Effective Problem Solving Is Key to Practice Success

DAVID J. BACZEWSKI, MBA

Like most healthcare organizations, retina groups are faced with challenges at every turn. It may seem that we are entering new territory, but today’s problems can be dealt with using the same processes we have employed for many years. Problem solving involves adapting changes in diagnostic modalities and treatments. A successful organization is able to adapt to these changes in an efficient, timely, and financially prudent manner.

David H. Orth, MD, founded Illinois Retina Associates, S.C., of Chicago in 1975. The practice began in a hospital in Harvey, Ill, a suburban town 23 miles south of downtown Chicago. Dr. Orth had a dream to bring university-style medicine to the suburbs and approached a forward-thinking hospital that agreed it was time to provide retinal services to its patients. At its humble beginnings, Illinois Retina had 3 employees and occupied 3 rooms with a few hundred square feet. The practice was fully equipped with 1 exam lane, a laser, a fundus camera, a desk, and 6 waiting chairs in the hallway.

Times were simpler then, but our practice still had problems and challenges to overcome. Some of the issues we faced included adopting new treatment methods and surgical procedures, improving financial performance, and redesigning the office to meet differing demands. It was also necessary to convince the ophthalmic community that providing retinal services was essential for the best care of their patients. Like any new practice, we worried about where new patients were going to come from and how we were going to handle them once they arrived. While we did not have to deal with resource-based relative value scales or the Health Insurance Portability and Accountability Act in those early years, Illinois Retina had issues. We needed to solve them and move on.

TODAY’S PRACTICE

Illinois Retina is currently an 11-physician group with 10 locations, 2 retina fellows, 85 employees, and 35 000 square feet of space dedicated to retina. Each location is fully equipped with all diagnostic and therapeutic capabilities. The physicians operate at 8 different fully equipped hospitals. The practice is actively involved with clinical research and has 7 open trials.

I can tell you that this transition was not easy, but our success has been built upon our approach to challenges and willingness to adapt to the changing environment. Open-minded problem solving, maintaining a positive attitude, and considering key constituents when making decisions help us to develop more successful solutions. As a group, we are also willing to take risks and make mistakes. The practice has continued to grow, serving a larger region, and, for the most part, has kept our referrals, staff, and physicians happy along the way.

TODAY’S CHALLENGES

Here are some of the issues facing retina groups these days: How are we going to transform our practice to meet the demands of new therapies? How am I, the doctor, going to care for all of our patients? Are we going to generate enough income and control our overhead in order to maintain the practice?

These issues are not much different than those we have been facing for the past 30 years. Most successful organizations use a common and simple process to solve problems:

• define the problem and the root cause
• gather pertinent information
• analyze the information
• discuss the alternatives and outcomes of each alternative
• implement the best alternative

WORKING TOWARD THE BEST ALTERNATIVE

Although the process may seem simple, execution may be extremely difficult. Developing a win-win solution can often be compromised by the hurried pace of a practice that tempts decision makers to develop remedies in the shortest possible time. I have spent years working in healthcare management and am amazed at how often decision makers act with only their own interests in mind. They can be close-minded to new suggestions, following their view of the facts, excluding key players and input, and pushing their solutions.

In an effective process, input should come from all levels of the organization. Feedback from referrals, when appropriate, is a key ingredient to success. Problem solving should be done with a commitment to seeking all information, spending time to analyze and select the best solution, and keeping an open mind. The goal should be to create a positive result, not a personal result.

Additionally, practices of any size make a significant investment in staff in the form of training, salary, and benefits. Get staff involved; let them be heard. Let them know you pay them to think and will act on their input.

PRESENTING A POSITIVE ATTITUDE

Displaying a positive attitude from the top down is important if a practice is aiming for success. The perception that you are able to overcome all obstacles sets the proper frame of mind to start the problem-solving process. When I was an ophthalmic photographer 20-some years ago, I viewed the difficult photophobic patient as the norm. Cooperative, clear media patients were a gift. Today I approach my daily activities the same way. I expect challenges, so that when I come to work I am ready to take them on.

A positive outlook is great, but avoid the “victim syndrome.” Have you ever had a claim rejected because an insurance company or health maintenance organization stated it was not submitted in a timely fashion? When asked, the staff insists they sent the claim on time. Is the response you receive from the insurance company, “Well that’s just the way it is?” Don’t be the victim. With a little extra effort this problem can be avoided.

We carefully monitor claims with selected insurance carriers to avoid the pitfall of a claim “not being received” within the contracted period. A 21-day checkup on all submitted claims is a possible solution. If the claim was not received, it is sent again and followed up on in another 21 days. At this point, 42 days has passed since the date of service and if a carrier has a 45-day rule, 3 days remain to resubmit the claim. The process continues and escalates until payment is received. This example is not meant to promote a claims follow-up procedure but to demonstrate how not to be victimized. The goal is to do what is necessary so that the practice is properly reimbursed for the care given and work done.

GROUP HARMONY

Harmony among the 4 groups of constituents — patients, referrals, staff, and doctors of the practice, both partners and associates, is vital to a practice’s success. Internally, all resources should be involved in decisions. By gathering input from everyone involved, practices can avoid the fallout of a bad decision based on incomplete information. If any one of these groups decides its issues are more important than any other, the “solution” will be short lived and have a negative impact on the group as a whole. A balanced approach yields optimal results.

DELIVERING QUALITY PATIENT CARE

I would be remiss if I didn’t mention quality patient care, which is expected, but not easily identified, by our patients. By definition, quality care should include the physician’s knowledge, appropriate diagnosis and treatment, and patient safety. If a practice is providing quality care, then they are almost guaranteed to have high and continued patient satisfaction and referrals, right? Not necessarily.

Patients assume they will receive the above-stated quality. What they seek and rate are surroundings, staff courtesy and competence, time spent in the office, physicians’ bedside manner, and the information given to them and their families.

The delivery of quality patient care from the clinical perspective may not meet the perceived needs and desires of the patient, and ultimately, the referral. Despite the fact that we are providing the highest quality of care, the patient may still experience 3-hour waits and then too short a visit with the doctor. These are examples of disconnects that occur when patient input is excluded from decision making.

Office surroundings, staff training, and schedules should be considered when it comes to patients. From the referral perspective, negative feedback from patients casts a dim light on your practice and can endanger your business partnership.

HOW NOT TO SOLVE A PROBLEM

Here is an example that illustrates a problem and the results of knee-jerk problem solving. A practice physician is struggling to get through his day, trying to accommodate the increase in intravitreal injection patients, keeping up with return patients, and making room for new patients. He decides the best approach to control patient flow is to schedule all types of patients every 5 minutes for the first 5 hours of the day with hopes of being done with patients by 5:00 pm.

The physician does not want to wait for patients during the day because it is inefficient. He meets with the office manager or scheduler and wants the new schedule implemented immediately. The office manger or scheduler thinks to him/herself, “This is a big change and will the computer schedule 5 minutes apart? Can the front desk handle a patient every 5 minutes? How about checkout? Can the techs handle a patient every 5 minutes? How about the imaging person or staff? How many patients need to be rescheduled? How many times have they already been rescheduled? What happens to the other doctors in the office and their patient flow?”

The doctor says, “Just do it,” leaving the staff person no alternative. This may result in the staff staying late and many patients and families being inconvenienced by having to change their schedules.

What appears to be a simple schedule change made by the doctor can have significant repercussions on patients, staff, and other doctors in the practice. The change may also affect referrals and, finally, the physician who requested the change to begin with. However, if the manager and physician follow a structured process and consider all of the facts, including all resources, and then select the best solution, the results will be far more desirable.

INCORPORATING A NEW THERAPY INTO A PRACTICE

Our practice is now handling the issues of incorporating anti-vascular endothelial growth factor (VEGF) therapy in the same manner it has addressed challenges for the past 30 years. There are problems with increased volume and longer days. Patients get upset when they wait too long and word gets back to the referral. The staff does not like to work long and unpredictable hours. Physicians who share our offices are not happy when a doctor schedules and uses resources without concern for their personal schedule and patients.

However, using simple but effective problem-solving techniques and considering all of our constituents, we are addressing the issues, analyzing the alternatives, and making changes. Some of our doctors are using block-injection schedules and some are seeing injection patients mixed into their regular schedule. Some doctors prep their own patients, while others have a trained nurse or technician prep the patient. Most patients are injected in the exam rooms and not relocated. We use carts with pre-setup trays for the injection supplies, which are wheeled into the exam room.

The practice has hosted educational seminars for referring doctors, resulting in a better understanding of anti-VEGF therapy on their part — including why patients are returning to our office so frequently. We are still working out a few reimbursement issues, but we are getting properly paid on about 96% of claims. As a result, we are reaching a point where schedules are more manageable, staff, patients, and doctors sharing the office are happier, and we have received feedback from referrals that they are happier.

Each of us is very busy, challenged, and stressed in today’s medical environment. Taking the time to implement the best possible solutions the first time is the ideal. Use a simple but effective problem-solving process, remain open minded and positive, and attempt to achieve harmony for the entire staff. It’s that simple. Good management and problem solving is more about consistent execution than a complex model. RP