4 February 2003
Clinical Services Initiative
UT Southwestern Medical Center at Dallas
Introduction
UT Southwestern Medical Center is embarking on a Clinical Services (“Transformation”) Initiative with a goal of achieving excellence in all aspects of the delivery of clinical care to patients. While we believe the quality of our medical care is in general excellent, we think it is now time to consider how to reorganize and transform the practice into a cohesive, patient-oriented program which will provide “best practice care” from both a medical and customer service perspective.
The purpose of the plan described in this document is to address the gap between the world-class quality of medical science found at UT Southwestern and the more ordinary and uninspired patient service standards that too often characterize how medical care is delivered within our practice. UT Southwestern aspires to be the best comprehensive medical center in the world. To achieve that distinction we must attain the highest levels of consistent excellence in all of our activities, and we must be universally perceived as a place where scientists, practitioners, and students come together in a setting that serves as a model for the practice of medicine.
Historically, prior to the initiation of this project, resources for clinical activities at UT Southwestern have been devoted largely to expansion. The practice first developed at Parkland Hospital, which served for many years as the principal teaching venue. The quality of patient service amenities there has always been limited by county budgets; nevertheless, both UT Southwestern and Parkland Hospital have prided themselves on delivering the best health care available to indigent patients anywhere in the world. Parkland Hospital is consistently rated among the nation’s best hospitals, an honor rarely held by public hospitals. Still, the need to have a setting for private patient care to support our educational programs was already apparent in the 1980’s. Physician trainees need exposure to the wide range of disease that occurs across all social strata to prepare them for work in the communities they will serve. And they need to understand the vital importance of service as well as science to the healing arts. Supporters in Dallas created the Zale Lipshy University Hospital, and the University of Texas approved funding for the Aston Ambulatory Center, to ensure that our students and faculty have the opportunity to develop the widest possible range of medical and service skills and to extend those skills as a model of practice for the world.
Broad success in building the private patient practice has caused rapid expansion. Even though we have engaged in virtually no clinical marketing activities, outpatient visits to our private ambulatory facilities have grown from 50,000 in 1985 to 400,000 in 2002, while elective hospital admissions now exceed Zale Lipshy’s capacity. Two years ago, UT Southwestern acquired the facilities of St. Paul Medical Center to assure expanded inpatient bed capacity on the campus. The Aston Center has been enlarged until available space and parking allowed no further expansion, and multiple other outpatient sites have been developed at the Seay Biomedical Building, the Clinical Services Building I, the Moncrief Cancer Center in Ft. Worth, and the professional office buildings at St. Paul University Medical Center. Clearly our efforts over the past ten years have concentrated on coping with very rapid growth.
Although the quality of service received by many of our patients is very good, the administrators and clinicians of UT Southwestern recognize that our system of health care has not achieved uniform service excellence. Insufficient attention and resources have been committed to support patient service values related to access, convenience, and clear communication. True excellence in clinical care must include not only expert physicians and state-of-the-art technology but also the delivery of service that is patient-centered, efficient, convenient, and gracious. We have identified weaknesses in the area of patient services, and we are committed to rectifying them through a comprehensive transformation of our clinical care delivery system.
Shortcomings in our current system manifest themselves in a number of ways. Patients often have difficulty getting help by telephone and frequently must deal with complicated automated messaging systems. They sometimes encounter employees who are incapable or unwilling to help. Scheduling is difficult, especially when multiple appointments on a single day are required. The recently expanded geographical distribution of the practice exacerbates this difficulty. Information on prescriptions, insurance, billing, and referrals across specialties is sometimes hard to obtain. Physicians, nurses, or other clinic personnel do not always return calls promptly. Medical record information is sometimes inadequate or incomplete, because much of the information is on paper forms or film records that are hard to access or missing. Patients often find it difficult to schedule an appointment with an individual physician because of restricted availability. Access to clinical trials is not as readily available as in some other leading institutions. It is all too easy for patients to conclude that because UT Southwestern is an academic center there is not a total commitment to take the time and make the effort to plan and deliver a total patient experience that meets the standards of the best the world has to offer.
These problems impact not only the patient’s experience but also the overall quality of the undergraduate and residency training programs at UT Southwestern, especially to the extent that they cause faculty to undervalue the outpatient clinics of the institution as training venues. It is also true that the commitment of the academic/clinical faculty to the research enterprise sometimes encourages the view that patient service is less important as a priority than the pursuit of innovative ideas and therapies. When patients’ reasonable expectations for personalized care and concern for their problems are perceived as secondary to faculty and trainee academic interests, there is an imbalance that must be addressed. While recognizing that many of the service problems highlighted above are increasingly common to most if not all medical practices (in part because of the pressures of managed care and medical reimbursement issues, and in part because of increasing regulatory burdens that magnify paperwork and impose on the time for personal interactions with patients), UT Southwestern is determined to resist and reverse the trend that has been experienced in all too many medical settings including our own.
UT Southwestern will be counted among the very best medical centers only if it provides levels of quality in patient services comparable to the quality that it has achieved in its clinical expertise, technology, research, and educational programs. Improvement of the patient experience is of paramount importance to the overall success of the institution, and we are committed to transforming our clinical services in order to provide a standard of care to our patients that is second?to?none.
Internal and External Evaluation
In August 2002, President Wildenthal charged a task force, made up of senior physicians, clinical management staff, friends of UT Southwestern, and retired clinic and administrative leaders, with identifying best practices in patient service in the outpatient facilities of the nation’s leading academic medical centers. These best practices could then be considered for adoption at UT Southwestern, where there is a concern that the quality of patient service is not as good as it should be. Subgroups of the Task Force, led respectively by Robert Alpern, M.D., Dean of the Southwestern Medical School, and John D. Rutherford, MB,ChB., Vice President for Clinical Operations at UT Southwestern visited seven leading academic medical centers: the University of California at San Francisco; Duke University; Johns Hopkins University; Massachusetts General Hospital (affiliated with Harvard Medical School); Northwestern University; Stanford University; and Vanderbilt University. More than a hundred clinical and academic leaders at these great institutions generously gave of their time for interviews by members of the task force, and we are grateful to them for their help. To the extent that there is benefit to the clinical program at UT Southwestern from this effort, it will be because of their open and generous support. UT Southwestern has assured each of the institutions that their identities will be protected in our reports when we identify specific initiatives.
Before visiting these institutions, the task force identified a number of open-ended questions related to institutional organization and culture and to infrastructure supporting clinical service that it wanted to address at each institution. The result was to garner a good deal of information about a wide range of topics relating to excellence in clinical service and the systems that support it in large academic group practices.
The report describing the results of the visits of the task force to the leading medical institutions is divided into the sections listed below.
I Strategies
II. Organization and Management
III. Culture
IV. Access
V. Service Support and Systems
VI. Human Relations and Training
I. Strategies
Key strategic business issues are similar at all of the institutions and include questions about the growth of the clinical service, the scale of primary care programs, the relative importance of clinical care and research, the need to insure financial success of the enterprise, and the place of the institution in local, regional, national and even international healthcare markets.
On the key issue of the strategy for primary care programs, most institutions visited expressed the view that the primary care service should be limited in size to that required to serve spontaneous self-referrals (with no particular effort to market or grow this service), institutional employees and friends, referrals from specialty care physicians in the group, and indigent care patients where there is a special historical obligation. Most institutions believe that the referral base for the specialty and surgical practices is and will continue to be primarily community and regional physicians not in the academic group practice. The notable exception, with a strategy to aggressively increase primary care activity, is in one of the larger cities visited where the institution has a favorable payer mix.
Success in third party contracting for both inpatient facilities and for in- and outpatient professional service is tied to the provision of indispensable tertiary and quaternary care (notably in cancer and neonatal care) in most strategies, although one institution has used corporate alliances among hospitals and physicians to insure a very large (and therefore indispensable) presence for its collective services in very large local and regional markets. One institution has aggressively raised having a high “patient service culture” to the level of a corporate strategy, but all institutions are working on improving patient service both because “it’s good medicine” and because they want to keep customers happy.
Most institutions are experiencing rapid growth and high demand for their medical specialty and surgical practices. All but one institution visited expressed an aggressive posture on growth of medical specialty and surgical care; in the case of the exception, demand for service in all elements of the practice is currently very high, with long patient queues for virtually all levels of service. All institutions visited acknowledged that they subsidize primary care (using various methods to be discussed below) on the principle that it makes strong contributions to the bottom lines of the hospitals and specialty practices in medicine and surgery.
All institutions identified a tight integration between the medical faculty practice group, outpatient facilities, and hospital facilities as being of major importance. For the institutions where the governance of one or more of these components was separate, a marriage of financial interests and cross-subsidization was recognized as necessary for mutual success.
Finally, several institutions identified strategies to gain competitive advantage through medical program development, from the practice of “prospective medicine” based upon discoveries in genomics, to the development of a large medical informatics program designed to equip the institution to be in the forefront of complex quantitatively based medical care and in the forefront of more efficient management of patient care through employment of clinical information systems.
II. Organization and Management
There are several issues regarding general management of the institutions we visited that materially affect patient service and therefore require comment. We have organized these comments under the following headings: consolidation of management; management of information resources; management by lines of service; management information; and contract management.
a. Consolidation of Management. Every institution we visited had either consolidated management of the inpatient facilities and the outpatient clinics or was considering such a consolidation for the near-term future. It can be said, based on our observations, that in a major academic medical center, hospital and ambulatory clinical services should be organized as a single, strategic clinical delivery system and business unit, insofar as possible. Most institutions visited also have medical/clinical leadership to whom both the physicians practice organization(s) and consolidated hospitals and clinics report. These are highly qualified, strong leaders of clinical and business activities who transmit a clear vision of the goals of the medical center. One clinical leader remarked that the increase in the importance of outpatient care is making seamless management of inpatient and outpatient operations increasingly important. There is still some variety in the institutions we visited in the reporting relationships of the outpatient clinics: some are managed by the faculty practice organizations; some are managed by the hospitals. In those cases where they are managed by the faculty practices, with one exception those practices are part of a larger health care system with responsibility for management of the hospitals.
b. Management of Information. Every institutional leadership team with whom we met stressed the importance of metrics to effective management in the academic medical center. Each institution we visited identified very significant data resources it employs, and each offered to share examples of reports it uses to review information with departmental leadership. One institution has a monthly “numbers day” meeting with department chairs and clinical leadership chaired by the CEO to keep a constant audit on clinical productivity and finances. In some places, individuals receive detailed information on their activities (RVU productivity, collections, patient visits, clinic throughput, etc) with local and national benchmarks. One or two institutions publish such data along with patient satisfaction indices, the results of clinic staff competency tests, etc. by clinic and even by individual. This underscores the importance of tools to gather management information from operating systems, the importance of familiarity with national and regional data about clinical and academic practices, and the importance of planning and analysis teams to medical center management.
Virtually every leader with whom we met made the same point, using essentially the same language: “physicians respond to data.” It would appear that the single most powerful management tool available in academic medical centers is measurement and disclosure. The most common perception by members of the visiting teams about management at the host institutions was of the extent to which metrics are used to shape attitudes and commitments as compared to the processes at UT Southwestern.
c. Management of Information Resources. It is becoming axiomatic that patient satisfaction is largely influenced by patients’ experiences with clinical information systems. Every institution we visited stressed the importance of information resources to the future of the health care delivery system, and every institution stressed that it is absolutely essential to have a single management structure for the development and administration of all clinical information systems activity enterprise-wide. Systems development activities, from the construction of electronic medical records, to financial systems, to service support systems, like physician order entry, PACS systems, scheduling systems, etc., are requiring very significant investment. The leadership at every institution we visited is committed to eliminating redundancy and lack of communication among systems and the personnel who develop and operate them. We will explore the uses of some of these systems later in this report. While there are significant variances among institutions about system design and architecture and the manner in which coordination will be achieved, it has become an established principle that there will be a single information systems leader as part of the health enterprise leadership managing the strategy for systems development and implementation.
d. Management by Lines of Service. A key organizational approach embraced by most of the medical centers we visited was the creation of “lines of service” or “centers of excellence” that cross departmental, hospital, and outpatient boundaries, for example in hematology/oncology activities. Typically, service lines have physician leaders reporting to head medical officers and administrative leaders reporting to hospital/clinic administration working in partnerships. The latter are responsible for assisting with strategic planning, developing budgets, and insuring the effectiveness of administrative communications. Institutions are recruiting highly talented and trained personnel to fill these roles. Both leaders are jointly responsible for the implementation of enterprise-wide standards in the clinics and for the development and evaluation of clinic personnel.
In some cases, both the lines of service structure and/or the old department structure is broken down into teams of physicians, nurses, and support personnel that are managed as small units with productivity and financial results requirements. Institutions where these variations from traditional departmental organization are tried caution that such arrangements depend heavily on the support of department chairmen and deans, who are frequently called upon by faculty seeking to have team or service line leaders overruled. In one case, primary care activity in internal medicine has been separated from the departmental structure entirely and reports through the clinic’s medical officers.
e. Contracting. As mentioned in the section on “Strategies,” academic medical centers all exist in managed care markets where access to patients insured by the largest third party payers is essential to maintaining the large referral base necessary to the provision of the long list of medical and specialty services required for the appropriate range of training and clinical research opportunity. Each medical center has services that are attractive to the third party payers, but in some cases those services may be in a narrow range, for example neo-natal intensive care, or pediatric oncology. The medical centers we visited make a strong effort to coordinate all contracting activity for professional services and hospital services to insure mutual support of those activities and to prevent either “whipsawing” or “cherry picking” by third party payers. Because they have unified management structures, the centers we visited avoid this problem with centralized management of contracting activities.
III. Culture
Most of the institutions we visited have very large research programs and all have deeply entrenched academic values. All have been organized for many years along departmental lines and have operated according to principles that delegate very substantial authority for determining program content and operational characteristics to departmental and divisional leadership. Successful careers for faculty at these institutions have depended heavily upon individual success in research and innovation. Patient care has always been important, but not necessarily the central focus of faculty effort. Patient service, most of the institutions acknowledge, has not always been a high priority.
During the past two decades clinical income has become increasingly important to the overall financial health of these institutions while the development of managed care has made patient care income more difficult to generate. Institutional leaders, recognizing the import of these developments, are seeking to move the cultural bias in the faculty in the direction of support for more active practices and in the direction of better patient service. No institutional leader we talked to sought to do this at the expense of the culture that supports research activity, but all identified “changing the faculty culture” as the key to improving patient service. Almost every institution indicated they were still struggling with the institutional culture.
Most institutional leaders with whom we met indicated that the cultural bias among the chairs at the great research institutions still strongly supports the ascendancy of the research enterprise. For the most part, they also indicated that the chairs understand the importance of achieving improvement in clinical service, and support the idea generally, but that behavior still reflects the old values. There is still prevalent the old notion of the department as a separate “silo” and a strong bias to think of the department good rather than the good of the whole, particularly insofar as clinical affairs are concerned. Some change is occurring as clinical chairs turn over and new people recognize the import of clinical success or failure.
Culture among clinic staff and administrative personnel regarding patient service also is seen to be a problem, to varying degrees, but one that can be solved with motivation and the introduction of standards and training. Some discussion about efforts to recruit “friendlier” types of individuals for patient contact jobs occurred, but this was not a theme in most of the discussions. Virtually every person we interviewed on this topic expressed the view that efforts to improve the patient service culture among staff will only work if department chairs and faculty actively support them. That, in turn, requires strong leadership from the top of the organization. Two of the larger institutions visited stressed the importance of staff satisfaction to improved patient service culture and one human resources leader indicated that “staff treat patients the way they are treated by faculty.”
There was a continuing theme that cultural change will only occur among academic physicians if they are provided with group and individual data about patient service and become partners in the effort to improve it. One institution uses a systematic program to solicit faculty opinion about the quality of service in the group practice and to address faculty satisfaction and morale problems. Several others conduct surveys of staff satisfaction to keep a check on staff attitudes.
Efforts to improve the service culture among faculty and staff in institutions visited include the following:
a. Compensation Plans and Commitment to Clinical Medicine. Every institution has some variety of compensation plan that rewards clinical service based upon clinical activity. Collections, RVU’s, patient visits, throughput during clinical sessions, weeks in clinic per year, weighted values for new and returning patients, and length of inpatient stay, all are among the variables used to develop compensation models. For chairs, overall financial performance of the clinical enterprise and/or of the hospital are used in one institution, as are scores in such measures as patient satisfaction indices.
In most of the institutions visited, practice varies considerably from department to department as to how compensation variables are weighted. One institution offers a consulting service through the central practice plan to help set up compensation models. Clinical leaders noted that introduction of these compensation variables must be done with care and that their effects must be monitored carefully to avoid unintended results. The use of collections alone in a surgical practice, for example, may lead to unwanted bias according to payer type.
b. Productivity Analysis. Every institution we visited had productivity standards for primary care physicians, usually couched in throughput per half-day (four hour) session. Most defined full time clinical service for a clinical primary care physician as eight half days per week. One institution required average minimum throughput of 12 patients per half day for family practice physicians and 10 per half day for general internists. Another uses a point system to weight new (3 points) and returning (1 point) patient visits and expected the achievement of an average of 16 to 18 points per half day. Still another required an average of 400 patient visits per year for each half-day per week. Some institutions encourage the development of full-time primary care practices; others discourage them and encourage clinical commitments ranging from half time to 70%. In one case, separate primary care practices within a single institutional structure have opposite expectations on the full-time part-time issue. In all of the institutions we visited the primary care workload expectation is clearly articulated. One physician leader advocated a written expression for each physician of the expectations for service in and out of the clinic.
Such expectations are not as widely in place in these institutions for productivity among medical specialists and surgeons, although incentive programs for surgeons and specialists with procedure-based practices are often based heavily (in one case entirely, for surgeons) on collections. One institution uses a point system to assess productivity in specialty clinics, but it was not clear how much penetration into the practice this point system has. It is true, however, that every institution we visited is making efforts to analyze productivity among physicians with clinical appointments in every department, whether full time or part time. Publication of the results of these analyses, in some cases by individual, is making members of the practices more aware of productivity issues for themselves and colleagues. One institution provides its physicians with a quarterly report that analyzes such activities as are measurable in terms of the distribution of sources for their appointments. In other cases, data is provided on a departmental basis at general meetings, while individual data is provided only to the individuals themselves. In at least one case, productivity data by individual is published and distributed on a monthly basis.
c. Clinical Trials Support. All of the institutions visited have opportunities for faculty to engage in clinical trials. Some of the institutions have very considerable clinical trials infrastructure and a clear strategic commitment to clinical trial activity. There was some discussion during the visits about the impact clinical trial activity has on the clinical service culture: the majority of commentators agreed, although not unanimously, that the impact is positive for several reasons. Patients are reassured that the institution is on the cutting edge (one medical administrator suggested that the days when research was a disincentive to patients are over and that the information age has made medical research activity a “turn-on” to those seeking treatment.) Most clinical physicians are happier because there is a research component to their work. And those who argue the benefits of “translational” research see strong clinical trials activity as beneficial, even to the programs in the basic sciences.
Clinical trials activity is seen to be more difficult to get started than in the past, particularly because of strict new rules and procedures relating to human subject testing, informed consent, and maintenance of confidentiality of data. IRB’s at the institutions we visited have seen their workloads increase very dramatically over the past several years. The need for trained research nurses is strongly felt in all the institutions, and several have determined that the economy supporting clinical trials needs central institutional support. One institution noted that it now spends $3 million annually supporting infrastructure for clinical trials.
d. Patient Service Campaigns and Credos. All of the leaders interviewed favored campaigns to improve patient service in their institutions; all agreed that leadership in the campaigns should come from the top of the organization; and all agreed that such campaigns should be identified and organized as such. There were differences, however in approaches to the content and style of the campaigns. In two cases, the institutions had undertaken multi-year branding, advertising, and service training campaigns that were institution-wide and highly organized. At both, patient service credos were adopted. At one, aggressive media advertising was employed. The effort in that case is given credit for moving the institution from #3 to #1 in perceived quality in market surveys in the metropolitan area in which it is located. Another institution adopted the strategy of improving quality unit by unit, concentrating in clinics with the highest potential to achieve excellence in a short period of time, in the belief that such an approach will cause excellence to “creep out into the institution.” No institutional credo was adopted. One institutional CEO expressed discomfort with credos, which he believed might fall flat in the sophisticated atmosphere of an academic medical center.
e. Uniforms. Several of the institutions visited used uniforms or dress codes or both for all clinic employees. An effort to install “career apparel” at one of the institutions—each employee wears a blazer that identifies his/her role as receptionist, greeter, technician, etc. by color—was given mixed reviews. Dress codes were deemed very successful at one of the institutions, as was the abolition of “casual Friday.” This institution asked a committee of employees to prescribe the rules for dress and found that their standards were quite high. There was considerable sentiment among most of the persons we interviewed that dressing well is good for morale and therefore has a positive impact on the patient service culture. Some level of uniform dress is also seen to give employees a sense of identification with the enterprise and to buoy up the individual’s sense of worth. One leader strongly emphasized that changing the patient service culture requires considerable emotional commitment—“passion” was the word used—and the institutions visited are, in some cases, using uniforms to insinuate a collective emotional commitment to service.
IV. Access
All of the institutions we visited subscribe to the view that reasonably rapid access to care is a key aspect of good patient service.
a. Clinic Schedules and Open Access. While there were several institutional projects to create standards and improve access to primary care, we found only a few instances where such projects are being tried in medical or surgical specialties. “Open Access,” a scheduling paradigm promoted by the Institute for Healthcare Improvement, is used to varying degrees by the primary care services of several of the institutions we visited. One institution uses it for all primary care scheduling. In that model, physicians schedule up to 35% of their clinic time in advance and reserve 65% for same-day scheduling. All appointments are scheduled for 20 minutes. Results: 2/3 of physicians like the system better than the old heavy advanced scheduling; the requirement for phone triage is greatly reduced; there is “maxpacking” of services, i.e. services are performed while patients are in the clinic that other wise might have been missed; appointment “no-shows” were reduced from 12% to 5%; and there is greater involvement of residents in patient care.
Other institutions are trying modified versions of Open Access in primary care service; one is trying it in dermatology as well, another in cardiology. Still another is employing the concept of what they call “rapid access” for GI endoscopy, scheduling the procedure solely on the basis of a primary care referral. One institution is also employing the concept of “group visits” in primary care, seeing patients with similar chronic conditions every one or two months in groups.
b. Hospitalists. There continue to be differences of opinion on the use of hospitalists, with most of the institutions visited opting in favor of their use. One primary care physician leader made the case that work is just not as interesting and intellectually satisfying for his physicians if they don’t carry through to the inpatient service. A survey done at one of the institutions found that continuity of care is not as important to patients when hospitalists take over as had been previously thought.
c. Medical and Surgical Specialties. At all the institutions, access to specialty medical and surgical care is still highly dependent upon doctor-to-doctor communication. To get special treatment in a busy appointments queue, even for acute conditions, requires a doctor talking to another doctor on a personal basis. This is usually managed for VIP patients through the medical dean or chief medical officer. (More on scheduling and VIP support services below.) All institutions reported that there continues to be very pressing demand in certain of the medical specialties and a serious undersupply of physicians in those practices. No clear strategy to address this problem was apparent in any of our visits other than continuing insistence on reviewing productivity related to clinic based compensation.
d. Primary Care Subsidy. Every institution we visited subsidizes its primary care programs, usually based on the observation that the primary care programs contribute importantly to the financial success of the specialties in the group practice and to the bottom line of the hospital. Numbers given to characterize the amounts of the subsidies ranged between $50,000 and $120,000 per FTE physician per year. It is difficult to compare these subsidies accurately because of the various methods of financing direct and indirect costs for clinic operations among the institutions. We believe the presence of these subsidies has strongly influenced the aggressive empirical analysis of productivity in primary care clinics that we encountered on every visit. In general, also, it was our impression, although we did not verify it systematically, that ratios of staff to physicians in the primary care practices of the institutions we visited were lower than we had anticipated them to be.
V. Service Support and Systems
A central purpose of our visits was to investigate service support and systems tools and organizational units that we might use to improve customer service in the outpatient clinics. As a general observation, the use of such tools as scheduling systems, telephone management systems, and registration systems is more centrally and aggressively managed at most of the institutions we visited than at UT Southwestern. Most institutions have adopted hybrid approaches to the use of these tools that recognize the functional differences among the practices in the large multi-specialty groups. Where consistency is required, it is usually in the application of standards for the clinics using the systems. In most of the institutions we visited, clinical personnel either report to central clinic managers (in an standard management tree) or to managers of departmental, service line, or clinical teams, who are matrixed to clinical/departmental managers and to central management of the outpatient clinic. Use of the scheduling systems, telephone management systems, and registration systems is standardized as much as it is practicable to do so, as is training for their use.
a. Registration Systems. All the academic medical centers visited are moving or would like to move in the direction of a single, central ambulatory and inpatient registration system in which a relatively limited number of experts in gathering patient demographics and verifying insurance establish a “front-end” record that is highly accurate. Clinic and business officers now understand that this “front-end” activity is the most important element in insuring efficient and successful collection of patient charges and are willing to make large investments to centralize registration and improve quality. Web-based registration systems are in limited use thus far, but are believed to have high potential for future use. Clinics are separating the registration and scheduling processes in favor of approaches that use telephone follow-up on scheduled appointments by registrars for pre-visit registration and coverage verification. Systems links to insure the appropriate communication of data between schedulers and registration personnel are created based upon the local organizational arrangements in place, particularly for scheduling. Institutions visited noted the significant level of complexity encountered in creating human and systems interfaces among systems and clinics. One institution noted that it took about three years to get a telephone-based registration system up and going. Another indicated that the project that was just coming on line to centralize registration for its hospital based outpatient clinic would employ approximately 100 people.
b. Scheduling. A variety of approaches to centralized scheduling are being tried in the institutions visited, but no institution was willing to assert that centralized scheduling is attainable or even desirable for specialists. Specialists reject central scheduling because scheduling clerks can’t be expected to differentiate among the very narrowly focused interests within specialty groups. Centralized scheduling for primary care physicians is being done at some of the institutions we visited and in some specialties under protocols supplied by the departments. Scheduling in primary care settings we visited is linked to call centers that manage both scheduling activities and other patient inquiries. IDX systems appear to be the systems of choice for both registration and scheduling.
c. Telephone Systems. No topic in the area of support systems got more fervent commentary than the issue of how to manage telephones. One manager in a large clinical system noted: “We get 5 million calls per year—telephones are the bane of our existence.” It was widely agreed that telephones are usually the source of very important first impressions.
All institutions use some forms of Automated Call Management (ACM).
Every institution we visited acknowledged difficulty with telephones, but each had a number of ideas and strategies being used to promote improvement. Among the tactics being employed were the following:
i. Publication of Health System-wide Standards for Telephone Management. Most institutions we visited had some form of standards for the management of telephones, with topics including the uses of ACM, limitations on ACM response trees, appropriate phone behavior, and required training of telephone responders. However, it is still the dominant pattern that the actual choices about language in responses and the structure of the call management tree are made by the departments without central administrative approval.
ii. Elimination of Multi-tasking. To the extent possible, clinics are attempting to separate receptionist functions from phone answering, as they are doing with registration and scheduling.
iii. Creation of Call Centers in Large Clinics. This effectively makes call management in those clinics a back room function. It is often paired with a clinic scheduling system.
iv. Single ACM Voice. One medical center uses a single voice in all ACM responses to achieve “branding.”
v. Mystery Caller Quality Control. Several institutions have continuous calling of clinics by “mystery callers” who rate responders for clarity, courtesy, etc.
vi. Analysis of Metrics on Responses. All the institutions we visited have some level of measurement on the timeliness of answerers, hang-ups, busy signals, waiting times, etc.
vii. Prescription of Strict ACM Limits. One institution prescribed that there could be no more than five options on a single ACM call level in each clinic.
viii. Tracking of Phone Referrals. In one institution, a messaging system used by phone operators to pass questions to clinics and physicians requires “closeout” of the calls, i.e. positive confirmation of the disposition, which is monitored for timeliness.
ix. Phone Interviews of Phone Personnel Before Hiring. One institution does this to try to identify those with a good telephone presence before hiring.
x. Special Telephone Access for Referring Physicians. In two institutions, external referring physicians are given a special line that is answered by personnel trained to help manage the relationship with referring physicians, whether they are seeking information about patients referred or seeking information about the availability of medical services.
xi. Training Programs. Telephone training is important in all of the institutions we visited and will be addressed in the section below on Training and Human Resources.
d. Electronic Medical Record. The concept of a single data repository which is entered in varying ways through a single, widely accessible patient registration system is being pursued at most medical centers visited, although there are differing concepts of appropriate strategies or whether even the term “repository” is appropriate. Most institutions are also pursuing the concept of the “master person” index because of the legacy of widely varying systems in diverse geographical and organizational entities. The leading centers we visited mostly favor a “best of breed” strategy for acquisition of systems supporting clinical and business operations. Certain features are deemed to be important for the deployment of a successful electronic medical record, including the following: presentation of a single physician-access interface enterprise-wide; creation of appropriate networks and communication capabilities among the various clinical systems; implementation of physician order entry systems; implementation of scanning and fax capture capabilities; implementation of messaging system capabilities within the medical record systems (there is some disagreement on this point); and implementation of electronic signature capability. Most institutions purchase EMR and related systems from outside vendors. At the one institution with a comprehensive rollout plan for the EMR, there were 34 FTE’s assigned to the project and a five-year plan for the rollout. Several institutions elected to roll out the EMR in the inpatient environment first, where the order entry process is well understood. All institutions stressed the importance of strong physician leadership to the EMR rollout. In the institution with the best-developed EMR in an outpatient setting, physician leaders were very enthusiastic about the effect on clinic workflow. One manager at another institution called the former policy permitting proliferation of disparate patient information systems at his institution “the worst strategic decision we ever made.”
Medical informatics was a major topic of discussion at one of the institutions we visited. A strong and convincing point made was that the presence of an institutional commitment to medical informatics in the academic sphere is a spur to the development of clinical information systems, and particularly the electronic medical record, in addition being an increasingly important academic pursuit because of its relevance to quantitatively based medical science.
e. Patient Relations and VIP Services. High patient satisfaction is a goal for all of the institutions we visited. Every institution maintains the principle that there is no difference in the quality of medical care offered to any patients, but that there are some differences in support services. In some meetings it was suggested that we should do more to shape patient expectations about service, because our resources are limited, behaving more like Southwest Airlines than Neiman-Marcus. Obtaining metrics on patient perception of patient service is important in all of the institutions we visited. All make some use of surveys to monitor patient satisfaction and several have set goals either institution wide or within the primary care practices to achieve target level scores on external scales. Press-Gainey instruments are used to obtain these metrics by most of the institutions we visited, and institutional leadership monitors both raw scores and percentile ranks. In two cases employee incentives in clinics are based, at least partially, on these rankings. In one case institution-wide rankings are posted as corporate goals and have a small impact on compensation for all employees. Several institutions had employee incentive plans based on patient service survey scores, but they were generally modest.
Surveys of patient satisfaction were faulted on two levels. In the case of Press-Gainey, it was pointed out that very modest changes in raw scores can have very large impacts on percentile rankings because scores tend to aggregate at certain levels. All written survey systems are faulted because they tend to get bi-polar responses, i.e. only very happy or very unhappy patients answer them. One institution faulted surveys that have long time periods between the clinic visit and completion of the survey. There was some discussion that phone surveying would be better, but it has not been widely tried because it is deemed too expensive.
Every institution has patient relations staff responsible for making the patient experience with the institution go smoothly and for conducting the surveys mentioned above. The institutions also had certain special programs to support patient relations that are worth mentioning:
i. VIP Services. All of the institutions have an office whose role it is to provide assistance to individuals who are donors and other special friends of the institution. These operations tend to be modest in scale and report to the development function in the institution. Some have elaborate categories into which VIP patients are divided, with different levels of individual attention prescribed by category. Special efforts to gain physician access for VIP patients are still referred to deans or chief medical officers and are not managed by service staff. Two institutions showed us token favors given to VIP patients routinely. Several institutions stressed the importance of educating all clinic employees in the rationale for and modest extent of VIP services to avoid resentments associated with perceived inequities in treatment.
ii. Greeters. Several of the institutions we visited employed greeters in the outpatient clinics, strategically placed to give directions, and evincing a well-dressed, upbeat persona designed to set the tone of the patient visit. In one case, this role was partially performed by uniformed security guards.
iii. Employee Patient Relations. Most of the institutions we visited were making conscious efforts to retain employee clinical business and even to provide special service to employees seeking access. Some of this activity is managed in VIP services offices. One institution has a specially named program designed to facilitate access and improve service for the institutions’ employees and their families. Part of the theory is that this program will contribute to the sense of excellence that in turn motivates employees to do their jobs well.
iv. Executive Physicals. Several institutions have executive physicals programs and programs specifically targeted at CEO’s in their communities. Executive physicals have to be conducted in a manner designed to impress the CEO that the service has special characteristics (such as patient education) to be successful. One institution mentioned designation as a preferred site by the Young President’s Organization as an effort to generate more executive physicals business. Another identifies the top 25 corporations in its service area and invites the CEO’s to use special access service for any person they wish to designate for such service. A key objective of these programs is to acquaint the executives with reasons the institution should be included on panels in their employee insurance programs.
v. Physician Relations. While most of the institutions we visited depend heavily on community physicians for patient referrals, only one or two identified programs that are targeted to promote good relations with physicians outside of their own networks. One is particularly interesting: it is a plan to create a team, made up of trained nurses, to call on referring physicians regularly to be sure their interests are identified and addressed. They will also serve as facilitators of access for their physicians, where they are needed.
VI. Training and Human Relations
We found that the institutions we visited pay a great deal of attention to recruiting, training, and motivating staff to promote good patient service experiences at their institutions. “Systems are not the problem, people are the problem” is the way one of our panelists put it. In the section on “Culture” in this report, we noted the widespread view that the only way to create a true patient service culture was to change some of the cultural characteristics of the academic environment. For the staff, change is promoted through the activities of personnel management and training. There are also some examples of faculty training programs that fit better in this section than in the section on “Culture” and are therefore covered (briefly) here.
a. Human Relations Management. Most of the institutions we visited had clinical organizational entities, including practice plans, that were substantially separate for operational purposes from the university institution/medical school of which they were either a part or with which they were affiliated. While routine processing of employment materials was often done in conjunction with the larger institution’s human relations/payroll office, substantial responsibility for employment and training rested with human resources personnel employed in the clinical entity. Clinic leaders queried about this pattern at two of the sites visited indicated that university-based HR functions tended to be too rigid or too slow and expressed satisfaction with human relations offices working under the direction of managers of the clinical enterprise
b. Training for Clinic Employees. Customer service training programs for clinic employees are mandatory at most of the institutions, but not all. Training periods varied from one day to two weeks and several programs required competency testing before employees were released to work in clinics. Some of these programs included some levels of technical training in clinic systems (like IDX registration), while others did not. One institution has the requirement that all employees undergo customer service training once a year. Another institution has created a large learning center where employees and faculty receive customer service training. Still another center identified as an example of unsuccessful attempts at training an effort to train employees and supervisors on how to relate to each other. A few institutions use customer service methods imported or adapted from successful national level customer service organizations, such as the Disney Institute. One institution had hired a former Disney trainer to redesign its training programs. Another institution requires clinic managers to take MGMA sponsored training. Virtually all the individuals we interviewed stressed that customer service training will not work well unless there is high employee morale and real support for the training back in the clinic units to which the employees are assigned.
c. Telephone Training. Several discussions during our visits were devoted to the topic of telephone training. For some, this is part of the customer service training mentioned above; others have retained consultants to do specialized training for those answering calls, in call centers and in clinic and departmental offices. In one case, this training takes eight hours and is done by a company called Phone Pro, which also monitors satisfaction by customers with telephone encounters.
d. Faculty Training Programs. There is little or no training for faculty in customer service as such, although there are several ways the institutions visited transmit to selected faculty the importance of patient service to the institution’s future. One institution has a special training (tuition paid) in the business of medicine for two physicians per year who are deemed to be faculty leaders. There is annual training in the functions of the group practice and billing and compliance for all physicians; goals and culture in the practice are part of this training. One institution has a three-day orientation program for new faculty held once each year in July at which the service goals of the practice are an important topic. At another institution, department chairs that serve on the board of the practice corporation (which in this case manages the clinics) have training in the role of the board member and the board’s standards for patient service.
