All medical practices are essentially small enterprises, not very different from any of the Fortune 500 companies. Practices generate revenue by providing services or selling products. They also have expenses for staff, rent, equipment and insurance. There are also elements of marketing, finance, human resources, etc. Like all companies, podiatric practices are challenged by inefficiency and the desire to continue improving on their profit margins.
When the typical private practitioner hears phrases such as “Quality Improvement,” “Total Quality Management (TQM)” or “Process Enhancement,” these terms might create images of an assembly plant making better cars or airlines with excellent on-time departures. But how would you feel if you owned one of those vehicles with exploding tires? What would you do if you found out your plane did not have the scheduled maintenance check?
Healthcare has similar applications and expectations. The quality standards are based on years of experience, standards of care and research. The public has very high expectations as a result of this. They do not have much tolerance for physicians and nurses who make any type of mistake. With healthcare’s focus on patient safety, there are major initiatives to make sure medical errors are significantly reduced or eliminated. Although healthcare is considered a service industry, our product is alleviating people’s illnesses or injuries. We make people feel better.
Where Does Quality Improvement Fit In?
Considering medical practices are small businesses, the concept of quality improvement is really making sure all the systems are running at peak efficiency. This way you can manage things that cost your practice time, material or money and maximize things that can enhance revenue, whether it’s spending more time taking care of more patients, dispensing more orthotics or doing more procedures. Your bottom line can be either maintained or improved, depending on the economics of your environment. If the process is perfect, the outcome should be perfect.
The basic tenet is improving the process to enhance customer satisfaction. The customer is everyone who has contact with your practice. Customers may be your patients, their family and friends, your vendors, your family and friends, your staff and their family and of course, you.
What does it mean to achieve customer satisfaction? In the case of your practice, it might be more money at the end of week. To your staff, it might be less time-consuming, non-productive paperwork. To your patient, it might mean a better clinical outcome. To your family, this might mean seeing you at dinnertime, instead of 9 p.m. every night. The bottom line is different for each customer but the end results are what make the biggest difference.
With the challenges that are occurring for healthcare, the issue is one of efficiency. The field as a whole needs to look at ways of making processes and systems more efficient. Those in healthcare are working as hard as they can. The issue is how to work smarter.
How can you apply the concepts of quality management to your practice? Like Dr. W. Edward Deming (see “A Brief History Of Quality Improvement”), we are going to look at an eight-step process that will help you take your practice to the next level.
1. How To Identify Areas For Improvement
First, focus on areas that are problematic or can have significant effects on the practice if it were to occur. For example, how many times does the front office staff tear up the office trying to rectify one lost charge slip? The amount of wasted time, both theirs and yours, when you have to redo another charge slip can be astounding. Of course, the ultimate outcome of this, if the charge slip were not found, would be lost practice revenue.
There are literally thousands of different issues the average physician executive must deal with. These issues include staffing issues, labor laws, OSHA compliance, accounting, material management, marketing, medical equipment, physical plant, professional organizations, legal issues, liability insurance and associates/partners are just a sampling of the administrative side of a practice. Combine this with the clinical side of private practice and you can have a real handful of challenges every hour.
So how do you focus on those areas?
Make a list of things that hurt the practice (decrease or take away money). This brainstorming could include your accountant, staff, partners/associates and significant others/spouses. In really progressive practices, it might even include patients and referral sources. Break these areas down into administrative versus clinical.
Administrative areas can include too many holes in the schedule, too many insurance denials of claims, not enough managed care contracts, decreasing managed care reimbursement, staff turnover, malpractice premium increase and failing medical equipment. Clinical areas can include non-compliance, excessively high rates of infection and surgical complication, chronic pain and poor surgical outcomes.
2. Key Tips On Prioritizing Areas
Prioritize these items based on Frequency (F), Severity (S), and Detectability (D). The Priority Score is the result of multiplying the F x S x D. The following scoring guide has been developed arbitrarily. You may find the definition for the scoring does not accurately reflect the challenges you may be undergoing in your community. Adjust the scoring to make it fit your practice.
Frequency Scoring Guideline
5: Occurs all of the time
4: Occurs 75 percent of the time
3: Occurs 50 percent of the time
2: Occurs 25 percent of the time
1: Never occurs
Severity Scoring Guideline
5: Could close the practice
4: Could cost the practice over $5,000
3: Could cost the practice over $1,000
2: Could cost the practice over $100
1: Will not cost the practice anything
Detectability Scoring Guideline
5: Could not automatically detect
4: Discoverable if someone outside of the practice were to look for it
3: Discoverable if a manager or physician within the practice were to look for it
2: Discoverable by line staff
1: Anyone could find it
Based on the scenario presented in the chart (above), we arbitrarily determined the score for each of the issues we have identified. Based on our own assumptions (and yours can be entirely different), we have deemed the decreasing managed care reimbursement is the most significant issue for our practice. The second issue is increasing malpractice premiums. In order to maximize our resources, a practice should prioritize how it goes about tackling the different problems.
3. Figuring Out What To Fix
Figuring out how to fix something sometimes requires a flow chart of the process to identify and understand potential bottlenecks or disconnects.
Look at the scenario of “too many denials.” You start the entire process by having Dr. X providing service to the patient. The doctor has the charge slip on the front of the chart and marks up the slip. The doctor gives the charge slip to the patient, who takes it to the front desk to make an appointment. The front desk files the charge slip on the stack of other charge slips from that day. At the end of the day, the billing person gets the charge slips and enters the information into the computer. The computer collates the data and sends everything to the insurance company.
What can go wrong? The doctor marks the wrong charges, wrong diagnosis, wrong charge slip or wrong patient. Any of this could result in an improper insurance claim form going out. What about the patient who loses the charge slip or alters it? This could have similar results.
Most front offices are space challenged, so misfiling or just being lost in the shuffle of things can occur. The billing person misenters information into the computer that mimics exactly what the physician did at the beginning of the process. Any single one of these points can lead to an insurance claim denial.
Let’s look at a clinical support process. All of us take sterilizing instruments properly for granted. All instruments we use for surgery are processed properly to avoid complications. If the instruments are improperly cleaned in the beginning, that can lead to contaminants in the surgical site, whether it is tissue, bacteria, virus, oil or cleaners. If the instrument is not properly dried, it can attract bacteria or alter the ability of the sterilization process to work effectively. If the autoclave does not achieve the proper temperature and pressure for enough time, it might not sterilize the instruments properly. As simple as it sounds, it is extremely difficult to use an instrument that is fresh out of the autoclave (it tends to melt gloves). The end result of this type of failure can be infection, delayed healing, chronic drainage or poor surgical results.
4. How Should The End Results Look?
Several processes can be improved in every medical practice. The important thing is identifying them, mapping out the process and determining how to improve them. Things like infection rates are monitored every day at every hospital. When they occur, the results can be clinically and economically catastrophic. In the situation of insurance denials, the amount of work that goes into resolving this can certainly have an immediate and long-term fiscal impact on a practice.
5. Identifying Problems Within The Process
To find the disconnects, blockages or problems with the process, you have to go back to your flow charts to see whether all of the variables have been accounted for. This is called a root cause analysis or RCA. The root cause analysis looks at contributing factors that lead to a particular outcome. For example, you look at your appointment schedule the day before to find it completely booked. At the end of the next day, it had several gaps.
What caused those gaps? One patient cancelled because of a family emergency while another patient did not come in because his ride never showed up. Perhaps the scheduler forgot to erase a patient from the day’s schedule because that patient had rescheduled and you had to block out time to meet with that health plan to renegotiate that contract.
Each one of these reasons is a contributing factor or root cause of the gaps in the appointment book. Although you still were in the office for those eight hours, the end results are what we tend to concentrate on. The outcome is less revenue production for the day but with a possibility of increased revenue production in the future. That hour you spent with that health plan resulted in successfully negotiating a 50 percent increase in your reimbursement for your services.
How do you get to the heart of the matter? This may require talking to line staff to see how things really do flow. You will need to identify the individuals who have the most knowledge about the specific process. If you have billing software that does not quite work right, you need to get on the line with technical support.
In that preceding scheduling scenario, you will want to talk to everyone who touches that appointment book. In some offices, that might be one person. In other offices, it could be several people. Once you find out how things are done, both right and wrong, you can focus on modifying the process to make the outcome perfect.
6. Get Your Staff Involved In Modifying The Process
Modifying the process means changing peoples’ practice or changing policies and procedure. Yes, it’s easier said than done. No one likes to change, especially if it is forced upon them. That is why the staff that is directly involved with the process should be involved with improving and implementing that process.
How many times do you go away to a great seminar, come back to the office on a Monday, tell the staff you are changing such-and-such process and they roll their eyes up into their heads? Your idea may be the best thing since powered surgical saws but they don’t buy it. You need to get those who are directly involved with a process to be involved in modifying the process.
In the situation in which you have identified a particular process to improve, your task is to empower or encourage those who are directly involved with that process to adopt it as if it were their own. The staff needs to provide input into these changes. These issues can be discussed at staff meetings or if there are breaks in the office day.
7. How To Monitor The Process
Anytime you modify a process, you need to monitor it to determine if the adjustments work.
Based on the scenario of missing charge slips, your indicator might be the number of missing charge slips at the end of the day. You may have had six missing slips a day so in applying the quality improvement concept to this issue, your target might be zero. If after a couple of weeks, your business office staff reports they have been averaging zero charge slips missing at the end of the day, that might indicate the new process is working.
If the same couple of weeks have passed and the staff has been averaging six charge slips missing a day, that might indicate the new process has not made a difference. You will need to go back to evaluate what happened. Chances are you did not identify all the root causes that had affected the process.
Monitoring the process can occur in a couple of different ways. For most medical practices, this can be a monitoring of performance over a period of time. You start monitoring something June 1 and go back to measure it September 1. This is called internal benchmarking: measuring yourself internally over a period of time.
The other monitoring process requires external comparative information. This can be data compared to other similar practices, professional organizations (your professional society, Medical Group Management Association or American Medical Group Association) or any other reference or research literature available. In this situation, you can measure yourself based on comparative snapshots or based on episodes of monitoring.
For example, if you feel you have a really high staff turnover rate of 50 percent over the past year, the professional journals may say the regional average for staff turnover is maybe 10 percent over the past year. For some reason, you are operating at 40 percent higher than the average in your region.
Many healthcare organizations use both internal and external benchmarking to determine how they are doing. Your medical practice could easily be measured for comparative performance in the same manner.
8. Re-Evaluate The New Process
After monitoring the changes in your new process for a period of time, go back and spot check the process to make sure it is performing to your standard. If you audit your new charge slip management process and find that after a year, the average number of missing slips is zero, you have accomplished your goal. This process now goes into a quality assurance or quality control mode. Monitor the process from time to time to make sure your quality standard is being maintained.
If you find the process is not performing at the level you want, you will need to go back and apply the quality improvement concepts to determine what needs improvement.
Many healthcare organizations will re-evaluate their lists of issues or challenges on an annual basis. These organizations often find the lists change and issues are removed or added. This starts another quality improvement cycle, with the goal of streamlining processes, eliminating errors and hopefully having a much improved outcome.
Quality assurance involves measuring or monitoring against a standard. Quality improvement is the process of moving the bar. In some cases, we try to move the bar higher. This can be having improved patient satisfaction survey results, an increased number of new patients, increased numbers of procedures performed or an increased number of referrals.
In other cases, we try to lower the bar. Each time an adverse occurrence or incident happens, we need to evaluate it, since we do not want these things to happen. These negative occurrences could be infections, surgical complications, patient complaints, etc.
The bottom line for quality improvement is not an issue of working harder but learning how to work smarter.
Dr. Chinn is the Chief Compliance Officer/Director of Quality Improvement at Ardent Health Services-Fremont Hospital in Fremont, Calif. He is also President/CEO of the Accreditation Compliance Group in Millbrae, Calif. He is a JCAHO hospital surveyor and a noted speaker on practice management and quality improvement. He can be reached at firstname.lastname@example.org or (650) 652-7943.