The Great Practice Makeover: Sweeter the Second Time

The troubles of solo family physician Roy Gondo struck a chord with lots of readers after we wrote about him last year. Considering the disorganized morass his office had become, everyone, myself included, sympathized mightily with him.

No matter how clinically capable and well-intentioned the good doctor may be, many wondered whether he’d be able to change his destructive habits, giving up control where necessary and prioritizing tasks more strategically.

One of Gondo’s biggest problems was a months-long charting backlog that threatened to engulf his Yakima, Wash., office in both paper and time-sucking work. While seeing about 20 patients a day, he was completing charts for only three or so of those visits. Contributing to this continually snowballing headache were a number of factors, including attention-diverting staffing difficulties and a propensity for random gadget-buying.

Pattern recognition

When Physicians Practice met him, Roy Gondo was moonlighting as both medical director for a prison and chief medical consultant in a psychiatric hospital - an additional workload he initially took on to supplement a beginning physician’s income.

This past spring, says his wife Angela, he made the big decision to focus on his private practice. As a result, Roy is pleased to report, “I have been better able to concentrate on the work I enjoy, which is my clinic and my loyal patient panel. In retrospect, I don’t know how I managed to perform all the functions that I did for nearly nine years!” Surely then, he now has time to keep the charting under control, right? Well …

“Maybe half he’ll finish during the patient encounter. The rest he doesn’t do until that night, or the next day, or two days later. I think it’s a habit,” says Angela. “He’ll spend a couple of hours making some sort of form, or doing something else, and [the charting is] just not a priority.”

In our original assessment, we feared that taking time off from the additional jobs or hiring a locum tenens physician to come in once a week - both fixes the Gondos had considered for allowing Roy to get caught up on the charts - would be at best stopgap solutions. Now, he says, “We have a hybrid system where my nursing staff enters data, I enter data during encounters (prescriptions, referrals, etc.), and the rest are transcribed via transcriptionist or voice software.”

I’m a little surprised to hear that this small practice took the rather extraordinary step of hiring an experienced transcriptionist to work in the office. Although a laudable effort to work with rather than against the physician’s work style, it didn’t necessarily address the root cause of the problem. “A couple of weeks ago, he was down to zero [charts],” prompting a practice-wide celebration, says Angela, “but now the count’s back up to 129. And in 15 or 20 minutes, it will go up again.”

An alternative that could improve efficiency is assigning medical scribe duties to a nonclinical staffer - this increases the chances of completing the note before a patient leaves your practice. (See the “Read More About It” box for more information.)

Roy Gondo’s transcriptionist, who puts in about 30 hours a week, also handles some front-desk and other administrative duties when she’s waiting for him to pass a pile of charts on to her. This fairly alarming reality makes an eventual slide back into the practice’s three-month lag between each patient encounter and bill submission an eminent possibility.

“We could be a model for other solo practices,” says Angela, justifiably proud of their increasingly savvy - and organized - technology deployment. “We have an integrated in-house billing and practice management system, a new server, a new phone system … .” The practice also has managed to get its e-fax software up and running, allowing direct importation of faxed information into patient charts - no printing required. Gondo did win the Qualis Health technology grant he’d been hoping for last year, too, which has helped fund some of these upgrades.

Nevertheless, Angela Gondo knows additional attention must be paid to smoothing work flows, and to tapping into Roy Gondo’s motivation. “This is his practice,” she notes, “so nobody’s going to put pressure on him” to stay on top of things.

Staff smart

Happily, many of the staffing issues that first drew Physicians Practice to Gondo’s aid have been resolved, although Angela Gondo is still obliged to spend far more hours in the practice than she’d like. Finding a qualified office manager has become a concern, as Angela says ads have produced lots of candidates with degrees but no medical office experience. She takes the requirements of her ideal manager a step further, saying she wants someone who’s worked in a small practice rather than a large multispecialty group.

What’s really important in this prospective staffer, though, is the list of characteristics Angela outlines - a willingness to roll up her sleeves and pitch in wherever needed and the ability to multitask - not where the candidate came by those skills. Don’t overlook less-obvious sources in employee searches, such as the nonclinical realm. Attitude and willingness to learn can carry more weight than specific experience. Think customer service settings, airlines, even retail. And don’t fail to ask friends and colleagues for their honest recommendations.

Roy Gondo explains that, within the parameters of the practice’s needs, he and Angela now apply these ideas to the fullest possible extent, actually creating roles specifically for certain job applicants. “We look at their past experiences, current interests, future plans - and we try to craft a position that they would find rewarding. A small practice like mine can afford to tailor job descriptions. … Being flexible has been a way to improve our odds of getting good candidates.

“We are a lot more cautious and follow up on every reference now,” he adds, saying he’s been pleasantly surprised by the candor of many of the responses they’ve received. “I believe it’s saved me a lot of grief on several occasions.”

In any case, it’s clear that the office manager search is a new item to add to the top of the priority list. And in truth, this is how most practices make changes - when an issue becomes sufficiently important in the eyes of the physician(s), hopefully before somebody reaches a breaking point. If, as the Gondos are aiming to do, you can get ahead of change and implement improvements before reaching a crisis, you’ve entered a significant new phase in the development of your practice.

In context

Roy Gondo still seems to do quite a bit of noodling with peripheral tasks, and that’s OK - if revising and re-revising his EMR templates, for example, provides him real satisfaction, and if Angela and the rest of the staff are willing and able to figure out workarounds to keep the major practice functions on track. Your preferred practice/business style may mean you’ll be happiest keeping things relatively small - and, in fact, really sweating the details.

I’m reminded of a physician who once approached me at a conference to ask, “What if I don’t want to have five clinics and a bunch of associates and $10 million a year in revenues? What if I just want to practice medicine, in my one little clinic, and make a decent living?” Make no mistake: We’re not saying that the only worthwhile practices are giant business machines. We do believe, though, in doing things the easy way - provided that it is also the smart way.

“He has changed a lot,” says Angela Gondo of her husband. “We have to give him lots of credit.” Happily, she continues, “The practice is on the right track … The huge change is that it’s much more relaxing now. Even I didn’t want to come into that environment myself every day - there was so much tension, just worrying about how the work would get done in a timely manner.”

“There will always be paperwork, no matter what. [But] there is time to catch up,” muses Roy Gondo. “However, when it comes to the kids growing up, there is urgency to spend as much time with them and give them as much love and childhood experiences to remember as possible. I want to take a week off and have a locum tenens or someone fill in for me so we can enjoy our lives as a family.” Sounds like a fantastic idea.

Laurie Hyland Robertson is a senior editor with Physicians Practice. She has been in the medical publishing field for 10 years, working editorially on both clinical and business-oriented healthcare topics. Share your fantastic ideas - or your need for a practice makeover - with her at LCHRobertson@physicianspractice.com.

This article originally appeared in the November 2007 issue of Physicians Practice.