Documents
Resources
Learning Center
Upload
Plans & pricing Sign in
Sign Out

Teams

VIEWS: 14 PAGES: 74

  • pg 1
									            Teams
Operational, Clinical, and Teamwork
             Overview
     Mike Davies, MD FACP
   Mark Murray and Associates
            Burning Questions
• How many support staff are needed in our
  practice?
  – How many will improve production?
  – How many will improve outcomes?
  – How many do other practices have?
• If we decide to hire, what professional types of
  person is best?
  – RN/LPN/MA/Other?
  – Social worker, case manager, other?
• Other burning questions?
         Related Questions
• What is our current team number and
  composition?
• Are we clear about our mission and goals?
• Are we working together as smoothly and
  efficiently as we could?
• Are we providing the right care for our
  patients?
• Is working with this team any fun?
• Do we get the job done well?
    Let’s get to the burning questions..
• What kind? (Who ARE support staff?)
• How many?

•   US Government (excellent data)
•   US Military (excellent data)
•   US Private Practice (survey data – fair data)
•   US HMO (excellent data)
        Who are Support Staff?
•   Medical Clerks       • Pharmacists
•   RN’s                   (including PharmD’s)?
•   LPN’s                • Case Managers?
•   Medical Assistants   • Social Workers?
•   Health Technicians   • Billing
                         • Others?
What are Support Staff Duties?
• Check in/out patients & Schedule
• Example Nursing Duties
  – VS; Prevention & Chronic Disease screening,
    information, care
  – Nursing evaluations; injections; office
    procedures
• Independent Follow-up clinics
  – BP; DM; Cholesterol; Anticoagulation
• Telephone calls
    Are These Support Staff Duties?
• Phlebotomy
• Billing (and other business office functions)
• Support for specialty or mental health clinics
• Other professionals not working directly with
  providers – i.e. dieticians, social workers
• Pharmacy prescription filling duties
  Team Composition and Number
    Large Govt. Healthcare US
• Adult Primary Care Tending toward Geriatric
  Practice
• 1100 Sites of Care
• ~4300 Providers
  – 2864 MD
  – 1393 Non-MD Providers (NP, PA)
• ~8,200 Support Staff FTEE
• Pro-Rated to time spent in clinic managing the
  panel of assigned patients
Bottom Line Average US Govt.
         Healthcare
     RN/Provider        0.6

     LPN/Provider       0.5

     Clerk/Provider     0.6

     MA/Provider        0.2

     Pharm/Provider     0.15

     Support/Provider   2.1
                US Military


• US Military Primary Care = 2.7-2.8
  support staff/provider FTEE
  – 0.5 RN
  – 1.8 LPN
  – 0.5 Clerk
FTEE            MGMA                    Safety Net
Provider**      1                       1**
RN              0.51                    0.3
LVN             0.63                    0
MA              0.53                    1
Med.            0.85                    1
Receptioinist
                        2.52/Provider          2.6/Provider
Case Manager    0           FTEE        0.3        FTEE



Clinical Support 1.67                   1.6
Staff/FTEE Pro.
Medical Record 0.4                      0.3
Gen. Admin       0.25                   0.17
                            MGMA

Specialty                   RN     LPN    NA    Clerk    Total Ratio

Multi-Specialty              0.4    0.6   0.9      0.4                 2.3

Medicine Single Specialty    0.6    0.5   0.9      0.4                 2.4

Surgery Single Specialty     0.4    0.6   0.9      0.4                 2.3

Cardiology                   0.4    0.4   0.6      0.6                  2

OB/GYN                       0.5    0.9   0.9      0.7                  3

Psychiatry                    0      0     1       0.2                 1.2
 HMO Team Composition
FTEE   Team Role
6      Physician
2.5    Nurse Practitioner                2.8/FTEE
                                         Overall
11.5   Medical Assistant/Support Staff
3      RN/Extended Role LVN
0.5    Exempt Manager
1.0    Behavior Health Med Specialist
1.0    Health Educator
0.5    Physical Therapist
  Team Composition and Number
          Summary
• Large Govt. US = 2.1 staff/PCP
  – (RN, LPN, Clerk, Pharmacist)
• MGMA = 2.52
  – (RN, LVN, MA, Receptionist)
• Safety Net = 2.6
  – (RN, MA, Receptionist, Case Mgr.)
• US Military = 2.7-2.8
  – (RN, LPN, Clerk)
• US HMO = 2.8 staff/PCP
  – (RN, LVN, MA)
What Is the Right Number?
Productivity




               # On Team
 Advanced Access
   Support Staff per Provider

 3.18 baseline




                          2.69




Nov 1998             Jan 2000
                         Wisconsin F.P. Group
Who?
              RN Team Member
                 Fee for Service Capitated

Workload         Less            Less
(Burnout)
Doc Visit #      Less            Less

Intensity of Doc Less            Less
Visit
Net Revenue      Less (Unless    More
                 replaced)
Clinical Care    Better          Better
          LPN Team Member
                 Fee for Service Capitated

Workload         Less             Less
(Burnout)
Doc Visit #      No Change        No Change

Intensity of Visit Same or Less   Same or Less

Net Revenue      Same             Same or
                                  Slightly more
Clinical Care    Better           Better
              RN/LPN Comparison
RN          Fee for     Capitated   LVN            Fee for     Capitated
            Service                                Service

Workload    Less        Less        Workload       Less        Less
(Burnout)                           (Burnout)

Doc Visit   Less        Less        Doc Visit #    No Change   No Change
#

Intensity   Less        Less        Intensity of   Same or     Same or
of Doc                              Visit          Less        Less
Visit
Net         Less        More        Net            Same        Same or
Revenue     (Unless                 Revenue                    Slightly
            replaced)                                          more
Clinical    Better      Better      Clinical       Better      Better
Care                                Care
Why Choose RN Based Team?


• If you are:
  – Thinking of moving to Alternative Pay
  – Have so much work you can’t possibly do it
  – Want to improve clinical care
Now let’s step back….

What is the big picture here?
      What is a Care Team?
An integrated group of professional and
 clerical staff whose processes and skills
 enable them to care for the needs of a
 patient population over time.
    What is a Care Team?
• Cares for a defined population of patients
• Measures process and outcomes for feed-
  forward and feedback
• Matches the activities to customer
  demand (uses the data to improve
  individual and population care)

Batalden, Nelson, et al. Continually improving the health and value of
   health care for a population of patients; the panel management
   process. Quality Management in Health Care, 1997, 5 (3). 41-51
                                       Total number of
                                           patients


                                                         Provider initiated
        Patient Demographics                             returns (Internal
                                                             Demand)




       Top 10 Diagnosis
                                                                  Daily walk-ins (External
                                                                         Demand)




Pt. Psychosocial and
    Cultural needs

                                                                     Seasonal Variation
                                     Population




      High Utilizers
                                                         Daily Phone Calls
        Self Care


                               Rx refill habits
            Team (2.5X FTEE)




Reception        Nurse
                               Provider
               Demand                                                       Capacity
                         Panel Size 2000
                                                    66 have Diabetes
      360 Patients are
          Over 65
                                                                                        Team (2.5x FTEE)



                                                    113 have Asthma

 60 Patients had
more than 10 Office                                                         Reception        Nurse
 Visits Last Year
                                                                                                           Provider
                                                   248 have Arthritis


                                                                        39% of Capacity is Physician Time
   130 are Clinically                                                   39% of Capacity is MA Time
                                           160 have Heart
      Depressed
                           228 have           Disease                   22% of Capacity is RN Time
                         Hypertension
             Basic Team Duties
• Clinical – WHAT to do
  – What are the main population needs?
  – What protocols and guidelines do we need?
  – What is the work?
• Operational – HOW to do it.
  – Process mapping and redesign
  – Space/staff use and redesign
  – Who will do the work?
• How “good” is the overall teamwork?
  – Putting it all together
Operational and Clinical Teams
                                               Far from agreement on
                                                  WHAT to do (what
                                               prevention and chronic
                                                disease guidelines to
                                                     implement)
 Clinical Teams: What to do?




                                          XX


                                                                               Far from agreement on
                                                                                HOW to do it (how to
                                                                             implement guidelines, how
                                                                                to support provider’s
                                                                                      efficiency)




                               Close to Agreement                       XX



                                    Operational Teams: How to do it?
   Operational Teams

This is about efficiency, reliability,
           and safety
       Flow Through the Office

Check-in to Nurse            Dr. in to Dr. out



             Nurse to Room                       Check-out to leave



                    Synchronization
                         Point



                                                          System
      How Processes Support Flow
                         1          1                                      1            1

                       Process    Process                                Process      Process




      Check-in to Nurse                  Dr. in to Dr. out



                         Nurse to Room                                Check-out to leave

  1            1

Process      Process
                                            1       1         1

                                        Process   Process   Process



                                                                                   Process
What are Some Clinic
    Processes?
   documentation
   medication refills
   lab review
   messages
   referrals
   forms management
     How Tasks Support Processes
                                 Specialist Referral Process
                                                             Physician orders
                                                                 consult




                                          4 minutes



                    Make Appointment
   Tasks                                                      Clerk calls to
                                                            make appointment




                                              5 minutes


                                                          Clerk gives appointment
                                                          reminder and directions
                                                                  to patient




Check-in to Nurse         Dr. in to Dr. out



              Nurse to Room                                Check-out to leave



                                                                                    Task
How Tasks Support Processes
 Specialist Referral Process:
               Physician orders
                   consult




4 minutes
                                       Task: Call to make
                                       appointment
                Clerk calls to
              make appointment



                                      Task: Give directions
5 minutes
                                      for specialist
            Clerk gives appointment
            reminder and directions
                    to patient
                                                     Task
Provider Roles (continuum)…

    • MD with non-consistent nurse and
      clerical staffing
    • MD with consistent nurse staffing,
      but inconsistent clerical staff
    • MD with consistent nurse and
      clerical staffing
    • Group of providers with consistent
      RN, MA, and clerical staff
Better!
Clerical Staff Roles: (continuum)
 • Scheduler at front desk or in central
   area
 • Schedules and takes messages for
   many
 • Scheduler accountable to a group of
   providers
 • Scheduler actually co-located with the
   providers and patients they support

Better!
 Nursing Roles: (Continuum)
  • Phone calls, rooming, paperwork,
    triage, scheduling
  • Nurse offers advice over the phone or
    through e-mail
  • Nurse manages populations of
    patients



Better!
   What are the attributes of a
         Care Team?
• Proactive vs. reactive
• Communicative vs. isolated
• Accountable to each other, and to the
  patient
• Uses measures for feedback
• Delivers high quality chronic, acute, and
  preventive care
     Attributes continued…….
• Cross-trained versus territorial
• Integrated versus separated
• Continuous flow versus flow based on
  urgency
• All staff work to highest level of training,
  experience, and licensure
Flow Through the Office
      Clinical Teams

This is about doing the right thing
               right!
           Clinical Teams
• Refers to the “what” we provide for our
  patients
• Depends on disease burden and evidence
• Good clinical teams use every team
  member to the greatest extent of their
  license
                         Panel Size 2000
                                                    66 have Diabetes
      360 Patients are
          Over 65




                                                    113 have Asthma

 60 Patients had
more than 10 Office
 Visits Last Year

                                                   248 have Arthritis




   130 are Clinically
                                           160 have Heart
      Depressed
                           228 have           Disease
                         Hypertension
ICD 9   Diagnosis
401     Essential Hypertension
250     Diabetes Mellitus
272     Disorders of Lipid Metabolism
465     Upper Resp. Infection….
V70     General Medical Exam
780     General Symptoms
473     Chronic Sinusitis
724     ….Back Disorders…
462     Acute Pharyngitis
477     Allergic Rhinitis
          Chronic Dz Clinical Goals
Diagnosis       Protocol? Our Outcomes Benchmark
HTN
DM Hgb A1c
DM Foot
DM Eye
DM Lipids
CVD Lipids
MDD New Meds

CHF Weight
CAP - Culture
          Chronic Dz Clinical Goals
Diagnosis       Protocol? Our Outcomes Benchmark
HTN                                   75%<140/90
DM Hgb A1c                            <12% > 9
DM Foot                               85%
DM Eye                                80%
DM Lipids                             >80% LDL<120

CVD Lipids                            <20% LDL>100

MDD New Meds                          >77%
CHF Weight                            >95%
CAP - Culture                         92%
     Prevention Clinical Goals
Prevention Protocol? Results   Benchmark
Flu shot
Colon Ca
Breast Ca
Cervical Ca
Pneumo. V.
MDD Screen
SUD Screen
Tob. Counsel
     Prevention Clinical Goals
Prevention Protocol? Results   Benchmark
Flu shot                       >90%
Colon Ca                       >75%
Breast Ca                      >90%
Cervical Ca                    >90%
Pneumo. V.                     >87%
MDD Screen                     >95%
SUD Screen                     >95%
Tob. Counsel                   >93%
                 Firm A Medical Outcomes: Baseline Through February '03
       80%

       70%

       60%
Goal




       50%
% At




       40%                                                                                                                 All Outcomes
       30%
                                                                                                                           p < .01
                                   A1c < 7.5
                                   LDL cholesterol <100
       20%
                                   BP < 140/90
       10%

        0%




                                                                                                            02
                                                                                                    2
                   02




                                                                                                                              03
                                                                           2




                                                                                                                      02
                                                                                          02
                                                        02




                                                                                   02
             e




                                       2
                            02




                                               2




                                                               -02




                                                                                                                                       03
                                                                                                 t-0
                                                                        l-0
                                   r -0


                                            r-0
           lin




                                                                                                         v-
                   n-




                                                                                                                             n-
                                                                                                                   c-
                                                                                          p-
                          b-




                                                                                                                                     b-
                                                     y-




                                                                                g-
                                                                n




                                                                                               Oc
                                                                     Ju
         se




                                 Ma


                                           Ap




                                                                                                        No


                                                                                                                 De
                                                   Ma
                 Ja




                                                                                                                           Ja
                                                                               Au


                                                                                        Se
                        Fe




                                                                                                                                   Fe
                                                             Ju
       Ba




                                                                         Month
                         Clinical Quality Indicators
                                                                                                                                               Oct 01 to Sept 05
                                                                 Primary Care Dx Management

90%

80%                                                77%
                                        74% 74%
                                                                                       72%
                                69%                                                                 70% 69% 71%                                                    70%
70%                       66%                                                                 66%                                                      66% 65%
                    63%                                                          64%
              61%                                                          60%
        58%                                                          57%                                                                     58% 59%
60%                                                                                                                             54%
                                                                                                                                      52%
50%                                                                                                                       47%


40%

30%

20%

10%

0%
                          % LDL < 100                                               % HgbA1c < 7.5                                          % BP< 140/90

      Oct to Mar FY 02     Ap to Sept FY 02       Oct to Mar FY 03         Ap to Sept FY 03     Oct to Mar FY 04   Ap to Sept FY 04    Oct to Mar FY 05     Ap to Sept FY 05
  Results:
  Improvement in CRC
  screening
             100%

             80%
% complete




             60%

             40%

             20%

              0%
                    ay




                              ay




                              ay
                               g




                               g




                               g
                                t
                               n
                               v




                               v
                              ch
                               b
                             ne




                             ne




                             ne
                               c




                            Oc
                           No




                           No
                           Au




                           Au




                           Au
                           De

                            Ja

                           Fe
                M




                           M




                           M
                           ar
                     Ju




                          Ju




                          Ju
                         M
                           2003-2005 CRC Screening
            Stage IV CRC
    from Charleston VAMC Tumor Registry
            through April 1, 2005

7
6
5
4
                                      Stage IV
3
2
1
0
     2003   2004   2005
 Teamwork

It matters! A lot!
              Teamwork!




Operational   Improvement   Clinical
                Team

               Home Team
          Airplane Accidents
• In an analysis of 35,000 reports of
  incidents over 7.5 years, almost 50%
  resulted from a flight crew error, and an
  additional 35% were attributed to air traffic
  controller error
• Communication was a significant factor in
  about ½ of the human errors.
                               How Hazardous Is Health Care?
                                                              (Leape)
                                          DANGEROUS               REGULATED                   ULTRA-SAFE
                                            (>1/1000)                                          (<1/100K)
                            100,000                 HealthCare
                                                                          Driving
Total lives lost per year




                             10,000



                              1,000
                                                                                        Scheduled
                                                                                         Airlines
                               100
                                                     Mountain            Chemical                   European
                                10
                                                     Climbing          Manufacturing                Railroads
                                                 Bungee                 Chartered                     Nuclear
                                                 Jumping                  Flights                     Power
                                 1
                                      1     10        100      1,000     10,000     100,000   1,000,000 10,000,000

                                                 Number of encounters for each fatality
                  Errors
• JCAHO Data of 2034 Sentinel Events
  – Majority resulted in death
  – Communication root cause in 60%
• VA Data of 10,000 near misses
  – Communication root cause in 55%
    It’s all about communication…..
             ………in a certain way
        Communication Example

An Actual Radio Conversation between US Naval Ship & Canadian
     Authorities off the Newfoundland Coast October 1995

• Canadians:
   – Please divert your course 15 degrees to
     the south to avoid a collision.
• Americans:
   – Recommend you divert your course 15
     degrees to the north to avoid a collision.
• Canadians:
  – Negative, you will have to divert your course 15 degrees
    south to avoid a collision.
• Americans:
  – This is the Captain of a US Navy ship.
    I say again, divert your course.
• Canadians:
  – No, I say again, you divert YOUR course.
• Americans:
  – This is the Aircraft Carrier USS Lincoln, the 2nd largest
    ship in the Atlantic Fleet. We are accompanied by 3
    destroyers, 3 cruisers, and numerous support vessels. I
    DEMAND that you change your course 15 degrees north, I
    say again, that’s one-five degrees north, or counter-
    measures will be undertaken to ensure the safety of this
    ship.
• Canadians:

  – This is a lighthouse. Your call.




 An Actual Radio Conversation between US Naval Ship & Canadian Authorities
                  off the Newfoundland Coast October 1995
                   Engagement
                            • 20% highly engaged
•   Challenge
                            • 40% moderately
•   Authority
                            • 20% unengaged
•   Autonomy
•   Stimulation
                            •   Sr. Mgr 53% engaged
•   Access to information
                            •   Directors 25%
•   Growth opportunities
                            •   Supervisors 18%
                            •   Non mgt 12 to 14%

                            • Higher in nonprofit sector
       Cooperation and Teamwork
                       % Favorable                   % Neutral             % Unfavorable

100%

90%

80%

70%                                                     56

60%

50%

40%
                                                        16
30%

20%
                                                        28
10%

 0%
                                           Q.27 Cooperation and teamwork


  Results are shown from most to least favorable
         Most Important Reasons
             People Leave
•    Lack of Respect
    1.
•    Not listened to
    2.
•    Not involved
    3.
•    No opportunity to increase
    4.
     responsibility
• 5. Can’t make an impact
• 6. Pay
                                       Do patients notice good teams?
                                                 Perfect Care (Patient Perspective) Correlated with
                                                Teamwork (Clinical Staff Perspective) for Ten Office
                                                                      Practices

                                       90
% Rating of Perfect Care by Patients




                                       80
   Using These Office Practices




                                       70

                                       60
                                                   R=.77; p=.01
                                       50

                                       40

                                       30

                                       20

                                       10
                                                                   From John H. Wasson MD - Dartmouth
                                       0
                                            0       0.5        1      1.5     2      2.5     3      3.5        4   4.5
                                                          Rating of Teamwork In Office Practices (5 is Best)
                                                                                                          From John Wasson
                Surgery Service Story
                        Surgery Service O:E Ratio
          1.8
          1.6
          1.4
          1.2
            1
          0.8
          0.6
          0.4
          0.2
            0
                       1                   2                  3
                           Best-Middle-Worst of 44 Services
                                   Morbidity Mortality



Young, et al. Best Practices For Managing Surgery Services: The Role of Coordination.
Health Care Management Review 22 (4), p 72 – 81.
    Well Functioning Teams Have:
•   Leadership and direction
•   Common aim
•   Population of patients identified
•   Shared work and process
•   Shared information
•   Flexibility
                             Team Performance Curve
                                                                                 High-performing
                                                                                    Team




                                                                          Real
                                                                          Team
               Performance




                             Work Group




                                                              Potential
                                                              Team

                                          Pseudo-
                                          Team

                                              Effectiveness

Source: “The Wisdom of Teams” Katzenbach/Smith
Defining an Ideal Place to Work!
                             Management
                   Trust the people you work for




                           Employee



 Be proud of what you do                    Enjoy the people you work with
       Job                                            Other Employees
                                                                         Staff Turnover 2002-2003

                           40.00%
13 Month Rolling Average




                           35.00%
                           30.00%
                           25.00%
                           20.00%
                           15.00%
                           10.00%
                            5.00%
                            0.00%   J-02   F-02   M -02   A-02   M -02    J-02   J-02   A-02   S-02   O-02   N-02   D-02   J-03   F-03   M -03   A-03   M -03    J-03   J-03   A-03   S-03   O-03   N-03   D-03




                                                                                                Voluntary                                                       Involuntary
                Summary

• We know typical support staff numbers
• We know typical support staff composition
• We can probably markedly improve
  efficiency
• We can discover population needs
• We know a key difference between good
  and great teams is teamwork!
          Next 18 months…
• Improve operational teams (LS 3)
  – Through “office efficiency” change ideas
  – Flow mapping & Task analysis
  – Measure lead time and cycle time
• Improve clinical teams (LS 4)
  – Identify and improve chronic disease care
  – Identify and improve prevention care
• Improve teamwork (Throughout)
  – Improve individual and team functioning
              Homework
• Measure lead time (operational)
• Discover top 10 diagnosis (clinical)
• Talley chronic disease and prevention
  protocols (clinical)
• “Take the test” page 3-11. Record
  answers on page 16 (teamwork)
• Read championship teams introduction
• DO module 1 and 2 in the book

								
To top