Teams
Operational, Clinical, and Teamwork
Overview
Mike Davies, MD FACP
Mark Murray and Associates
Burning Questions
• How many support staff are needed in our
practice?
– How many will improve production?
– How many will improve outcomes?
– How many do other practices have?
• If we decide to hire, what professional types of
person is best?
– RN/LPN/MA/Other?
– Social worker, case manager, other?
• Other burning questions?
Related Questions
• What is our current team number and
composition?
• Are we clear about our mission and goals?
• Are we working together as smoothly and
efficiently as we could?
• Are we providing the right care for our
patients?
• Is working with this team any fun?
• Do we get the job done well?
Let’s get to the burning questions..
• What kind? (Who ARE support staff?)
• How many?
•
•
•
•
US Government (excellent data)
US Military (excellent data)
US Private Practice (survey data – fair data)
US HMO (excellent data)
Who are Support Staff?
•
•
•
•
•
Medical Clerks
RN’s
LPN’s
Medical Assistants
Health Technicians
• Pharmacists
(including PharmD’s)?
• Case Managers?
• Social Workers?
• Billing
• Others?
What are Support Staff Duties?
• Check in/out patients & Schedule
• Example Nursing Duties
– VS; Prevention & Chronic Disease screening,
information, care
– Nursing evaluations; injections; office
procedures
• Independent Follow-up clinics
– BP; DM; Cholesterol; Anticoagulation
• Telephone calls
Are These Support Staff Duties?
•
•
•
•
Phlebotomy
Billing (and other business office functions)
Support for specialty or mental health clinics
Other professionals not working directly with
providers – i.e. dieticians, social workers
• Pharmacy prescription filling duties
Team Composition and Number
Large Govt. Healthcare US
• Adult Primary Care Tending toward Geriatric
Practice
• 1100 Sites of Care
• ~4300 Providers
– 2864 MD
– 1393 Non-MD Providers (NP, PA)
• ~8,200 Support Staff FTEE
• Pro-Rated to time spent in clinic managing the
panel of assigned patients
Bottom Line Average US Govt.
Healthcare
RN/Provider
0.6
LPN/Provider
0.5
Clerk/Provider
0.6
MA/Provider
0.2
Pharm/Provider
0.15
Support/Provider
2.1
US Military
• US Military Primary Care = 2.7-2.8
support staff/provider FTEE
– 0.5 RN
– 1.8 LPN
– 0.5 Clerk
FTEE
MGMA
Safety Net
Provider**
RN
LVN
MA
Med.
Receptioinist
Case Manager
1
0.51
0.63
0.53
0.85
1**
0.3
0
1
1
0
Clinical Support 1.67
Staff/FTEE Pro.
Medical Record 0.4
Gen. Admin
0.25
2.52/Provider
FTEE
0.3
1.6
0.3
0.17
2.6/Provider
FTEE
MGMA
Specialty
RN
LPN
NA
Clerk
Total Ratio
Multi-Specialty
0.4
0.6
0.9
0.4
2.3
Medicine Single Specialty
0.6
0.5
0.9
0.4
2.4
Surgery Single Specialty
0.4
0.6
0.9
0.4
2.3
Cardiology
0.4
0.4
0.6
0.6
2
OB/GYN
0.5
0.9
0.9
0.7
3
0
0
1
0.2
1.2
Psychiatry
HMO Team Composition
FTEE
6
2.5
11.5
3
0.5
1.0
1.0
0.5
Team Role
Physician
Nurse Practitioner
Medical Assistant/Support Staff
RN/Extended Role LVN
Exempt Manager
Behavior Health Med Specialist
Health Educator
Physical Therapist
2.8/FTEE
Overall
Team Composition and Number
Summary
• Large Govt. US = 2.1 staff/PCP
– (RN, LPN, Clerk, Pharmacist)
• MGMA = 2.52
– (RN, LVN, MA, Receptionist)
• Safety Net = 2.6
– (RN, MA, Receptionist, Case Mgr.)
• US Military = 2.7-2.8
– (RN, LPN, Clerk)
• US HMO = 2.8 staff/PCP
– (RN, LVN, MA)
Productivity
What Is the Right Number?
# On Team
Advanced Access
Support Staff per Provider
3.18 baseline
2.69
Nov 1998
Jan 2000
Wisconsin F.P. Group
Who?
RN Team Member
Fee for Service Capitated
Workload
(Burnout)
Doc Visit #
Less
Less
Less
Less
Intensity of Doc Less
Visit
Net Revenue
Less (Unless
replaced)
Clinical Care
Better
Less
More
Better
LPN Team Member
Fee for Service Capitated
Workload
(Burnout)
Doc Visit #
Less
Less
No Change
No Change
Intensity of Visit Same or Less
Same or Less
Net Revenue
Same
Clinical Care
Better
Same or
Slightly more
Better
RN/LPN Comparison
RN
Fee for
Service
Capitated
LVN
Fee for
Service
Capitated
Workload
(Burnout)
Less
Less
Workload
(Burnout)
Less
Less
Doc Visit
#
Less
Less
Doc Visit #
No Change
No Change
Intensity
of Doc
Visit
Less
Less
Intensity of
Visit
Same or
Less
Same or
Less
Net
Revenue
Less
(Unless
replaced)
More
Net
Revenue
Same
Same or
Slightly
more
Clinical
Care
Better
Better
Clinical
Care
Better
Better
Why Choose RN Based Team?
• If you are:
– Thinking of moving to Alternative Pay
– Have so much work you can’t possibly do it
– Want to improve clinical care
Now let’s step back….
What is the big picture here?
What is a Care Team?
An integrated group of professional and
clerical staff whose processes and skills
enable them to care for the needs of a
patient population over time.
What is a Care Team?
• Cares for a defined population of patients
• Measures process and outcomes for feedforward and feedback
• Matches the activities to customer
demand (uses the data to improve
individual and population care)
Batalden, Nelson, et al. Continually improving the health and value of
health care for a population of patients; the panel management
process. Quality Management in Health Care, 1997, 5 (3). 41-51
Total number of
patients
Provider initiated
returns (Internal
Demand)
Patient Demographics
Top 10 Diagnosis
Daily walk-ins (External
Demand)
Pt. Psychosocial and
Cultural needs
Population
Seasonal Variation
High Utilizers
Daily Phone Calls
Self Care
Rx refill habits
Team (2.5X FTEE)
Reception
Nurse
Provider
Capacity
Demand
Panel Size 2000
66 have Diabetes
360 Patients are
Over 65
Team (2.5x FTEE)
113 have Asthma
60 Patients had
more than 10 Office
Visits Last Year
Reception
Nurse
Provider
248 have Arthritis
130 are Clinically
Depressed
228 have
Hypertension
160 have Heart
Disease
39% of Capacity is Physician Time
39% of Capacity is MA Time
22% of Capacity is RN Time
Basic Team Duties
• Clinical – WHAT to do
– What are the main population needs?
– What protocols and guidelines do we need?
– What is the work?
• Operational – HOW to do it.
– Process mapping and redesign
– Space/staff use and redesign
– Who will do the work?
• How “good” is the overall teamwork?
– Putting it all together
Operational and Clinical Teams
Clinical Teams: What to do?
Far from agreement on
WHAT to do (what
prevention and chronic
disease guidelines to
implement)
XX
Far from agreement on
HOW to do it (how to
implement guidelines, how
to support provider’s
efficiency)
Close to Agreement
Operational Teams: How to do it?
XX
Operational Teams
This is about efficiency, reliability,
and safety
Flow Through the Office
Check-in to Nurse
Dr. in to Dr. out
Nurse to Room
Check-out to leave
Synchronization
Point
System
How Processes Support Flow
1
1
1
1
Process
Process
Process
Process
Check-in to Nurse
Dr. in to Dr. out
Check-out to leave
Nurse to Room
1
1
Process
Process
1
1
1
Process
Process
Process
Process
What are Some Clinic
Processes?






documentation
medication refills
lab review
messages
referrals
forms management
How Tasks Support Processes
Specialist Referral Process
Physician orders
consult
4 minutes
Tasks
Make Appointment
Clerk calls to
make appointment
5 minutes
Clerk gives appointment
reminder and directions
to patient
Check-in to Nurse
Dr. in to Dr. out
Nurse to Room
Check-out to leave
Task
How Tasks Support Processes
Specialist Referral Process:
Physician orders
consult
Task: Call to make
appointment
4 minutes
Clerk calls to
make appointment
Task: Give directions
for specialist
5 minutes
Clerk gives appointment
reminder and directions
to patient
Task
Provider Roles (continuum)…
• MD with non-consistent nurse and
clerical staffing
• MD with consistent nurse staffing,
but inconsistent clerical staff
• MD with consistent nurse and
clerical staffing
• Group of providers with consistent
RN, MA, and clerical staff
Better!
Clerical Staff Roles: (continuum)
• Scheduler at front desk or in central
area
• Schedules and takes messages for
many
• Scheduler accountable to a group of
providers
• Scheduler actually co-located with the
providers and patients they support
Better!
Nursing Roles: (Continuum)
• Phone calls, rooming, paperwork,
triage, scheduling
• Nurse offers advice over the phone or
through e-mail
• Nurse manages populations of
patients
Better!
What are the attributes of a
Care Team?
• Proactive vs. reactive
• Communicative vs. isolated
• Accountable to each other, and to the
patient
• Uses measures for feedback
• Delivers high quality chronic, acute, and
preventive care
Attributes continued…….
• Cross-trained versus territorial
• Integrated versus separated
• Continuous flow versus flow based on
urgency
• All staff work to highest level of training,
experience, and licensure
Flow Through the Office
Clinical Teams
This is about doing the right thing
right!
Clinical Teams
• Refers to the “what” we provide for our
patients
• Depends on disease burden and evidence
• Good clinical teams use every team
member to the greatest extent of their
license
Panel Size 2000
66 have Diabetes
360 Patients are
Over 65
113 have Asthma
60 Patients had
more than 10 Office
Visits Last Year
248 have Arthritis
130 are Clinically
Depressed
228 have
Hypertension
160 have Heart
Disease
ICD 9
Diagnosis
401
250
272
465
V70
Essential Hypertension
Diabetes Mellitus
Disorders of Lipid Metabolism
Upper Resp. Infection….
General Medical Exam
780
473
724
462
477
General Symptoms
Chronic Sinusitis
….Back Disorders…
Acute Pharyngitis
Allergic Rhinitis
Chronic Dz Clinical Goals
Diagnosis
HTN
DM Hgb A1c
DM Foot
DM Eye
DM Lipids
CVD Lipids
MDD New Meds
CHF Weight
CAP - Culture
Protocol? Our Outcomes Benchmark
Chronic Dz Clinical Goals
Diagnosis
Protocol? Our Outcomes Benchmark
HTN
75%<140/90
DM Hgb A1c
DM Eye
<12% > 9
85%
80%
DM Lipids
>80% LDL<120
CVD Lipids
<20% LDL>100
MDD New Meds
>77%
>95%
92%
DM Foot
CHF Weight
CAP - Culture
Prevention Clinical Goals
Prevention Protocol? Results
Flu shot
Colon Ca
Breast Ca
Cervical Ca
Pneumo. V.
MDD Screen
SUD Screen
Tob. Counsel
Benchmark
Prevention Clinical Goals
Prevention Protocol? Results
Flu shot
Colon Ca
Breast Ca
Cervical Ca
Pneumo. V.
MDD Screen
SUD Screen
Tob. Counsel
Benchmark
>90%
>75%
>90%
>90%
>87%
>95%
>95%
>93%
Firm A Medical Outcomes: Baseline Through February '03
80%
70%
Goal
50%
% At
60%
40%
30%
All Outcomes
p < .01
A1c < 7.5
LDL cholesterol <100
20%
BP < 140/90
10%
Month
Fe
b03
03
Ja
n-
De
c02
v02
No
Oc
t-0
2
02
Se
p-
g02
Au
Ju
l-0
2
-02
Ju
n
Ma
y02
r-0
2
Ap
Ma
r -0
2
Fe
b02
02
Ja
n-
Ba
se
lin
e
0%
Clinical Quality Indicators
Oct 01 to Sept 05
Primary Care Dx Management
90%
80%
74% 74%
70%
60%
58%
61%
63%
66%
77%
72%
69%
64%
57%
66%
70% 69% 71%
70%
66% 65%
60%
58% 59%
54%
52%
47%
50%
40%
30%
20%
10%
0%
% LDL < 100
Oct to Mar FY 02
Ap to Sept FY 02
% HgbA1c < 7.5
Oct to Mar FY 03
Ap to Sept FY 03
Oct to Mar FY 04
% BP< 140/90
Ap to Sept FY 04
Oct to Mar FY 05
Ap to Sept FY 05
Results:
Improvement in CRC
screening
80%
60%
40%
20%
ne
Au
g
No
v
De
c
Ja
n
Fe
b
M
ay
Ju
ne
Au
g
Oc
t
No
v
M
ar
ch
M
ay
Ju
ne
Au
g
Ju
ay
0%
M
% complete
100%
2003-2005 CRC Screening
Stage IV CRC
from Charleston VAMC Tumor Registry
through April 1, 2005
7
6
5
4
Stage IV
3
2
1
0
2003
2004
2005
Teamwork
It matters! A lot!
Teamwork!
Operational
Improvement
Team
Home Team
Clinical
Airplane Accidents
• In an analysis of 35,000 reports of
incidents over 7.5 years, almost 50%
resulted from a flight crew error, and an
additional 35% were attributed to air traffic
controller error
• Communication was a significant factor in
about ½ of the human errors.
How Hazardous Is Health Care?
(Leape)
DANGEROUS
(>1/1000)
100,000
REGULATED
ULTRA-SAFE
(<1/100K)
HealthCare
Total lives lost per year
Driving
10,000
1,000
Scheduled
Airlines
100
Mountain
Climbing
Bungee
Jumping
10
Chemical
Manufacturing
Chartered
Flights
European
Railroads
Nuclear
Power
1
1
10
100
1,000
10,000
100,000
Number of encounters for each fatality
1,000,000 10,000,000
Errors
• JCAHO Data of 2034 Sentinel Events
– Majority resulted in death
– Communication root cause in 60%
• VA Data of 10,000 near misses
– Communication root cause in 55%
It’s all about communication…..
………in a certain way
Communication Example
An Actual Radio Conversation between US Naval Ship & Canadian
Authorities off the Newfoundland Coast October 1995
• Canadians:
– Please divert your course 15 degrees to
the south to avoid a collision.
• Americans:
– Recommend you divert your course 15
degrees to the north to avoid a collision.
• Canadians:
– Negative, you will have to divert your course 15 degrees
south to avoid a collision.
• Americans:
– This is the Captain of a US Navy ship.
I say again, divert your course.
• Canadians:
– No, I say again, you divert YOUR course.
• Americans:
– This is the Aircraft Carrier USS Lincoln, the 2nd largest
ship in the Atlantic Fleet. We are accompanied by 3
destroyers, 3 cruisers, and numerous support vessels. I
DEMAND that you change your course 15 degrees north, I
say again, that’s one-five degrees north, or countermeasures will be undertaken to ensure the safety of this
ship.
• Canadians:
– This is a lighthouse. Your call.
An Actual Radio Conversation between US Naval Ship & Canadian Authorities
off the Newfoundland Coast October 1995
Engagement
•
•
•
•
•
•
Challenge
Authority
Autonomy
Stimulation
Access to information
Growth opportunities
• 20% highly engaged
• 40% moderately
• 20% unengaged
•
•
•
•
Sr. Mgr 53% engaged
Directors 25%
Supervisors 18%
Non mgt 12 to 14%
• Higher in nonprofit sector
Cooperation and Teamwork
% Favorable
% Neutral
100%
90%
80%
56
70%
60%
50%
40%
16
30%
20%
28
10%
0%
Q.27 Cooperation and teamwork
Results are shown from most to least favorable
% Unfavorable
Most Important Reasons
People Leave
•
•
•
•
1.
2.
3.
4.
Lack of Respect
Not listened to
Not involved
No opportunity to increase
responsibility
• 5. Can’t make an impact
• 6. Pay
Do patients notice good teams?
% Rating of Perfect Care by Patients
Using These Office Practices
Perfect Care (Patient Perspective) Correlated with
Teamwork (Clinical Staff Perspective) for Ten Office
Practices
90
80
70
60
R=.77; p=.01
50
40
30
20
From John H. Wasson MD - Dartmouth
10
0
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Rating of Teamwork In Office Practices (5 is Best)
From John Wasson
Surgery Service Story
Surgery Service O:E Ratio
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
1
2
3
Best-Middle-Worst of 44 Services
Morbidity Mortality
Young, et al. Best Practices For Managing Surgery Services: The Role of Coordination.
Health Care Management Review 22 (4), p 72 – 81.
Well Functioning Teams Have:
•
•
•
•
•
•
Leadership and direction
Common aim
Population of patients identified
Shared work and process
Shared information
Flexibility
Team Performance Curve
High-performing
Team
Real
Team
Performance
Work Group
Potential
Team
PseudoTeam
Effectiveness
Source: “The Wisdom of Teams” Katzenbach/Smith
Defining an Ideal Place to Work!
Management
Trust the people you work for
Employee
Be proud of what you do
Job
Enjoy the people you work with
Other Employees
13 Month Rolling Average
Staff Turnover 2002-2003
40.00%
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
J-02
F-02
M -02
A-02
M -02
J-02
J-02
A-02
S-02
O-02
N-02
D-02
Voluntary
J-03
F-03
M -03
A-03
M -03
J-03
J-03
A-03
S-03
Involuntary
O-03
N-03
D-03
Summary
• We know typical support staff numbers
• We know typical support staff composition
• We can probably markedly improve
efficiency
• We can discover population needs
• We know a key difference between good
and great teams is teamwork!
Next 18 months…
• Improve operational teams (LS 3)
– Through “office efficiency” change ideas
– Flow mapping & Task analysis
– Measure lead time and cycle time
• Improve clinical teams (LS 4)
– Identify and improve chronic disease care
– Identify and improve prevention care
• Improve teamwork (Throughout)
– Improve individual and team functioning
Homework
• Measure lead time (operational)
• Discover top 10 diagnosis (clinical)
• Talley chronic disease and prevention
protocols (clinical)
• “Take the test” page 3-11. Record
answers on page 16 (teamwork)
• Read championship teams introduction
• DO module 1 and 2 in the book