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But then they went on to showcase so many other innovative, efficiency-building, patient-friendly, and staff-oriented undertakings that our panel of seven judges deemed The Allergy and Asthma Center the Grand Prize Winner for 2002.
"If there's a long-term vision" for the practice, says director William Smits, MD, "it's a freestanding, comprehensive respiratory care center which is the best in the world. And I don't mean that arrogantly. That's the ultimate long-term vision. If people — both patients and staff — realize that, I think they would choose to come here."
Smits refers to the practice as "a yes organization. If anyone is ever saying 'no' to a patient, they need to step back and ask why." Staff flourish in an environment where "people are OK with making mistakes because that's how we learn," and where Smits himself — the sole physician on staff — is far from being the center of the universe.
"It's not Dr. Smits' office," he says. "The importance of that is to spread the responsibility and have people take more ownership. Ideally I would love to see this place run without me, in the sense that [it] would be beyond any single personality. That speaks to a very healthy organization and team."
And clearly, a key part of the team is the patients. "Fundamental to everything that occurs is that we make the interaction between the provider and patient perfect," says Smits. "We want it to accomplish everything that the patient would possibly imagine and then maybe even more. So rather than just walking away satisfied, they're actually — possibly — delighted. That's a formidable goal to do that with every visit."
But like a professional athlete who runs that extra mile or makes that tough goal, this practice does it with a skill and finesse that makes it look almost easy.
Patient Satisfaction
Highlights:
Of the five categories that formed the basis for this year's Physician Practice of the Year competition — technology, office management, finance, personnel, and patient satisfaction, Smits says patient satisfaction is the most important — "all the others hinge on that."
In fact, the practice's mission statement is "We're building relationships to last a lifetime." A personalized section in each patient's chart is one way the practice lives up to that goal. In it, there is something personal noted about that patient — a hobby or pastime, for example — so the physician or nurse practitioner can spend the first few minutes of a visit connecting with a person, not just treating a condition.
Because conditions that the practice treats frequently, like asthma, require ongoing patient involvement and self-monitoring, patients receive a personalized Asthma or Allergy Action Plan in the form of a binder containing a detailed regimen for their condition. Smits and his staff find that standard educational materials, such as a one-sheet with instructions, are ineffective.
"If you just give somebody a piece of paper and say, 'Do this whenever you have trouble,' eventually it gets lost or forgotten," says Smits. "The patient has to be able to identify with this and find it. So we glamorized it; we put it in a three-ring binder with a picture of the patient on the front so it makes it their own. It gives that little extra sense of ownership."
This approach to education is a hit with patients as well as nurses. "People can take control of their asthma and treat it on their own before having to come in," says RN Taryn Ealey. "If they begin to flare up, they know what to do. The patients like it, especially children, and it helps parents feel more at ease, knowing that if something happens they have the information right in front of them."
Calls from patients needing help controlling their conditions dropped off significantly once the personalized plans were in place. "That was how the nurses bought into it," Smits notes.
Follow-up is essential to the overall patient experience. New patients receive a phone call one week after their initial visit to make sure medications are being used properly and are effective; selected existing patients may receive a call from a staff member within two or three days of a visit to see that they are improving and retaining the treatment information that was discussed.
In addition, patients who cancel appointments or who have not returned to the practice for a full year are surveyed as to why. About 70 percent of nonreturning patients say their primary-care physician has renewed the regimen because it is working well; 15 percent say they have gotten better and no longer need medication. Ninety percent of nonreturning patients report being satisfied with the care they received, and the practice has only one or two no-shows a day.
Smits recognizes that the process of getting healthcare isn't easy for many patients, so he tries to put the practice in the role of patient advocate whenever possible. "There are so many hurdles to getting a patient to do anything, we try to overcome those as best we can." For example, patients in financial need are helped in qualifying for Medicaid. Complimentary full courses of medications and patient assistance programs are made available to patients with special needs.
Perhaps most impressive, sample medications and durable goods for the first two weeks are provided free to all patients — thanks to generous pharmaceutical reps.
"Usually by the time patients are seeing a specialist, they have had failed treatments. By offering the samples, the patient doesn't have to put out any money for a drug that they may be reluctant to spend money on," says Ealey.
"This is far above and beyond a two-day sample," Smits says.
"Patients just love this, and compliance to therapy skyrockets."
Along the way, Smits tries to educate patients about bigger-picture challenges
related to their healthcare — formulary changes, for instance. "One of
the large insurance companies here just took all of their allergy medicines and
put them all third tier. That means more out-of-pocket money for the
patient." So, for the first time, Smits is considering — reluctantly —
prescribing some generic prescriptions. "That becomes a huge
challenge," he says.
The answer? More patient education. "We tell patients, 'We want you to recognize that the insurance company is motivating [this] change. So if this [medication] doesn't work, please call your insurance company and let them know.' Because it's very easy for patients to think it's the doctor's fault. We want the responsibility to go where it lies."
Personnel
Highlights:
Smits believes that one negative attitude can deflate the entire organization. So he and his management team are highly selective in recruiting staff.
Candidates for nursing positions, as well as front- and back-office positions, undergo a series of three interviews: the first is essentially a screening; the second consists of a few hours of hands-on experience by having the candidate "shadow" an employee in a similar position. This allows the practice to receive feedback on the potential hire from several different employees in different areas. The third interview is with the management team.
Smits admits the process is time-consuming, but it helps the practice hire just the right type of employee. "We're looking for someone who's enthusiastic about what they do, and very detail-oriented. We also ask them to send an accompanying letter that describes [their] unique qualifications. You'd be amazed how many people don't do that. They're automatically eliminated because they can't follow directions."
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The rigorous hiring process results in extremely low turnover. "We've only had one or two nurses choose to leave for their own professional reasons," Smits says. "Aside from that every nurse has stayed on with us."
The practice believes that skills and formal education are not the main criteria when they make a hiring decision — a good attitude wins out overall. "It's more important to have the 'soft,' interpersonal skills. That makes all the difference," says practice administrator Linda Smits.
Once staff members are hired, cross-training and promoting from within are common. Nurses rotate on a daily basis between the regular office, telephone triage, the shot room, the same-day clinic, the infusion suite, and clinical research, which goes a long way toward preventing staff burnout.
Other positions are highly specialized, like the IT officer and the staff coding specialist. According to IT officer Randy Louth, "This is the first medical office I've worked where they're so open and adapted to new technology."
Dr. Smits, who is a strong proponent of lifetime learning, brings that opportunity to his staff through regular educational meetings at which members of the group share their particular areas of expertise. For example, "a nurse will talk about mixing allergy serum, and our information officer might give a shortcut of the day in Microsoft Outlook."
Visiting experts are featured as well. "We had a communication professor from the university come here. We had a managed-care specialist who gave a presentation about managed-care penetration around the country and in this state; then we had a talk on teamwork." The entire staff also enjoys an annual trip to the conference of the American College of Allergy, Asthma, & Immunology.
Overall, says Smits, the practice is a happy and fun place to work because
"we like to work around the life of the individual." That means perks
like flex time, a matching 401K plan, health coverage, and reimbursement for
medical expenses
and tuition.
"We try to bring people on and hope that the practice grows around the people, not their job description," says Smits.
Technology
Highlights:
"Part of what's allowed us to get where we are is the appropriate implementation of technology," Smits says, estimating that Louth saved the practice about $200,000 last year, not only by helping to implement new processes but negotiating the best possible deals on everything from cell phones to radiology equipment.
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"We try to keep any implementation of technology really simple," says Smits. And for some technological undertakings, implementation really is as simple as letting staff try out a tool and discover for themselves how well it works.
"We have PDAs at the nurses' station that carry medications and side-effect profiles. It's actually easier to access than [looking it up] on the computer — it's much sharper," says Smits. "So we said to the nurses, 'Here's this Palm Pilot, let me show you how to use it, and see what you think.' And we left it there for the nurses to try it out."
PDAs help Smits and his two NPs structure their days, and allow phone nurses to answer patient questions quickly. They also include physician referral information and allow users to glean data from medical texts. The staff was sold on the idea.
The Palm Pilots are "a great resource for the nurses," says Ealey, "because you don't have to flip through the PDR, which is thicker than a phone book. I use it almost every day."
Other technological systems in the practice have taken time to evolve. Smits knew a PC upgrade would allow for greater communication among the machines, but "that was going to be a significant cost," he recalls.
"We started thinking about adding PCs to the 11 exam rooms when [they cost] $1,500 to $2,000 each. When they broke the $1,000 barrier, we had to look at it harder. I think we paid $600 to $700 in each room to upgrade those."
Looking back on that decision, he adds, "The ultimate
justification to do it was that we realized we could add a screensaver that did
advertising for us. We can't get better advertising for less money. And on top
of that we got much better access to information in the rooms that allowed us to
have access to digital images and so forth."
Fast forward to today: the practice uses electronic medical records (EMR) that are accessible from all 60 workstations, including one in every exam room. Wireless laptops are available to all employees, giving them access to EMRs or the Internet anywhere in the building, or by home computer. All prescriptions are entered into patients' electronic records and printed out, reducing pharmacy callbacks and the risk for error.
The EMR is also integrated with the billing software. HCFA forms are printed with laser signatures, and are transmitted electronically to those payers that are equipped to receive them, resulting in the quickest payment possible. Diagnoses and CPT codes are linked, which drastically cuts rejected claims.
Smits acknowledges that not all practices have the resources to become so technologically sophisticated. So what does he believe are the must-haves for small practices?
"Clearly an EMR is important. It's just a no-brainer that if you can pull up 10 different records on your computer, you don't have to be going to the file cabinet. ... Secondarily, some sort of billing software is absolutely vital. That's the lifeblood of the practice. And from a patient safety standpoint, something that writes or prints out prescriptions is very helpful. Those are three things any small practice can easily implement."
Regardless of the size of your practice, Smits offers an apt philosophy: "All decisions to implement technology are weighed against a simple question: Does this technology improve patient care?"
Office Management
Highlights:
The practice management "obsesses about office flow" — a healthy obsession for an office that sees an average of 64 patients a day. Ongoing evaluation and improvement keep the pace steady.
"We met with a management consultant who's an expert in flow, and we're focusing our attention on a couple of our bottlenecks," says Smits. "We found that [patients] were waiting an average of 11 minutes in the reception area. So we need to be better about bringing them back to the exam room more quickly. The other bottleneck, which was 10.8 minutes, was the physician lag time [when the patient is roomed, waiting for the physician]. ...We are passionate about getting that time down."
The practice uses both high- and low-tech tools to regulate patient (and staff) flow. A lighting system is used to track each patient's status during a visit, from check-in to check-out; staff can determine how many patients are waiting, where the physician is, and how long he has been there by looking on any computer terminal.
"It's really helpful to be able to look at it in the exam room," Smits says. "We don't want to shortchange the patient but we want to be constantly aware. It works in a good way, too; if it's a slow day and you see no patients waiting, you can give the patient an extra five minutes."
The office has a 12-line telephone system that can route up to 300 calls a day; every call is picked up within three rings by a live person, not a recorded message. Everyone in nursing and administration is trained to answer the phone, schedule new patients, and enter triage calls. And "patients rave about the quick callback time," says Smits. Clinical questions are answered by the dedicated phone nurse of the day, and Smits makes time to answer other calls between visits.
Many office visits can be averted when patients speak with a triage nurse first. When patients do visit the office, their insurance cards are scanned into the electronic chart for quick access, eliminating the need to physically pull a paper chart, and countless hours for office personnel. The scanned insurance card can later be printed or faxed to the payer, the patient, or another physician's office. Such advances have so far reduced the overall appointment time, from check-in to check-out testing, including education and treatment, from 78 minutes to 65 minutes.
Looking at office flow from a broader perspective, the practice took a bold
step toward increasing patient access and increasing efficiency by opening a
same-day clinic. "Yes, this means same-day appointments!" laughs
Smits. "An office staff member pointed out that we needed to address the
issue of scheduled patients having to wait longer because of accommodating sick
patients. One meeting later, the same-day clinic idea was born."
Smits had a sense the clinic would be popular, and made long-term plans to grow
it, but "within the first week or two we had about 25 patients in there,
and we knew we couldn't wait six months before making more room." The
clinic is typically staffed by a receptionist, a nurse practitioner, and two to
three other nurses, and "the patients are very happy to have it," says
Smits. "This includes new patients who typically wait two to three months
for an appointment elsewhere," he adds.
Patients who only need allergy shots also enjoy enhanced efficiency by visiting the dedicated shot room, which remains open during the lunch hour and accommodates before- and after-work appointments. Shot room patients are given a photo ID card that is scanned when they come in. Their name instantly appears on a computer in the back area, where a nurse is stationed and collects the necessary vials before the patient is called for the injection. For those patients who have a box of serum vials, an additional photo is applied to the outside label of the box, reducing the risk of medication error.
Smits believes that "as a result of this efficiency and comfort, there is enhanced patient compliance" with allergy shot regimens. "Patients know they can get in and out quickly, without having to wait the typical hour at their family physician's office." Patients are required to stay at the practice for 30 minutes after their shots so staff can monitor them for adverse reactions — still, the average length of visit in the shot room is just over 30 minutes. Smits says it has been so popular that "people are driving from up to 11/2 hours away. Most children brave their shots to get little prizes. And social gatherings are occurring regularly — rumor has it that several romances are developing" among shot room patients.
Finance
Highlights:
Ancillary services like the shot room and same-day clinic, on-site CT scans, X-rays, and lab testing go beyond boosting patient satisfaction and improving outcomes — they provide an important source of revenue for the practice. Not only does "one-stop shopping" make it easier for patients to receive their care here, ancillary services contribute to an estimated 25 percent of charges.
The practice's large patient database — "the largest volume of
patients in the region on a computerized database with outcomes," according
to Smits — has allowed the practice to pursue another, perhaps less common
revenue stream: conducting clinical trials.
"Because of our computerized medical record, we could identify patients who
would be good fits for various studies," says Smits. "The [EMR]
allowed us to recently fill up two clinical trials within a few days, unlike
other research sites, where that might take six to 12 months. And often [we're]
reimbursed five to 10 times what a typical visit would be."
Because pharmaceutical companies and medical-supply firms have an interest in the success of the practice, staff members have become more savvy in asking for educational grants to help defray the costs of educational materials.
The practice has also reached out to insurance company representatives, adhering to the belief that "claims resolve quickly with someone on your side," says Smits. "Each company representative has been personally invited to the practice to explain how claims might be better processed. We're also in the process of inputting the fee schedule of every contract into the computer system so that it can easily verify the accuracy of each reimbursement."
Still, the philosophy at The Allergy and Asthma Center is to accept virtually all patients, regardless of their insurance plan or lack of insurance, or their ability to pay. Because patients frequently switch back and forth between insurance plans, the practice preverifies coverage for allergy shots, CT scans, and other services.
"Some offices just go ahead and bill the patient" when a claim is denied, says Linda Mix, who works in the billing office. "We go out of our way to make sure we get all the right information. We do a lot of the leg work. It's easier for us to take five minutes to make a phone call and get what we need."
While the practice has enjoyed rapid growth —- it has nearly doubled its staff size in two years and sees 1,000 more patients per month than at its inception five years ago — Smits says one of the smartest financial moves any size practice can make is "to make a commitment to an internal marketing campaign."
He recognizes many physicians are squeamish about marketing, but Smits insists that all businesses need to do it. "It's OK to have a brochure to give to active patients that represents the practice: Here's something that explains our practice and what we do. The majority of marketing occurs by word of mouth anyway." He estimates that 80 percent of his existing patients verbally refer new patients to the practice. "If people are having a good experience, it's fine for doctors to ask their patients to share that. It doesn't really cost any money."
But Smits still prefers to go the extra mile to reach out to patients in the community. "We run a newspaper advertisement two or three times a week. One thing that's increased people's awareness of what we do is ... we'll advertise for certain patients [for clinical trials]. So people are aware that we've become a nationally recognized research facility as well. We also have an excellent rapport with the various news agencies, so often if there's an allergy story they'll call us, and they'll put our commentary on the nightly news."
Health fairs and other community events present opportunities for the staff to make themselves known. "We'll be at the Asthma Walk [sponsored by the American Lung Association]. We've got at least 30 employees and their family members attending this. And, of course, we're all wearing our Allergy and Asthma Center T-shirts."
The importance of reaching out to referring physicians is not lost on Smits. "When I moved here, I received one letter from a doctor welcoming me," he recalls. "I didn't know that doctor [then], but to this day I know who that is. That had quite an effect on me. It's not unusual for me to go visit some of the doctors who refer to me and take them some coffee or candy just to say hi and make sure we're providing the level of service they expect."
Additional winners
Personnel category
Winner: Urology of Indiana
Practice Vitals
Urology of Indiana has been around for than more than a century, and it continues to subscribe to the old-fashioned philosophy of lifetime employment for its staff members. In a healthcare labor environment in which top employees are in high demand, that's an ambitious retention goal. But for financial, clinical, and patient satisfaction reasons, practice administrator C. Alan Hughes says it's a worthy objective.
"Once we see that they fit into our environment, we want them to stay for their entire careers," says Hughes. "We think there's a real value to having staff members together who've worked together for years — it creates real synergies."
Besides, he says, it's less expensive in the long run to keep employees, even at higher salaries, than to keep replacing them with younger, seemingly bargain alternatives. There's a substantial cost just to recruit someone, plus a seasoned employee can often do the work of two rookies. One office in the practice has not lost an employee in two years, and the group's overall retention rate of 25 percent is good, especially since the salaries it pays — while higher than average — don't shatter industry standards.
The secret, says Hughes, is to create an environment of teamwork, unity, and fun. Managers help out with back- and front-office duties such as check in and scheduling. Occasionally, the office closes for midday cookouts, and other, frequent "just for fun" events are just as useful for recruitment as retention because word gets around to prospective employees.
Urology of Indiana also provides incentives to employees for jobs well done, like its monthly "mission in action" awards for workers who best exemplify the practice's mission, and its "copay bounty" program, which pays employees 50 cents for every copayment collected.
"Our management philosophy is to use a carrot instead of a stick to motivate people," says Hughes, "and to clearly define goals and then set people loose to accomplish them."
Patient Satisfaction Category
Winner: The Elizabeth Wende Breast Clinic, Rochester, N.Y.
Practice Vitals
Keeping patients happy in a practice that sees some 300 every day at a single site is no easy task. Yet it's the very difficulty of the challenge that has forced The Elizabeth Wende Breast Clinic to be so diligent about empathizing with, and listening to, its patients — the foundations of a practice with satisfied customers.
"Every single day it's a challenge, and it's something we work on all the time," says administrator Theresa Wade. "You have to be very sensitive to what your patients are saying. If you're not listening to patients, you're making a mistake."
But the Elizabeth Wende Breast Clinic doesn't simply listen to its patients — it solicits their opinions with a 15-question survey kept in the reception area and sent to patients several times a year. Staff members are trained to look patients in the eye and answer their questions without rushing. The clinic answers every survey that requests a response, and it has implemented many of the suggestions it receives, including reducing wait times, designing a more female-themed reception area, and offering patient gowns in all sizes. One big change was the creation of a patient advocate position to track patients' movement through the office and to address their concerns directly.
Hiring the advocate "was well worth the expense of her salary," and the number of patient complaints is noticeably down, reports Wade.
Technology Category
Winner: Maryland Healthcare Associates,
Waldorf, Md.
Practice Vitals
It's only natural that the winner in the technology category would be truly a
pioneer in the field. While many practices are still researching electronic
medical record systems (EMRs), Maryland Healthcare Associates has been using one
for 10 years.
"A lot of practices don't want to make the investment in an EMR. We have found that using technology systems saves money over time and allows us to buy additional equipment for the office or hire more physicians because of the savings," says Tracy Harrison, manager of operations. For instance, the practice has saved more than $100,000 since eliminating the need for staff to search for, pull, and refile charts.
When integrating technology into the practice, says Harrison, everyone agreed that it should not interfere with the ability of clinicians to provide compassionate care to patients and should not add time or complexity to the practice model. The practice chose an EMR system an individual programmer had developed, and had it customized.
The system has worked well for Maryland Healthcare, recording more than 3 million patient encounters in the past decade. Data entry is made in a standard chart format with the ICD-9 diagnosis, treatment, plan, medications, outcomes, and ancillary procedures. Physicians enter these elements at their desks or in exam rooms. Patients leave with a computer-generated summary that includes a diagnosis, current medications, treatment instructions, and follow-up visit information.
Notably, the practice does not regularly use an automated telephone attendant. "We do answer the phone as much as we can with a live voice. We tried using an automated system only and patients didn't like it so we went back to staff answering phones. A phone call to our office is often a first impression for patients and we want to make it a good one."
Finance Category
Winner: Urology San Antonio, PA
Practice Vitals
Shortly after the merger that created the practice, Urology San Antonio realized that the heavy managed-care environment it had benefited from would soon become more oriented toward less lucrative capitated fee-for-service. The solution? Develop broader and deeper revenue sources.
"We needed to find other things that would generate new streams of revenue," says COO Michael Dermer. "And we did a pretty good job of expanding both horizontally and vertically."
One example was the practice's decision to get involved in clinical trials. Urology San Antonio now has a thriving side business, participating in about 18 trials a year and collecting some $1.3 million in services performed along the way. The practice also bought its own lithotriptor, a device for breaking up large kidney stones. For years, lithotriptors carried heavy, seven-figure price tags - too rich for the average practice. But in 1998, when the price for a good device came down to around $500,000, the practice jumped on the opportunity.
"We'd been controlling the volume of business [for lithotripsy services] but not the revenue," says Dermer, noting that Urology San Antonio had previously been a member in a lithotripsy consortium, in which it was collecting only a fraction of the revenue the group generated. "We knew the purchase would pay for itself pretty quickly."
Then in 1999, the practice purchased a two-building retail strip center, converting it into medical space, including a surgical center and offices, and entering into lucrative partnerships. One is with HealthSouth, which owns 51 percent of the surgical center; Urology San Antonio surgeons perform the procedures while profits are split 51-49, with HealthSouth paying rent to the practice. It also rents office space to other practices.
Office Management Category
Winner: Blair Medical Associates Inc., Altoona, Pa.
Practice Vitals
Blair Medical Associates, which receives an average of 500 patient calls a day, realized in 1999 it could be more efficient by creating a call center. The center is currently staffed by full-time licensed practical nurses and medical assistants who take patient calls from 8 a.m. to 5 p.m., returning calls — on average, 330 — throughout the day until 6 p.m.
Every call is classified into six categories ranging from "urgent," needing immediate attention to "normal," relaying normal test results to patients. "Since most of the calls are from patients who need same-day help, the call center staff is able to get quick answers by checking and updating a physician's schedule with appointments and conferring with him on prescriptions, all through an electronic medical record," says Susan Conrad, the call center supervisor.
Each interaction with a patient becomes part of the patient's record. All patient requests are recorded in the electronic document, signed by the nurse who took the information, and routed to the physician. The physician can then return it to the nurse or send it to a particular call center category for attention.
The long-term goal is to have satellite office calls come directly to the call center. According to Conrad, the call center provides patients with a higher level of service and staff is able to focus on patient interactions — in person or on the phone — without being interrupted.
Joanne Tetrault, managing editor for Physicians Practice, last wrote about the malpractice crisis and resolving staff conflict in the September/October issue. She can be reached at jtetrault@physicianspractice.com.
This article originally appeared in the November/December 2002 issue of Physicians Practice.