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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

EFFECTIVE UTILIZATION OF SUPPORT STAFF TO INCREASE PROVIDER PRODUCTIVITY

COMMUNITY HEALTH OF SOUTH FLORIDA, INC

Mae K. Goins, Vice President for Nursing

outline
OUTLINE

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
OVERVIEW OF CHI
  • 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
Family Services

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
OVERVIEW OF CHI
  • 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
E.H.R. and E.O.H.R.
  • 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
work on productivity
WORK ON 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
productivity the chc dilemma
PRODUCTIVITY – the CHC dilemma
  • 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”
why a productivity model
WHY A PRODUCTIVITY MODEL?
  • 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
productivity drivers
PRODUCTIVITY DRIVERS

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

Productivity

=k Hours x Pt supply x Doc speed

Total Work Vol.

PRODUCTIVITY DRIVER #1: # of Hours Worked:
productivity driver 2 patient supply
PRODUCTIVITY DRIVER#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

Productivity

=k Hours x Pt supply x Doc speed

Total Work Vol.

PRODUCTIVITY DRIVER #2: Patient Supply:
productivity driver 3 provider speed
PRODUCTIVITY DRIVER #3: Provider Speed:

Productivity

=k Hours x Pt supply x Doc speed

Total Work Vol.

productivity driver 3 provider speed17

Productivity

=k Hours x Pt supply x Doc speed

Total Work Vol.

PRODUCTIVITY DRIVER #3: Provider Speed:
productivity driver 3 provider speed18
PRODUCTIVITY DRIVER #3: Provider Speed:

Productivity

=k Hours x Pt supply x Doc speed

Total Work Vol.

productivity driver 4 total provider work volume examples of shiftable work
PRODUCTIVITY DRIVER #4: Total 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
PRODUCTIVITY DRIVER #4: Total 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
PRODUCTIVITY DRIVER #4: Total 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
SUPPORT STAFF UTILIZATION TO INCREASE PROVIDER 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
WHICH SUPPORT STAFF?
  • 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
UNIT STAFFING STRUCTURE
  • 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
effective support staff utilization how
EFFECTIVE SUPPORT STAFF UTILIZATION – HOW?
  • 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
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
PROVIDER WORK VOLUME

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
PROVIDER WORK VOLUME

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
UTILIZATION OF DIRECT SUPPORT STAFF IN CHI- 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
utilization of direct support staff in chi nursing encounter
UTILIZATION OF DIRECT SUPPORT STAFF IN CHI- 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
UTILIZATION OF DIRECT SUPPORT STAFF IN CHI- 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
UTILIZATION OF DIRECT SUPPORT STAFF IN CHI- 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
UTILIZATION OF SUPPORT STAFF IN CHI- 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
PROVIDER WORK VOLUME 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

Productivity

=k Hours x Pt supply x Doc speed

Total Work Vol.

# OF HOURS WORKEDGoal: To ensure Providers are seeing patients max hours
patient supply
PATIENT SUPPLY

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
PROVIDER SPEED

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
IN SUMMARY

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
INGREDIENTS FOR SUCCESS

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
MODELS OF EFFICIENT DIRECT SUPPORT STAFF UTILIZATION
  • Provider assignment models
  • Exam room assignment model
  • Broad roles model
  • Hybrid models
models of efficient direct support staff utilization46
MODELS OF EFFICIENT DIRECT SUPPORT STAFF UTILIZATION
  • 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
MODELS OF EFFICIENT DIRECT SUPPORT STAFF UTILIZATION
  • 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
MODELS OF EFFICIENT DIRECT SUPPORT STAFF UTILIZATION
  • 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
INGREDIENTS FOR SUCCESS

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
WHERE DOES AN ORG START FROM?

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
WHERE DOES AN ORG START FROM?

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

where does an org start from55
WHERE DOES AN ORG START FROM?

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
POTENTIAL CHALLENGES
  • 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
“TAKE HOME MESSAGES”
  • 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

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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