President for Nursing. OUTLINE. Overview of CHI Productivity drivers Barriers to Productivity Strategies to improve productivity

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Effective utilization of support staff to increase provider productivity l.jpg

EFFECTIVE UTILIZATION OF SUPPORT STAFF TO INCREASE PROVIDER PRODUCTIVITY

COMMUNITY HEALTH OF SOUTH FLORIDA, INC

Mae K. Goins, Vice President for Nursing


Outline l.jpg
OUTLINE PRODUCTIVITY

Overview of CHI

Productivity drivers

Barriers to Productivity

Strategies to improve productivity

Efficient utilization of support staff within each productivity driver

How to make it all happen

Challenges to be anticipated

Take home messages


Overview of chi l.jpg
OVERVIEW OF CHI PRODUCTIVITY

  • Patients

    • 71,000 users, 365,000 encounters

  • Ethnicity

    • 56% Hispanic, 28% Black, 6% Anglo, 10% other

  • Insurance

    • 59% Uninsured, 14% Medicaid, 2.4% Medicare, 2% Private, Other Public 22.6%

  • Income level

    • 60.9% (<100%), 9.3% (101-150%), 2%(150-200%)


Community health of south florida inc services and programs l.jpg

Family Services PRODUCTIVITY

Pediatrics

Obstetrics and Gynecology

Behavioral Health

HIV/AIDS Program

Oral Health

Optometry

Podiatry

2 Urgent Care Centers

Lab

3 Pharmacies

Radiology – 2 sites

School based Health Care Services

Health Connect

Migrant Health Care

Homeless Program

Health Education

Transportation

Temporary assistance to the needy (TANF)

WIC Services

Marketing

COMMUNITY HEALTH OF SOUTH FLORIDA, INC- Services and Programs


Overview of chi5 l.jpg
OVERVIEW OF CHI PRODUCTIVITY

  • Staffing

    • 600 staff members

    • 30 different cultures!

  • Providers

    • 60 Practitioners

    • Specialties: FP’s, Internists, Pediatricians, Ob/Gyn MD’s, CNM’s, ARNP’s, Dentists, Radiologist, Optometrist, Psychiatrists


E h r and e o h r l.jpg
E.H.R. and E.O.H.R. PRODUCTIVITY

  • Implemented E.H.R. and E.O.H.R through integration effort

  • E.H.R.

    • Sage’s Medical Manager

    • Commenced upgrade to Intergy product

    • All Providers and services paperless except OB and BH (in few months)

    • Includes lab interface, prescription writing, e-documentation, imaging, etc

  • E.O.H.R.

    • Dentrix

    • All Dental Providers and all dental sites

    • Including digital imaging


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WORK ON PRODUCTIVITY PRODUCTIVITY

  • Focus on Productivity in past 2 years

  • Explored innovative, sustainable approaches

  • Tested some strategies in some sites

  • Rolled out and continue to roll out lessons learned

  • Will share the reasoning behind our activities and specific strategies implemented with support staff


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PRODUCTIVITY – the CHC dilemma PRODUCTIVITY

  • Continues to be a hot topic in many CHC’s

  • Many below goal

  • Different opinions about reason for below average numbers

  • Multiple unsuccessful attempts to improve

  • Consultants also utilized

  • Unsustainable solutions

  • Implications?

    • Need for a completely different approach

  • Learned about the value of using Models to improve chronic disease care in BPHC Collaborative Inialtives

  • Basis for consideration of use of a “Productivity model”


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WHY A PRODUCTIVITY MODEL? PRODUCTIVITY

  • Models

    • Framework approach to problem solving

    • Entire horizon addressed

    • Less “shooting off the hip”

    • Minimizes destructive passionate positions

    • Reduces potential for blame games and finger-pointing

    • Decreases bias

    • Increases buy in

    • Increases chances for sustaining change

  • Especially with pROduCtIviTY


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PRODUCTIVITY DRIVERS PRODUCTIVITY

Productivity

=k# of hrs worked x Patient supply x Provider speed

Total Provider Work Volume

Productivity drivers:

  • # of Hours Worked

  • Patient Supply

  • Provider Speed

  • Total Provider Work Volume

  • What issues do FQHC’s have with each of these?


  • Productivity driver 1 of hours worked l.jpg

    Productivity PRODUCTIVITY

    =k Hours x Pt supply x Doc speed

    Total Work Vol.

    PRODUCTIVITY DRIVER #1: # of Hours Worked:


    Productivity driver 2 patient supply l.jpg
    PRODUCTIVITY DRIVER PRODUCTIVITY#2: Patient Supply:

    • Patient supply

      • # of Patients seen by end of day

        =(Scheduled patients) – (No shows) + (Walk ins)

    Productivity

    =k Hours x Pt supply x Doc speed

    Total Work Vol.


    Productivity driver 2 patient supply15 l.jpg

    Productivity PRODUCTIVITY

    =k Hours x Pt supply x Doc speed

    Total Work Vol.

    PRODUCTIVITY DRIVER #2: Patient Supply:


    Productivity driver 3 provider speed l.jpg
    PRODUCTIVITY DRIVER #3: PRODUCTIVITYProvider Speed:

    Productivity

    =k Hours x Pt supply x Doc speed

    Total Work Vol.


    Productivity driver 3 provider speed17 l.jpg

    Productivity PRODUCTIVITY

    =k Hours x Pt supply x Doc speed

    Total Work Vol.

    PRODUCTIVITY DRIVER #3: Provider Speed:


    Productivity driver 3 provider speed18 l.jpg
    PRODUCTIVITY DRIVER #3: PRODUCTIVITYProvider Speed:

    Productivity

    =k Hours x Pt supply x Doc speed

    Total Work Vol.


    Productivity driver 4 total provider work volume examples of shiftable work l.jpg
    PRODUCTIVITY DRIVER #4: PRODUCTIVITYTotal Provider Work VolumeExamples of “shiftable” work

    Productivity

    =k Hours x Pt supply x Doc speed

    Total Work Vol.


    Productivity driver 4 total provider work volume examples of shiftable work20 l.jpg
    PRODUCTIVITY DRIVER #4: PRODUCTIVITYTotal Provider Work VolumeExamples of “shiftable” work

    Productivity

    =k Hours x Pt supply x Doc speed

    Total Work Vol.


    Productivity driver 4 total provider work volume examples of shiftable work21 l.jpg
    PRODUCTIVITY DRIVER #4: PRODUCTIVITYTotal Provider Work VolumeExamples of “shiftable” work

    Productivity

    =k Hours x Pt supply x Doc speed

    Total Work Vol.


    Support staff utilization to increase provider productivity l.jpg
    SUPPORT STAFF UTILIZATION TO INCREASE PROVIDER PRODUCTIVITY PRODUCTIVITY

    • Which

      • Which support staff?

    • How

      • How can they be best utilized to maximize productivity?

    • In the context of CHI’s experiences!


    Which support staff l.jpg
    WHICH SUPPORT STAFF? PRODUCTIVITY

    • Staff whose function have a direct or indirect impact on patient flow

      • Direct support: Nursing staff, Front desk staff

      • Indirect support: Medical records staff, Allied Professional staff, MIS staff


    Unit staffing structure l.jpg
    UNIT STAFFING STRUCTURE PRODUCTIVITY

    • Multi-Provider units and Single-Provider sites

    • In Multi-Provider units

      • 2 Providers

      • 4 Patient Care Technicians (PCT)

      • 1 LPN

      • 1 Patient Financial Services Specialist (PFSS)

    • In single Provider sites

      • 2 PCTs, 1LPN and 1 PFSS

      • PCTs cross-trained to perform most PFSS functions

    • RN’s serve as Clinical Coordinators


    Median of support staff per fte fp as per mgma l.jpg
    MEDIAN # OF SUPPORT STAFF PER FTE FP -as per MGMA PRODUCTIVITY

    MGMA 2001 Cost Survey


    Effective support staff utilization how l.jpg
    EFFECTIVE SUPPORT STAFF UTILIZATION – HOW? PRODUCTIVITY

    • Long list of options

    • Utilization of productivity model presents effective structure to understand utilization and to facilitate discussion


    What role does support staff play within each of the 4 productivity drivers l.jpg
    WHAT ROLE DOES SUPPORT STAFF PLAY WITHIN EACH OF THE 4 PRODUCTIVITY DRIVERS?

    Provider productivity depends on:

    # of Hours Worked

    Patient Supply

    Provider Speed

    Total Provider Work Volume

    Productivity

    =k Hours x Pt supply x Doc speed

    Total Work Vol.


    Provider work volume l.jpg
    PROVIDER WORK VOLUME PRODUCTIVITY DRIVERS?

    Issue: Costly and inefficient to use professional/higher paid staff to perform work that someone else could

    GOAL

    Move all “shiftable” work to the less expensive staff OR to patients

    Strategy

    Outside the box thinking

    Look for best practices in other centers and in private sector

    Productivity

    =k Hours x Pt supply x Doc speed

    Total Work Vol.


    Provider work volume29 l.jpg
    PROVIDER WORK VOLUME PRODUCTIVITY DRIVERS?

    6 areas consume majority of Provider’s patient encounter time and can be performed by others

    Ensuring availability of reports

    Consults, labs, procedures, etc

    Obtaining patient histories

    Interval histories

    Assessment of compliance with preventative health and disease specific guidelines

    Completing defined components of physical exam

    Patient education

    Completion of requests for tests and procedures

    Support staff can make a difference

    CHI’s experience

    Productivity

    =k Hours x Pt supply x Doc speed

    Total Work Vol.


    Utilization of direct support staff in chi check in registration process l.jpg
    UTILIZATION OF DIRECT SUPPORT STAFF IN CHI PRODUCTIVITY DRIVERS?- Check in/Registration process

    • ALL patients

      • Review “quality care sheet”

    • Established patient

      • Due for Depression screening  PHQ-9 given to patient

      • Due for Learning Needs Assessment  Form given to patient

      • Advance Directives not formulated  Form given to patient

    • New patient

      • New patient history form

      • Health maintenance education sheet

      • + Depression screening, Advance Directives as well

      • New patient labs

    • Planning to implement

      • Disease specific hand out printed for patient

        • Patient decision support

        • Taking advantage of patient wait


    Example of quality care sheet l.jpg
    EXAMPLE OF QUALITY CARE SHEET PRODUCTIVITY DRIVERS?


    Health maintenance education sheet l.jpg
    HEALTH MAINTENANCE EDUCATION SHEET PRODUCTIVITY DRIVERS?


    Utilization of direct support staff in chi nursing encounter l.jpg
    UTILIZATION OF DIRECT SUPPORT STAFF IN CHI PRODUCTIVITY DRIVERS?- Nursing Encounter

    • Patient history review and update

      • Compliance with

        • Medication, Diet, Exercise, etc

      • Recent tests or procedures since last visit

      • Recent visit to E.R or Hospital

      • Recent surgery

    • Entry of information from paper forms into E.H.R.

      • New patient history form, PHQ 9, Learning needs assessment, etc

        Value of use of E.H.R.’s documentation templates



    Utilization of direct support staff in chi nursing encounter35 l.jpg
    UTILIZATION OF DIRECT SUPPORT STAFF IN CHI PRODUCTIVITY DRIVERS?- Nursing Encounter

    • Review of “quality care sheet” and Assessment of compliance with

      • Procedures e.g. Pap, Mammogram

      • Tests e.g. HbA1c, Lipids, Creatinine

        • A1c done at point of care

      • Specialist referrals e.g. Podiatry, Optometry

    • Procedures, Tests or Referrals ordered

      • Documented in record

      • Forms completed

    • Initiation of self management goal setting process

      • Tool presented to patient



    Utilization of direct support staff in chi nursing discharge l.jpg
    UTILIZATION OF DIRECT SUPPORT STAFF IN CHI PRODUCTIVITY DRIVERS?- Nursing Discharge

    • Review of Provider’s Care Plan

      • Additional referrals, tests ordered

    • Print out of patient education handouts

      • Links to hand outs e.g. www.familydoctor.org

    • Print out of patient medication list

      • New patients, change in meds, etc

    • Education on available educational programs

      • Diabetes education; Chronic Disease Self Management Program for elderly, etc


    Utilization of support staff in chi post discharge l.jpg
    UTILIZATION OF SUPPORT STAFF IN CHI PRODUCTIVITY DRIVERS?- Post-Discharge

    • Patient tracking

      • Abnormal labs and tests

      • Referrals

    • Management of Patient Registries

      • Selected diseases e.g. DM, HTN

      • Overdue for specific labs e.g. Lipids, HbA1c

      • High risk e.g. elevated BP, abnormal paps

    • Patient calls

      • Appointment reminders, follow up on treatment or invite to group medical visit or patient education sessions


    Provider work volume summary of use of support staff in chi during a patient s visit l.jpg
    PROVIDER WORK VOLUME PRODUCTIVITY DRIVERS? Summary of use of support staff in CHI during a patient’s visit

    Productivity

    =k Hours x Pt supply x Doc speed

    Total Work Vol.


    Of hours worked goal to ensure providers are seeing patients max hours l.jpg

    Productivity PRODUCTIVITY DRIVERS?

    =k Hours x Pt supply x Doc speed

    Total Work Vol.

    # OF HOURS WORKEDGoal: To ensure Providers are seeing patients max hours


    Patient supply l.jpg
    PATIENT SUPPLY PRODUCTIVITY DRIVERS?

    Goal: maximize # of patients seen

    # of patients seen

    = scheduled – no shows + walk ins

    Role of support staff

    No shows

    Educate patients on no show policy

    Call patients >2days prior to appointment

    Notify Providers of cancellations

    Follow up on no shows

    Walk ins

    Ensure all walk ins sign in

    Facilitate visit with effective triage

    Obtain as much info as possible

    Manage waiting time expectations

    Productivity

    =k Hours x Pt supply x Doc speed

    Total Work Vol.


    Provider speed l.jpg
    PROVIDER SPEED PRODUCTIVITY DRIVERS?

    Goal: Increase # of patients a Provider can see per unit time

    Role of support staff: Ensure

    Minimum interruptions possible

    Each Provider has and utilizes at least 3 exam rooms

    All exam room fully equipped and similar

    All support staff available during patient care time

    Providers are respectfully nudged along

    Providers are aware of accumulating backlog

    Proactively inform patients of backlog and importance of keeping visit focused for sake of patients waiting

    Environment for Providers to perform best work

    Productivity

    =k Hours x Pt supply x Doc speed

    Total Work Vol.


    In summary l.jpg
    IN SUMMARY PRODUCTIVITY DRIVERS?

    Support staff can be effectively utilized to increase Provider productivity through their ability to positively influence all 4 productivity drivers!

    • # of Hours Worked

    • Patient Supply

    • Provider Speed

    • Total Provider Work Volume


    Ingredients for success l.jpg
    INGREDIENTS FOR SUCCESS PRODUCTIVITY DRIVERS?

    Adequate Provider:Support staff ratio

    Effective deployment of support staff

    Training

    Supporting policies and procedures

    Inclusion of key components of expectations in job descriptions and evaluations

    Commitment to success

    Productivity

    =k Hours x Pt supply x Doc speed

    Total Work Vol.


    Models of efficient direct support staff utilization l.jpg
    MODELS OF EFFICIENT DIRECT SUPPORT STAFF UTILIZATION PRODUCTIVITY DRIVERS?

    • Provider assignment models

    • Exam room assignment model

    • Broad roles model

    • Hybrid models


    Models of efficient direct support staff utilization46 l.jpg
    MODELS OF EFFICIENT DIRECT SUPPORT STAFF UTILIZATION PRODUCTIVITY DRIVERS?

    • Provider assignment models

      • Support staff assigned to:

        • A particular Provider

          • Used in CHI’s single Provider sites

        • Group of Providers

          • Used in CHI’s multi-Provider units

      • Benefits of both types of Provider assignment models

        • Provider, Support Staff and Patient satisfaction

        • Easier to train staff



    Models of efficient direct support staff utilization48 l.jpg
    MODELS OF EFFICIENT DIRECT SUPPORT STAFF UTILIZATION PRODUCTIVITY DRIVERS?

    • Exam room assignment model

      • Support staff assigned to particular exam rooms regardless of Provider using room

      • Utilized in CHI’s Doris Ison Urgent Care Center

      • Benefits

        • Less distraction of support staff away from exam rooms for other duties

        • Support staff has better oversight of needs of patients in rooms; potential advantage with waiting time

      • Disadvantages

        • Potential patient dissatisfaction with inconsistencies in assigned support staff and Providers


    Models of efficient direct support staff utilization49 l.jpg
    MODELS OF EFFICIENT DIRECT SUPPORT STAFF UTILIZATION PRODUCTIVITY DRIVERS?

    • Broad roles model

      • Support staff responsible for all the services and care for a given patient on day of visit

        • (Receptionist only welcomes patients)

        • Nursing support staff calls patient to an available exam room

          • Checks in patient

          • Collects co-pay

          • Completes vital signs and assessments

          • Performs lab work, procedures, etc after Provider encounter

          • Collects additional fees

          • Discharges patient

        • Works with another patient while Provider is with patient


    Ingredients for success50 l.jpg
    INGREDIENTS FOR SUCCESS PRODUCTIVITY DRIVERS?

    Adequate Provider: Support staff ratio

    Effective deployment of support staff

    Training

    Structured and repetitive

    Supporting policies and procedures

    Required to sustain change

    Inclusion of key components of expectations in job descriptions and evaluations

    Critical to sustain change and to hold accountable

    Commitment to success

    Probably the most critical factor

    Productivity

    =k Hours x Pt supply x Doc speed

    Total Work Vol.


    Where does an org start from l.jpg
    WHERE DOES AN ORG START FROM? PRODUCTIVITY DRIVERS?

    Establish a Productivity Task Force

    Inclusive of key Leadership and Process owners

    Utilize PI principle and methodologies; Reason

    Helps ensure thorough problem analysis

    Encourages all to be engaged

    Solutions arrived at are more likely effective and sustainable

    Define Productivity Goals

    All must be on same page

    Look at appropriate external benchmarks

    Review Productivity Drivers

    Keeps group focused


    Where does an org start from52 l.jpg
    WHERE DOES AN ORG START FROM? PRODUCTIVITY DRIVERS?

    Perform baseline analysis

    Flow chart patient flow

    Collect objective patient flow data

    Use volunteers or students

    Commence completion of worksheet

    Address ALL components

    # of Hours worked, Patient supply, Provider Speed and Total Work Volume

    Consider prioritizing

    However start from low hanging fruit

    Define responsible persons

    Be as detailed as possible


    Productivity work sheet l.jpg
    PRODUCTIVITY WORK SHEET PRODUCTIVITY DRIVERS?


    Productivity work sheet54 l.jpg
    PRODUCTIVITY WORK SHEET PRODUCTIVITY DRIVERS?


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    WHERE DOES AN ORG START FROM? PRODUCTIVITY DRIVERS?

    Track progress by monitoring performance

    Productivity, Revenue, Patient and Staff Satisfaction, Quality of Care, No show rate, Overtime hours

    Provide feedback to care teams and leadership

    Celebrate successes

    Keep at it!


    Potential challenges l.jpg
    POTENTIAL CHALLENGES PRODUCTIVITY DRIVERS?

    • Follow through on action items

    • Ownership of components of productivity drivers

    • Finger pointing

    • “Providers Job” or “Nurses Job”

    • “Hyper-sensitivity” to productivity at cost of quality of care and meeting patients’ needs

    • Resources for patient flow studies

      • Consider volunteers, students

      • Build into staff work

    • Culture of limited staff appreciation

      • Adversely impacts “joy of work”, etc


    Take home messages l.jpg
    “TAKE HOME MESSAGES” PRODUCTIVITY DRIVERS?

    • Improving Productivity in a CHC must not be quick fix

    • ALL the Productivity drivers must be individually addressed

    • Maximizing # of hours worked is a low hanging fruit

    • Ensuring an adequate patient supply presents best bang for buck

    • Improving Provider speed is challenging and may yield marginal benefit

    • Decreasing Provider work volume by shifting work ensures the best sustainability AND IS THE DRIVER MOST INFLUENCED BY SUPPORT STAFF

    • Key Ingredients for success with Effective Utilization of Support Staff:

      • Adequate Provider Support Staff Ratio

      • Effective deployment of staff

      • Elimination of ALL biases

      • Commitment to success

    Productivity =k # of Hours x Pt supply x Provider Speed

    Total Work Vol.


    Effective utilization of support staff to increase provider productivity thank you l.jpg

    EFFECTIVE UTILIZATION OF SUPPORT STAFF TO INCREASE PROVIDER PRODUCTIVITYTHANK YOU

    COMMUNITY HEALTH OF SOUTH FLORIDA, INC

    Mae K. Goins ([email protected]


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