1. Teaching Leadership and Practice management in Patient -Centered -Medical –Home Maria V. Gibson, MD, PhD Peter J. Carek, MD, MS William J. Hueston, MD

2. Leadership requirements for physicians primary care physicians Skills in planning and management quality assuranc e information technology Communication and team building Business Operations Management Quality assurance Information technology Communication, team building Leadership

3. RC-FM Requirements for Practice Management 100 hours of management and leadership instructions: didactic and practical Prepare residents to assume leadership roles in practices, communities, and profession of medicine. FMC must be primary site for teaching

4. ACGME Curriculum Recommendations for Leadership and Practice Management Training Current billing practices: designing and managing a budget Assessment of practice staffing needs Employment law and personnel management The impact of new technologies on practice Determining value in the marketplace Assessment customer satisfaction Measurement of clinical quality, tort liability and risk management Office scheduling systems Alternative practice models Principles of public relations and media training

5. “From Residency to Reality” AAFP recommendations for Practice Management curriculum for Family Medicine residents didactic modules of business operations, planning, risk management, health information technology, office roles and staffing, quality measurement and improvement, regulatory issues, and vendor relationships

6. Preparation for Practice SC AHEC Graduate Survey – >1/3 of graduates felt poorly or very poorly prepared in practice management (Carek, 2000) – <80% of graduates felt well prepared for practice in practice management (Carek, 2010) Graduates 1999-2003 vs 2005-09 – Well prepared in practice management: 46.8% vs 61.9% Carek, 2001; Carek, 2012

7. Confidence in Practice Management Skills Practice Management SkillResidentGraduatep Searching for position after residency2.262.070.30 Writing CV2.092.200.54 Applying for hospital privileges3.062.28<0.0001 Understanding legal aspects of contract3.312.610.0002 Negotiating a new job contract3.162.750.023 Job Interviewing2.222.490.11 Obtaining proper medical licenses2.812.340.01 Understanding CME2.922.600.11 Obtaining malpractice insurance3.172.760.03 Managing office personnel3.123.020.60 Business and financial concerns of practice3.382.990.05 Applying principles of risk management3.292.640.0007 Medical coding and billing procedures3.042.18<0.0001 Taylor, 2006

8. Gap between didactics and practical leadership skills

9. Trident / MUSC Family Medicine Practice Management rotation evolution AAFP didactic course, Financial planning, Malpractice Insurance, Contract negotiation 2007 + PCMH, Physician performance, Leadership, Team Building Training 2011 +Coding and billing, Medical Directorship, PPST, Quality measurement and improvement 2009

10. Changes in the Leadership and Practice Management Training when entering the PCMH phase PCMH concept Leadership styles Innovative care models Knowledge Hands on Management of FMC Patient care quality assessment and improvement-six sigma methodology Skills Team work training Improving Efficiency and Patients satisfaction Practice

11. PCMH training: After the training residents will: Initiate change, advance project from idea to implementation Implement change using Lean Sigma approach Leadership roles in practices, communities, and profession of medicine

12. Forms of educational training during Leadership and Practice Management rotation Longitudinal year around lectures and workshops Practice Problem Solving Team Project Express self learning Individual Didactic Sessions Medical Director of FMC

13. Teaching PCMH concept: AHRQ resources

14. Teaching PCMH concept: NCQA resources

15. Teaching PCMH concept: The Joint Commission resources

16. Leadership and Team Building Skills Training: The PACE Palette P ersonal A and C ompany E ffectiveness

17. Team communication and conflict management : TKI -instrument The 2 basic behavior dimensions of conflict : Assertiveness Cooperativeness The 5 modes for responding to conflict situations: Competing Collaborating Compromising Avoiding Accommodating

18. The Five Conflict-Standing Modes CompetingCollaborating AvoidingAccommodating Compromising

19. Typical team building assignment 1. Create a team for implementation of new drug screening test in the FMC 2. Assign the tasks based on the PACE palette knowledge to your team members 3. What difficulties do you predict for this team during their discussions

20. Practice Problem Solving Team (PPST) project Purpose: Identify FMC problem Come up with a solution, write proposal Implement the proposal Using System based approach of – Six sigma methodology and – “Root-cause analysis (RCA)” as well as – evidence from “best practices” come up with a proposal (implement the proposal) for solution of the Practice Problem identified for you by Family Medicine Department Practice Manager.

21. PPST learning objectives Analyze problems thoroughly and effectively Be effective when solving problems as a team Communicate complex issues visually and verbally Take the emotion, opinion and speculation out of problem solving Develop a process/systems approach to managing operations Anticipate problems to prevent them from occurring Frame each problem as an opportunity to learn and improve Outline problems in the context of the overall goals Prioritize problems efficiently and objectively

22. Practice Problem Solving Team Implementation Innovation Performance and efficiency Practice operations

23. Six sigma DMAIC problem solving methodology Practice Problem 2 Measure 3 Analyze 4 Improve 5 Control 1 Define

24. 2010-2012 Residents PPST projects implemented at the Family Medicine Center: Optimization of chronic pain management – Chronic pain management registry – Utilization of new UDS screen for chronic pain management patients Clinic efficiency improvement: – utilization of nursing resources – Monitoring of patient flow Optimization of well child exam Utilization of resources for patients with ADHD Medicare wellness exam implementation Preventative care for patients with chronic medical problems Analysis of billing pattern for Diabetes visits Group visits implementation Apprentice model of precepting

25. Billing and coding for physicians Physician trained in coding and billing: 2 hour analysis of personal billing pattern, introduction to RVUs Insurance claim specialist: Analysis of most commonly denied claims Certified Coder: 1 hour personal audit and training Longitudinal curriculum for PGY2-3 Led by faculty and certified coder

26. Coding and billing teaching assignment “If you continue your performance as of Last week at the FMC what your compensation going to be if your incentive plan is wRVU based with physician conversion factor of $40”

28. Physicians performance Forms of teaching: – Practice manager 2 hour session: Evaluation of physicians performance Types of incentives Quality based forms of incentives – Contract negotiation training session with physician trained in practice performance Introduction to RVUs Simulation session of contract negotiation

29. Medical Directorship Training Daily rounding (Patients, staff, physicians) Daily FMC operations participation Communication with patients Management meetings Practice assessment

30. Schedule for Practice management resident 7:30 Department Medical Director breakfast meeting (monthly) 8AM FMC rounding 8AM FMC management meeting (weekly) 8:30 Four hour clinic session 1PM Rounding 1: 30 Triage: answering messages, patients concerns PPST /Scheduled training sessions

31. Didactic training sessions during Practice management rotation: Practice operations Physician financial performance and contract negotiation Principles of billing and coding. Payers introduction Patient satisfaction, Practice operations and staff management PCMH Leadership evaluation and training Team building and conflict resolution Financial management

32. Express-self learning lecture modules: Negotiation Marketing Science of reliability: patient safety in health care Practice culture (vignettes)change

33. Discussion Find this presentation on: http://tinyurl.com/7sbfvfrhttp://tinyurl.com/7sbfvfr Find rotation documents on :http://tinyurl.com/78occfo