Patient care and the bottom line aren’t so far apart in a medical organization – be it physician practice, specialty clinic or hospital. In this instance, when a multi-provider Pediatric Oncology and Hematology Clinic engaged us, improvements within workflow and patient flow, plus (re)training in coding and documentation practices, meant the medical practice could enjoy happier patients and increased revenue. The clinic’s goals centered on enhancing their young patients’ clinic time and optimizing processes to increase revenue. We conducted an analysis and formulated a clinic improvement with active participation from both staff and leadership, focusing on:

• Patient flow and workflow processes
• Coding and documentation practices
• Staff satisfaction and communication needs

Phase I
Through chart audits and facilitated staff work sessions, we documented current processes and gathered clinic team input. Additionally, Derry, Nolan developed documentation and clinical templates to support coding best practices, then trained clinic staff on use.

Phase II
Our aim:

• Decrease patient wait time
• Decrease patient’s overall length of stay
• Increase staff satisfaction

The action plan continued the teamwork sessions, which revealed where new processes would provide the most benefit. Derry, Nolan developed clinic workflow recommendations that furthered a “Patient-driven Model” for optimal patient access. Team functions re-aligned to support the model, and re-arranged workspace promoted use of the newly implemented workflow.

A daily communication forum ensured the clinic team better anticipated patient needs and prioritized accordingly. Additionally, the newly developed Lead RN role was integral in implementing the changed processes, keeping communication channels open and upholding established standards within the nursing team. Physicians used compressed schedules to maximize both clinic time and patient “face time.”

Project Results

• Improved revenue by 30% per year
• Increased patient encounters/productivity up to 3 visits per day
• Decreased patient wait time by an average of 28 minutes

“Derry, Nolan & Associates helped us modify patient flow, scheduling efficiency, coding capture and staff members’ roles, improving both our care and our bottom line.”
Dr. Ronald Louie, Medical Director
Mary Bridge Children’s Pediatric Hematology/Oncology Clinic

Contact Derry, Nolan & Associates to learn how we can help your medical practice improve satisfaction metrics and the bottom line.

Physician practices are all-too-often the target of embezzlement. Physicians’ own traits of compassion, humanitarianism and a desire to help patients, are exploited, causing crippling of financial and morale status within the practice.

During our long career in healthcare, as clinic managers, administrators, CEOs and medical practice consultants, we’ve borne witness to the emotional and financial tragedy embezzlement takes on physicians, their staff and their medical practice’s well-being. It never fails to appall us that those who propagate such crimes are frequently the very individuals the physician entrusts with decision-making authority. Practice managers are, sadly, often major offenders – because a successful embezzler needs access to funds, such as the checkbook, patient accounts and cash. Sometimes it’s the receptionist, handling co-pays, or billing personnel, with the ability to siphon monies easily, who are the culprits.

Embezzlement isn’t always dramatic – like the administrator who lifted original business checks and wrote on duplicate copies names of the clinic’s larger medical vendors, eventually taking nearly $300,000, or the manager who fabricated a night-time employee to “pay.” Because physicians are often (and understandably) more focused on patient care than the business side of medical practice, tales like these are common.

Top 10 Embezzlement Warning Signs

1. Missing inventory (office and medical supplies, such as eyeglass frames)
2. Changes in practice revenues
3. Increased refunds, write-offs and adjustments
4. Checks that lack supporting documentation
5. Unusual medical practice staff relationships with vendors (kickbacks)
6. Fluctuations in the general ledger expense accounts
7. Increased patient complaints about billing issues
8. Increased practice clerical errors
9. Unusual employee behavior (suddenly showing signs of living beyond their means, not taking vacations, taking work home frequently)
10. Questionable purchases (petty cash variances, items unaccounted for, personal expenses found on company credit cards)

Prevent Overwhelming Loss – Bonding & Backgrounds

To help protect your physicians medical practice, consider bonding, a type of insurance that reimburses medical offices for losses. Health plans and other payers follow this practice already, due to a federal law that requires bonding of all staff with financial responsibilities. Unfortunately, small practices may not think to take this simple precaution, because the physicians may feel they “know” their employees too well and that it would be indicative of mistrust. But it’s just good business. Also, be certain to have fraud insurance.

Always conduct a thorough reference and criminal background check on any potential new medical practice employees. We often recruit for billing management and practice management during medical practice consulting engagements that involve interim practice management, and this common-sense step is standard operating procedure for us. Whether working with a medical recruiter or doing it yourself, take the time for this important follow-through. When you speak to a potential staff member’s former employer, pay close attention to what they don’t say as well as what they say. For instance, ask if they’d consider re-hiring the person if the opportunity arose; if they hedge…well.

Physicians want to focus on patient care, and the administrative headaches often seem as though they take time away from that. So think of it this way: The well-being of your medical practice is important to the continued care, and well-being, of your patients. If the business side is taken care of, then through it, you will be able to provide patient care for years to come!

For Further Reading
Minimizing the Risk of Financial Fraud
Busting Embezzlers

Medical practices: For more information about good audit practices, medical practice staff recruiting, and avoiding embezzlement, contact Derry, Nolan & Associates.

When a local six-bed Sleep Disorders specialty practice found itself without a manager, they asked us to work with them as interim management and recruiters. They also wanted to correct workflow inefficiencies and expand the sleep beds by two.

Crystal Nolan, (principal) and Dee Collins, RN, stepped in as interim managers over a four-month period. In addition to daily operational oversight, the two helped recruit the new manager, plus performed an operational and financial assessment. Concurrently, fellow consultant Julie Titus conducted an in-depth coding analysis. After the assessments and analyses, the team recommended and helped implement several major process improvements.

Patient Schedules

• Decreased follow-up visits from 30 minutes to 20 minutes and patient consult visits from 45 to 40 minutes to help increase volume. The appointment time change alone resulted in over 100 more consults per year.
• Installed Murphy beds in two of the sleep rooms, allowing them to double as consult rooms, thereby negating space limitation concerns.

Front Office

• Instructed staff to fully use the internal e-mail system for communications, e.g. incoming messages for physicians were stored in an e-mail folder in the sleep clinic file, which also saved time and reduced errors.
• Recommended the use of an automated reminder call system, rather than individual confirmations, to alleviate individual appointment reminder calls, freeing up front desk to help with more administrative duties.

Workflows

• To speed up MA’s work, we transitioned several tasks to the Front Desk, as well as making process changes that allowed the MA sufficient time to complete room turnover.
• Reception would do the download while the MA roomed the patient. Additionally, reception would add the previous Weight and BMI (body mass indicator) to the chart form when doing chart prep work.
• Implemented the use of automated Blood Pressure, oxygen saturation, temperature and pulse machines, instead of using a manual BP, second device for oxygen saturation and pulse, and a third for temperature, saving MA’s time.
• Recommended physicians complete dictation immediately after patient visit. This gave the MA an additional five minutes to handle download handoff and complete rooming processes, ensuring the physician gets out on time.

Financial Analysis

• The internal coding audit undertaken based on results from a CMS peer review showed one physician in particular was default and under coding. Rather than base coding on time, we recommended it be based on examination elements to reflect the study and treatment more accurately.

Derry, Nolan and Associates worked in tandem with the leadership team to place the new manager. Crystal helped ease the transition, providing a comprehensive report to help the new manager decide how to focus her energy and best use staff resources. As the team continues its workflow improvement tasks under the guidance of the new manager, the Sleep Disorders Clinic is on the path to further its expansion goals, as well as positively affect its bottom line.

Client Testimonial
“Derry, Nolan & Associates performed an operational and financial assessment leading to coding opportunities, streamlining scheduling, improving workflow processes and assisting in the recruitment of a new sleep center manager. Also, the interim management they provided was exactly what we needed to help identify internal issues.” — Mitch Weinberg, MD PhD, Vice President, Medical Affairs, Evergreen Healthcare

Ambulatory Surgery Centers (ASC) are busy – really, really busy. And yet one of the most time consuming processes is essential to their business – gaining ASC Medicare Certification through either AAAHC or AAAASF, whichever is most appropriate to their ASC. Working with experienced medical practice consultants who have deep experience with ASC Development is key, as the case study below indicates. Plus, this ASC took the opportunity to eliminate waste in workflow and improve overall operations.

Accreditation & Improved Workflow Processes make Clinic Vision a Reality
A local multi-clinic Eye Surgery Group with Ambulatory Surgery Centers (ASC) engaged us to help weigh the choices for accreditation, as well as for project management and oversight for the certification process. We worked with the ASC practice on the development and implementation of the chosen AAAASF Accreditation, including creation of policies, procedures and conducting a mock survey. Additionally, our ASC staffing redesign resulted in a projected $270,000 annual savings.
Phase I

• Review of accreditation standards for comparison to the client’s exiting Medicare (DOH) Certified ASC facility, as well as current operational policies and procedures, governing body documents, personnel policies, OSHA standards and Fire and Safety procedures.
• Assisted in the Functional Program and Facility physical layout design.

Phase II

DNA’s engagement continued in order to help coordinate completion of the required initial application documentation and ready the ASCs prior to the Accreditation site visit.
• Facilitated weekly leadership meetings to review progress and assign tasks. DNA also participated in the ASC facility design and safety requirements, including meeting with the DOH representative.
• DNA’s Certified Coder worked closely with the coding department, verifying and updating the ASC’s retinal fee schedules, facility and professional codes.
• Conducted mock survey site review for readiness prior to the survey visit. Clinic passed Accreditation after the initial site survey visit.

Phase III

The Medical Director requested that DNA conduct an operational assessment at designated ASC sites that would provide insight into patient flow, support staffing model and RN resource allocation. Recommendations were:
• Align Medical Assistants with appropriate tasks, freeing RNs to clinical focus.
• Assign RNs work that used their clinical, rather than administrative, skill set.
• Use a Just-in-Time (JIT) supply ordering methodology to improve space utilization as well as cash flow.

Results
Cost savings due to staffing model adjustments provided a cost-decrease of $8-10 per hour per FTE. Benefits included, savings totaled approximately $43-54,000 annually for a single ASC. Standardization of the proposed care delivery system throughout the four ASCs could approximate annual savings as high as $270,000.

The Eye Surgery Clinic stands as a proactive example of an organization ensuring their investments were solid and well-founded. Stakeholder decision-making had accurate, well-researched assumptions of volume and net revenue to rely on. The medical practice as a whole retains a sustainable position for cost-cutting due to initiatives undertaken during the Accreditation process. Natural attrition will allow continuation of staffing redesign, leaving the right staff doing the right work in the right amount of time.

Our clients are the best! See what another ASC client had to say about Derry, Nolan & Associates:

“I love my new ASC. The practice, office, and operating room space were flawlessly developed and managed by the team at Derry Nolan. Without them, I would not have arrived at this splendid practice setting.”— Dr. Dan Downey,
Downey Plastic Surgery

Physicians are feeling the pain and frustration of lowering Medicare reimbursements, increased malpractice insurance costs, new patient influx on the decrease, and rising overhead. In the meantime, physician compensation is lower. And by the way, the staff would like annual raises. It’s enough to drive physicians and their medical practices nuts!

But, there is a method to relieve those frustrations, as the case study synopsis below shows.

Medical Practice Efficiency: Case Study
We recently completed a long-term engagement with a multi-specialty medical practice. Their situation will probably sound familiar to many of you:

• Multiple service delivery locations – some doing well, some not so much
• Flat revenue vs. climbing expenses (rent, staff, lab, inventory)

Their goals (ambitious, but do-able) were to:

1. Reduce Costs
2. Increase Revenues
3. Increase Efficiency
4. Improve Patient Satisfaction
5. Improve Staff Satisfaction

We began with a medical practice operational and financial assessment, to measure cost structures, service lines, governance and related operations. From there, we were able to implement process improvements that led to millions – yes, millions of dollars in savings.

Waste can kill a medical practice – just look at our overall healthcare system inefficiencies:

• Paper-based systems accounts for 6% of annual overspending
• Administrative inefficiency and redundant paperwork accounts for 18% of healthcare waste
• Billing and administration take up one-quarter of the average US hospital budget
• US doctors spend nearly 8 hours per week on paperwork and employ 1.66 clerical workers per doctor*

Approach and Results
Our approach with the multi-specialty practice was to eliminate non-value added work to achieve better patient, provider and staff satisfaction while increasing revenue opportunities. In other words, implement our mantra: “have the right people doing the right work in the right amount of time for the right pay.”

Using Lean principles (and MGMA cost data benchmarks), we benchmarked costs, redesigned processes, helped with organizational restructure (including executive leadership changes) and implemented new policies. You can find details in the presentation on our website’s media section, but the final results were:

• $3.8 million saved in expenses!
• Increased physician compensation
• Increased lab and imaging profitability
• Improved morale

We’re proud to report that the organization has sustained the improvement gains. Plus, they continue to benchmark and raise the bar with ongoing waste reduction efforts!

Snippet:
“Efficiency is integral to a more cost effective, productive medical practice.” — Barbara Derry & Crystal Nolan

Download the presentation that inspired this blog.

*healthcare inefficiency statistics taken from a report by Robert Kelley, vice president of healthcare analytics at Thomson Reuters.

Marketing is one of the biggest challenges a budding entrepreneur faces. One of the first rules is to make sure everyone you know is aware of what you’re doing. So when we began Derry, Nolan & Associates Medical Practice Consulting Services in 2003, our first step was to tell everyone we knew in the healthcare and medical field. After years in healthcare and being members of professional associations such as the Washington State Medical Group Managers Association (WSMGMA), that added up to a lot of breakfasts, lunches and dinners (Crystal gained 12 pounds)!

Next, realizing that a physician or medical practice group would likely contact their attorney or accountant if they were having financial issues or needed temporary practice management, we began visiting area firms. We set out to “wow” them with our LEAN training, our years of experience and of course, our bubbly personalities! Barbara went kicking and screaming – she did not like talking about herself. Crystal, being gregarious and a natural marketer, pulled her along.

Three months later, the phone began ringing and hasn’t stopped yet. Sure, there are days of no calls and we don’t land every prospective client, but we’re established and proven as a healthcare medical practice consulting firm. In fact, Derry, Nolan & Associates’ results-driven reputation is known in not only Washington, but also Oregon, Alaska and Montana.

Our marketing efforts continue to evolve with the times. We advertise our medical practice consulting services on industry-related websites, such as WSMGMA and Pierce County Medical Association’s Physician Directory. We present educational seminars at specialty medical practice and industry conferences. We write and publish many articles in medical journals such as King County Medical Society’s The Bulletin and the multi-state healthcare publication, Washington Healthcare News.

Most recently, we took the deep dive into social media with this blog. Plus you can find us on Facebook and follow us on Twitter!

That said, the best advertising remains word-of-mouth, for which we are very grateful to our many clients and colleagues who consistently recommend us to others!

Snippet
“Nobody becomes visible or in-demand by keeping quiet.” — Crystal Nolan

Get free consulting! Derry, Nolan & Associates’ offers a free, one-hour initial healthcare medical practice consultation.

Remember in our first blog entry, we told you that one part of our blog is about being true to yourself and taking risks? It’s part of being a successful entrepreneur. Well, some of our setbacks, and successes, are attributable to very personal stories that led us to quit our jobs and pursue the dream of owning our own business.

In 2002, hit with serious health issues, as well as personal loss, we each took a step back to re-examine our lives and reconsider our careers. Barbara, dealing with the stress of ever-increasing responsibilities in a new position and new boss stress, learned she had “pre” breast cancer. After a painful stereotactic breast biopsy, surgery and several months’ regimen of Tamoxifin, she was miserable. Severe hot flashes, depression, anxiety and loss of concentration – all supported her breast oncologist’s very clear message: If you want to prevent getting breast cancer, you need to remove the major stressor in your life. When leaving her doctor’s office one day, her husband turned to her and said, “Barb, you make a great salary, but no job is worth your life. I think it’s time you start your own business.” That was seven years ago, and Barbara has had no further episode.

Around the same time, Crystal’s right leg began swelling to the point she could barely walk, plus she was having chest pain and difficulty breathing. Unknown to her, a life-threatening deep vein thrombosis and pulmonary embolism was brewing. Told there was a very real possibility she would not survive more than 48 hours, she was hospitalized for a week, but all she could think of was relieving the excruciating pain. Both sons were called to her side, one flown in by naval aircraft carrier. When released, instead of resuming her customary healthy lifestyle, she went to months of doctor’s appointments, strictly monitored Coumadin levels, and dealt with chronic leg swelling. So when her younger brother, dying of lung cancer, told her that “people who don’t take risks, don’t have shit!” she listened.

Very scary incidences paired with heartfelt advice from loved ones. What more catalyst did we need? So in March 2003, Derry, Nolan & Associates, Healthcare Medical Practice Consulting Services, became a reality. We’ve never looked back.

Today, our client list includes Oncology, Cardiology, Multi-specialty, Family Practice, and Plastic Surgery Clinics, as well as Ambulatory Surgery Centers. We use a structured, consultative approach to eliminate waste, help clients become more profitable, more flexible in scheduling, and most importantly, happy in their daily work. Knowing how invaluable family time is, we help providers get home at a reasonable hour – that’s much more important than dictation or paperwork. Sometimes (one of our favorite roles) we act as healthcare interim executives and help healthcare organizations as they recruit for a permanent replacement.

In seven years of healthcare medical practice consulting, we learned to cherish our freedom to be creative, to laugh, to mentor others, and to help ensure our clients have the right people, doing the right work, in the right amount of time. We also learned – and take this to heart – never settle for less than your full potential!

Next time…our approach to marketing and how we launched Derry, Nolan & Associates!

Want to raise eyebrows? Advise a physician or medical practice that they’ll be paying to update, or implement, their compliance program. As medical practice consultants, we frequently discover that our healthcare and medical consulting clients need to update their compliance program. Here’s an anecdote “from the trenches” that demonstrates how consternation can turn to understanding.

Recently, Barbara Derry presented a proposal to a specialty group. Afterwards, one physician chastised her, feeling that our fees were too high for a coding and documentation audit. She left thinking that DNA wouldn’t win the project. Imagine our surprise when the practice not only hired us for the project, but also added compliance program redesign to the engagement’s scope. To top it off, they paid us in full by year-end!

The Office of Inspector General (OIG) and CMS dictates the guidelines that medical practices and other healthcare organizations must follow related to governance, coding and billing practices, and auditing and monitoring reporting structures. Some providers object, but there is no denying that rampant fraudulent billing occurs nationwide – particularly in the four test states (Florida, California, Texas and New York) of the 2005-2008 Recovery Audit Contractors (RAC) demonstration program. An effective compliance program can help avoid fraudulent billing.

How can you tell if your healthcare organization’s compliance program is effective? Here are common areas that DNA examines:

• Organizational behavior: Is the business philosophy compliance-driven? How is employee awareness and support? Physician compliance? Overall compliance program credibility?
• Compliance Awareness: What is the overall employee awareness of your compliance program? Its policies and activities?
• Oversight and response: What’s the activity level of the compliance officer and management in the regulatory process? Disciplinary consistency? Discovery and investigation? Error documentation? Employee satisfaction?
• Education Program: How many employees are educated, how often, and what are standard attendance percentages?
• Coding and claims accuracy: How well does the practice audit and monitor findings, such as coding and documentation errors, claim errors and claim rejection/denial percentages?
• Coding and claims processes: How many services are un-billable due to poor coding practices? How many claims are processed and properly use charge master and coding/claim technology?
• Corrective action: How usable and accessible are reporting mechanisms? What’s the interaction with carriers and intermediaries? How efficiently are reported concerns resolved?
• Quality Improvement Program: How responsive and adaptive is it to industry and regulatory changes? Does it efficiently distribute information? How is the business and financial success of the practice?

The OIG is very busy, determined to curb fraudulent billing practices and recuperate monies paid incorrectly over the past several years. There are literally hundreds of healthcare providers now under corporate integrity agreements (CIAs) that last five years. If a healthcare organization is under a CIA with the OIG, it means they must closely follow specified methods and activities that ensure they meet statutory and regulatory standards, and report properly. Discover the targeted areas at http://oig.hhs.gov/fraud/cias.asp.

Our advice? Be ready; be in compliance.

DNA Snippet
The Obama Administration says that it is going to crack down on improper payments made by all government programs, which in 2009 totaled $98 billion according to federal agency estimates. (GovernmentExecutive.com)

For help assessing or updating your medical practice’s compliance program, contact Derry, Nolan & Associates.

Webster’s dictionary says benchmarking is “a standard by which something can be measured or judged.” In a recent post, we mentioned the need to use the right yardstick to measure patient loyalty. Benchmarking is one of the best tools to see how your medical practice stacks up against others in a similar specialty or size.

Blame it on Xerox Corporation – in addition to copiers, they began official benchmarking practices. Now, in addition to corporate America, medical practices, clinics, hospitals, and pretty much any healthcare organization uses benchmarking to compare processes (coding, overhead, staffing ratios, accounts receivable) with others in the same or similar specialty. Using such high performer comparisons helps the medical profession raise the bar for best practices.

Why is it important? Quite simply, benchmarking provides a structured approach to data gathering and analysis. It helps you, in practice/clinic management, to develop the best strategies, and points you in the direction of the best operational decisions, too. Because it quantifies the measures of performance, medical practices are able to truly measure the gap between their own organization and “best practices,” not to mention competitors. Best of all, knowing what you’re up against encourages creative thinking and stimulates innovation.

To benchmark, follow these steps:

1. Identify the problem – do you want to lower overhead? Increase collections?
2. Determine areas for attention – staffing ratios, 120-day A/R
3. Obtain buy-in from decision-makers
4. Know how you do things now, so you know what needs to change/improve
5. Compare to peer groups
6. Gather accurate data
7. Communicate the improvement action plan
8. Develop dashboard indicators and continuously measure against them!

Start with realistic goals – like reducing patient wait time by 15 minutes or introducing Just-in-Time ordering to reduce overstocked inventory. And benchmark based on factors that relate to cost, quality and timeliness – internal factors. Monitor and re-evaluate at set intervals so Continuous Quality Improvement becomes the culture.

Above all, remember: Benchmarking is not a one-time event but a continuum.

DNA Snippet
For the complete presentation of “Why Benchmark?” given by Crystal Nolan at the WA-OR MGMA meeting in 2009, visit the Derry, Nolan & Associates website.

You’ve measured loyalty, not just satisfaction, in your medical practice. You have a responsive, patient-service oriented staff. Your practice staff is happier than they’ve ever been; retention is solid. Now what?

In an earlier post, we mentioned how airlines, retail stores and luxury hotels – such as the Ritz-Carlton* – can and should drive loyalty through courtesy, but that healthcare’s differentiator is the use of empathy. Empathy, caring and compassion through acknowledgement of patient’s feelings.

So what can your medical practice learn from a world-class hotel? World-renowned service standards. After all, the Ritz-Carlton and healthcare are similar in the way they both deliver a product/service that the customer wants defect-free, when and how the customer wants it, and through providing genuine care and concern for that customer.

Then there’s benchmarking, also familiar to healthcare organizations, the Ritz-Carlton’s leadership constantly seeks out businesses to benchmark, always looking for the best metrics to ensure that their employees find work meaningful.

Last but not least is staff satisfaction, hugely important to success. Management recognizes that helping employees as they seek to deliver genuine care to guests, or swiftly fix breakdowns in a compassionate manner, gives employees satisfaction (hence, retention and happy customers). How do they help employees? By acknowledging what they learn, data-wise, and sharing it.

• Objectives are manageable and anchored to the company’s core values, always open to refinement.
• Corporate storytelling demonstrates how staff can personally make a difference and deliver “Wow” experiences.
• Leadership and staff view the entire business as a two-way relationship – with mutual accountability.
• Corporate values and financial objectives align, clearly showing how living the values results in business success.

Mutual accountability and transparency works – whether in the luxury hotel business or in your medical practice. Think about how you help your staff deliver genuine care and swiftly fix breakdowns. Do you share good and bad feedback? Look for the best in competitors and measure against it? Live the values you promote at work?

We know that achieving Platinum Level Customer Service is one thing, but that keeping it takes practice. It’s definitely do-able, so persevere! If you need an objective, professional helping hand, Derry, Nolan & Associates is here to help you reach and sustain your customer service goals.

DNA Snippet
“Achievement is largely the product of steadily raising one’s level of aspiration and expectation.” —Jack Nicklaus

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