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Ambulatory Operations Design Team

Ambulatory Operations Design Team Final Recommendations to the Practice Plan Board Summary Report APPENDIX. April 21, 1997. CONTENTS. 1.0 Clinical Centers 2.0 Organization & Management Structure 3.0 Staffing Model

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Ambulatory Operations Design Team

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  1. Ambulatory Operations Design Team Final Recommendations to thePractice Plan BoardSummary ReportAPPENDIX April 21, 1997

  2. CONTENTS 1.0 Clinical Centers 2.0 Organization & Management Structure 3.0 Staffing Model 4.0 Space Allocation & Management 5.0 Cost Allocation Methodology 6.0 Clinical Neurosciences Profile 7.0 Resident Clinics 8.0 Decision Matrix 9.0 Areas Requiring Further Examination 10.0 Implications11.0 Changes in Practice Patterns12.0 Charge to the Oversight Committee

  3. 1.0 CLINICAL CENTERS

  4. 1.0 CLINICAL CENTERS • ENT • Endocrine • Gastrointestinal • General Internal Medicine • Heart Services • Lung • Ophthalmology • Plastic Surgery • Psychiatry • Musculoskeletal • Neurosciences • Spine • Transplant • Urology • Vascular Surgery • Women’s Health • Flex Space (General Surgery ?)

  5. ENT Vestibular Lab Speech Audiology ENT* Center • Close Proximity • Cancer Center PT, OT ENT* Neurosurgery Facial Nerve Clinic

  6. ENDOCRINE CENTER • Close Proximity: • Heart Center Endocrine Center Diabetes Endocrinology Obesity Lipid

  7. GASTROINTESTINAL CENTER GI Surgery General Surgery Endoscopy Gastrointestinal Center* • Close Proximity • Radiology Hepatobiliary Surgery Colorectal Surgery GI Medicine Ultrasound Motility Monometry * Includes Minimally Invasive Surgery

  8. GENERAL INTERNAL MEDICINE CENTER Rheum/ Orthopedics OB/GYN General Internal Medicine* Mental Health Urologic Center Dermatology Infectious Diseases Primary Care Geriatrics * General Medicine may include a diagnostic center (e.g., conduct triaging of walk-ins, etc.)

  9. HEART SERVICES CENTER • Close Proximity: • Cath Labs • EP/Tilt Tables • CDL Services: • Stress tests • Thallium Stress • Echocardiograms • ECG Center • Holter Monitors • Nuclear Cardiology Tests • Cardiac MRI • Pacemaker, ICD • Other Services: • Rehab • Radiology (Chest X-ray) • Laboratory Heart Services Center Cardiac Surgery Cardiology

  10. LUNG CENTER Lung Center Pulmonary Function Lab Radiology Sleep Center** Pulmonary Medicine Allergy Medicine* Thoracic Surgery * Assumes allergy medicine includes Asthma ** Sleep center will remain as an inpatient service; not in close proximity to the ACC

  11. MUSCULOSKELETAL CENTER Neurosurgery Orthotics & Prosthetics Musculoskeletal Center Physical Therapy Radiology Rheumatology Bone and Mineral Diseases Orthopedic Surgery

  12. NEUROSCIENCES CENTER Physical Therapy Neurosciences Center • Close Proximity • Ortho • Musculoskeletal • Cancer • ENT Electro- diagnostics (EEG, EMG) Rehab Medicine Neurology Neurosurgery

  13. OPHTHALMOLOGY • Close Proximity • Vision Ctr • Private MD offices Ophthalmology Barnes Retina Institute Orbital Center

  14. PLASTIC SURGERY • Close Proximity • Breast Center • Pain Management Plastic Surgery Hand Center Orthopedic Surgery

  15. SPINE CENTER • Close Proximity: • Urology Spine Center Rehab Pain Management Orthopedic Surgery Neurosurgery

  16. TRANSPLANT CENTER Transplant Center* Transplant Surgery Nephrology Hepatology * The Transplant Center is a new clinical center that groups kidney and liver transplant, Hepatology and Nephrology. Heart and lung transplant will be co-located with the Heart and Lung Centers respectively.

  17. UROLOGY CENTER • Close Proximity: • Stomotherapy • Rad Onc • Renal transplant • Radiology • Nuclear Med • CT • IVP • Interventional Urologic Center* • Shared Services: • Endoscopy • Infertility • Urodynamics Urologic Surgery OB/Gyn

  18. VASCULAR SURGERY • Close Proximity • Heart Center Vascular Surgery Interventional Radiology Vascular Lab

  19. WOMEN’S HEALTH CENTER Internal Medicine Women’s Health Center • Close Proximity • Outpatient ORs • Rad Onc • Med Onc • Plastics Breast Center: Breast Radiology Breast Surgery OB/GYN Support Services: Education Genetic Counseling

  20. CLINICAL CENTER GROUPINGS Group 1Group 2 Group 3 Stand Alone Heart Services Endocrine Lung VascularClinical Neurosciences Spine Musculoskeletal PlasticsWomen’s Health Urology Transplant Gastrointestinal General Internal MedicineFlex Space (General Surgery ?) Ophthalmology ENT Psychiatry

  21. 1.6 FLEX SPACE CENTER Flex Space Center* Burn/Trauma Overflow General Surgery ? * The Flex Space Center will occupy a pod or a portion of a pod. This pod will support Burn/Trauma, General Surgery (?) and any overflow from other Clinical Centers.

  22. 2.0 ORGANIZATION & MANAGEMENT

  23. LEVELS OF RESOURCE SHARING Define optimal level of support staff sharing from a patient focused, clinical effectiveness, quality of care perspective that recognizes physician efficiency.

  24. 2.1 LEVELS OF RESOURCE SHARING No sharing (Assigned to Individual Phys) Level 4 C O N T I N U U M Shared within a Subspecialty Level 3 Level 2 Shared within a Clinical Center Level 1 Shared Across Entire Site Resource Sharing Pyramid

  25. LEVELS OF RESOURCE SHARING: Criteria for Sharing Criteria • Narrow clinical focus • Highly sub-specialized knowledge required • Relates to one physician or small group • May not be limited to outpatient setting No sharing (Assigned to Individual Phys) Level 4 • Narrow clinical focus • Specialized knowledge required • Relates to a subspecialty or small group of physicians • Outpatient setting only Level 3 Shared within a Specialty • Clinical focus and clinical knowledge required at the Center level • Regular assignment with a Clinical Center • Dedicated to ambulatory setting • Potential for cross training between similar Centers Level 2 Shared within a Clinical Center Level 1 • Relationships with physicians at Clinical Center not essential • Same level of service needed by all Centers • No clinical knowledge needed Shared Across Entire Site

  26. 2.2 LEVELS OF RESOURCE SHARING: Functional Differences Between Levels Function Criteria • Narrow clinical focus • Highly sub-specialized knowledge required • Relates to one physician or small group • May not be limited to outpatient setting Resources Assigned to Individual Phys (No Sharing) • Nurse Coordinator • Nurse Practitioner • Specialized RN • Specialized Technician Level 4 • Narrow clinical focus • Specialized knowledge required • Relates to a subspecialty or small group of physicians • Outpatient setting only • Specialized RN • Specialized Scheduler • Specialized Technician Level 3 Resources Shared by Physicians within a Specialty • Clinic Manager • Referral Expert • Standard RN • LPN • Medical Technician • Billing Clerk • Medical Records Technician • Check-in/Check-out Clerk • Standard Scheduler • Cashier • Clinical focus and clinical knowledge required at the Center level • Regular assignment with a Clinical Center • Dedicated to ambulatory setting • Potential for cross training between similar Centers Level 2 Resources Shared Within a Clinical Center • Facility Manager • Registrar • Patient Accounts Rep. • Cashier • Standard Scheduler • Transcriptionist • Patient Escort • Concierge • Housekeeper Level 1 • Relationships with physicians at Clinical Center not essential • Same level of service needed by all Centers • No clinical knowledge needed Resources Shared Across Entire Site

  27. 2.3 CLINICAL SUPPORT MANAGEMENT STRUCTURE: Reporting Relationships Reporting Relationships Examples of Functions • Hospital and physician • Department/Division and physician Level 4 No sharing (Assigned to Individual Phys) • Nurse Coordinator • Specialized Technician • Clinic Manager • Specialized RN • Specialized Scheduler • Specialized Technician • Standard RN • Medical Technician • Medical Records Technician • Check-in/Check-out Clerk • Standard Scheduler • Clinic manager/Practice Plan • Designated physician/Practice Plan Shared within a Specialty Level 3 • Clinic manager/Practice Plan • Designated physician/Practice Plan Level 2 Shared Within a Clinical Center • Registrar • Cashier • Patient Escort • Concierge Level 1 • Facility manager • Practice Plan/Hospital Shared Across Entire Site

  28. 2.4 CLINIC MANAGER: Position Description To ensure consistency across clinical centers, standard position descriptions will be applied to all base staffing model roles. Clinical Center Manager PRELIMINARY • Position Summary: Position functions as the manager of clinical operations within (a) defined clinical center(s). • Manages the clinical operations of the Clinical Center • Responsible and accountable for all aspects of day-to-day operations • Assures positive patient experience • Assures smooth patient flow • Responsible for the clinical support staff • Manages clinical support staff • Conducts performance reviews • Ensures competency of nursing staff • Interfaces with Medical Director to ensure operational efficiency • Plans and implements appropriate facility utilization (room use and assignments) • Coordinates the quality improvement activities within the Clinical Center(s) • Manages performance of the Clinical Center • Prepares budget in consultation with the Medical Director(s) • Monitors compliance with practice standards (e.g., report cards) • Participates as member of the Clinical Center management team • Participates in the Ambulatory Management Forum (refer to page 28) • Position reports to:Medical Director and Practice Plan Operations

  29. 2.5 CLINICAL CENTER MEDICAL DIRECTORS • Physician representative of the clinical center group to ensure operational issues have physician input • Involvement in hiring/firing process for clinical manager and senior clinical support staff • Participates in the performance review process (directly or indirectly) of all clinical support staff • Designated liaison between the Clinical Center and the Practice Plan • Physician liaison across clinical centers

  30. 2.6 ENSURE ACCOUNTABILITY TO PHYSICIANS Examples ofFunctions Accountability • Direct accountability to physician as determined by hiring entity (hospital/ department/division) No sharing(Assigned to Individual Phys) Level 4 • Nurse Coordinator • Specialized Technician • Clinic Manager • Specialized RN • Specialized Scheduler • Specialized Technician • Standard RN • Medical Technician • Medical Records Technician • Check-in/Check-out Clerk • Standard Scheduler • Part of hire/fire process • Significant input on performance evaluation Shared within a Specialty Level 3 • For manager & senior clinical positions: part of hire/fire process and significant influence on performance evaluation • For basic level positions: influence through clinic manager Level 2 Shared Within a Clinical Center • Registrar • Cashier • Patient Escort • Concierge Level 1 • Physicians need to know who is the administrator responsible Shared Across Entire Site

  31. 2.7 SUPPORT FUNCTIONS: Accountability to Ambulatory Operation Ambulatory support services need to be accountable to the ambulatory operation. Ambulatory Support Services • Registration, scheduling and medical records are key to the ambulatory clinical operation. If there is not direct accountability to the ambulatory operation, then it will need to be established in some other way. • Ambulatory support functions need to be accountable to the ambulatory operation through: • management structure • matrix reporting relationship

  32. 2.8 NURSING ORGANIZATION: Ambulatory Nursing Requirements The ambulatory nursing practice has identified a specific set of identified needs in order to meet JCAHO standards and maintain service excellence within the ambulatory operation. The structure to support nursing in the ambulatory setting needs to be determined. Ambulatory Nursing Requirements • Chief nursing officer function • Credentialing • Verification of licensure • Ensure alignment of Human Resource policies and nursing credentialing • Maintenance of competency • Re-certification in specific clinical procedures • In-service education • BLS/ACLS • Linkage to the Department of Nursing • Nursing orientation • Practice Standards • Policies and Procedures • Grand Rounds • Quality assurance • Linkage to professional nursing organizations • Professional development opportunities • Continuing education

  33. 3.0 STAFFING MODEL

  34. 3.0 STAFFING MODEL: Objectives • Define comprehensive list of functions related to an ambulatory visit. Identify which functions must be conducted within the ambulatory setting and which may be performed in another setting • Develop standard staffing model to support the flow of patients within a pod and develop role descriptions • Ensure functions are assigned to the most appropriate position • Develop set of questions to guide the development of customized clinical staffing models within a clinical center

  35. STAFFING MODEL: Projected Visit Volume The ambulatory operations staffing model must be designed to support the projected visit volume within each pod or pair of pods. Assumptions 1 pod = 8-12 examination rooms 2 pods per intake area 16-24 examination rooms per intake area (2 pods) 40,000 visits/year intake area 50 weeks of clinic operation/year50 hours/week 800 visits/week per intake area 5 days per week 160 visits per intake area per day

  36. 3.1 BASE STAFFING MODEL: Level II Functions in all Clinical Centers Patient Service Representative Check-In Process1 Patient Service RepresentativeCheck-Out Process2 Medical Assistant Responsible for defined clerical functions at the beginning of a patient visit Responsible for defined clerical functions following a patient visit Responsible for managing patient flow within a pod/center and for conducting defined basic clinical functions Four roles have been identified to form the standard staffing model across all clinical centers. ROLE DESCRIPTION MANAGEMENT Clinic Manager • Responsible for administrative and operational issues for one or more pods/clinical centers BASIC PATIENT FLOW 1& 2 The check-in and check-out processes are distinct roles that will be conducted in two separate areas within close proximity. Patient Service Representatives may be cross trained to perform both check-in and check-out functions.

  37. BASE STAFFING MODEL: Position Descriptions Patient Service Representative1Check-In/Check-Out Processes PRELIMINARY • Position Summary: Position is responsible for the handling the processes related to arrival and department of patients to the Clinical Center. As the initial or final contact in the patient encounter at the center level, the Patient Service Representative plays a critical in the delivery of excellent patient service. • Check-In Process • Welcomes patients upon arrival to the patient intake areas and conducts standard check-in process • Provides patient with estimate of wait time and directs patients to waiting area • Verifies registration information of all patients according to established standards • Obtain forms from patients (as required) and forwards them to the Medical Assistant • Conducts referral checks (e.g., HMOs) in accordance with established protocols • Provides cross-coverage of the Check-Out Area as required • Collects co-paysCheck-Out Process • Schedules return appointments according to direction of clinical staff • Schedules basic tests following Clinical Center protocols • Conducts pre-certification of specific tests • Schedules other physician visits as directed by clinical staff • Responsible for fee ticket capture & charge entry • Collects co-pays • Provides directions to patients to move to the next point in their ambulatory visit (e.g., ancillary services) • Liaises with Patient Transport Services to provide assistance to patients • Provides coverage of the Intake Area as requiredOther Responsibilities (Check-In/Check-Out) • Answers telephone calls and directs them to the appropriate member of the patient care team • Participates in Clinical Center quality improvement initiatives • Position reports to:Clinical Center ManagerTraining: Patient Service Representative Orientation (Check-In Process, Check-Out Process) • Patient Registration • Customer Service for Ambulatory Operations 1 All Patient Service Representatives will be cross-trained to perform check-in and check-out functions

  38. BASE STAFFING MODEL: Position Descriptions Medical Assistant PRELIMINARY • Position Summary:Position functions as a Medical Assistant to physicians and clinical staff and assumes primary responsibility for coordinating patient flow.Basic Functions: • Maintains proper patient flow by escorting patients to examination rooms • Transports medical record and any additional forms delivered by the patient to examination room • Prepares patient for examination/visit (physician/specialty preference) • Prepares examination rooms between visits • Cleans and stocks examination rooms • Monitors supplies, maintaining inventory and following established control proceduresCenter Assigned Functions: • Assists staff as necessary with patient care and office functions • Performs patient care techniques [e.g., Vital signs (if done), assists physicians with special procedures (e.g., cast, splint or suture application and removal)] • Other duties as assignedPosition reports to:Clinical Center ManagerRequirements:Certification (1 year) plus two years of experienceTraining: Medical Assistant Orientation Patient Service Representative Training Registration Process Training Customer Service Training

  39. 3.2 CENTER-SPECIFIC CLINICAL STAFFING (In Addition to Base) • Center-specific clinical staffing requirements are determined by each center • Degree of sharing across specialties within the center is dependent on the level of function • Clinical staff dedicated to a single specialty are charged directly to the Department

  40. CENTER-SPECIFIC CLINICAL STAFFING MODEL The following questions need to be discussed with the clinical leadership of specialties planning to co-locate to determine what clinical support services are required in addition to the base staffing as detailed in section 3.1. Discussion Questions 1. What are the clinical staff requirements directly related to patient visits within this center? 2. What is the scope of each clinical function outlined in #1? 3. What is the level of clinical expertise that is required? 4. What clinical functions cannot be shared across more than one specialty given the answers to #1, #2 and #3? 5. Is the proposed model economically viable?

  41. 4.0 SPACE ALLOCATION & MANAGEMENT

  42. 4.0 SPACE ALLOCATION & MANAGEMENT: FPP Board Delegation of Powers The Faculty Practice Plan (FPP) Board is ultimately accountable for the management of space within the ambulatory setting. However, the responsibility for developing recommendations concerning the allocation and management of space may be delegated by the FPP Board to the Medical Directors’ Committee. The Faculty Practice Plan will “… govern and manage all ambulatory care operations including but not limited to the functions of space allocation and the provision of support services.” (Delegation of Powers)

  43. SPACE ALLOCATION AND MANAGEMENT: Space Allocation Assumptions Space Allocation Assumptions • Initial space allocation is based on:- Scope of services- Location- Volume projections (using managed care filter) • Average of 6 visits per examination room/day • 50 hours minimum of operation/week • 50 weeks per year - Programmatic changes • One floor of the ACC will be dedicated space for academic offices • One floor of the ACC will be dedicated space for private physician offices • Wherever possible, practice space will be designed to be generic to promote maximum flexibility and allow time- sharing across specialties • Assumes increase in primary care volumes and ambulatory teaching

  44. 4.1 SPACE ALLOCATION AND MANAGEMENT Review of ACC Space Allocation & Operating Assumptions • Change in practice patterns required to adjust to new operating model • 50 hours per week • 50 weeks/year • 6 visits/examination room/day • Implications include: • extended hours of operation (e.g., 7:00 a.m. - 5:00 p.m., Saturday hours) • new schedules for staff (e.g., 10 hours/day, 4 days/week, flex times) • steady patient flow (140 patients/intake area/day)

  45. 4.3 SPACE ALLOCATION AND MANAGEMENT: Request for Space Adjustment A request for space adjustment may be initiated by a clinical center to add to or reduce its space allocation within the ambulatory setting. Space adjustment requests must be accompanied by the following supporting documentation: Request for Space Adjustment Part A: Current Utilization Profile • Statistics (e.g., room turnover rates, appointment backlog, etc.) • Volume data • Current clinic schedule (include hours of operation) Part B: Additional Space Requirements • Detailed description of additional space requirements (e.g., new program) Part C: Recommendations for Consideration • Recommendations of viable options (provide detailed description of 1-3 options for consideration ) • Financial implications (e.g., additional rent) Part D: Department/Division Approval • Department/Division approval for increased costs

  46. 5.0 COST ALLOCATION METHODOLOGY

  47. 5.0 COST ALLOCATION METHODOLOGY Revenues will continue to flow back to individual departments Expenses will be charged back to individual departments based on utilization General ACC budgets approved annually by Centers, Departments/Divisions and the Faculty Practice Plan Notification of changes to general ACC budgets to same groups

  48. BUDGET APPROVAL WORKING ASSUMPTIONS Annual ACC Clinical Center budgets will be developed by the Center Manager in conjunction with the Medical Director Departments represented in the Clinical Center will have final budget approval The Manager and Medical Director will have purchasing authority within the parameters of the approved budget Purchasing expenses beyond the approved budget will require Departmental approval

  49. COST ALLOCATION METHODOLOGY Clinic managers will be charged with the responsibility of allocating expenses back to departments. ILLUSTRATIVE = Allocated expense Rent Shared Building Practice Plan Center Department/ Services Services Division DGSF($ per square foot) DGSF($ per square foot)or Utilization Exam rooms orUtilization Utilization Cost Allocation Base Options • Pods • Office space • Public Areas • Overhead & Maintenance • Building Costs • Transport • Concierge • Base level staffing • Pre-registration • Scheduling • EMR • Information Systems • Additional clinical staffing (Levels 2 & 3) • Supplies • Level 4 staffing COST CENTERS Pods Ancillary ServicesPrivate Physician OfficesAcademic Offices Direct Expense(No allocation) (If appropriate)

  50. 5.5 COST ALLOCATION & PERFORMANCE MONITORING: Tools The Clinical Chairs approved a set of practice standards that apply to all clinical practices within WUSM. To assist in monitoring access and utilization, examples of tools have been designed to assist Medical Directors and Clinical Center Managers track performance on selected indicators. • Cost allocation and performance monitoring tools are designed to be used by Medical Directors and Clinical Center Managers to monitor performance on a monthly basis within a clinical center • Examples of such “tools” include: • Clinical Center Profit & Loss Statement (refer to example on page 50) • Clinical Center Report Card (refer to example on pages 51-53) • Additional reports could be designed to monitor otherpractice standards (e.g., communication with referring physicians, inter-department referrals) or to meet center specific needs

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