AMA STEPS Forward® Series Announcement: [00:00] Hello, and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today—solutions that help put the joy back into medicine. AMA's STEPS Forward® program is open-access and free to all at STEPSForward.org.
Taylor Johnson: [00:23] Hello, and welcome back to the AMA STEPS Forward®: Private Practice: Attending to Business podcast, a 10-episode series exploring the business side of private practice. In this series, we talk about how to navigate business operations and practice efficiency solutions to create and support a thriving and sustainable medical practice business. I'm your host, Taylor Johnson, manager of Physician Practice Development at the American Medical Association. And I'm joined by my colleague and cohost, Meghan Kwiatkowski, program manager of Private Practice Sustainability, also at the AMA. Collectively, we have two decades of experience in private physician practice, and we continue to support physician practices in our current work at the AMA. Before we start, I want to emphasize that this episode is for general informational purposes and should not be relied on as medical, legal, or other professional advice. Listeners are always encouraged to consult a professional advisor for any such advice.
Meghan Kwiatkowski: [01:21] So, Taylor, to start us off, can you discuss some of the common workflow challenges that private practice physicians face?
Johnson: [01:32] Top of the list administrative burden. I think we hear that all the time, dealing with the clinical workflow and trying to make it as streamlined as possible to include a lot of the new technologies, as well as a lot of the new requirements that practices have for documentation, for example. And then that also goes into documentation burden on the physician. So what do you have to make sure is documented in the medical record so that you are meeting all of your requirements? Most recently, I think we hear this a lot, the staffing shortages, so not having adequate amounts of support staff, for physicians to care for patients during clinic. Also, staffing shortages, on the administrative side as well. So we're low at the front desk, we're low in billing, low in authorizations, and all of that just delays patient care. So you know, those are really important things that may not be at the top of mind for a lot of people, but they do have negative impacts on patient care almost immediately.
Kwiatkowski: [02:44] Yeah, absolutely. Impacting patient care means not only negative impacts on the patients, but negative impact on the staff. Staff gets overwhelmed, things potentially can fall through the cracks in terms of getting a claim submitted or answering a phone call or something like that. And, you know, kind of slows down the overall workflow of the practice.
Johnson: [03:07] Right. And I think, you know, one of the things we hear a lot and one of the things that we work on every day, is really how do we get information out to private practices so that they can become more efficient in their everyday clinic. Meghan, can you just cover some of the core principles of practice efficiency, and just touch on why it's important for these private practice physicians?
Kwiatkowski: [03:33] Yeah, I think the most well-known most common method when talking about efficiency in any setting really is Lean. So it's a collection of principles that help practices run more efficiently and effectively, as a result, improve population outcomes. So the focus of Lean is to minimize waste in every process, which then adds value for the patient, for the physician, and the entire care team. And Lean empowers the care team to take initiative and find the root cause of critical problems during their day-to-day work through their daily practice. Finding and fixing the root cause of any problem addresses it for good, instead of just putting a band aid on it, so to speak, which could lead to other potential issues down the road. Another tool that physicians can use is called PDSA—Plan, Do, Study Act—that is a method that provides a really straightforward, but iterative approach to quality improvement in a practice, and the framework is easy to adopt. And you can do it regardless of practice size or resources. And so each piece of that PDSA is you plan by developing an initiative; you do by implementing that plan; you study by analyzing the results of what you've done after you've implemented a change; act by adjusting any process based on the results that were found while studying implementation of your plan. Some people might know this as PDCA, which is Plan, Do, Check, Act. It's basically the same thing, but looking for the root cause of a problem and then running these improvements, like goals of PDSA, are two really important core ways physicians can improve their practice efficiency.
Johnson: [05:29] Yeah, and I think those are really just so important, because on a larger scale, yes, you can look at your overall practice. But I think that, for both Lean and PDSA, you can also use those on very small workflow changes as well. They're really scalable, and really, really useful for small practices to learn.
Kwiatkowski: [05:53] Yeah, absolutely. I think it doesn't have to be a large-scale practice change, it can be moving the printer from one area of the office to the other. That's the example I always like to use, when I'm talking about it, does moving the printer from one area of the back office to another help increase your efficiency? You know, instead of having to walk, you know, to the other side of the office, if it's right behind the desk, where the staff can reach it. Does that help with the lags in workflow? Can you talk about ways to assess the efficiency of a practice? Where should they start?
Johnson: [06:26] I would say they need to start by identifying the areas in their practice that they feel are wasteful. So a good way to do this is by talking to your team, they probably know a lot better than the administrators or the physician where there is waste in the system, because they are working through those workflows every day. So ask them if they are doing things that they feel are completely unnecessary, or if they're duplicative and could easily be changed to save hours every day. An unwritten rule is if you're thinking about changing a workflow, think about the hours that it would save you and your team. So let's say you expect the workflow change to save you two hours a day. The natural flow would be to identify obstacles in that workflow that will cause it to fail and not save time. While you're going through that if you know that this won't work for 50% of the patients, that's okay. You would still be saving an hour a day, which is worth implementing the change. Now, you don't want to implement something if it would only save time for one patient a day. That's not going to be worth the time spent on the new implementation. The AMA STEPS Forward® team actually put together a really great resource called the de-implementation checklist. That is a great place to start.
So one approach would be for practices to begin evaluating and de-implementing in groups. An example is start looking at all the policies and procedures in place for compliance and the EHR (Electronic Health Record). Can you work with your EHR vendor to reduce signatures, verification, or number of logins required, all of those things are very, very quick changes that could end up saving physicians and staff ample amount of time during the day. Practices can also start to see if processes can be automated or completed electronically. Some questions to ask would be is there an option for automated appointment reminder messages? So can your EHR actually be programmed with a script and told to call X amount of days before the appointment to remind the patient of their appointments so that the staff isn't spending time doing that? Can you obtain prior authorizations online instead of waiting on hold with an insurance company? Are your electronic remittance advice or your ERA set up for electronic delivery directly into the EMR (Electronic Medical Record)? That really, really helps with posting payments. So when the payments come in, if your ERAs are set up for electronic delivery, they're delivered into the EMR, and then the EMR can post those in batches for you so that you're not sitting there wasting time posting individual payments line by line. Are you signed up for direct deposit with insurance payers? This obviously helps with your cash flow. Have you worked with your EMR to create order sets, key phrases, or other EMR templates that decrease clicks and typing during the patient visit?
So there are a lot of ways to cut down on time for the physicians and the staff with pre-populated or pre-saved data that it would just be one click and it populates into the EHR instead of having to sit there and type out the same thing multiple times a day for multiple patients. And so it's worth really noting that all of these things may seem daunting and time-consuming to set up. So having to sit there with the EHR vendor, make sure that all of these things are coded correctly. And you know, coming into the correct places and working with the bank and things like that to get your direct deposit set up. But the payoff is well worth it. In the long run, I would say. Yeah.
Kwiatkowski: [10:28] Absolutely. Are there other areas that physicians can be mindful of that can help them increase efficiencies? I know you've mentioned a lot there. But anything else that comes to top of mind?
Johnson: [10:40] Yeah, so I think something that is relatively new, but dramatically increases efficiency is establishing a pre-visit planning process. When the staff is scheduling patient appointments, they can provide appointment information and any testing or lab work orders that should be completed prior to the patient's appointment. So this process might include sending out mail or electronically, sending an initial patient visit form to give the patients more time to gather important information like their medication, surgical history, other contexts for their care team, which saves time during the actual appointment. Also, if the patient completes the testing prior to the appointment, it allows the physician to create a treatment plan at the patient's visit, instead of having to examine the patient, send the patient for labs and testing, schedule a follow-up appointment to review the results, then create a treatment plan for the patient. So it really allows them to do everything in that one visit instead of having to spread it out over multiple visits.
The next thing that I wanted to mention was team-based care is something that can really improve efficiencies in practice. Now you have to check with your state regulations and find out if other members of your staff can assist in the patient's visit and documentation process. But if they can, that can be really helpful. So many times physicians feel that they need to do everything in the patient's visit when that's not always the case. So some questions to ask would be can your MA (medical assistant) or nurse complete some of the documentation for this visit? Does your EMR allow patients to enter health history? Or their history of present illness for that specific day? Can your staff schedule follow-up appointments when they are rooming the patient for you? Or can they even do something as little as pull up lab results or diagnostic testing so that the physician doesn't have to sit there and wait for it to load when they get into the room. The last thing that I wanted to talk about was a layout of your clinic. And so this might not be something that is top-of-mind for increasing efficiency. But it is a huge factor. It's really important to evaluate the layout of the clinic and make sure it follows the flow of patients. You don't want anyone to be zigzagging around the office in the middle of an already busy clinic. Streamlining the physical clinic flow could take minutes off of each patient visit and decreases the stress on physicians and their support staff. Did I miss anything, Meghan? Or do you have anything that you wanted to add?
Kwiatkowski: [13:31] I think this episode speaks to my whole heart because I'm a big process-efficiency, process-flow person. So I just…I really love this episode. You know, as you mentioned, the layout of the clinic is a big area for increasing efficiency opportunities. Moving the printer, if it doesn't make…if it's in a location that doesn't make sense, your staff are wasting a couple of minutes a day walking to a different place in the office to get printouts. Those couple of minutes add up. And then you have a workflow that doesn't make sense that takes precious minutes away from your staff, from you. Really an important area to underscore.
Johnson: [14:18] Yeah, definitely. And I know that the STEPS Forward® team, they have done so much research and so much work in the efficiency space. So can you just cover a few of the key resources to support physicians when they're thinking about how to make their practice more efficient?
Kwiatkowski: [14:42] Of course, yeah, I think we would be remiss if we didn't mention some of the great resources that are out there to help practices increase their efficiencies. So I mean, you mentioned the de-implementation checklist. That's one of them. But then we also have the Saving Time playbook, which walks practices through how to identify those inefficient areas of their clinic and take steps to improve those areas. We have a Lean health care module or toolkit, which walks through the core concepts of efficiency in general, and then gives examples of implementations for practices. I mentioned the concept earlier, but we also have a module on PDSA, which walks you through ways to accelerate quality improvement in your practice, and then implement those changes. And they're certainly more that are probably relevant, but those are some key ones. Anything else that you think should be mentioned, Taylor that I didn't?
Johnson: [15:43] No. Kind of looking forward, can you talk a little bit about what we have planned for private practice physicians in this realm of improving efficiency?
Kwiatkowski: [15:55] Yeah, of course. So the Private Practice Simple Solutions Initiative, which we've mentioned on another episode, that is in full swing, a lot of great sessions coming up. But that initiative is really all about easy process implementations or de-implementations, that would have a quick impact on the efficiency of your practice. That's really the whole goal of the initiative is to provide insight and education on a topic and then offer opportunities for the attendees of the session to then make a quick change—something that will have an immediate direct contribution to efficiency changes, workflows. We don't want to take away any more precious time from physicians from their very busy days. The goal is, again, is to really have these sessions be additive in terms of the knowledge that has been taken from them, but then be able to improve the time saved in their practices and increase the overall efficiency. And then we're working with the folks in our membership team to bring additional benefits to the AMA members that would increase the efficiency of your practice at low cost. More to come on that for sure. But we have our private- practice members in mind, certainly as we think about what would be helpful to them as we continue to offer resources and support. Do you have any other final comments or thoughts that you'd like to share, Taylor?
Johnson: [17:23] No, I think we've left our listeners with a lot to consider for today. But thank you so much for all of your insight and explaining some of these efficiency tools that we have. I think that's really going to be great for them.
Kwiatkowski: [17:38] Absolutely. It's like I said, No episode nearer and dearer to my heart. I'm always excited when we have an opportunity to talk about quality improvement and efficiency and flow. So thanks for joining me in the conversation today, Taylor.
Johnson: [17:52] The tools and resources mentioned in today's episode are linked in the podcast description and available on the AMA website. CME is also available for this episode on the AMA's ed hub and linked in the podcast description. I'm Taylor Johnson and this has been Private Practice: Attending to Business. Thank you for listening.
AMA STEPS Forward® Series Announcement: [18:12] Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA's STEPS Forward® program is open-access and free to all at stepsforward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series, STEPSForward.org.
CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.
If applicable, all relevant financial relationships have been mitigated.
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