1. WSMGMA Annual Meeting May 8-10, 2006 Best Practice Delivery Model based on Efficiency Principles Presented by: Barbara Derry, BSN, FACMPE Crystal Nolan, MHA, FACMPE Principals: Derry, Nolan & Associates, LLC

2. DERRY, NOLAN & ASSOCIATES, LLC Why are Efficiency Principles So Important? $350 Billion a year, or 22% of the total amount spent on healthcare, is wasted through redundant paperwork. (Source: Forbes, May 24, 2004, “Sawbone Solutions, Stat” p. 96 Efficiency is one of the six dimensions of health care performance cited in the Institute of Medicine’s (IOM) landmark 2002 report: Crossing the Quality Chasm

3. DERRY, NOLAN & ASSOCIATES, LLC US Health Care Needs a Face Lift Don M. Berwick, M.D. co-author of the Institute of Medicine’s landmark report calls for nothing less than a redesign of the U.S. health care system, citing myriad inefficiencies throughout the work processes of health care.

4. DERRY, NOLAN & ASSOCIATES, LLC Efficiency Defined According to the IOM’s report, “Efficiency is the reduction of waste and, thereby, the reduction of the total cost of care should be never-ending, including, for example, waste of supplies, equipment, space, capital, ideas, and human spirit.”

5. DERRY, NOLAN & ASSOCIATES, LLC Redesigning Delivery of Care Current efficiency design rule: Cost-reduction is sought New efficiency design rule: Waste is continuously decreased. Results: An increase in patient satisfaction & revenue opportunities

6. DERRY, NOLAN & ASSOCIATES, LLC DNA’s Approach to Efficiency Elimination of non-value added work to achieve better patient, provider, & staff satisfaction while increasing revenue opportunities Typically, we find a minimum of 40% of work-process steps do not improve outcomes and are not necessary

7. DERRY, NOLAN & ASSOCIATES, LLC DNA’s Approach to Efficiency Most common reasons given by providers and staff: We’ve always done it this way; This is the way I was trained; “What if” scenarios I don’t know….

8. DERRY, NOLAN & ASSOCIATES, LLC Improvement Goals for Specialty Clinic—A Case Study Increase patient encounters by increasing efficiency and patient flow Increase staff satisfaction through workflow redesign Improve coding and documentation practices All lead to increased revenue

9. DERRY, NOLAN & ASSOCIATES, LLC Background Physicians came from diverse backgrounds into a new clinic within an integrated health care system: Military HMO Free-standing, independent group

10. DERRY, NOLAN & ASSOCIATES, LLC Challenges Encountered Despite new facility, physicians and staff were unhappy Staff convinced more staff necessary Physicians’ schedules driven by nursing needs Patient volumes and revenue were flat Nursing-centered model rather than patient-centered (patient & physician waits too long) Low charge per encounter

11. DERRY, NOLAN & ASSOCIATES, LLC Identified Risks Lack of documentation to support level of billed service Under coding (under valuing) Inefficient patient/workflow Decreased staff satisfaction

12. DERRY, NOLAN & ASSOCIATES, LLC Phase I - Goal Successful Chart Audit through development of clinical templates to capture essential documentation and billing elements

13. DERRY, NOLAN & ASSOCIATES, LLC Action Plan Establish team work session to facilitate input “All staff are responsible for the coordination of patient care” Operational assessment of current information and flow Redesign Professional fee ticket Redesign Facility fee ticket Development of 2-3 clinical templates to capture required documentation Provide education/training for new documentation tools Conduct coding and documentation audit on use of new documentation tools

14. DERRY, NOLAN & ASSOCIATES, LLC Coding to support level of service being provided Outcomes

15. DERRY, NOLAN & ASSOCIATES, LLC Outcomes (cont.) Documentation to support coding

16. DERRY, NOLAN & ASSOCIATES, LLC Outcomes (cont.) Increase in Revenue

17. DERRY, NOLAN & ASSOCIATES, LLC Phase II - Goal Continue to improve coding and documentation practices, and increase patient encounters/visits Increase staff satisfaction

18. DERRY, NOLAN & ASSOCIATES, LLC Action Plan Continued teamwork sessions Provide on-going coding and documentation support to accurately match level of service to CPT and ICD-9 codes Monitor effectiveness of documentation template and modify as needed to maximize effectiveness

19. DERRY, NOLAN & ASSOCIATES, LLC Action Plan (cont.) Redesign the staffing model and core processes to ensure the right people are doing the right work at the right time Transition from an “RN driven model” to an “MD and Patient driven model” Determine MD capacity Analyze patient flow to determine bottle necks and road blocks

20. DERRY, NOLAN & ASSOCIATES, LLC Action Plan (cont.) Block MD schedules and open up the templates to allow full use of clinic time (compressed schedules) Re-align team functions of staff Encourage patients to arrive early for labs to be drawn, or prior to appointment if appropriate Re-arranged work space Daily “team huddle” Lead Nurse assigned as “Air Traffic Controller” Discharge patient when care is “done” Design, implement and utilize flag system

21. DERRY, NOLAN & ASSOCIATES, LLC Outcomes Completed final documentation template Decreased length of stay from an average of 114 minutes to 82 minutes. 28% improvement

22. DERRY, NOLAN & ASSOCIATES, LLC Outcomes (cont.)

23. DERRY, NOLAN & ASSOCIATES, LLC Outcomes (cont.)

24. DERRY, NOLAN & ASSOCIATES, LLC Outcomes (cont.) All staff take lunch and breaks Elimination of overtime Two “protected” afternoons to catch up with chart review and clinic administrative functions

25. DERRY, NOLAN & ASSOCIATES, LLC Into the Future Lead nurse mentoring Continued development of communication among staff Staff to adopt goal for an average length of stay in the clinic to be 60 minutes Continued management and physician support Reinforcement of changed behaviors and successes Staff discussion forum

26. DERRY, NOLAN & ASSOCIATES, LLC Summary Total investment: $83,000 Phase I$18,000 Phase II$65,000 Projected gross revenue improvement at: 1 Year$239,418 5 Years $1,197,092

27. DERRY, NOLAN & ASSOCIATES, LLC Audience Participation Audience identifies a major time-consuming, redundant work process Discuss possible solutions to re-design a more efficient work process