Physiatry Practice Management Resources

Care teams free doctors to make the best use of time

The IDCOP participants are still trying to work out the right size and composition of a care team. But the consensus seems to be that it should include two or three physicians and four or five staff members who should be cross-trained to back each other up. That flexibility saves time and prevents work from slowing down or halting when a key person is missing.

In the past, notes Frank Littell, the staffers in his practice did their own jobs and ignored everyone else's. Scheduling, for example, was the province of phone receptionists, not nurses. But it's the nurses who know more about patient needs. Under the new system, they can schedule, and the receptionists (all LPNs or medical assistants), who now sit in the back office, can order refills with the help of protocols. (The few greeters left in the front office just collect copayments and alert the care team when patients arrive.) Having the receptionists do 75 percent of refills, he adds, has greatly reduced the number of charts he has to look at.

While nonphysician members of the care team rotate through jobs other than their own, they primarily focus on one thing at a time. This, he says, produces greater efficiency and fewer errors than the previous system, in which his nurse often got backed up and would be rushing between different tasks.

Although ThedaCare hasn't yet formed care teams like those at PeaceHealth, it's changing staffers' job descriptions. Instead of Greg Long's nurse handling referrals to specialists and labs between her other duties, as she does now, receptionists will be in charge of referrals. They'll have time to do them once incoming phone calls are routed directly to the triage nurses.

Other staffers now do paperwork that used to drain hours from Long's schedule each week. The radiology technician fills out patient reports for normal mammograms, and Long's nurse does the same for normal Pap smears. A medical-records clerk has been trained to complete disability forms, each of which used to take Long 15 to 20 minutes.

FP Gordon Moore of Strong Health notes that even small time wasters can add up to gross inefficiency. At Fairport Internal Medicine, for instance, the day's appointment schedule was posted on a piece of paper between the front office and back offices. "Whenever a patient called to change an appointment, the receptionist would have to get up from her desk, walk back to look at the schedule, get back to the patient on the phone, then go back to see if another appointment was available," Moore says. "The nurses also had to walk back and forth to look at this piece of paper." The solution was to use the practice's computerized scheduling system not only for booking patients ahead, but also for adding and dropping appointments on the day's schedule.

Some simple changes can not only improve efficiency but raise staff morale, as well. At the Latham Medical Group, for instance, charts used to be filed in a small, cramped area upstairs, and the doctors would be furious because, half the time, they couldn't find charts in time for appointments. The situation was so frustrating that about two-thirds of the medical-records staff quit last year. After the practice created a better record room downstairs and relabeled the charts by number instead of name, doctors were able to get their hands on most charts, and the staff turnover stopped.

Greater efficiency also pays off in terms of patient satisfaction. Prior to the redesign of Frank Littell's office, for example, patients complained they couldn't get through to the office by phone. Afterward, the percentage of callers who hung up or were cut off dropped from 35 to 8 percent, he says.

Not all care requires an office visit

The idea of caring for some patients without seeing them may appeal more to physicians in highly capitated practices than to those who depend mainly on office visits for income. But to IHI president Don Berwick, "The more you can move demand away from office visits, the more time you'll have to deal with patients who really need personal interaction."

Ed Enos of the Latham Medical Group points out, "Patients don't always want to come to the office. Sometimes they just want advice from one of our triage nurses." A woman with a urinary tract infection, he adds, can drop off a urine specimen and, depending on the test result, might receive a prescription for an antibiotic without seeing a physician. This option, he notes, "is very convenient for working women."

Now that the triage nurses in Greg Long's practice spend less time on routine visit scheduling, "they're able to do more active management of diabetics over the phone," he says. "They're instructing patients on diet and exercise, getting them scheduled for their eye exams, and so on."

Long believes this kind of activity limits return visits. "We've always assumed that people have to get their care in face-to-face visits. But a big part of IDCOP is getting people to do more care management over the phone or the Internet. That's going to decrease the need for visits."

A growing number of physicians, both inside and outside IDCOP, are communicating with patients by e-mail. A few doctors are even using e-mail to handle their patients' simpler health problems.

For AAFP President Bruce Bagley, this approach is "a bit of a stretch." On the other hand, he points out, "We're doing a lot more telephone medicine now than we did five or six years ago. That doesn't necessarily mean we're diagnosing and treating over the phone, but we're giving out health advice that people used to come to the office for."

The toughest obstacle: Cultural change

Ultimately, the biggest challenge to re-engineering is not technological, but behavioral. Physicians aren't used to thinking of themselves as part of a team; and, even if they see the need for change, Bagley points out, "they're fearful it's going to interfere with their patient focus."

"The question is, should we gear up to provide customer service at all hours of the day, or should we inform patients that we're here after hours for acute care only? Some of our docs believe we should be providing all services at all times, and others tend to resist that." Latham's solution: Put on extra nurses to take routine calls in the evening, and ask physicians to respond to insistent callers only. The doctors have complied, and Enos believes this has raised patient satisfaction.

Physicians are also reluctant to take responsibility for problems they create with their staff, contends Gordon Moore of Strong Health. "In the typical doctor's office, the staff views the customer as the doctor, not the patient," he says. "If an employee angers the doctor, she's in trouble. And that's wrong. So you get into a re-engineering workshop and you try to figure out why so many patients are complaining that they're not getting test results on time. It's because Dr. So-and-So sits on his hands, not getting the forms back in time to patients. The secretaries know this. They're the ones getting the heat. But the patients won't say boo to the doctor; he walks on water. That puts the secretaries in the middle, and it's a miserable position.

"So when we're getting ready to switch to same-day scheduling, we tell the doctors, 'You've got to take responsibility and be available to sign the forms.' When you do that, you take away a lot of pressure and make it easier for the secretaries to do their jobs."

Knee-deep in the redesign process at PeaceHealth, Frank Littell finds that "stress is up, but satisfaction is up. We hope the stress level will come down." Before that happens, though, the group will have to do a better job of planning for contingencies. Some of the pressure would be relieved if PeaceHealth hired more midlevels, he says. But just as important, he emphasizes, the physicians need to start planning their vacations cooperatively. "Traditionally, doctors just sign out. That doesn't work in a group doing open access. They have to be more cooperative. We're still dealing with some of the realities of culture and history."