Top Five Solutions for Better Service

"Any physician has the opportunity to lift the level of service in the practice. It's a question we physicians should ask ourselves more often: 'What can we do?'"

So says Chicago internist Henry Palmer, one of several dozen physicians and administrators I interviewed during a two-year research project.

Over the last several months, while writing this exclusive article for Physicians Practice, I have also included a portion of the journal's readers in the study, which I began in response to a new program idea from participants in my service quality workshops for medical practices. Relying on my experience in conducting depth interview and focus group research, I've sought answers to the question: "What can physicians do to improve service in their practices?"

An analysis of the qualitative data gathered during the interviewing process revealed five overarching suggestions by physicians for improving service, ranging from the process-oriented to the practical to the interpersonal. All affect the level and quality of service your patients experience, and all are endorsed by your colleagues in practices across the country.

Plan ahead

Scott Allen, patient accounts manager at Ocean Beach Hospital and Medical Clinic in Ilwaco, Wash., suggests that physicians "start with this question: 'Where does the majority of [my] revenue come from?' Then a decision that would improve service to that population would be a wise investment."

Whether your practice aims to reduce patient wait times, speed up information retrieval, or seize an opportunity to expand clinical services, participants agreed that careful planning must come first to ensure success, and ultimately, improve service. Six key planning steps emerged in the stories shared by the interviewees:

• Identify the Issue. Examining opportunities as well as problems will uncover potential areas for improvement.
• Do Your Research. Taking the time to gather and analyze all pertinent information will help you explore available options.
• Identify a Specific Plan. Before undertaking any new process or service, analyze: who will it affect and how; who will implement it and who will manage it; when and where will it start; how much will it cost in terms of money and manpower; and how long will it take to achieve return on investment (ROI) in terms of finances and improved service.
• Start Gradually. Up-front training, education, and pilot programs will help set the stage for the complete implementation.
• Work Through the Transition. Ask staff for their suggestions; offer them encouragement and appreciation throughout the transition.
• Take the Plunge. Once appropriate modifications have been made, whether to personnel, processes, or equipment, implement the change throughout the practice.

Pediatrician Stephen Mallard, public health medical officer for Eastern Health Center, part of the Jefferson County Department of Health in Birmingham, Ala., followed this six-step process when his large multispecialty organization realized that productivity and efficiency were not what they should be. Patients were experiencing long wait times for available appointments and everyone -- staff included -- was frustrated.

Mallard and his colleagues realized that implementing open access scheduling was their solution -- it would give patients the access they demanded and alleviate the staff's scheduling frustrations. In order to assess the feasibility of this idea and iron out any implementation problems, Mallard offered his pediatrics department for a three-month pilot study.

He explains, "It was important for us to try it and work out the kinks, and then we worked toward a larger implementation throughout the organization [which was completed in October 2002]."

To help them manage their regular duties as well as phase in new processes and services, staff members were involved in the planning, a fact Mallard credits for the successful transition to a template that is now 30 percent prescheduled and 70 percent same-day appointments. He also emphasizes the importance of a healthy dose of physician appreciation: "I bought a lot of donuts and hosted plenty of pizza parties," Mallard says.

Now that the transition has been made, Mallard finds that service has improved dramatically. "Wait time for appointments has decreased from an average of 46 days to the same or next day, and patients are now able to see their own doctors when they want. Also, the change has increased employee satisfaction due to the sense of ownership and accomplishment they have about the process."

Henry Palmer, of Chicago, agrees that proper planning was essential when his practice implemented an EMR/practice management system. Responding to his group's frustration about "all the paper and the resulting inefficiencies," he made sure the technology would meet their needs by visiting sites or talking with individuals who had already implemented various modules of the technology.

He added systems gradually, starting from the basic billing and scheduling modules, then incrementally adding electronic prescriptions, a lab interface, a managed-care system, and an elaborate quality care module, finishing with electronic charting capabilities and imaging  --  the last but also the most necessary module for any practice to go paperless.

This gradual implementation over a period of three to four years allowed staff to become comfortable with the technology. Even so, Palmer confides, "That first day when I started seeing patients without paper charts was very scary! I thought, 'Wow! This is not the way I am used to doing things.'" But because he planned carefully before making the change, he can now look back and say that "going paperless totally revolutionized my practice. None of us would even consider returning to the paper charts. We can serve our patients better because the immediate access to information allows us to respond quickly and appropriately to their needs."

Embrace technology

Technology can improve internal systems and enhance service by, among other things, streamlining information retrieval, simplifying writing and refilling of prescriptions, and improving patient access.

Greg Pecchia of Tustin, Calif., who has been in family practice for 20 years, says, "Five years ago we decided to purchase a practice management platform integrating clinical, financial, and document workflow within a single application. Since then the practice has become more efficient in the handling of information, like intraoffice messaging, physician-patient voice and data messaging, and document management, and the management of processes such as billing and scheduling."

The practice has also increased profitability. "As a result of reducing the square footage needed for chart storage and the office space for a billing supervisor and bookkeeping functions [now outsourced] raw overhead costs have decreased from approximately 65 percent to 50 percent or less. We also have been able to reduce our FTE from over 4 to 2.5 per physician."

Pecchia has noticed the positive impact these improved efficiencies have had on service. "Although they weren't completely aware of what actually occurred, patients used to complain about the delays and complications involved in the coordination of their care. Now, we frequently prepare the necessary documents and coordinate with other appropriate entities [insurance carriers, labs, and hospitals] while the patients are in the exam room or office, and they walk out the door with the necessary forms, contacts, educational materials, and other pertinent information. This 'real-time' capability has been praised almost universally by our patients for the improved service level we are now able to routinely deliver."

Remote accessibility to medical information during a patient emergency is another clinical and service benefit of technology. "When I am at home and receive a call from the ER, I can go to my computer and in a moment have the patient's chart right there on the screen," says Palmer. "Then I can access any information necessary, or even fax an ECG directly to the ER." Pecchia adds, "Now office clinical and support staff have 24/7 access to any component of the clinical or financial database from any registered workstation -- office, home, or remote/wireless locations."

Admittedly, cost can be a stumbling block for many physicians when it comes to implementing technology that will improve service. However, as Palmer observes, "When you see a big price tag, you have to remember that you don't pay it all at once. You borrow the money or you lease the equipment and it becomes part of your monthly operating expenses."

Chip Bounds, a partner at Berkley Family Practice in Moncks Corner, S.C., agrees, saying that the cost of the group's EMR/practice management system is outweighed by the savings and value it has brought to the practice. "First, I looked at the financial ROI by figuring the cost over three years, and it was $1,300 per doctor per month. That's a reasonable amount considering the time saved in looking for charts, phone calls to pharmacies, and so forth, and expenditure savings [approximately $126,000 per year] in salaries for staff positions we have eliminated." Bounds explains that, at the time, an outright purchase of the system would have cost approximately $170,000, but if they were buying today the price would be about one-third that amount. 
"We also experienced a dramatic clinical ROI for our diabetic patients," Bounds says. "By using Excel, I could query our database and get immediate results as to who was in control and who was not. This kind of immediate tracking just couldn't be done if we were still using paper." Bounds points to the positive results: "Because of the population disease management we have been able to establish standardized treatment protocols for this chronic disease state which lowered the patients' hemoglobin A1Cs from an average of 8.3 to a tad over 7."

Bounds also identifies a personal ROI that hits home with any practicing physician. "Because using this technology makes more efficient use of my time, instead of staying here until
7 p.m. doing paperwork, now I am out the door by 5:30 at the latest. The old way of doing things cost me time with my family, and I don't know how you put a price tag on that.

"The increased efficiency has allowed me to see three to four more patients per day," Bounds adds, "and the increased availability makes them happy while at the same time generating a little more revenue for the practice. Also, the clinical impact has pleased our diabetic patients. Now they are under control, many of them for the first time in their lives."

Expand clinical services

Clearly, technologies that help you run the operational aspects of your practice improve service in ways patients may not notice nor realize. But responding to patient demand for added clinical services shows patients you're truly attuned to their needs.

Bob Glazer, CEO of ENT and Allergy Associates of Tarrytown, N.Y., says that his practice recently obtained 11 videostroboscopes at the very reasonable price of $5,000 each per year on a three-year lease-to-buy arrangement. These instruments will allow the practice to offer diagnostic voice disorder tests in the office and will bring in a projected $350,000 in additional revenue per year.

Glazer explains, "Since videostroboscopy requires a specialized diagnostic tool with a separate CPT code, we are now able to bill for something we have not been able to bill for in the past." And from a service perspective, "Now that we can diagnose these patients in our offices we can offer them one-stop shopping, and we anticipate a positive impact on patient satisfaction."

Anne Williams, the practice administrator of Surgical Associates in Tulsa, Okla., says that patient demand has led her practice to establish a program in bariatric surgery. "After Carnie Wilson was on television talking about her surgery," Williams says, "our phones rang off the hook to see if we offered it. We didn't, so we decided to take a closer look."

One of the practice's current surgeons had stopped performing bariatric surgery in the past, frustrated because many patients did not alter their eating and exercise behaviors. So the group solicited information from the Bariatric Surgery Association and an outside consultant that revealed two characteristics of the most successful programs: pre-surgery patient education and post-surgery support.

Since August 2001, Surgical Associates has performed 145 bariatric surgeries, and they find that their comprehensive pre- and postsurgery programs not only meet their patients' service needs but they also appear to be bringing about the necessary behavioral changes.

Williams adds, "Helping these patients make this major life change has become a real motivator for my staff, so much so that they volunteer to stay after hours to provide educational sessions, clinical services, and personal encouragement."

Expanding clinical services does not have to carry a big price tag. Some practices have added services that have relied upon current staff and facilities, brought in additional revenue, and also met patient needs, such as employment physicals or drug screenings.

Scott Hayworth, president and CEO of Mount Kisco Medical Group in New York suggests three criteria to consider when adding any clinical services, large or small: "A practice should consider their current patient volume, potential reimbursement for the added services, and the profitability of the venture."

Create a learning environment

The physicians interviewed for this project agreed that it's important to educate themselves, not only in the clinical areas so essential to patient care, but also in the business of running the practice. At Glazer's practice, "We have reports, including financial statements, receivables reports, balance sheets, and production by physician, that are issued weekly, monthly, and yearly for the physicians to review on their own and in board meetings. We also do benchmarking data on clinical indicators which help the doctors look for additional diagnostic tools to better evaluate and serve our patients."

Wayne Eisman, MD, president of ENT and Allergy Associates, says, "Because we have access to vital financial information, we have the ability to make timely decisions that will give us leverage in how to proceed strategically as a practice. Patients benefit from the resulting investments, such as those in new technologies and physical plant renovations, from the moment they enter our front doors until the moment they leave."

Staying informed about what is happening among the staff is another important part of a doctor's ongoing informal education and can lead to improved service. Andy Hare, director of patient access for the University of Alabama Health Sciences Center in Birmingham, describes how his patients and his practice benefit from the doctors' participation in staff meetings.

"After our doctors were involved in front-end staff meetings, they began to code more accurately and staff became more comfortable with approaching them about any missing or invalid information. Because of this we have eliminated the backlog at check-out, thus getting our patients on their way much more quickly. We also have decreased the average daily amount of charges suspended due to edits by 89 percent." Hare continues, "Physician attendance at staff meetings also shows the employees that the doctors are interested in the issues that affect them, and that leads to happier, more patient-friendly staff."

A service-oriented practice needs to have a well-trained staff  --  beginning with an effective orientation program and extending through regular ongoing training. Physicians can play a key role in that process by supporting in-house programs delivered by experts and consultants as well as outside training sessions.

Paula Dion-Watson, business manager for Oregon Urology Specialists in Eugene, Ore., explains: "Often our doctors present a portion of the training themselves, increasing our staff's ability to be more helpful to patients. For example, one of our physicians presented on a program on vasovasotomy. Now, when patients phone with questions, like 'How many procedures has this doctor performed? Will I be awake during the procedure?' all staff have answers. Then, the patients don't have to wait for their appointments to get some of their smaller, less clinical concerns addressed."

Professional associations are good educational resources for administrators in matters that can improve both service and practice management. Some physicians interviewed recommended purchasing memberships for their administrators and sending them to conferences sponsored by groups such as the Medical Group Management Associations (MGMA) and the Professional Association of Health Care Office Managers (PAHCOM).

According to Eisman, "Bob Glazer's participation in AOA [Association of Otolaryngology Administrators] gives us a way of taking the temperature of the industry." For example, Glazer says, "The videostroboscopes at 11 of our 18 locations were leased after I learned about the technology at an annual AOA conference."

Many physicians emphasize the importance of patient education with regard to service, and several of them have prepared informational notebooks that are either given to the patients or placed in exam rooms and reception areas for them to read while waiting. Arnold Weil, MD, CEO of Non-Surgical Orthopaedic & Spine Center, P.C., in Atlanta, has taken patient education a step further -- he has dedicated a whole room to it.

The Education Center, located next to the reception area, contains posters, books, articles, and videos. Weil reports, "Now my patients can participate more actively in their treatment because they are better informed about their conditions and the available non-surgical options, and I am able to spend less time explaining concepts because patients have learned about them in the Center."

Be the role model for service

"Doctors have to set the example of how to provide service," says Bounds. Palmer agrees: "The physician sets the standard for the practice, no question about it." So let your own behavior be an example of how people -- staff and patients  -- should be treated.
Staff observe how physicians interact with one another, so the place to start setting the example is with your colleagues. "When staff see doctors treating each other with respect it sets the example for how they should work together and also how they should relate to the patients," says Hayworth.

According to many of the physicians interviewed, collegial respect means not saying negative things about your colleagues in front of staff, keeping any disagreements inside the doctors' meetings, and maintaining a cordial and friendly demeanor from physician to physician. "Thirty-four years ago when our two founding doctors began this practice, they decided that they would always have a collegial relationship and they would always treat each other fairly," says Williams, "and our 12 surgeons are still practicing that today."

Staff also notice when doctors are willing to work together in order to meet patients' needs. April Hagmeier, practice administrator for The Chester Clinic, a family practice in Chester, Ill., describes the positive impact that her physicians' collaborative resolution to problems has had on staff. "We were having coverage difficulties when our doctors took vacations. So the physicians got together and found a solution  --  when one of them is gone for a week or more, then the other doctors come in on their days off to provide coverage. This cooperative solution has set a great example for the staff to follow as well as expanding access for our patients and easing the financial pain we would otherwise suffer when a physician is away."

Being open to feedback is another way physicians can set an example for their staff; often the administrator is the best source for such information. "We [the managers and administrators] are probably the first to hear compliments, suggestions, or complaints from patients and staff -- often they won't tell the doctors but they will tell us," says Dion-Watson.

"It's not always easy for a physician to hear what administrators have to say, because sometimes the information they have to convey sounds like criticism," says William Smits, medical director of the Allergy and Asthma Center of Fort Wayne, Ind. "'You need to do something different' is not what most doctors like to hear. It's important for us to remember that it's not meant that way. Our behavior is probably having some kind of negative impact on the practice or the administrator would not bring it up."

"Physicians should be accessible and available to their administrators, and also be open to criticism and willing to change," says Weil. "The staff will observe this and follow that lead, and it will show in their dealings with patients."

Hayworth believes that physicians should serve as role models for staff when it comes to patient interactions as well. "We cannot mandate things from the staff that we are not willing to do ourselves. We should treat our patients well, because our staff will 'read us' and act in a similar fashion."

The physicians who were interviewed cited several specifics with regard to patient interactions that would set the "right tone" for staff to emulate:

• Flexibility. Be willing to understand the patient's situation and make appropriate adjustments. For example, be willing to see a patient who may be running a few minutes late.
• Listening. Don't interrupt too soon. Value what patients say, even if it isn't vital to the diagnosis.
• Respect. If the staff hears the doctor making derogatory statements about a patient, it gives them license to do the same.
• Take Time. Even if you are rushed, don't let your patients see it. Sit down and connect with them. 
•  ... But Be Time-Conscious. Don't keep patients waiting unnecessarily. Get back to them on test results in a timely manner and do whatever you can to stay on schedule.
• Solicit Questions. Answering patients' questions during the encounter saves phone time later.
• Explain Things. Patients appreciate sufficient information provided in language they can understand about what you are doing during a procedure, what you have found, and what the treatment options are. This is also a proven way to reduce risk for malpractice suits.

Smits felt that setting the example begins even closer to home: "You should treat your staff the way you would want your patients to be treated and they will mirror that behavior."

The key to the success of any plan to enhance service begins and ends with physicians themselves. The physician-generated ideas presented here are offered as a way to help you gain a clearer understanding of what you can do to create and maintain a practice where service not only lives, it thrives.

Vicky Bradford, PhD, is the president of the Bradford Company, a Denver-based training and consulting company that specializes in service quality and patient satisfaction in the medical practice setting. She can be reached via vjbradford@prodigy.net; or visit www.thebradfordco.com.

This article originally appeared in the May 2003 issue of Physicians Practice.