Change vs. Transition

Change vs. Transition

We will do a series of posts on the concept of change! Change is a word we hate – maybe it’s not the word but what it stands for. There are three things that are certain in life: taxes, death, and change. We deal with it on a daily basis. Most people think of it as NO WAY and continue or revert back to doing it the way they know.

Let’s think in terms of transition rather than change. Perhaps using a different word will help put a different spin on what you are trying to do. Perhaps even this won’t work and it falls back on your shoulders as a practice manager or leader. Let’s look at this more fully.

Change is easy to announce, we want to do things differently. You get together with your team, talk about how things are done and everyone agrees to try something different. The meeting is adjourned and everyone goes to their work area and talks to their staff about the change. All listen and agree that it is a good idea. So you think it is done and all will be better. A week later nothing has happened, things are being done the way they always have been done.

Transition on the other hand requires a “PLAN” which means the acceptance of the new way is not enough. It is necessary to develop a way to implement it. This will mean a commitment. This will mean training or re-training. This will mean communication. And communication means talking, demonstrating, writing memos, etc. and doing it over and over again to reinforce the idea of changing how things are done.

We are so busy in our world that we do not take the time to effectively implement what was agreed upon as a way of improving patient care.

So here are the two questions to ponder:

1. What did you do wrong and how could you have done things better to make the transition to the new and better way of doing things? 
2. Why did you waste time having a meeting about the issue in the first place? Remember, we know that we waste 25% of our day, a meeting with several team members that accomplishes nothing is a good example of waste!

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.

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.

photo credit: via photopin cc

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.

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?

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?