Insight in Leadership in the Medical Practice

In the November issue of the Harvard Business Review an article by Sawhney and Khosla identify some interesting questions on where to look for new ideas. I believe that we should not only focus on the “problems” that we face but more importantly look at what opportunities there are for us to better serve patients. The glass is always half full. Here are some of their insightful questions:

• Is your market share or revenue abnormally low or high in a geographical market? 
• Are you having unusual success with a specific customer (e.g., patient) segment? 
• What’s most frustrating about your products, processes, or workplace? 
• What bothers you personally about your business (yes your practice is a business)? 
• What work-arounds do people use to get their jobs done? 
• What beliefs do you hold sacred? 
• Why do things have to be this way? 
• What opportunities would be opened up if we abandoned those assumptions and beliefs? 
• What are the social, cultural and environmental factors that affect your preferences and behaviors? 
• How can you create solutions that respond to those factors? 

Take a look at these questions at your next board or leadership meeting. Openly discuss them and develop strategies to transition your practice for a brighter future.

PC and FMEA (not FEMA)

At the recent MGMA pre-con where I conducted a Yellow Belt Certificate program there were some interesting testimonials on some of the tools that we talk about in our Lean Six Sigma programs.

One practice manager, who attended a similar program last year went back to the practice and implemented the Project Charter idea. She got other members of her management team to look use them and now relies on them! Her model is to identify projects, complete the form and use that as a guide for project focus and completion as well as an effective communication tool. She doesn’t worry about how things are going but accesses an internal drive to check on things. If she has questions, sees they miss a milestone she can follow up with that manger. She is able to inform physician leaders and others on the status of projects without having to track down and interrupt others related to the projects.

Another manager noted that they used the FMEA – Failure Mode and Effects Analysis model. I have trouble with this since I went through Katrina and have a tendency to pronounce it FEMA! They identify an issue and bring the team together to brainstorm the steps noted around the problem. The list is developed then they use the Severity, Occurrence and Detection ranking system to identify the one or two aspects to address first. Basically, the FMEA model has the team assign a number from 1 to 10 with 10 being the highest to the issue. So you consider how severe it issue is, frequency of occurrence and how easy or difficult it is to detect it. The SOD assigned numbers are multiplied together to get an overall ranking of each issue. The higher the number the greater the priority of effort to address it.

The key point here is that there are a number of projects that are faced in the practice daily and that the tools available under Lean are there for you to use. Keep reviewing the tools and apply as appropriate.

More from the Maxwell presentation at MGMA and a Lean Belt

John Maxwell's Speech at MGMA

I was intrigued by the themes and concepts that John Maxwell espoused during his presentation. His key points have been a part of what we talk about when we look at the MGMA Lean Six Sigma Belt program. Those points were:

Culture – in order to change, to grow, to eliminate inefficiencies, and to improve patient care your culture must focus on or allow changes to achieve these outcomes. It is essential that you understand your culture – this is not expressed just in words in a mission or value statement but more likely in deeds. Stating your values around quality care, respect, etc. is not the true culture. It is what occurs, activities, tasks and daily words used that creates and defines your culture. Take a serious look at yours.

Value – we talk about Lean principles are built on the concept of adding value to the customer. Value-add activities and tasks built into your culture will lead your business to be successful. Eliminate non-value add activities! Imagine if you made an effort to add value to someone or something every day and this attitude became pervasive throughout your business.

Rule of 5 – in Lean programs we talk about the FIVE whys. A great set of questions about why you or one of your fellow employees is doing something or doing it in a certain way. You can always improve by asking your self why. Slightly different is the Maxwell rule of 5 but it built on the same principle. Work to improve daily, and focus on five steps or ways that you can improve. Do it daily.

Finally, Maxwell talked about the importance of working together as a team. Work in a positive culture that encourages growth, that allows you individually to grow and at the same time improve the outcomes of your team.

It was amazing to hear him talk about so many of the keys that we identify in our belt programs!

Maxwell at MGMA in Vegas

John Maxwell the leading expert on “Leadership” was the Monday morning keynote and what a great presentation. It was build around his 15 Invaluable Laws of Leadership.

One of his laws it that of INTENTIONALITY. Growth doesn’t just happen! We often talk about our experiences as part of our growth. Do you have twenty years of experience or one year of experience 20 times? You don’t automatically grow; it is a process an effort. The best teaching part of our experience though is the evaluation; do we stop to evaluate our experiences as we grow? We should.

When you wake up in the morning challenge yourself with a simple concept, whom am I going to add value to today! This will set a framework of a positive attitude.

Another key law is that of CONSISTENCY, which he highlighted as a boring concept. You always want to hear how good you are from other, hearing you being defined as consistent is one of your best compliments. Motivation gets you going but discipline gets you growing!

He has a rule of five citing a story of chopping a tree with an axe five swings today. Five swings tomorrow, the next and the next. This is to say that there are five things that you should do everyday related to your purpose. These five things will provide you with a focused result, success. They will also lead you to be consistent in your daily life. As an author his rule of five for each day is: read; think; file, ask questions; and write which he does each and every day including holidays and vacation days.

His final rule covered in the presentation was the rule of ENVIRONMENT – your surroundings must be conducive to growth. People are your most appreciable asset, what are you doing to grow them in your work place.

Consistent from what we heard from Lou Holtz – attitude, focus on the now, and grow. What a great set of principles and concepts from both. I hope my sharing this with you spreads the word and encourages you to identify your attitude, live in the now and consistently strive to grow. This will make you a better person and have a positive impact and all you come in contact with.

Lou Holtz and MGMA

At the MGMA Annual Conference, AC, Lou Holtz the hall of fame Football coach of schools such as Arkansas, Notre Dame, and South Carolina gave the Opening Key Note address. What a great presentation.

He talked about a five-part plan built around the idea that “titles are from above, leaders are from below!” What a concept!

His five-part plan:

• Attitude – have fun and add value to your self and your practice.
• Passion to succeed – to win in his world, your definition of success is yours but you must have a passion for it.
• Focus on your purpose – we are individuals but in the world we are a team, one that needs each other to achieve our purpose.
• Make sure you are growing and not dying, we need something to hope for.
• Make good choices, help your children make good choices (your fellow employees make good choices).

His acronym here was to WIN – what this stands for is

• What’s
• Important
• Now

His three rules:

• Do what’s right
• Do everything to the best of your ability
• Show people you care

Throughout his presentation he offered stories to support each of these key points – awesome for an 83 year old who was up and on TV until 3 AM Eastern time and spoke to us at 3 PM Pacific time!

Above all – in the football vernacular – do not attack the performer, attack the performance!

Very glad to have had the opportunity to hear him!

Passive Aggressive Physician Responses in the Medical Practice

A lot of comments lately on the fact that the doctor does not want to change, they don’t feel the “pain” or accept a reason for change. More importantly, we hear that the administration brings up an issue at the monthly board meeting. There is discussion about the issue and eventually there is a vote or consensus reached that the recommendation for change it accepted.

The next day however, the doctor does not change to the new way. Instead indicates that the decision does not apply to them, it is for others. Or I’m about to retire and I don’t have to change. Or I don’t like someone telling me how to run my practice.

So passive response = yes to the vote followed by aggressive = no I won’t change is the result. In my years, this is a very common situation.

How do you deal with it? A recent article in Psychology Today offers some suggestions:

• Don’t over react when you find out about the response, this may lead to even more of that behavior 
• Don’t force the change 
• Proactively deal with the situation 
• Get the doctor involved with what might work in their specific practice. Work with the supportive staff to help. Identify the problem and seek a solution that will work. 
• There may have to be direct consequences for the lack of acceptance of the change. This can be accomplished with peer pressure, e.g., comments at the next doctor meeting. It may also be accomplished by some form of monetary penalty if there is a tie to the lack of change in behavior to some risk to the practice. 

How does this fit in with the purpose of this blog? If you believe that improvements in care are necessary, there will have to be changes made. These changes will impact the physician practice directly. Even though many changes can and will be transparent, there are others that be direct.

A Medical Practice Issue: Too Darn Many Decisions!

Recently an attendee at a conference answered the question about how much time do I waste with 90%! When asked if she really meant that, she said yes. There are constant interruptions throughout my day. When asked with another “why” (using the 5 why technique) it was that the staff kept asking questions. I think this is a very common trend for many administrators interruptions are impacting your productivity. Thus when we suggest implementation of Lean Principles and the use of the many tools available, the answer very often is we don’t have time.

It may be that we have not developed/trained the staff or maybe we haven’t provided the parameters within which others can and should be capable of making decisions. The staff is required to make decisions all the time. From deciding whether or not a patient who does not have their co-pay should be seen, to the patient at triage who wants to add the second child to the visit since the two kids are there, to what to do we do in a real emergency.

It would seem that if you tracked the reasons for your daily interruptions on a basic log you would begin to get patterns either by individuals, positions, or circumstances that you could begin to address. There may be immediate teachable moments.

There also may be opportunities to create guidelines for the staff to address the issues they face. Some of the guidelines will have to be addressed at the physician level and many may be addressed with common sense guidelines by you and your administrative team (assuming you have support!).

A decision involves defining the problem/issue, gathering the data, considering alternatives, choosing the best of these alternatives, and implementation. Simple straightforward model that you should use every time. The key in any of these decisions however may not be that you make them in a vacuum, instead you involve the staff on each of the steps!

The key though to long term success is follow up. The Continuous Process Improvement, CPI idea, where you re-visit the circumstances at an appointed time later, e.g., 4 weeks. You will find out whether or not the decision was appropriate and followed or if they have reverted back to their old ways. Ask the “why” set of questions to make sure that you are solving the problem that was presented.

Delegation through involvement and development will lead to better decision making but also free up more time for you to work on other issues with the constant goal of improving patient care.

Healthcare Quality Costs Too Much

In the last post, I mentioned the cost of a denial as $25 and that it is a waste time and money in your medical practice. If we really look at the idea, we should understand that to meet a healthcare quality standard, there is a cost associated.


There are four cost of quality categories to understand:

Appraisal costs: 

• These costs relate to audit and reviews of the processes in place. 
• These can be a waste, e.g., reviewing every encounter every time for every provider, even a simple 99213! Review yes, but every time NO! Identify the patterns of errors, use those as teachable moments, stop reviewing every transaction, and set up a random audit pattern later. 

Prevention costs: 

• These costs associate with training, new equipment, supplies, etc. 
• The goal here is to spend money preventing defects from occurring. These might include spell check, changing from carpet to a non-slip tile floor 

Internal failure costs: 

• These costs are what we did wrong 
• These include the demographic errors in claims submission, discussed in the prior post, wrong prescription, non-documentation of what was done 

External failure costs: 

• These costs are associated with an activity outside of the practice. 
• These might include an insurance company asking for additional information on a claim that we know is unnecessary, wrong supplies sent, back orders on supplies 

This is not to say that any of these costs are bad or good. The point is to have you recognize that there are costs associated with providing quality service to your patients.

The next time you think about cutting costs, don’t just say cut overtime, instead think about areas where there is waste, where you can re-focus the staff efforts, track where errors occur and work to fix them. If we accept the 25% of your workday is wasted premise we can find areas where costs are expended unnecessarily.

It is these costs, changing how things are done that can and will make a difference

The Medical Practice Front Desk Screwed Up Again

An insurance claim that results in non-payment due to a denial is a waste! Statistically we know that the cost of handling a denial is about $25. Costs start from input, maintenance of the account, receipt of the EOB, the RE-WORK, re-submission and the time value of money. If your practice has only 10 denials a week that’s $250 times 52 totaling $13,000. You’re not writing a check for that amount but you might as well.

The cost is in the re-work where staff can be doing something else with their time. Today’s cash flow has a greater percentage of patient payments than ever before.

The main source of denials is from demographic errors. Is that what your denial report shows? You do get and review a denial report at least weekly, right?!

Let’s assume it’s at the front desk. How about doing a Gemba and checking things out and you will find phone, patient questions, noise, copying, scanning, patient check in and check out and many other activities. Draw a process map and see what steps are there and who makes what decisions.

This simple step will create a picture, which should result in changes as to how this key area is handled. How about shifting staff from the denial management department to the front desk. You won’t need the staff in the back if the front is staffed correctly! This is an assumption and jumping to a conclusion. More importantly, it is intended to suggest that a look at your denials, making an effort to repair them by using Lean tools and determining that many activities can be changed.

Challenge one is to look at your denial report, identify the main source of denials, calculate the cost of processing them, evaluate the main source, use the time as a teachable moment, and things will improve.

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Helpful Worksheets for PDSA and DMAIC Deployment

In making presentations and talking with many administrators over the past several months one of the things that seems to always be there is we don’t have time to do this, we really like the idea of utilizing Lean principles BUT. . . .

My response is yes, I agree but if we remember that we waste 25% of our work day by doing non-value add tasks, we have to find the time.

OK – so that’s a lot of talk but we don’t believe it.

In order to help a little further, we have created a couple work sheets that might help with your efforts. First is a guide for the PDSA deployment platform for those who choose that model. We ask questions and give space for answers.

The second is a checklist of deliverables for those who choose to use the DMAIC deployment platform. This will help guide you through key steps to achieve your project management goal.

As mentioned on several occasions it is not important to me or anyone but you as to which deployment platform you use. The key is to use one to help guide you and give you structure in the process.

The key then is to use one of these tools, find a “simple” problem and work for a quick, small win. This will prove to yourself and others that the concepts works. You can then either work on another problem or go back to the first problem and work on continuous process improvement.

To get your copy of both or either form please visit this link at the www.owendahlconsulting.com web site.

It’s Not Just to Provider

Another experience, simple treatment in office for poison ivy – my nemesis! Called my PCP and was told he could not see me but there is a new mid-level provider available later that day if it would be OK to see her. Of course that would be fine. The experience was typical – arrive at the office, hand over the credit card, wait 20 minutes and then escorted to the exam room. Treatment was as expected, a steroid shot, prescription and on my way home.

About a month later we receive a statement indicating we owed ~$190 for a level 4 office visit and that the insurance company had denied payment due to provider not part of the network. We called, staff indicated they  were aware and that the claim would be re-billed under that doctors name since credentialing had not been completed for the new mid-level. They would also look into the documentation for the appropriate level of care, they know that I am a consultant and understand the process.

High Tech Creates Patient Inconvenience

A few weeks ago I had the misfortune of walking on a sidewalk and having a car jump the curb and hit me from behind. Fortunately, it was in a parking lot and the car was not traveling very fast and it was a knock down rather than a flight!

My wife drove me to a 24 hour free standing emergency room (affiliated with a local hospital – important later), the cost of the ambulance was vey high and I was not hurt that badly. The experience there was fine, seen timely, X-rays, staff handled paperwork and my personal needs very well. I am critical of these types of things, as you will see in other posts. Nothing broken so discharged home to rest.

Experience in an Emergency Department and Hospital Admission

The next series of posts will relate to recent experiences I have had while being a patient or involving personal experiences with family members as patients. The goal is to share ideas from the VOC – voice of the customer – perspective and encourage all to consider these as well as your own experiences. This is a “research” project on understanding the customer experience.

Recently, the EMS team was called to my home to take a family member to the Emergency Department of the closest hospital to our home. We had a very nice experience in the ED, staff worked well, kept us informed as to what was going on and what would happen while there. It was determined that an inpatient admission was in order. We were told that a “hospitalist” would see us either in the ED or shortly after arriving on the floor.

Practical and Gemba

Let’s get practical. Applications of some of the tools we have talked about have produced some interesting results.

• A three doctor practice in the Houston area looked at their patient cycle time, improved their scheduling process, shifted tasks between staff members and were able to increase patient visits by four per day.
• Tools used: flow chart, run chart (we will see one later), brainstorming.
• A large practice in the mid west was reviewing their cash flow. The CEO simply used the “5 why” technique and found out that there was an automatic hold of 14 days on the AR. The reason given finally was that there was a problem with the billing system several years ago and that became the policy.
• Key tools used was the 5 why which came in a brainstorming session.
• A large oncology group decided to track compliance with care plans, which were developed and agreed upon. They monitored the results and determined that peer pressure and consequences were the best way to see improvement. Compliance increased from 35% to greater than 50% within three months and as of now compliance continues to improve.
• Key tools used was cause and effect diagram (we will see one later), flow chart, brainstorming, session with EMR vendor.

There are many more. One of the keys here is the involvement of the staff through brainstorming. It is not possible for one person to fix or solve all your problems. Utilizing staff knowledge and encouraging them to be involved is essential to the success of an efficiency program.

Another key term and concept in Lean is “Gemba” which literally means “the real place”. We think of it as the place where the work is done. It is essential that those involved go to the Gemba to see how, what, why, and/or when things are done.

Manage for Perfection

The final principle is to manage toward perfection. Here we can integrate both the prior four principles addressed as well as the concept of Six Sigma. Six Sigma refers to defects. A defect in your practice could be a medication error, the wrong size of gloves in the exam room, or something like that that is not correct.

To strive for perfection is to smooth out the flow and eliminate any defects that you may have.

As mentioned in the previous blog, you will have many days that are not efficient and you may get frustrated. You may want to stop reading this blog since it seems ideal and is not realistic. I hope you will stick with it. Your goal has been to improve patient care in any way possible. These tools discussed and more tools to follow will help. In addition, we will shift to more practical applications, experiences that the author has had as well as those from others who are willing to share with you what works.

Pull

With you process map, value stream understanding, and goal of continuous flow, there is one more thing that is critical. How much work is done at each step along the way, how many resources are necessary to insure that work is “pulled” between steps instead of “pushed”. This basically means your staffing and work distribution should be such that when a patient has completed one step, the next step is ready for them, etc. The assembly line should pull rather than each step pushing.

This can be managed by doing a process map of each of the stops in the cycle. The smaller process map will tell you how many tasks, when the time required to complete that step is understood you can consider the staffing required. For example, the triage step requires vital signs, weight, reason for visit, and perhaps other activities in your practice. How much time is required for each activity to achieve the total time? Can each MA manage this step while the prior patient is in with the provider? Or will it be necessary for additional staff since there is more than one provider utilizing the triage station at the same time?

Continuous Flow

It is more efficient to have a nice day with positive flow. The assembly line should flow continuously with as few interruptions as possible. Here’s a question, asked previously but now is the time to really answer. How much time does the typical patient spend in your office? Most EMR programs have ways to record this data, pull a report by provider, location, and day of week. If you do not have that luxury, simply track the first established patient per hour per provider per location for one week. So for Dr. A at 9 AM on Monday established patient one checks in and checks out, record that time on a log. At 10 AM the first established patient checks in and check out. Do this for a week. This will give you the baseline to know the answer.

Process Map and Value Stream

The second principle noted was that of a value stream. The key word here is value when you ask the question does what I am doing now add value to the customer or does it not. If so, that value add step should continue. If not, ask yourself do I need to do this or do I need to do this at this time? Thus we are identifying value add, VA, and non-value add, NVA, to our consideration of meeting the VOC!

Voice of the Customer

The next five posts will highlight the five principles mentioned in the first post.

As mentioned in our introductory post, the VOC is critical to the success of any business but also to the development of and implementation of Lean Management in your medical practice. Just exactly is your customer looking for when they come to your medical practice? They have a list of questions, symptoms or needs. The individual visit is addressed at triage and with the direct encounter with the provider. The patient leaves with a plan and is “happy”!

But why did they choose you in the first place? Did you really meet their expectations during that visit? These are critical questions to find answers. So you now do a patient satisfaction survey and you find out that they don’t like to wait? Can you find out more?

Basics of Lean

Lean Management has been made “famous” by Toyota Motor Company and its “Toyota Production System”, TPS. Authors James Womack and Daniel Jones authored the first major publication, “Lean Thinking” in which they highlighted five principles:

• Value desired by the customer (VOC) 
• Value stream for each product/service 
• Product (service) flow continuously 
• “Pull” between steps 
• Manage toward perfection 

We will highlight each of these in many ways throughout the history of this blog.

One of the cornerstones not listed as a principle but certainly key the success of your efforts to become more efficient is to eliminate “muda” or waste! It has long been known, and no one will really argue that we waste time each day. How much time do you and each of your employees waste in a normal day? It is estimated that this will amount to 25% of your day, that’s two hours, that’s 120 minutes! Can you find ways to eliminate 10% of that muda, or 12 minutes? If everyone in the office was more effective for 12 minutes each day, let’s say there are five people in the office that means we have improved productivity by one full hour!

Introduction to This Blog

We all can agree that the world of the medical practice is changing rapidly. The moves to value based payment models, emphasis on quality, patient satisfaction, payment mechanism changes, evidence based medicine, and so much more are creating the need for today’s practice manager and the team to revise its focus. We no longer can do things “the way they have always been done!”

Here is where this blog will come into play. The goal is simple to share ideas and practical solutions with readers on what has been tried and worked or in some cases did not work in achieving the ultimate goal of every medical practice – meet patient expectations by providing the highest quality of care possible.

Peter Drucker said it best when he noted that for a business (the medical practice is a business!) to be successful you must first serve the customer, profits and financial success will follow. The principles behind the management theories of Lean and Six Sigma highlight the “Voice of the Customer”, VOC, as their cornerstone. Focus on meeting the customer needs on everything that is done, every task accomplished in the most efficient way and time, will lead to improved service to the customer.

In this blog, we will look at the principles of Lean Management and Sigma Magma. This may have already turned off some readers! Since these principles started in the manufacturing arena, they cannot nor do they apply to the medical practice. Please read on, I hope to convince you of just the opposite.

Let’s assume the patient has made the phone call and is now at the office prior to their appointment time. They will be checked in, move through triage, visit with the provider, immediate follow up activity as directed by the provider, and check out. This is basically a five-step cycle. If you think it through, each step is sequential and resembles an assembly line!

The first few posts will provide more detail and background on the principles of Lean and Six Sigma. Included will be some practical suggestions on applying those principles. It is hoped that readers will gain benefit from many of these posts and apply the concepts discussed in ways appropriate for their practices. Overtime, it is hoped that readers will share with the author their stories, which will be converted to more practical suggestions for others to attempt.

Remember the ultimate goal is to meet the VOC in a way that is satisfying and at the same time improves their individual health status.

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