2003 Practice of the Year

An established quality assurance program, a commitment to community education and local charities, and a dedication to providing their patients the most comprehensive care possible are just a few of the reasons that Southern Indiana Pediatrics (SIP) was voted the Grand Prize Winner of the 2003 Practice of the Year competition by our panel of judges.

Add to the mix that SIP is open seven days a week and 365 days a year - yes, even on major holidays - and you've got a practice that clearly goes the extra mile for its patients.

"The partners of this practice have determined that availability to patients is a core value," says Sandy DeWeese, chief operating officer for SIP. It's part of what the partners and employees call the "SIP Heart," a dedication to providing the children and parents in the area with medical care and education that are second to none.

The practice includes 11 pediatricians and four nurse practitioners, and books over 100,000 patient visits each year at three office locations - two in Bloomington and one in rural Bedford, Ind. The sheer volume is impressive enough before you consider some of the special circumstances associated with treating children.

"One of the big challenges is you've got two sets of patients," says James Laughlin, MD, president of SIP. "You have the child who's your patient, and then you have the parent. You have to have the ability to communicate with the child as well as the parent. That makes us unique, because part of the success ... [in] healthcare and good relations is making a connection with both the child and the parent."

Center of the community

From the beginning, SIP has seen itself as more than just a medical practice.

"We've actually had a strategic plan that we've revised every year or two since we started," says Laughlin. "One of the aspects of our strategic plan was that we want to become the place where people come in our service area for pediatric information and advice. In order for us to do that, we have to make ourselves available as a source of information and education."

In that role, the practice and its partners work with the Riley Hospital for Children in Indianapolis to provide continuing medical education on pediatric- or nursery-related topics to pediatric subspecialists, family practitioners, nurses, and other local healthcare workers. SIP's annual CME conference, now in its fourth year, has grown steadily in size each year and attracts providers across the state. SIP physicians and nurses also teach community education classes on child and adolescent health and safety at the YMCA and through the local school system.

When they are not involved in community outreach efforts, many SIP partners and employees are engaged in charity work through the SIP Foundation. In addition to donations to a local children's science museum and the Bloomington Hospital Foundation, SIP has helped raise money for the Monroe County School System to purchase milk vending machines to replace soda machines in school cafeterias, provided bicycle helmets at cost or for free to local families with children, and distributed information to local driver's education companies on safety tips for teenage drivers - all of which have helped to raise the profile of Southern Indiana Pediatrics as the premier center for comprehensive childcare and education.

Those efforts are sustained within the practice as well. To provide one-stop care to its patients, SIP contracts with a pediatric specialists in cardiology, urology, pediatric surgery, and neurology to practice on-site as needed.

"Our practice is big enough, and we service a big enough geographic area, that it basically becomes a convenience factor for patients to just come to our office for consultations and appointments or follow-ups from surgery," says Laughlin.

SIP collects demographic and insurance information for the specialists, provides nursing support, and collects a fee based on the time and space each specialist uses. "It becomes cost-effective for the specialist to come here and provide that follow-up or consultation locally," says Laughlin.

It also allows SIP to provide its patients with a high level of consistent care. Patient records are all kept in one place, which allows both primary-care physicians and specialists immediate access to the most recent information and to each other. Hallway consultations between pediatricians and specialists are one of the perks of this arrangement, according to Laughlin.

Creating a one-stop practice for both primary and specialty care isn't just good for patients, it's good for business. "We don't look at this necessarily as a revenue generating thing for us, and I don't think the specialists look at the visit itself as a revenue generator for them, but the business they get because of that consultation - and most of it ends up with the surgical specialties - is good," says Laughlin.

Always open

Though some practices simply pay lip service to patient access - and many make concerted efforts to achieve it - Southern Indiana Pediatrics embodies it. Its offices are open seven days a week, 365 days a year. Even on major holidays, there is always a physician available for appointments. Though this may seem incredible to other practices, for SIP it's an arrangement born of necessity.

"We always had office hours Saturday morning and would often have to come back into our office and see patients later in the day. Sunday, I ended up being open in the morning just to try to take care of questions and calls that came in," explains Laughlin. "I tried to be gone in the afternoon, but when you're covering for a number of other doctors you just can't quite get away."

In pediatrics, sick visits take on a particular sense of urgency. Not only do parents worry about their children, they also have to worry about taking time off from work or other commitments to bring sick children to the doctor. For SIP, it was a question of balancing the needs of their patients with the needs of their employees.

"I always tell my partners and employees that we have to look at obstacles as opportunities," says Laughlin. "When the demands on pediatricians and physicians have increased so much that we basically have to be available 24 hours a day, seven days a week, we need to find a way to do that but still preserve our sanity and do the right thing for patients."

SIP's solution was to eliminate call altogether. With regular office hours during weekdays and weekends, and an urgent care clinic that opens for evening hours, physicians provide ample opportunity for patients to be seen. "Our evening and weekend hours are strictly a convenience for the patients, and a secondary convenience for us so that we can set up a schedule for our physicians. They know they're going to work this block of time on Saturday," Laughlin says.

Without call, physicians are able to preserve some semblance of a normal life outside the practice. They know the exact times they'll be working and can plan accordingly. "When you're finished seeing patients, you're able to go home and rest that evening because you're not going to be called," says Sheryl King, MD, an SIP partner. That's especially helpful to physicians like King, who has five children.

Although patient satisfaction is the primary reason for SIP's extended hours, Laughlin sees other benefits as well. "It spreads out our overhead over that many more hours, so it kind of helps our bottom line," he notes.

As if day, evening, weekend, and holiday hours weren't enough, SIP guarantees same-day visits for sick patients. "The line that we often use is 'Children don't get sick on schedule,'" says DeWeese. A parent who can't get an appointment for three or four days may never make an appointment at all - or, worse, might make an appointment somewhere else. SIP wants to make sure all of its children are seen as soon as possible, although it's not always easy.
"We just work as long as we need to," Laughlin says with a laugh. "We try to provide open slots in our schedule every day so that we can accommodate those patients. We never start the day with no openings."

The telephone provides another point of patient access. Phone calls are answered beginning at 7 a.m. - an hour before the offices open for business; parents can continue to call until 10 p.m., two hours after the offices have closed. For after-hours coverage, SIP contracts with a local hospital to provide pediatric nurse phone triage.

Who's answering the practice phones morning and night? Nurses. SIP physicians have developed a set of protocols that help their nurses answer basic care questions and provide immediate feedback to parents. If parents want to book appointments, nurses handle that duty as well. DeWeese admits this may be a more expensive approach than other practices take, but she believes it's money well spent. Not only does it prevent parents from having to recite a list of symptoms to several different people, it also builds trust between parents and nurses.

"[They] know they can call in anytime during the day and ... they're going to get their question answered by someone who is a professional and qualified to answer those questions," says Laughlin.
It also saves physicians time. "I can take one call and be tied up for 20 or 30 minutes, and basically that's my hour," says King. But with nurses manning the phones, King is free to concentrate on patients who already have appointments.

And SIP's telephone triage might actually save money. "It's one of the things that we think makes this quite a deal because [physicians] don't get paid for [phone time]," says Laughlin. "On the other hand, it does save the patients and insurance providers quite a bit of money when you can take care of problems on the phone that they'd otherwise have to come in for."

Staff that fit

With three separate offices, DeWeese feels it's important to make sure that everyone who works for the practice fully understands and accepts its patient-centered values before they begin working.

"We've worked hard on the orientation program to make sure there's a consistent feel, especially when you have more than one location," says DeWeese. "It's not only what information is conveyed, it's the way in which that information is conveyed. Having that face to the community is very important to us."

In the past year, SIP has spent time looking at how they orient clerical staff. "People at the front desk are the first face that parents and children see when they come into the office. We care how those people are treated and greeted and how we're collecting information," says DeWeese.

Once a good fit between the staff and practice is established, they build on it: SIP tends to promote nonclinical staff from within the practice.

"When I started at the practice, I started as a receptionist. I know what is involved in that job. Each of my billing staff members started as receptionists. So they understand what that job entails, and then they were kind of groomed into the billing department," says Tommi Dukes, health information manager.

As a result, the "SIP heart" is as evident between employees as it is in the practice's core values. "We are just like a close-knit family here at SIP. We're a really good team, and the doctors are really supportive," says Mary Ann Gardner, LPN, a billing representative who also works part-time as a nurse for the practice.

Self-assessment and improvement

In an effort to constantly improve as a practice, SIP has implemented its own quality assurance program. Audit tools are developed based on standards of care and other criteria; a select group then pulls charts from each physician and compiles both individual and comparative data.

"The question that drives the topic is, 'Are there areas where we can improve the care to our children?'" DeWeese says. "We identify those areas and discuss where we might have the greatest impact on care." In the past, the practice has reviewed data on radiology overreads, the diagnosis and treatment of ADHD patients, and the appropriate use of antibiotics. "When you do something like this and you pull the data out and you see that you're doing a great job with, say, radiation overreads, that can be rewarding," says DeWeese.

The practice also performs an annual audit of its documentation and coding to check for compliance. It also breaks down productivity indicators - volume of visits, average charges, revenue per visit, expenses, overhead percentage - by individual physician and reports these numbers back to the partners.

DeWeese stresses that this is a group effort, one to which the partners are dedicated. "A key component for this working is a high level of trust among the providers," she says. "Our quality improvement is in no way punitive. It's intended to say, 'Let's look at this ourselves and see how we can be better.'"

The practice also conducts regular patient satisfaction surveys, which routinely score over 90 percent on questions having to do with practice responsiveness and provision of information. DeWeese also used to track patient wait periods, but now she prefers to measure how long patients perceive their wait time. "Because it doesn't really matter what the clock says, does it?" she points out. "It's how long they feel they waited."

All of this is part of Southern Indiana Pediatrics' strategic plan, which DeWeese uses in making day-to-day decisions. The practice outlines operational, provider planning, and financial goals they want to accomplish in the next year, two years, and five years, and revisits and revises it every year. "This is a working document," she says. "The strategic plan is on my desk 100 percent of the time."

Collections count

Just as it does in other areas, SIP audits its billing and collections department and compares itself to the national average. When it discovered two years ago that its rate for collections within 60 days was only 58 percent - in the average range for most practices - the practice decided to take action.

"We involved our billing staff and asked what was slowing us down," says DeWeese. "What were some things we could do, improvements we could make, to really make this be more efficient."

After changing collection policies and the number of times per week it submitted electronic claims, SIP also decided to provide incentives for collection. For every quarter that the practice's collection rate stays over 65 percent, billing staff is paid a bonus. According to DeWeese, that's made all the difference.

"This morning one of our billing staff just came down to tell us she'd like to come in on Saturday and do some extra work," DeWeese says. "They're self-motivated by reaching these goals." The incentive plan has been good news for the practice as well. After choosing percentage of dollars collected within 60 days as its benchmark, the practice has increased that figure to 71 percent, up from 62 percent.

The practice has spent time cleaning up its claims, making sure that all information - from a patient's insurance to the physician's coding - is entered correctly into the system. "Our practice is 36 percent Medicaid, so doing things correctly is absolutely critical for us," says DeWeese. The practice's two certified professional coders help the physicians, nurses, and clerical staff with coding education, while the billing staff proofs claims before submission.

Generating clean claims from the outset has made a big difference, according to Dukes. "We used to have rejections from Medicaid 20 pages long. When we went to clean claims, it's now eight pages or less."

"We can't collect what we're due if we make mistakes," adds Laughlin.

While the self-audits, the weekend work, and the charity involvement all add to the effort involved in running a large, multisite pediatric practice, the partners and staff at SIP take on these tasks happily. "We really see tangible results in our community, and the physicians that work in this practice, and the NPs and the staff - they love doing this," says DeWeese. "You can feel that in everything they do."

Robert Anthony, managing editor, special projects, for Physicians Practice, can be reached at ranthony@physicianspractice.com.

This article originally appeared in the November/December 2003 issue of Physicians Practice.

Our Regional Winners

Western Region
Shepherd Eye Center
Las Vegas, Nev.
Practice type: Ophthalmology
Established: 1968
Physicians: 8
Employees: 100
Patients: 50,000
Locations: 3 clinics, 1 surgical center
Web site: www.shepherdeye.com In hindsight, John Shepherd, MD, regrets allowing his successful practice to be acquired by a large management firm in 1996. It was a popular trend at the time, but "after that, we never had control of our finances," he says. "The financial information was inaccurate, and we had no idea what the real financial status was."
By the time he and his partners reacquired the practice from the now-defunct management company, it was in trouble: Overhead was too high by 20 percent, the practice was overstaffed by some 15 percent, and its sinking laser surgery center was causing a drag on revenue. "We had to make some drastic changes," Shepherd recalls.
Among them: it assigned a "problem area" to each owner-physician and began holding weekly management meetings to discuss progress. It also implemented cost-saving technologies, including an electronic medical record and practice management system. As a result, the practice saves more than $52,000 a year, including the salary of one office assistant. For example, it saves 10 hours a week by printing medical records for patients and referring physicians straight from the electronic document, rather than pulling the chart, copying it, and refiling it.
But with all the changes Shepherd Eye Center has made, its founding philosophies of patient service and positive staff relations remain. Shepherd and his partners believe a happy staff and happy patients are two sides of the same coin. "They're on the front line: patients have contact with staff a lot more than they do with us physicians," says partner Steven Montgomery. So the practice works hard to address employee concerns about professional development and flexible scheduling.
The effort to keep staff happy as a way of keeping patients happy appears to be working: patient satisfaction survey scores hover around 98 percent.
Such flexibility for staff can be expensive, says practice administrator Christina Kennelley, "but certainly not as expensive as hiring and training a new employee." And happy employees are loath to quit, even though raises are modest. "We have several employees who have been working here for 20 years, and others who've been here for over 10 years," says partner Steven Hanson.

Southwest Region
Southeast Texas Medical Associates
Beaumont, Texas
Practice type: Multidisciplinary
Established: 1995
Physicians: 19
Employees: 175
Patients: up to 800 patients per day
in clinic, home health, physical therapy,
nursing home, hospital, and hospice care
Locations: 3
Web site: www.setma.com
When James L. Holly, MD, and his partners launched Southeast Texas Medical Associates, or SETMA, by combining three smaller groups, they started with four physicians and 23 employees. Today, the group has 34 clinical providers (including 15 nonphysicians) and 300 employees, serving virtually every medical need of the population of Beaumont, about 80 miles east of Houston, from pediatrics to a nursing home practice.
"We also run a moderately complex reference laboratory and we do lab work for 22 nursing homes and 100 other physicians," says Holly. "And we operate a home health agency, a physical therapy department, a hospice mobile X-ray, and we have a very large hospital practice. We manage about 60 percent of the emergency care in this community. What we're trying to do is build an integrated network that works in an integrated fashion."
To do it, SETMA has gone almost entirely digital. Its NextGen EMR and practice management systems allow the practice to incorporate disease-state management tools to "make it easier to do things right [clinically]," says Holly, while electronic documentation allows the practice to prove it did everything right. For that reason, diabetic patients in Beaumont receive the same standard of care that they would in, say, New York City, because the EMR reminds providers of the standards of care.
Technology has also offered SETMA a host of practice management and financial advantages, Holly says, noting hundreds of thousands of dollars saved over the years in transcription and staff costs associated with paper charts, administrative supplies, reduced time on the phone, and substantial increases in collections and charge capture. Transcription costs alone have been reduced by $340,000 a year, collections have increased by more than $1.2 million annually, and coding and charge capture are up 20 percent.
"You can [manage a practice] without [technology] systems, no question about it - people have done it," he says. "But ... you can't be aware of what you're doing and really control what you're doing without the systems."

Southeast Region
A Woman's View
Hickory, N.C.
Practice type: Gynecology and
internal medicine
Established: 1996
Physicians: 2
Employees: 27
Patients: 16,000
Locations: 1
Web site: www.awomansview.com

Soon after John Lovin became the administrator for his wife's gynecology practice a few years ago, he saw that some processes needed improving. And as a former fast food restaurant manager where speed and customer service are crucial, Lovin was in his element.
The way the practice evaluates new technologies is one example of how Lovin put his experience to work - and the staff and physicians do their part to make the process a success.
"[My wife] keeps up with medical research, new procedures, and new technologies," says Lovin. But the practice doesn't jump at every technological advancement that comes along; it makes deliberate decisions about adding new equipment that will ultimately benefit patients. If there is a financial benefit for the practice, so much the better.
"Two easy decisions were [adding] ultrasound and DEXA [bone density scanning]," says Lovin. "We were able to call the payers and find out how much they would pay us. We knew how much it would be to lease the machine and pay a technician. We also knew how many we were referring out. It made financial sense as well as sense for our patients."
Patients save time and may get a quicker diagnosis than they would by making an extra trip to a lab. "We are doing 12 to 14 [DEXA scans] a week," says Lovin. "Seventy-eight percent of those either have mild or severe bone loss. That, to me, is why we are here - to find that kind of problem."
The practice has also worked hard at improving patient access and collections. It hired new staff, including one dedicated to answering phones and another to auditing superbills. In addition, it has doubled the number of phone lines open to patients.
Despite making these strides, members of the practice know their work isn't done. "I think the mistake many offices make, particularly doctors, is they get to a point where everything is running smoothly and they think they've got it fixed forever," says Lovin. "There's no silver bullet. It's not a drain, it's more like plugging a colander - a lot of little things are leaking away. Likewise, a lot of little things added together make a difference in our revenues and doing more things for our patients and employees."

Central Region
The Asthma and Allergy Center
Fort Wayne, Ind.
Practice type: Asthma and allergy
Established: 1997
Physicians: 1
Employees: 47
Patients: 10,000
Locations: 3
Web site: www.allergyasthmacenter.com

Once again, our judges gave high marks to The Allergy and Asthma Center, which was the Grand Prize Winner of last year's Practice of the Year competition.
The practice has maintained excellence in a number of areas, including word-of-mouth referrals (75 percent of existing patients refer new patients); productivity (up to 119 patients per day); clinics dedicated to same-day patients and headache/sinus patients; and a commitment to quality in hiring, as its team of 20 registered nurses proves.
Since last year, the practice has added a North Satellite Clinic located in the fastest-growing area of Fort Wayne, and has developed an online virtual tour of its facilities.
"We had a large number of patients on that side of the city who had been driving significant distances to see us," says director William Smits, MD.
The North Satellite Clinic saves patients, on average, a 30-minute drive they would otherwise have to make to get to the main office, and offers many of the same amenities, including nine patient rooms, a shot room, and a large waiting room with a separate pediatric waiting area. Two of the exam rooms are designated as "family rooms" with more space, additional chairs, play tables, TV, and videos.
Smits remains the only physician at the practice. Typically, he sees patients three days a week at the main office, one day a week at the satellite, and at a third clinic in neighboring Auburn, Ind., one morning every other week. The two nurse practitioners, whom Smits oversees, have similar schedules.
How is it possible that a single physician at the helm of such a large practice can provide ongoing, high-quality care? "Because of our excellent patient education efforts, patients primarily are able to achieve health and well-being on their own with the guidance of our office," says Smits. "And with our advanced information systems, we are able to readily access their medical records 24 hours a day."
To respond to physician requests to visit the practice, there is now an online educational course and virtual tour of its facilities. For more information on the virtual tour, please contact Jennifer Wright at (260) 432-5005.

Northeast Region
Physicians Health Alliance, Inc.
Dunmore, Pa.
Practice type: Multispecialty
Established: 1996
Physicians: 27
Employees: 115
Patients: 65,000
Locations: 9
Web site: www.phaweb.org
With 11 sites throughout Lackawanna County, Pa., including OB/GYN, pediatrics, family medicine, and internal medicine offices, it would seem the people at the helm of Physicians Health Alliance (PHA) have enough to keep them busy. Simply maintaining day-to-day business operations and ensuring high levels of care for such a large system is challenge enough - and it's one that PHA has met. In fact, the practice has been commended for excellence by the Medical Group Management Association as well as local health plans before being named a regional Practice of the Year winner.
But being an efficiently run, high-quality practice is not enough. PHA's First Impressions Customer Service Program rewards staff members for a job well done and collects patient feedback that helps guide operational decisions.
"We leave forms in the waiting room or checkout area that allows the patient ... to recognize one of the employees who has helped them," says operations manager Joanne Schmidt. "In our last quarter we had 70 recognitions and we only have about 110 support staff. That really says a lot."
Staff involvement in decisions is critical to ensuring that any operational changes make sense for individual offices and the organization as a whole. Patients, too, play an important role in decision-making. In 2001, the Patient Advocacy Group (PAG) was formed, including 49 patient-members who were recommended by their physicians to participate.
PAG members have offered feedback on issues ranging from how many telephone menu options should be included on an office answering machine to patient impressions of the malpractice crisis.
On the latter issue patient activity proved especially helpful. PHA developed a letter that patients could send to state legislators about the malpractice situation in Pennsylvania.
According to CEO Karen Murphy, "[Patients] identified the way we should communicate about the malpractice crisis...and that letter was eventually adopted by many area practices and hospitals to educate people about what the malpractice crisis is and isn't." Overall, Murphy adds, "What has been most helpful is listening at the level where the people do the work."