My OBGYN

Like a twentysomething who can't fully grasp the idea of being an adult, MyOBGYN is suffering the effects of a growth spurt that it
hasn't quite gotten used to. In the early '90s it was a four-physician practice that delivered about a dozen babies a month.

Now, with five doctors, four certified midwives, three locations in surburban Atlanta, and about 80 deliveries a month, the day-to-day problems - staff turnover, patient flow, collections - all stem from a larger issue of unevenly implemented, inconsistently applied policies and direction. Those should be the cornerstone of any practice, particularly a growing one.

"We have a lot of big ideas, we have a lot of things we want to do, but we don't ever seem to get things going. We commit to everything and do nothing," explains practice manager Anne Campbell.

The practice seems to have a sense of what to do to turn things around, but has trouble making change happen.

For example, MyOBGYN believes (rightly so) that it would be more efficient if every exam room were stocked exactly the same way. That way, medical assistants would know in one glance what was missing from a room when they're cleaning it, and physicians would have everything within reach when they need it.

The practice even has a room-stocking form that staff can use at the end of each day to check off that each room has everything on the list. But in reality, the rooms aren't ever stocked as the list specifies, and the end of the day finds most rooms incomplete. Campbell can't really explain why.

In some respects, it's no wonder. There are lots of distractions from the bigger picture in the daily whirl of a practice currently handling 430 active OB patients. And written policies just don't go far when staff and physicians already have set patterns.

Start With the Big Picture

The practice has to look at the larger landscape before tackling the smaller bumps in the road. Start by:

• Ramping up physician leadership - Top management absolutely has to live and breathe by the priorities they set and the tone and direction they want for the practice. It's their job to show everyone why new policies matter and to demonstrate that they care about them.
  

• Getting everyone involved - Everyone at the practice, regardless of which doctor they work with or whether they work in the front or the back office, needs to understand the problems, be part of finding solutions - and know why it matters. It's the difference between wanting to truly change things and getting yet another policy memo to file away.

In this practice, as in many, staff loyalty (especially clinical staff) tends to be to individual providers, not to the practice, says Campbell. "That may be why buy-in on policies and procedures doesn't always work."

Physicians talk about teamwork, but if push comes to shove, they'll defend their own staff rather than stick to set policies. The tone and allegiances in the practice are setting things askew, which takes us right back to the critical piece of physician leadership. Only when that is firmly established can MyOBGYN work on its other problems.

Turnaround Turnover

"Though we feel the salary and benefits are competitive, and despite the staff giving us positive feedback about employment with our practice, we keep losing some of our best, and we don't know why," says Steven Rabin, MD. Campbell agrees that turnover was high early in the year, especially for clinical staff, though she didn't have an exact count.

The practice's salaries are certainly fair, if not generous, and the benefits package is handsome:

• Medical and dental coverage after 60 days' employment; the practice pays $200 toward the monthly premium
  

• 401(k) after 60 days and a profit-sharing plan
  

• 15 days paid time off in years one to four of employment

So what's the problem?

In exit interviews, departing employees mention salary as an issue, but also complain that their needs and requests weren't taken seriously, Campbell says. Staff feel that the practice owners don't care.

"Our response to that has been, 'Well, who did you talk to about this?'" Campbell guesses staff are more likely to complain to one another than to make a problem heard by physicians.

If staff are indeed loyal to and report to one physician (in practice, if not on paper), it is impossible for a manager like Campbell to stem employee turnover. She doesn't really know what's going on. A rushed physician doesn't have time to handle personnel issues - or may wrongly assume a manager has it under control.

Tips to make sure concerns are heard and addressed:

• Put one person in charge of staff, ideally the office manager; less ideally, one of the physicians. All the physicians should obviously have input on salaries, policies, and hiring and firing decisions during executive meetings, but they need to rigorously resist the urge to otherwise get involved. If someone on staff raises a concern, the physician should be sympathetic but should tell the person to address it with the staff manager.
  

• Provide each office with a colorful suggestion box, and encourage staff to submit anonymous suggestions or concerns. There are no negative consequences associated with making a suggestion. The idea is that everyone in the practice needs the office to work its best and everyone should help in that effort. Publicly announce suggestions and the proposed course of response.
  

• Give staff specific and regular opportunities to explain their needs. Schedule short monthly or bimonthly meetings to touch base with staff. Check up on how they are feeling about work, what's bugging them the most, where they need help. Ask about things outside of work - how it's going with their new daycare provider, and so on. Annual performance reviews or hurried hallway discussions aren't sufficient to address staff complaints.
  

• Educate, educate, educate. If you set a policy, explain exactly what was going wrong before, precisely and in hard numbers how that affects the practice's ability to treat patients and keep paying everyone's salary, and how the new policy should help. Be open to getting better ideas from the staff. For example, MyOBGYN might decide to make its salary decisions more public. Most of its salaries fall into benchmark ranges for the region published in the most recent copy of the Health Care Group's Staff Salary Survey (www.healthcaregroup.com). Staff should know that their pay is determined, in part, by such norms. If they can get a better benchmark - say if they know a dozen people doing their same job in cities MyOBGYN serves and who have higher salaries and better benefits - they should be encouraged to present it. Similarly, MyOBGYN might put the value of its benefit structure in numeric terms. Staff should realize what their total compensation is worth, not just what they see in their paycheck.

Good business decisions are welcome, in other words. Simple complaining isn't.

Get Patients Moving

Patients complain about long waits, which usually are caused by bottlenecks in the verification process and unclear priorities in rooming patients, says Campbell.

The practice rigorously preverifies insurance coverage for every appointment, but about 20 percent of the time, staff don't have the information they need to complete the verification. When they call the patient to get the missing data, they often end up waiting for the patient to come in before getting what they need. That takes time, and the other patients start to stack up.

"That's what puts the kink in the process. That one patient slows three others down," Campbell says.

Making matters worse, the physicians all have different rules about whether patients can be seen "out of order." That is, if patient 1 is waiting for verification, but patient 2 is ready, should patient 2 be seen first?

Campbell also worries that there may be some breakdowns in communication between the front desk and the MAs about patient arrivals, and confusion on the part of some MAs about who to room first and how quickly. This is a situation ripe for finger-pointing. It'll always be someone else's fault unless the practice can find out exactly what's going on.

Get everyone involved in a patient-flow measurement study for a week. Attach a timesheet to the front of each chart. At each point in the process - check-in, rooming, physician sees patient, patient check-out - the appropriate staff member notes the time. At the end of the week, enter the data into a spreadsheet to see where the delays are. Share the results with everyone on staff, and ask for their suggestions. The idea is not to blame individuals, but to diagnose and treat a problem in process.

Depending on what is uncovered, here are some possible solutions:

• It may sound sacrilegious, but it's OK to relax the verification process slightly. Continue to preverify when you can, but when you can't, don't make patients miss their appointment times. Instead, collect a $10 copay, and ask the patient to sign a notice stating that, if the service is not covered, they may be responsible. Then, room the patient and continue with the appointment. Alternatively, patients can use the toll-free number on the back of their card to call the payer from your office to confirm coverage on this date for this service. The patient lines are usually faster than the lines for physicians.
  

• Use small timers like those they hang on coffee pots in Starbucks. Every time the front office puts up a chart, they also press a timer button. If the timer goes off, and the chart and patient are still up front, the MAs need to find out why. Is the previous patient taking longer than normal? Did the MA lose track? Place responsibility for clearing the waiting room on the MAs.

Be sure to do a follow-up study after changes have been implemented to see if they are working.

Again, physician leadership is vital. The doctors need to support the process at every step - and to take responsibility for their own role in back-ups. This isn't about individual preferences or unusual circumstances surrounding a particular patient. The goal is to keep everyone's mind on the higher goals of improving processes, improving revenue, and, above all, treating patients right. Set a higher tone.

Collect For All It's Worth

Rabin and Campbell both worry that collections are lower than they should be - and that too many accounts go to collections when they should be collected in-house.

Improving collections, like all the other processes, depends on everyone's involvement, from the front-desk staff who gather demographic information to the billing staff who work denials.

They need to see how MyOBGYN compares to national norms from the Medical Group Management Association for OB/GYN on time in accounts receivable and net collections. Ask for their ideas about what would make it easier.

Here are some policies to consider:

• Don't set time-based benchmarks for sending accounts out. Many practices wait until 120 days to send an account to collections. Instead, if the very first bill gets returned by the post office, there is no forwarding address, and your billers can't find the individual, send the account to collections right away. The agencies are skilled at hunting people down. Sending a second or third bill to the same wrong address gets you nowhere.
  

• Send your second and third bills in quick succession - try sending your first two statements out within 30 to 45 days - and with increasing urgency. Don't let 120 days pass by before letting the patient know you are serious. (Go to http://www.PhysiciansPractice.com and visit the Tools section for sample letters.)
  

• Make sure your front office is sufficiently staffed and trained to boost collections by getting accurate data from the get-go. It's better to pay for an extra front-desk person than to lose more than the cost of that person's salary to subpar collections.
  

• Try to boost time-of-service collections. The practice already does preverification, so it should be able to collect nearly every copay, at least some deductibles, and all old balances. It's awkward to ask for money, so train staff so it is being done consistently. Literally give them scripts to use to politely get copays from patients. Measure and publish results in this area, too.

All of these ideas provide a good foundation for MyOBGYN to address its turnover, patient flow, and collections issues. But just as you need to get patients' buy-in and ask their thoughts to get them to stick to a treatment plan, all the policies and suggestions in the world won't help without physician leadership and staff participation.

Pamela Moore, PhD, CPC, is senior editor for Physicians Practice. She has been writing for physicians on practice management topics for more than seven years, and is a recognized speaker and commentator on healthcare management. She can be reached at pmoore@physicianspractice.com.

This article originally appeared in the November/December 2005 issue of Physicians Practice.