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Teams by zhangyun


Operational, Clinical, and Teamwork
     Mike Davies, MD FACP
   Mark Murray and Associates
            Burning Questions
• How many support staff are needed in our
  – 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
• 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
• 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
• 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
• 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.
     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
                        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

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
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
• 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?

               # On Team
 Advanced Access
   Support Staff per Provider

 3.18 baseline


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

Workload         Less            Less
Doc Visit #      Less            Less

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

Workload         Less             Less
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
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
Demand       Capacity

         39% of Capacity is Physician Time
         39% of Capacity is MA Time
         22% of Capacity is RN Time
             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
   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


How Processes Support Flow

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

              Nurse to Room                   Check-out to leave

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

                    Make Appointment

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

              Nurse to Room                   Check-out to leave

How Tasks Support Processes
 Specialist Referral Process:

                   Task: Call to make

                  Task: Give directions
                  for specialist

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
Clerical Staff Roles: (continuum)
 • Scheduler at front desk or in central
 • Schedules and takes messages for
 • Scheduler accountable to a group of
 • Scheduler actually co-located with the
   providers and patients they support

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

   What are the attributes of a
         Care Team?
• Proactive vs. reactive
• Communicative vs. isolated
• Accountable to each other, and to the
• 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
• All staff work to highest level of training,
  experience, and licensure
Flow Through the Office
      Clinical Teams

This is about doing the right thing
           Clinical Teams
• Refers to the “what” we provide for our
• Depends on disease burden and evidence
• Good clinical teams use every team
  member to the greatest extent of their
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
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%
Clinical Quality Indicators
Improvement in CRC
       Stage IV CRC
from Charleston VAMC Tumor Registry
        through April 1, 2005

It matters! A lot!
          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?
• 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
• Canadians:

  – This is a lighthouse. Your call.

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

Results are shown from most to least favorable
         Most Important Reasons
             People Leave
•    Lack of Respect
•    Not listened to
•    Not involved
•    No opportunity to increase
• 5. Can’t make an impact
• 6. Pay
Do patients notice good teams?

        From John H. Wasson MD - Dartmouth

                                    From John Wasson
                Surgery Service Story

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

Source: “The Wisdom of Teams” Katzenbach/Smith
Defining an Ideal Place to Work!

                   Trust the people you work for

 Be proud of what you do                    Enjoy the people you work with

• We know typical support staff numbers
• We know typical support staff composition
• We can probably markedly improve
• 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
• 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

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