Carol Stryker

One of the most interesting things to me about physicians is their ability to make quick decisions.  Any problem directly in front of them will have their full attention for as long as it takes to observe the situation, pull information from their personal databanks, and process both.  My best guess is that this is a skill ingrained during their training.  (What does MD stand for?  MAKE A DECISION!) 

As necessary and effective as this problem-solving method can be, it does not solve physicians well in the management of non-medical tasks and issues.  A recent personal trip helps illustrate.

An important high school reunion for my husband was to be held outside Washington, D.C.  He responded immediately to the invitation, mostly because he only had to click "yes" and "send."  It was also easy to arrange a hotel for the visit because the Reunion Committee had made that just as simple.  That's where things sat for several months.

Several weeks before the event, we carved out some time on a Friday night, when we were both tired and frazzled, to make our airplane reservations.  We added some days after the reunion, but neither of us had more than a vague notion of what we would do with the time.

Time flew by and we were both overwhelmed with what needed to be done to avoid leaving anyone in the lurch while we were gone.  We had plane tickets and a place to sleep the first four nights and nothing else except structured plans for the reunion. 

Here are just some of the sub-optimal things we experienced after:

• It took quite a long while to decide on a rental car company, mostly because I was making arrangements for the next day and did not know the area.  I was doing it on my phone and did not have the benefit of a map for context.

• After a hard day of driving, we arrived at Kitty Hawk, actually Wright Brother National Memorial, just as its gates were being locked.  That meant the unexpected need to spend the night and visit the memorial the next day.  Who knew they actually lock up national parks?

• Not leaving Kitty Hawk until noon, we didn't arrive at Charleston, S.C. the next day until about 8 p.m.  This meant we disrupted plans with friends for a mid-afternoon arrival. Driving through Charleston during rush hour and later through some remote and poorly marked areas well after dark made for another very long, hard day.

•  The plan was to pick up the Blue Ridge Parkway at Ashville, N.C. and check out the foliage.  We got there just as the visitors' center was closing and learned that lodging was going to be a problem.  We ended up sitting in the parking lot at dusk, looking for a room.

• We did find a room, but it was thirty miles south and pretty substandard.  It was noon the next day before we got back to the Ashville visitors' center.  Basically, we'd lost close to a whole day.

• We had such a good time that we decided to keep the car an extra day.  That meant calling the rental company.  Unfortunately we were in a part of the parkway that has no cell service.  I had to beg a landline from one of the concessionaires.  After working my way through the rental company's automated answering system, it told me it was too late to extend the rental through the automated system.  I had to start over again and ask for an operator.

• We returned the car to Reagan National and took the Metro to a stop near our next hotel.  When we asked them to come pick us up, they said it would be half an hour because the driver was on a run to Reagan.   It had not occurred to us that we could be fetched there, but all we had to do was ask to find out.

• None of the bumps in the road individually did serious damage to what turned out to be a great trip. 

• All of them taken together wasted a lot of our limited time and increased our costs.

• The snags could all have been avoided with just a little bit of prep time on our part.  The benefits would have significantly exceeded the effort expended.  We just did not carve out any pre-trip planning time.

A medical practice is far more complex, and the costs and frustration are monumentally larger.  This means the effort to plan ahead and deal with things in context is even better spent.

Articles

Doctors are used to making quick decisions, but when it comes to some tasks, you have to think ahead. Prep time is your friend. 

When Managing Non-Medical Tasks, Plan Ahead

Every business, including a medical practice, regularly encounters challenges.  Enterprise survival requires solving critical problems.  Profitability and job satisfaction require effective solutions, defined and implemented efficiently.  Physicians can improve the quality of business-problem solutions by applying a model that serves them well in the clinical part of their practice:  A SOAP note.

SOAP notes are second nature to current practitioners and their staffs. Utilizing the format in non-clinical diagnoses requires learning no new techniques and leverages the thinking process already understood and employed.

A SOAP note can cover all the elements of standard business problem solving:  Identification (

In a clinical setting, the SOAP note seldom proceeds from S to P without some jumping around.  That experience gives a valuable insight into business problem solving.  While the novice (and most EHRs) want to believe the process is linear, the truth is that some jumping around between steps is almost inevitable.

How is the problem being experienced?  What are the symptoms?  As with evaluating a patient, there is no requirement at this point to know why revenues are down, staff turnover is up, or patients are complaining. You simply need to clearly describe the sub-optimal situation.

This is the step for gathering data, both objective and subjective.

Why is income down?  Are billings down?  If so, are fewer patients being seen?  If not, which delinquencies or write-downs are growing?  All of this data is objective and can be retrieved from financial and activity records.

Why are patients complaining more?  Do they not understand that they have more financial responsibility?  Are they frustrated that the office schedule is unreliable or inconvenient?  This data is subjective and is best gathered in interviews.  If the practice is reluctant to ask patients directly, the front-office staff can be an excellent proxy.  Physicians rarely have good insight into the reason for disgruntled patients.

It takes analysis or assessment to turn data into actionable information. This element of the process tends to be a linear series of questions and their answers.

What is the fundamental cause of the problem?

In business, as in medicine, this is the most important question to ask and to answer correctly.  Developing a solution for the wrong problem can do more harm than good.

If a drop in income has come from fewer physician hours in the office and it corresponds to a maternity leave that is about to end, that resource issue will resolve itself with time.

Is the problem systemic or random variation?

This is an especially important distinction to make when dealing with unhappy patients.  If one patient in a hundred complains about the examining room gowns, her complaint must be addressed respectfully but there is no need to start a search for a more palatable alternative.

If sixty patients complain, the problem is systemic and needs a more complex solution than an apology.

What are potential solutions to a systemic problem?

Any potential solution deserves to be listed.  This is not the time to eliminate options out of concern that they will be too expensive or complicated.  There is not enough information at this point to reliably estimate expense or complexity.

Value is the ratio between benefit and cost, and cost is the total cost of ownership and use.  Something that costs little but fails often is never a good option.  Something that costs a lot but makes staff more productive can be a very good option.

There are many different kinds of risk.  Financial is only one.  Time to implement is a risk, as are reputation and patient satisfaction.

Which option offers the best combination of value and risk?

This is almost always a subjective decision and it is a mistake to force it based upon objective data.

This will look like any treatment plan, although there will be more interim checkpoints and deadlines.

Identify the steps necessary to move from the status quo to the desired outcome.

Using a proven methodology which the practice understands and trusts is a better way to approach non-clinical challenges that adopting a B-school protocol that is unfamiliar.

Practitioners are used to applying SOAP notes to clinical problems, but they can be used effectively for business issues as well.

Using SOAP Notes for Business Problems

Having excess staff is never a good thing. Just enough is the level where most practices are aiming to be. The problem is that many offices work with an erroneous definition of “just enough.”  As a consequence, phones ring off the hook, patients are dissatisfied, overtime is excessive, and basic tasks are neglected.

As an example, consider the challenges in staffing the front desk in a practice that sees 90 patients a day, and a benchmark that says patient registration for that specialty takes an average of 10 minutes. Straight arithmetic says that two full-time people at the front desk are more than enough:

90 patients/day X 10 minutes/patient X 1 hour/60 minutes = 15 hours/day < 2 front desk staff

So why is the waiting room always full of frustrated, waiting patients, while the exam areas are full of frustrated providers waiting to see patients they know are in the office? Here are a few ways to understand why 2 full time people are not enough.

Patient arrivals are not spaced over eight hours.

If the morning appointments are scheduled from 8 a.m. to 11 a.m. and afternoon appointments are scheduled between 1 p.m. and 4 p.m., patients are only being registered about six hours per day, not eight.

90 patients/day X 10 minutes/patient X 1 hour/60 minutes = 15 hours/day

15 hours/day X 1 man-day/6 hours = 2.5 front-desk staff members

Fractional staff should usually be rounded up.

If the workload is steady throughout the day, you can’t add or subtract half a person.  If it happens that the practice schedules really quick appointments in specific windows, it may be able to take advantage of fractional supplemental staffing during those periods.

The determining factor in a schedule is how long the appointment is expected to take, and the time required for registration is not usually a part of the calculation.  If the providers expect appointments to require, on average, either 15 minutes or 30 minutes, the logical move is to schedule all appointments on the hour, half-hour and quarter-hour.

The waves are not much of a problem in our example, assuming the practice has staffed the front desk with three people, no registration takes more than 10 minutes per patient, and the patients all arrive on time.  What are the odds? 

Some registrations will take longer than the average.

New patients may have to complete documents upon arrival.  Existing patients may need to update records or discuss a payment plan.  The printer may jam or the computer may need to be rebooted. 

Staffing to the average time required to perform a specific task does not account for ancillary disruptions that are inevitable.

The practice may have picked up that extra half of a staff person by assigning extra duties to the front desk.

That makes sense in terms of fully utilizing staff.  What happens, however, when a patient presents for registration at the same time the phone rings?

Staff members get sick and take vacation.

Scheduling models cover all of the time a practice is open and seeing patients.  No staff members are actually available all of that time.  If we assume each employee will be out of the office 10 days per year, the front desk in our example will be short-staffed for six weeks.

10 days/employee X 3 employees X 1 week/5 days = 6 weeks

Staff members take a leave of absence or quit.

Turnover is the big wild card in determining staff requirements.  The best available method to predict future experience is to look at what has happened in the past.  If turnover at the front desk has historically been 30 percent a year and it takes two months to hire a replacement, the front desk, in our example, can be expected to be short-staffed for almost another eight weeks.

3 employees X 30% X 22 days/month X 2 months X 1 week/5 days = 7.92 weeks

Averages are useful tools, and so are back of the envelope calculations of staffing requirements.  Effective staffing, however, requires active awareness that averages will be exceeded about half of the time, random glitches will occur, and staff members are predictably absent at least part of the time.

One blogger looks at the problem of a practice being understaffed and how to solve that issue through basic arithmetic. 

Using Math to Predict Staffing Needs

A recent, highly publicized incident reminded me that it is as important for medical office staff to know the hierarchy of practice values, as it is for them to know what those values are. 

In early August, a Lowe's customer in Danville, Va. specifically requested that a black person not deliver her order.  The store manager complied anda firestorm ensued.  It was a perfect case of competing values, and a lack of clarity as to their relative importance.

The store manager was operating under an imperative to make the customer happy, a core value in most retail and service enterprises.  Unfortunately, he ran afoul of what Lowe's says is a higher value for the company:  "Zero tolerance for discrimination of any kind."  It isn't clear how much harm the incident did to Lowe's.  It is clear the manager lost his job.

In light of this, here are some lessons for medical practices leaders:

It can be unsettling to consciously acknowledge that, in a given situation, we are willing to sacrifice one principle in service of another.  The reality is that each of us does it every day, most often without realizing the tradeoffs.  Most individuals do it automatically because they ideally have coherent internal value systems.

The relativism is more problematic when we must rely upon other people, e.g., medical staff, to execute those tradeoffs for us.  Unless the leader acknowledges that tradeoffs are sometimes necessary, the staff will be far less likely to consider competing values and far more likely to respond consistently with the most often repeated mantra.  The Lowe's manager made that point.

Give staff a framework for choosing between competing values, according to the practice's value system.

Once the leader has articulated her values, she needs to do a pair-wise comparison to determine their relative value. 

For example, assume a physician's top three values are patient safety, patient satisfaction, and getting home on time.  If patient safety and patient satisfaction conflict, what wins?  What about patient safety and getting home on time?  Patient satisfaction and getting home on time?

If staff members are clear about what's important and what is more important, they can perform consistently within the practice's values.  It is not too much to post these, discreetly, at workstations so that employees have a ready guide whenever confronted with a situation.

Provide staff for explicit guidelines to identify tradeoffs that must be reserved to the physician.

Part of being comfortable in making a decision is clarity about the decisions that need to be delegated up.  It is not effective for the physician to be a part of handling every single patient phone call.  It is not safe for the physician to leave the management of all phone calls to staff. 

A set of bright lines will give staff the confidence to operate relatively autonomously, because the bright lines will tell them when to call for help.  It will also give the physician confidence that he will be involved appropriately.

It is essential to articulate the values of a medical practice.  The necessary next step is to acknowledge their relative value, and provide clear guidelines on when the physician's judgment is required to resolve value conflicts.  From there, all three must be clearly and consistently communicated to medical staff members.

We’re all willing to sacrifice one principle for another. As a practice leader, you must develop a framework to choose between competing values.