EFFECTIVE UTILIZATION OF SUPPORT STAFF TO INCREASE PROVIDER PRODUCTIVITY

1. EFFECTIVE UTILIZATION OF SUPPORT STAFF TO INCREASE PROVIDER PRODUCTIVITY COMMUNITY HEALTH OF SOUTH FLORIDA, INC Mae K. Goins, Vice President for Nursing

2. 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

3. 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%)

4. 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

5. 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

6. 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

7. 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 BH ends here.BH ends here.

10. 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� BH ends here.BH ends here.

11. 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

12. 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? Models Framework approach to problem solving Value 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 Models Framework approach to problem solving Value 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

13. PRODUCTIVITY DRIVER #1: # of Hours Worked:

14. PRODUCTIVITY DRIVER#2: Patient Supply: Patient supply # of Patients seen by end of day =(Scheduled patients) � (No shows) + (Walk ins)

15. PRODUCTIVITY DRIVER #2: Patient Supply:

16. PRODUCTIVITY DRIVER #3: Provider Speed:

17. PRODUCTIVITY DRIVER #3: Provider Speed:

18. PRODUCTIVITY DRIVER #3: Provider Speed:

19. PRODUCTIVITY DRIVER #4: Total Provider Work Volume Examples of �shiftable� work There are a number of functions performed by Providers either during or after a patient�s visit that, if completed by support staff, could assist them move patients faster. For eg the Provider has to provide patient education on diet, exercise and preventative care e.g. pap smears, colon cancer screening, etc. The Provider also has to update flow sheets that also cost him/her time. And then he/she has to complete lab and procedure request forms, in addition to documenting them in the chart.There are a number of functions performed by Providers either during or after a patient�s visit that, if completed by support staff, could assist them move patients faster. For eg the Provider has to provide patient education on diet, exercise and preventative care e.g. pap smears, colon cancer screening, etc. The Provider also has to update flow sheets that also cost him/her time. And then he/she has to complete lab and procedure request forms, in addition to documenting them in the chart.

20. PRODUCTIVITY DRIVER #4: Total Provider Work Volume Examples of �shiftable� work

21. PRODUCTIVITY DRIVER #4: Total Provider Work Volume Examples of �shiftable� work When we look at all the work our nursing staff has to do, would you say they are better of in prison or at work. Lets see what you think.When we look at all the work our nursing staff has to do, would you say they are better of in prison or at work. Lets see what you think.

22. 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!

23. 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 Summary of drivers and productivity by Blake Question is: how can support staff influence this. First though: who is support staff Summary of drivers and productivity by Blake Question is: how can support staff influence this. First though: who is support staff

24. 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

25. MEDIAN # OF SUPPORT STAFF PER FTE FP -as per MGMA MGMA�s 2001 Cost Survey, breaks down the median number of staff members per FTE physician for family practices as shown below. (Warning: Do not expect the sum of these numbers to equal the overall median staff-per-FTE-physician ratio; that is determined separately.) MGMA�s 2001 Cost Survey, breaks down the median number of staff members per FTE physician for family practices as shown below. (Warning: Do not expect the sum of these numbers to equal the overall median staff-per-FTE-physician ratio; that is determined separately.)

26. EFFECTIVE SUPPORT STAFF UTILIZATION � HOW? Long list of options Utilization of productivity model presents effective structure to understand utilization and to facilitate discussion Summary of drivers and productivity by Blake Question is: how can support staff influence this. First though: who is support staff Summary of drivers and productivity by Blake Question is: how can support staff influence this. First though: who is support staff

27. 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 Models Framework approach to problem solving Value 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 Models Framework approach to problem solving Value 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

28. 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 Flow chart patient visit Post in staff common area Ask for input Create final flow Flow chart patient visit Post in staff common area Ask for input Create final flow

29. 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 Flow chart patient visit Post in staff common area Ask for input Create final flow Flow chart patient visit Post in staff common area Ask for input Create final flow

30. 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

31. EXAMPLE OF QUALITY CARE SHEET

32. HEALTH MAINTENANCE EDUCATION SHEET

33. 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

34. EXAMPLE OF CUSTOMIZED E.H.R. TEMPLATES

35. 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

36. EXAMPLE OF CUSTOMIZED E.H.R. TEMPLATE

37. 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

38. 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 Can we create a custom report for pts with last visit bp > XCan we create a custom report for pts with last visit bp > X

39. PROVIDER WORK VOLUME Summary of use of support staff in CHI during a patient�s visit

40. # OF HOURS WORKEDGoal: To ensure Providers are seeing patients max hours Lowest hanging fruitLowest hanging fruit

41. 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 Biggest bang for buckBiggest bang for buck

42. 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 Most challenging to addressMost challenging to address

43. 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

44. 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 Most challenging to addressMost challenging to address

45. MODELS OF EFFICIENT DIRECT SUPPORT STAFF UTILIZATION Provider assignment models Exam room assignment model Broad roles model Hybrid models

46. 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

47. COMPARISON OF THE 2 TYPES OF PROVIDER ASSIGNMENT MODELS Summary of drivers and productivity by Blake Question is: how can support staff influence this. First though: who is support staff Summary of drivers and productivity by Blake Question is: how can support staff influence this. First though: who is support staff

48. 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 Summary of drivers and productivity by Blake Question is: how can support staff influence this. First though: who is support staff Summary of drivers and productivity by Blake Question is: how can support staff influence this. First though: who is support staff

49. 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

50. 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 Most challenging to addressMost challenging to address

51. 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

52. 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

53. PRODUCTIVITY WORK SHEET

54. PRODUCTIVITY WORK SHEET

55. 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!

56. 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

57. �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 No doubt that with these a chc can be successfulNo doubt that with these a chc can be successful

58. EFFECTIVE UTILIZATION OF SUPPORT STAFF TO INCREASE PROVIDER PRODUCTIVITYTHANK YOU COMMUNITY HEALTH OF SOUTH FLORIDA, INC Mae K. Goins (mgoins@hcnetwork.org