Study of Safety Net
Operational
p
and
Organizational Efficiencies
Peter D. Jacobson,, JD,, MPH
Judith Calhoun, Ph.D., and Valerie Myers, Ph.D.
AcademyHealth Annual Meeting
28 June 2010
Methods
• Research questions
– Operational
p
efficiencies
– Organizational models
• Qualitative
Q lit ti interviews
i t i
– Components of an efficient clinic
– Strengths/challenges
– Strategies for improving efficiencies
– How organized
• Data
D
collection
ll i
Sample
p
N=29
Sites
N 29 Sit
FQHC -14
14
Free Clinic -12
Hybrid
y
-3
Interviews
by
I t
i
b Clinic
Cli i Type
T
H b id
Hybrid
10
Free
Clinic
FQHC
52
34
• CEO/Executive**
• Medical Director/Clinic Director**
• Nurses/Direct Worker
• Clerical/Reception
• Various Volunteers
**Indicates that this role was interviewed at each site
N= 96 Interviews
What we asked about. . .
Administration
Medical &
P
Preventive
ti Care
C
Enabling
g Services
Components of an Efficient Clinic
• Staff
– Leadership
p
– Transparency
• Open communication
• Clear expectations
– Requisite education and training
– Reliability and dedication
Components of an Efficient Clinic
• Aligned vision
– Clinic mission is consistent throughout staff
• Partnerships
– With local hospitals
hospitals, physicians for referrals
• Processes
– Appointment scheduling
– Patient flow
– Established policies/procedures
• Quality of care
What works most efficiently?
y
Common Strengths
31
Appointment scheduling
It Varies. . . 2
Medical Care
&
P
ti
Preventive
Services
115
Data collection
18
Billing
18
16
Patient wait time
Administration
142
Referrals
Record keeping
Enabling
Services 90
All work equally 2
14
12
What works most efficiently?
y
Common Strengths
It Varies. . . 2
33
Patient Flow
20
Coordination of Care
13
Referrals
Translation/Interpretation
Insurance eligibility…
Enabling
Services 90
8
15
Patient education
16
Outreach
16
Case management
Medical Care &
Preventive
S
Services
i
115 Administration
142
20
Continuity of Care
All work equally 2
20
Most Efficiently
y byy Clinic Type
yp
47
50
45
40
35
30
25
20
15
10
5
0
40
FQHC
42
19
12
Administration
Hybrid
16
FQHC
41
FQHC
36
Medical &
preventive
S i
Services
Free Clinic
11
Enabling Services
FQHC
What contributes to efficiencies?
Structure Culture
12
3
Process
68
Patient
P
ti t &
Community
Factors
23
IOM Aims
16
Administratiion
54
Human
Resources
102
Clinicians
Committed Staff
Staff Knowledge
Staff Training
Leadership
Teamwork
Volunteers
Do you measure efficiency?
Medical & Preventive Care
19
Flow
Referrals
Multi-faceted visits
Enabling Services
3
Administration
34
Internal Reports
pp
Appointments
Patient Feedback
What key challenges do you face?
Common Challenges
Paper Records
Rx
Patient flow
Transportation
Appointment…
Patient Wait Time
Continuity
y of Care
Information System
Referrals
Human
Resources
94
11
11
12
Political
8
13
21
Structural
317
21
21
25
43
IT system
system’s
s impact on efficiency
•
•
•
•
•
•
•
•
•
Slow processes
No computer system
No reports
Time could be spent on other things
Multiple systems
Can’t communicate w/ community
Barriers to data sharing
Technical challenges
Lack of EMR integration
Strengths of the computer system
34
14
9
7
Functionality
1
1
1
Human Factors
FQHC
0
0
Training
Free Clinic
Hybrid
What key challenges do you face?
Political
8
Human
Reso rces
Resources
94
Common Challenges
53
Staffing
11
Volunteers
Communication
8
Structural
317
Key
y Challenges
g by
y Clinic Type
yp
80
80
77
70
60
50
52
40
30
30
20
10
7
17
3
3
2
2
5
0
HR
Political
Hybrid
Structural
Free Clinic
Symbolic
FQHC
0
What could be done to improve
efficiencies?
Human
Resources 70
Process
62
Recruit
R
it Providers
P
id
Access to Specialists
Patient Educators
Staff Training
Staff Communication
Patient and
C
Community
it
Factors
8
Plant
35
Appointment Scheduling
Healthcare Reform
Transportation
IInformation
f
ti System
S t
Improved Layout
More Resources
Needed Improvements by Clinic Type
35
31
30
24
25
19
20
16
14 14
15
7
10
4
4
4
5
3
0
0
Processes
Plant
FQHC
People
Free Clinic
Patient
Factors
Hybrid
Preliminary Conclusions
• Far more challenges mentioned than efficiencies
• Structural
S
challenges most prevalent
• Free Clinics face the greatest hurdles in mission
critical areas: medical care, staffing, IT
• FQHCs
Q
fare better relative to IT and HR
• Substantial variation and lack of sharing best
practices (e.g.,
(e g appointment scheduling works
well for some, but a nightmare for others)
Preliminary Conclusions
• Administration works most efficiently
– Low numbers and long list of efficiencies
– Considerable variation in what works
– Little commonality in strengths across clini
• FQHCs
FQHC mentioned
ti
d efficient
ffi i t medical
di l care
twice as frequently as free clinics.