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Dr Bernard was a National Health Care Scholar and served at a Federally Qualified Health Center in Immokalee, Florida for six years after her residency. She then worked for a large out-patient hospital group before opening her own practice, which she con

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Scott Urquhart, PA-C, DFAAPA; Wendy Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP; Margaret Fitzgerald, DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC, FNAP; Angela Golden, DNP, FNP-C, FAANP; Jordan Mast, MMS, PA-C; Sally K. Miller, PhD, APRN, PMHNP, FNP-BC, AGACNP-BC, AGPCNP-BC, FAANP 

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 Today we are featuring my conversation with with Rich Miller, chief strategy officer of Qgenda, after his recent presentation at the Medical Group Management Association's virtual Medical Practice Excellence conference.

Here's a brief excerpt from the program summary: As we move through the Recovery stages of the pandemic healthcare organizations and practices are overhauling technology and processes to accommodate COVID-19 safety protocols and return to more typical operating levels. They're having to make quick adjustments. So just balancing a new combination of telemedicine visits and in person visits, or transitioning to touch free workflows. These critical guidelines and policy changes are impacting patient flow without the right technology and visibility. And these changes can negatively impact patient access and throughput.

Prior to his appearance at the conference, Rich also contributed an article to Physicians Practice about how providers and practices as a whole can 

Our conversation centered around clinical capacity which, Rich explains, is very broad in concept but fundamentally refers to brining providers and patients together in the most efficient way possible.

 One of the ways that I think about clinic clinical capacity is sort of like two funnels coming down towards each other. So, the health system, and the patient system is very much like a funnel of in-taking new patients and doing initial diagnosis and triage, etc, etc, and trying to get them to those points and care.

And that sort of happens over and over again as we move people through that system of diagnosis and treatment, as well. The same is true of providers. So whether it's as far out as making sure that providers are onboard and properly in their credential to work in various locations, and all that kind of thing, the kinds of things that big health systems think about, all the way down to just saying, “Well, how many people do we have in this Urgent Care Clinic today, to see patients who, you know, show up for a walk in or, you know, scheduled patients?” So really clinical capacity, in its simplest form, is the marriage of those two things.

At the small scale, it's really very similar between, you know, a large health system and a small private practice with a with an office practice because those large health systems are made up of lots of small units that work just like that. So an orthopedic unit for a major health system, versus orthopedic unit, for a private practice group, really what they're trying to do is they're just trying to make sure that they can take as many patients as possible, while providing a very high degree of care and not burning out those providers while they're doing it.

 Like a lot of other areas of healthcare, the pandemic had a cascading effect on capacity management, according to Rich Miller.

 So, you know, the Coronavirus, the effect was really dramatic, and really just cascaded all throughout the health system.

You know, on the macro level, the effect of COVID-19 had a huge effect on the concentration of patients. So, we went from, you know, ORs being booked up and patients coming in for elective procedures and people coming into ambulatory clinics to, you know, see a specialist about a shoulder that's aching, that's my shoulder aches here sometimes. So, I naturally the point to that. And those things all got just canceled and shut down and all of those resources were then shifted over into our intensivist areas, the ICU, places like that. And suddenly you have, you know, these massive spikes, especially in places early on, like in April, during the surge in New York City and surrounding areas, Massachusetts, you had an incredible surge in these ICS where they were literally, you know, repurposing any possible room that they could in order to take care of these very, very sick patients.

Also, at the macro level, because there was this huge interruption to the kind of regular business of health care, there was a massive, massive interruption to revenue. So typically, in health systems, surgery is about 50% of your revenue. And even if you're an independent private practice provider, and you're a surgeon, surgeons are incredibly important for your revenue. Certainly, ambulatory revenue is still a real part of that. But both ambulatory and surgical revenue were cut way back way back. So there's a huge shortfall in revenues for 2020 that these hospitals are facing at the same time, that they had to spend more on facilities and PBE and all that kind of stuff. So Big macro effects.

On the micro level, the areas where we are providing care really changed dramatically. And a lot of it had to do with making sure for example, that we had the right level of isolation when people were in waiting rooms and things like that, I had an experience. And I'm going to talk about this a little bit at the practice excellence conference of going to my primary care provider for a regular physical. I drive up and there's like a sandwich board sitting in the in the parking lot that says, “Please call this number before you walk in, and I call it at some of the front desk.” So literally triage and people in their cars, like they want you to stay in your car and make a phone call. So people got very creative about how we were going to distance those patients. And immediately they asked, you know, did you take your temperatures, we asked you last night, were you good? Have you had any contact with anyone in the last, you know, blah, blah, blah, etc, etc, and went through and evaluated whether or not I would be safe to enter that space. And to their credit, that process worked incredibly smoothly. And, you know, boom, boom, boom, I was in the exam room and working with my physician. So that was terrific.

Things like the amount of cleaning and turnover that we have to do, every exam room now has to be cleaned after every patient has really added huge pressure on a system that already was pretty pressurized. The last thing I want to say about it is that it changed. It elevated, I should say the importance of different people you see all the time in healthcare, like for instance, the people who do the laundry, and the people who sanitize and turnover rooms and housekeeping and people who transport patients. Now, people who worked in those roles were suddenly critical critical providers of care, and where in the past, you would only schedule maybe you schedule your physicians, and we'll schedule our you know, advanced practice providers or our nurse practitioners and stuff. Now, we saw how systems that went from, you know, 3000, people under that kind of very precise scheduling to 30,000 people, literally housekeeping people, and need to be able to communicate with those people immediately. So suddenly, a lot more people were involved with carrying out the project. And it really is amazing what health systems have done in the way that they adapt. And it's just, it's been incredible seeing clients and friends and what they've done and been through.

 Managing clinical capacity often requires tools that are already at your practice, but new innovations are always on the horizon.

 Typically, what you would find in a small setting is, you know, a paper or Excel spreadsheet, or emails kind of flying around. You know, in some of the best cases, you have a really, really good administrative system, front desk person and scheduler who is just incredibly vigilant about making sure that those schedules really tie off. So, in general, what we see for tools are pretty rudimentary; certainly, there's going to be small EMR and things like that for booking this patient encounters. But oftentimes, there's very little by way of hard information about how things like exam rooms and provider time are being managed.

One of the things that's exciting for me is the way that we're using provider scheduling, to get right down into the nitty gritty of managing the day to day.

So I've actually worked in provider scheduling since 1998, a very long time. I'm dating myself here a little bit. And, you know, originally it was like, you know, who's on call and, and just trying to understand who the kind of go-to person is for care. But over time, there has been a steady march, closer and closer to now that's kind of the way that I like to say. Where in the past, we may have gotten to saying, “Well, this person is working today”, and then gotten to the place of saying, “Well, their first patient is eight and then I expect them to close at their clinic by 4pm today. Now we're even getting into place where we're saying, this physician is working in three these three exam rooms. This is a medical assistant, that's working with us. And those patients are being roomed and set up and ready for an encounter with their provider. So the provider walks in at this stage of set, and they can have a very productive conversation and get right down to take care of their. So, scheduling has really started to evolve to get more real time. And rooms management is certainly a big part of that.

 Ultimately, your ability to effectively manage your clinical capacity can have ripple effects in patient outcomes, provider satisfaction, and even practice revenue.

 I think that, you know, my wife is a provider and so I know a lot about how, you know, she feels about her day when she has crazy clinics that are piled up sky high, and then other days where maybe she's, you know, seeing 60% of patients that she should be able to see, all the time knowing that there's this incredible backlog of people who are waiting to see her.

So, I think that the real central theme of this is: how do we rationalize this process? How can we make sure that we have a really nice steady flow of patients so that providers aren't overwhelmed, they have time to work on their note and make sure that the wrapping of those cases appropriately that they can spend adequate time with each patient and provide the care that they need to, while at the same time identifying where they're underutilized resources.

That's something that is absolutely incredibly common, where providers have, you know, canceled appointments or scheduled as schedules that aren't managed very vigilantly? Maybe the person doing the scheduling that day wasn't doing a particularly good job, but one of the areas that is really, really poorly managed is facilities and rooms. And if you ask a typical provider, you know, do you have enough rooms in your ambulatory clinic, or in your office? They almost universally say, “No, we do not have enough rooms, because I don't have rooms when I want them.” So my perception is that provider is there just aren't enough rooms available in this facility.

Now, we've done lots of studies and actually looked at how those facilities really run. And the fact of the matter is, that rooms are really incredibly underutilized, that lots of rooms sit empty. And the reason that people perceive that rooms aren't available, isn't that rooms aren’t actually available—that there isn't actually physical space—but the spaces are so mismanaged that when they need a room, they can't identify, can I take this room and someone else gonna come and take this room? So there's a tremendous amount of wasted space there.

In the big application, whether you are, you know, a huge Health System, or you are an independent private practice, is you, if you start thinking, well, I guess we need to go out and get more rooms, now you're building facilities or leasing new facilities, that is incredibly expensive. So now we're seeing this change, where health systems and practices are saying, let's really look at how we're using this, let's implement a system that gives us some strong idea of what our utilization looks like, and maybe we can put off, you know, building that new $7 million facility.

 Up next, Rich discusses how some of his clients streamlined their clinical capacity management.

 It's interesting, we had a client who contacted us and said, you know, we have a huge problem with the way that we're managing rooms. This is University of Alabama, actually. And one of the things that they were struggling with is that they really didn't understand how many rooms are being used and whether or not rooms were booked whether patients were booked to those rooms. And so, our service team being a bunch of maniacs decided, hey, you know, let's just take our product as it exists today, and see if we can put something together to help these guys out. And so they kind of configured the product and sort of a weird way to accomplish what they were trying to do. And this happens all the time in software, people like come up with unexpected uses for your software, and you kind of use it in sort of a strange way to try to make that outcome happen. And what was startling is even using what was very rudimentary, we were able to increase the number of patient visits by 7.4%, increase in the clinical session volume by 4.7%. So, these are things that they were really able to, to measure as outcomes from implementing the system.

Physicians Practice® spoke with Rich Miller, chief strategy officer of Qgenda, about practices' clinical capacity management during the pandemic and what you can do to optimize your capacity management strategies.

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