Building the Right Care Team
1 Care Team Work Analysis (CTWA)
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 (panel of patients and/or caseload).
2
Horizontal Flow for the Office
Vertical Flow for the Office
Nonpatient Care Work
Appointment Work: Direct Patient Care
We see schedule We don’t see waits
4 Direct Patient Care
Nonappointment Work: Indirect Patient Care
How Time is Deployed or Allocated
Clinic Meetings Proc ASC D S D S D S D S 5Balance Between and Within Each OR Hospital Consults/Rounds Call D S D S D S
Demand
Capacity
6 39% of Capacity is Physician Time 39% of Capacity is MA Time 22% of Capacity is RN TimeThe Two Most Important Elements in
Completing Clinical Care Tasks?
• Staff doctor vs resident • Practice size
• Provider age
7 • Year of graduation from medical school
• Training • Feedback • Team
Benefits of a Primary Care Team
What do you think?
8
Business Case for Care Teams
• Nursing, administrative, clerical, and aids all
independently related to productivity measured by both
visits and billing.1,2
• Strong positive correlation between number of support
ff d d i i d b i i k3
9
staff and productivity as measured by visits per week.3
• Held true for secretaries, RN’s, LPN’s, and medical
technicians.3
1. Reinhardt U. A production function for physician services. Rev Econ Stat. 1972;54(1):55-66. 2. Thurston NK, Libby AM. A production function for physician services revisited. Rev Econ Stat. 2002;84(1):184-91. 3. Brown DM. Do physicians underutilize aides? J Hum Resour. 1988;23(3):342-55.
Business Case for Care Teams (cont)
Strong relationship between both administrative support staff and medical support staff and physician productivity
(as measured by revenue per physician).4
10 4. Pope GC, Burge RT. Economies of scale in physician practice. Med Care Res Rev. 1996;53(4):417-40.
What Does a Care Team DO?5
• Population management • Just in time • Minimize steps 11 • Patient focus • Measures
• Match activities to demand • Links
5. Batalden PB, Mohr JJ, Nelson EC, Plume SK, Baker GR, Wasson JH, Stoltz PK, Splaine ME, Wisniewski JJ. Continually improving the health and value of health care for a population of patients: the panel management process. Qual Manag Health Care. 1997;5(3):41-51.
Burning Questions
• How many support staff are needed in our practice? • If we decide to hire, what professional type of person is
best?
• How do we use our existing resources best?
12 • How do we use our existing resources best?
Medical Group Management Association Cost
Survey: 2000 Report Based on 1999 Data
$187,842 $176,894 $241,289 $227,890 200,000 250,000 300,000 F T E P h ysi ci an
Profitability for Family Medicine Groups by Number of FTE Staff per FTE physician 13 $90,908 $176,894 0 50,000 100,000 150,000 , 2.0 3.0 4.0 5.0 6.0 7.0 8.0 M e d ian Reven u e after Op erati n g Co st p e r
FTE Support Staff per FTE Physician
Reprinted with permission from the Medical Group Management Association, 104 Inverness Terrace East, Englewood, Colorado 80112. www.mgma.com. Copyright 2000
Who Makes Up the Care Team?
14
Group of smiling doctors and healthcare professionals. http://office.microsoft.com/en-ca/images/results.aspx?qu=doctors&ex=1#ai:MP900422773|. 20130209.
Provider Roles (Continuum)
Continuum of function : • MD with no nursing staff
• MD with nonconsistent nurse staffing
15 • MD with consistent nurse staffing
• 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 area • Schedules and takes messages for many • Scheduler accountable to a group of providers
16 • Scheduler actually co-located with the providers and
patients they support
Woman on phone. http://office.microsoft.com/en-ca/images/results.aspx?qu=woman+on+phone&ex=1#ai:MP900442333|. 20130209.
Clerks Are Important
Conrad, analyzing the AMA’s Physician’s Practice Cost and Income Survey from 1997 found + relationship between weekly hours of clerks per MD and the number
of MD visits.6
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6. Conrad DA, Sales A, Liang SY, Chaudhuri A, Maynard C, Pieper L, Weinstein L, Gans D, Piland N. The impact of financial incentives on physician productivity in medical groups. Health Serv Res. 2002;37(4):885-906.
Nursing Roles (Continuum)
• Phone calls, rooming, paperwork, triage, scheduling
• Nurse offers advice over the phone or through email
18 • Nurse manages populations of patients
What Are the Attributes of a Care Team?
• Proactive vs reactive • Communicative vs isolated
• Accountable to each other, and to the patient • Uses measures for feedback
19 • Delivers high quality chronic, acute, and preventive
care cross-trained vs territorial • Integrated vs separated
• Continuous flow vs flow based on urgency
• All staff work to highest level of training, experience, and licensure
Foundations of an Excellent Care Team
• Patient value is key
• All team members roles & responsibilities should be standardized & clear
• Each individual is key to team success
• All team members should know in advance of having to
20 • All team members should know in advance of having to
make decisions based on set parameters whether they have the authority & permission to do so.
• Need reliable communication & process for conflict resolution must be very clear
• Come up with own examples of staff appreciation
Teams:
Know Your People – Know Your Processes
Processes • Identification • Measurement
People
• Know each other • Teamwork C i i 21 • Mapping • Identification • Communication
Optimal Care Teams
Rules:
• Elevate all members of the team to the highest level their education, training, and experience will allow • Move work away from the constraint in the system
22 • Move work away from the constraint in the system
Assure that all work to highest level…
• Determine everyone’s highest level; research provincial and government regulations • Provide competency training and
23 testing to raise skill levels where
necessary
• Help all become aware of each team member’s skills and interests
• Cross-train where appropriate • Empower the team
Blood pressure cuff being used during a medical examination. http://office.microsoft.com/en-ca/images/results.aspx?qu=blood+pressure&ex=1#ai:MP900423013|. 20130209.
Then…
Divert all unnecessary work away from the provider in a way that:
• Enhances the patient-provider relationship
24 • Promotes trust in the care team
• Builds the relationship with the care team
• Provides high quality care
Defining the Work:
Examples of Common Processes
• Referrals • Messages • Refills • Rooming • Advice 25 • Teaching • Order entry
• Care under protocol registration • Records retrieval • Billing • Phones • Authorization • Medication • Monitoring • Scheduling
Businesswoman and filing cabinet. http://office.microsoft.com/en-ca/images/results.aspx?qu=filing&ex=1#ai:MP900442356|. 20130209.
Job Analysis
• Survey of 7 practices
• Extensive interview of provider, nurse, pharmacist, clerk (1 to 2 days)
• Standardized description of tasks
26 p • 243 tasks identified
Task Categories
• Administrative – Scheduling, phones • Prevention – Education, treatment • Treatment M di ti d 27 – Medication, procedures • Diagnosis– History, Physical, ordering & interpretation of tests
• Relationship
Who COULD Do Task?
Doc Nurse Clerk
Administrative Y Y Y Prevention Y Y P 28 Treatment Y P N Diagnosis Y P N Relationship Y P N
Who SHOULD Do Task?
Doc Nurse Clerk
Administrative N N Y Prevention P Y P 29 Treatment P P N Diagnosis Y P N Relationship Y P N
Impact of Task Reassignment
Positive Considerations • Increase capacity of expensive resource • Save $ Negative Considerations • Pain of change
• Match of job with individual preferences and talents?
30 $
• Clarify roles in team
Task Reassignment: The 4 Ts
• Task • Team • Timing • Terrain 31 TerrainTask Reassignment Examples
• Assistance with undressing for exam • Vital signs
• Phone answering
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Perspective # 1
From the view of the current job category and the work done
Tasks by Job Category
RN MD Clerk/Scheduler
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WW - Workload Analysis Cycle 2 (Minutes) 5,632 , 28% 1,118 , 6% 35 2,545 , 13% 10,765 , 53%
Direct Activity Indirect Activity Non Patient/Provider Related Activity Travel
Non Patient/Provider Related Activity
6% 2% 19% 3% 6% 12% 3% 4% 3% 2% 0% 36 18% 5% 6% 2% 7% 3% 1% 1%
Conference Inservice Research/ Lit Review Educational Resource Development Quality Improvement to Current Resources Meetings Meeting Preparation Informal Conversations Mileage Form Completion Timesheet Completion Staff Activity Report Completion Committee Work Email: Reading/ Writing Providing Orientation Receiving Orientation Team Lead Scheduling: Staff / Service Staff Scheduling: Outlook/ Webview Other
Perspective #2
From the view of the task itself
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What is the Work?
Who is/should be doing it?
Task
Clerical
MA
RN
Provider
Registration
Rooming
Refills
38Refills
Advice
Order Entry
Med. monitoring
Teaching
Work Analysis Example
Task/Process Who does it now In a perfect world who would do it Book appointments Nurses Clerical support Take incoming calls Providers Clerical support
39 Chart prep Triage Med refills Financial authorization Etc
Work Analysis Worksheet by Task
Task/Process Who does it now? In a perfect world who would do it?
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Team Exercise
Step 1: Using the Process Survey Worksheet, rate your
current office processes
Step 2: Choose one of the problem-some processes
identified and map this process using the Flowchart
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Worksheet
Step 3: Using the Task Worksheet, list all the tasks
associated with the mapped process and identify
who does it now and who could/should do it Step 4: Refer to the “considerations” for task analysis (on
the next slide)
Considerations for Completing Task
Analysis
• Identify all tasks
• What can be eliminated? Combined? • Identify who currently does these tasks • Should they be doing them?
42 • Should they be doing them?
• Are all working to their highest level?
• In a perfect world, who would/could/should do these tasks?
• What is the plan to deliberately move toward that ideal?
