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    Owen J. Dahl
    Owen J. Dahl, MBA, FACHE, LSSMBB

    Healthcare in the United States is often described as a “sick care” system — taking care of patients when symptoms or disease are present. That same approach of dealing with disease, rather than prevention and wellness, is prevalent in healthcare management.

    A sick care system approaches the patient on a continuum — the patient is well, then transitions to a stage of disease — at which time the system steps in. How about your approach to management? Many of us look at the demands and stresses of managing access, supply, staffing and finances as a disease to cure rather than opportunities for proactive and engaging management. As managers and leaders, we need to consider our own transition from disease to wellness to address whatever mess we face.

    In today’s industry, the major emphasis is on achieving value-based care — care delivery focused on quality, provider performance and the patient experience, measured by gold stars and incentive reimbursement models. Ask yourself:

    • Are you meeting the process metrics to achieve an incentive?
    • Are your patients getting the best outcome?
    • How is this being measured?
    • Are you optimizing resources to achieve the desired outcomes?
    Value-based management

    In The Age of Scientific Wellness, Leroy Hood and Nathan Price offer a prescription for transforming patient care they call “P4,” which applies four principles to transition from the current sick care system in the United States toward a wellness approach:

    1. Predictive
    2. Preventive
    3. Personalized
    4. Participatory.


    Providers applying the P4 principles to patients will eventually achieve improved wellness, dramatically enhancing outcomes and reducing costs. For administrative leaders, this approach will have different but equally beneficial outcomes.

    Predictive

    BP = 200/120. HbA1c – 9.0. Height – 5’8”, weight 250lbs. These vital signs help providers make daily decisions relative to the patient and devise a care plan — a predictive path to wellness in the future.

    As a manager, what data do you have that helps you predict the future of practice operations?

    • Days in A/R reaching 72 — Reducing this number to 30 could significantly improve cash flow, enabling investing in new equipment, higher wages, recruiting another provider and the like, thereby avoiding cash flow delays that could interfere with future decision-making.
    • Overhead 73% — Reducing overhead increases profits, enabling more opportunities.
    • Turnover at front desk of 40% and patient satisfaction at 3.5 out of 5 — Patient satisfaction narratives point to turnover at the front desk, raising questions about stability and how the rest of the office is managed. Stabilizing this area will boost satisfaction scores, enhancing managed care negotiations and attracting more patients.
    • Extreme variance in no-show rates by provider — Dr. A has a no-show rate of 16%, while Dr. B’s rate is 2%. Any data gathered must be actionable, not just informational. We must take action to fix Dr. A’s problem. What should we review? What aspects are relevant not only to the whole organization but also to diagnosing a problem and moving toward a wellness outcome? What other key performance indicators (KPIs) do you look at regularly? What about engagement of staff (e.g., Gallup organization survey model)? What about patient turnover, payer audit results or activities by department? The big picture? You get the idea.


    Who do you serve as a manager — the patient, the doctor, the C-suite, the corporate office or employees? Whatever the answer(s), the key consideration is the value you provide through your daily efforts. The data generated should assist in building out that consideration. When analyzing a process, do you identify waste and actively work on creating and measuring a value stream to minimize the waste?

    Start by identifying your current situation and comparing it to historical data using trend analysis, and then benchmarking your findings against industry standards. With this information, decide who needs to see the data and how they will use it.

    Clearly identifying and sharing the current state to those who can influence it should result in strategies that enhance outcomes and help achieve the ideal state. Is a one-time fix possible or is adopting a continuous process improvement (CPI) approach more reasonable? Think about a set of stairs — one foot after the other as you progress to your goal of reaching the top. With CPI, you improve to a level, maintain that level for a period, then move to the next, level off and continue toward the goal, always focusing on achieving the desired state.

    Beyond the data and analytics, there is the future of medicine that must be considered in relationship to each employee. Consider the impact of telemedicine, remote patient monitoring and the advent of AI. The future is both exciting and cloudy as consideration is given to the relationship to each employee.

    Preventive

    Providers take the necessary steps to address sickness during each patient visit. Is there adequate focus on wellness or do constraints like time, resources, or knowledge hinder such focus? Knowing the current state is crucial in developing a strategy and assembling the appropriate, available tools to treat the patient. A preventive approach leads to wellness.

    As a manager, what do you do with your data to help you achieve a state of wellness? Your days in A/R and overhead are above the benchmark and require your attention. How can you fix these issues and also ensure that these metrics do not revert to unacceptable levels?

    As in medicine, there have been many theories and strategies related to overall management. Monumental approaches in the United States include F.W. Taylor’s The Principles of Scientific Management in the early 1900s, Elton Mayo’s Hawthorne studies in the 1920s, Peter Drucker’s management by objectives (MBO) in the 1950s and 60s, W. Edwards Deming’s total quality management (TQM), the 1990s strategy of “reengineering,” Motorola and Six Sigma, the Toyota Production system, Lean and Agile. These all espouse the idea that things can be improved using their specific approach. As Deming noted, “every system is perfectly designed to get the result that it does” — and not necessarily good ones. The Lean Six Sigma philosophy of providing value to the customer by eliminating waste and focusing on what is important to them is a great approach to improve your systems. Embracing a philosophy that prioritizes a preventive approach and the elimination of waste in all organizational systems can lead to better customer experiences and health outcomes, making it a worthwhile goal.

    Your analysis reveals issues with your scheduling schema, such as patient complaints about lengthy phone wait times, the extensive process to schedule a new patient visit and long delays in seeing the provider:

    • Who does what when?
    • Who creates the scheduling schema?
    • How is it managed?


    Developing a SIPOC (supplier, input, process, output, and customer) diagram is useful. The SIPOC diagram functions similarly to a computer processing data, treating the patient or employee like the data input. It helps you track how this input is received and transformed into an output, in this case a schedule. Another useful tool is a flowchart to visualize what is happening and spot gaps or blocks in the system flow. After identifying these gaps, a team can leverage a cause-and-effect analysis to uncovering the root cause(s). This involves categorizing potential factors like policies, staffing levels, and training, and then examining how each category might contribute to the problem or opportunity. This information guides the development of solutions.

    It is understood that the initial fix will not solve all aspects of the problem (disease) but identifying the causes that have the biggest contribution will lead to the most impactful solution. As with CPI, revisiting the issue for further steps toward resolution may be necessary.

    Personalize

    Everyone has their own DNA — genetically and metaphorically. Each employee comes with their own background, shaped by race, ethnicity, culture, experiences and more. When we acknowledge that each employee is unique, generalizing an approach to onboarding, training, discipling and rewarding may not be effective.

    Once you assess an applicant’s skills, you should consider how their personality will fit within the practice or department. Develop an individual plan for integration and improvement based on their needs, goals and how they fit into your team. Do you have the skills, time and patience to assist the employee on their career path? What metrics will you use to determine their contribution to the mission?

    A recent graduate of a certified medical assistant program has applied for a position. She has a friendly personality and hopefully the basic skills. You assign a mentor to help her integrate into the office. She has learned and grown professionally; the provider is highly complementary of her efforts. She grows in the position and eventually becomes a mentor to others. Success is measured by the increased number of patients the provider sees and the improvement in patient satisfaction scores.

    Listening is the most effective form of communication you have in dealing with everyone.

    Are you taking notes and considering the options to integrate and develop them as key contributors to your team? Once you have determined this, the implementation begins:

    • What level of training and subsequent freedom do you allow?
    • How frequently will you follow up? What is your next step in the training process?
    • Do you have another member of the team that can mentor the employee?


    A team member in the call center does not agree with the “scripts” used for addressing patient issues and feels that team members should be given more latitude in communicating with the patient. He understands that there are key data points that need to be obtained but feels a more personal approach to the patient will result in fewer no-shows and cancellations of new patient visits. The results have proven successful: When patients arrive at the office, they even ask to meet him in person. Doing away with key scripts and personalizing the exchange has produced positive results, all done by engaging and listening to team members.

    An alternative strategy involves becoming a coach — someone who develops the employee and their skills by identifying areas of needed improvement and offering advice on how to improve. Taking time to engage and listen, and then offering guidance on how to better address a situation, will go a long way toward developing and retaining staff as opposed to a daily quota.

    Participatory

    Providing a prescription or plan for the patient is not enough; the patient must follow through with the implementation of the plan, as their participation and compliance is essential. However, this may be constrained by finances, their insurance coverage, environmental factors and various social determinants of health (SDoH), as well as their own comprehension and commitment to achieve the desired outcome. Recognizing this and finding ways to enable patient compliance to the plan will lead to a successful outcome.

    As a manager you recognize that you cannot do it alone — you need a team working together. Selecting team members and developing their personal plan is only a part of the process. Integrating, providing direction, allowing freedom to succeed and even fail provides teachable moments and growth opportunities.

    Team members are process owners — it is their knowledge and experience that make things happen. As process owners, do they have the training, tools and time to meet the targeted outcome? Are there subject matter experts (SMEs) who can provide support and advice to the team? What is your coaching strategy that will result in overall value improvement? This is where you, as a manager, step back and observe. Encourage the team member to assume a greater role in addressing the issues at hand. Their ideas, based on their direct involvement in the daily work, bring more insight to the problem than any manager could. In effect, the team member becomes the project manager who may become a mentor or coach to others as the process evolves. This can result in new ideas and better ways of doing things.

    Today, we hear more about patient frustrations and experiences. It is time that we encourage team members to exercise their listening skills with patients and apply their skills to fixing the problems at hand. Seeing one more patient a day relieves some access issues. Engaging with patients on a personal level improves satisfaction scores and enhances word-of-mouth exchanges in the community with positive results.

    Go back to the concept of listening and how it might relate to the four Ps:

    • Predictive: Are you hearing/seeing the things that are wrong?
    • Preventative: Look for opportunities to improve
    • Participatory and personalized: Use the people resources available to work as a team to achieve value for the patient and the organization. Recognize the individual contributions made, as well as the group/team accolades. Flexible, individualized fringe benefit approaches (e.g., offering childcare, elder care, tuition reimbursements, contributions toward retirement plans) designed to meet the needs of employees will help achieve your goals for retention.

    Transition to wellness

    Think in terms of wellness: is the patient/organization well? Is the disease state chronic? If so, how best can the provider manage that condition? Is their ability to achieve desired outcomes — in a compliant fashion that reflects the organization’s mission — doable in a cost-effective manner?

    As a manager, can you change your perspective on how you approach your daily workload? The stresses and demands placed upon today’s healthcare manager — whether in the C-suite or managing a department or supervising the front desk — are great and getting more so. The challenge lies in using the available predictive data to change thinking to that of a preventative approach. To recognize each employee as an individual bringing their background and strengths. To recognize that you cannot do it alone, to take the personalized resources that are there, utilize their skills and knowledge and integrate them into a team to achieve the desired outcome.

    Where do you go from here?

    • Gather the right data.
    • Set the targets and goals.
      • Prevention and wellness
      • Value to the customer
    • Achieve those goals through:
      • Selection
      • Training
      • Mentoring
      • Coaching
    • Recognize the contributions of each individual as well as those of the whole team.
    • Achieve cost control and an improved financial picture for the patient and the organization.

    A manager can learn a lot from considering the P4 idea and applying the value-based principles found in Lean Six Sigma and those in value-based care.

    Owen J. Dahl

    Written By

    Owen J. Dahl, MBA, FACHE, LSSMBB

    Owen Dahl, MBA, FACHE, CHBC, LSSMBB, is an independent consultant with more than 40 years of experience managing medical practices and providing healthcare consulting services. Owen has worked as a chief executive officer (CEO) for a physician practice-management company with combined revenues of more than $75 million and 18 groups under contract, as CEO for a merged hospital with a 300-bed facility, and as president of a physician practice-management and billing company. Owen has presented at several state and national MGMA meetings, as well as to audiences from the Association of Otolaryngology Administrators, Association of Dermatology Administrators/Managers, American College of Rheumatology, American Academy of Dermatology and others. He has also authored Think Business! Medical Practice Quality, Efficiency, Profits; The Medical Practice Disaster Planning Workbook; coauthored Lean Six Sigma for the Medical Practice: Improving Profitability by Improving Processes, and written several articles and provided interviews for numerous journals. Owen is an adjunct professor at the University of Houston, Clear Lake, and is conducting a distance learning program at the University of New Orleans. He has also taught at Our Lady of Holy Cross College and Loyola University.


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