Patient Workflow

The Patient Protection and Affordable Care Act has increased access to care, estimated to be at least 10 million enrollees, depending whose numbers you believe. But without a corresponding increase in the number of physicians, it’s overtaxed an already overburdened care delivery system.

The patient-centered medical home (PCMH) is one of a number of programs aimed at address-ing the problem from both patient and the physician perspective. According to the Agency for Healthcare Research and Quality, the PCMH “is a model of primary care transformation that seeks to meet the healthcare needs of patients and to improve patient and staff experiences, outcomes, safety, and system efficiency.”

Making that transition is a lot easier said than done. Practice administrators often rely on the specialized expertise and “fresh eyes” that an outside consultant can bring to a practice. Under-standing how to create and optimize a patient workflow, for example, is critical in order to qualify for PCMH accreditation, but it’s something that many practice managers have never done be-fore.

A patient workflow follows a patient through a practice visit from beginning to end. It can serve as a skeleton upon which the rest of the PCMH can be fleshed out. When the practice manager, physicians and support staff understand where each patient is supposed to be at any given step during the visit process, then everyone knows what electronic health record (EHR), diagnostic, counseling or other steps must be taken to continue managing the patient’s health according to PCMH best practices.

Kenneth T. Hertz, CMPE, principal consultant, MGMA Health Care Consulting Group, has a wealth of experience in helping administrators transform their practices into a PCMH-accredited institution.

Last year, Hertz did just that with a practice in Lincoln, Nebraska.

The need for a broader perspective

“[The practice] wanted an independent, third-party perspective that could bring a broader vision to address these issues,” Hertz recalled.

To show the current workflow and ultimately create a more effective one, a practice manager would need time, expertise and the ability to “move around the practice sight unseen — kind of in a cloaking device,” explained Hertz. “When I come in, I’m an outsider,” he noted, adding that it’s more likely that staff will be honest with him than with a practice manager and perform as they’d normally perform.

“Everybody stands a little more upright and focuses more when the practice manager is watch-ing,” Hertz said. “It’s more difficult for the manager to get a true and honest picture.”

He begins the patient workflow construction process by assigning himself a lot of homework. “Before I come on site, I’ll ask for some basic information,” Hertz explained. “If you’ve got any written workflow schematics, I’d like to see those — they didn’t. I’ll look at schedules, patient vol-umes, staffing ratios, physician schedules.” He continued, “I’ll also talk with the administrator to determine if he or she has identified any specific areas that need to be tackled,” because admin-istrators usually know what the pain points are in their practice and whether the practice is staffed according to benchmarking standards. 

After all of that information is compiled, Hertz hits the road, typically committing three to four days to working with the practice administrator and staff. They agree to a common objective. Hertz tours the facility and meets everyone, and then he gets down to work.

Constructing the workflow, start to finish

“‘My work’ consists of following patients as they check in, as they are roomed, then go through any diagnostic testing, and then go through check-out,” Hertz explained. 

That is obviously a simplified explanation for a complex process.

“I observe processes in specific areas and how they function,” he added. “In some cases, I will spot interview various staff members. In other cases, we’ll set up scheduled interview time with department managers and team leaders and go through a series of questions to understand what’s happening, what’s working and what’s not working.”

He closed each day of his on-site audit with a daily debrief with the practice administrator, “covering what I’ve seen — my observations, my opinions — and find out if I’m on the right track or if I missed anything.”

It’s a critical component of what Hertz calls a “collaborative process.”

What problems can a streamlined workflow solve?

When patients have a streamlined experience during their regular physician visit — roomed in a timely manner, seen quickly by the nurse, followed soon after by the physician, ushered smooth-ly through payment and efficiently processed during each step throughout — then not only can the physician effectively manage that patient’s care according to PCMH standards, but it also truly builds the practice around the needs of the patient.

These patients are less likely to utilize emergency department (ED) or out-of-network care be-cause their needs are being met by their PCMH. “The reduction in ED utilization was a function of numerous changes within the workflow,” noted Hertz. The triage nurse protocol was modified to handle incoming inquiries in a more effective and efficient manner. Hertz recommended bet-ter training for certain positions, changed responsibilities and standardized protocols. 

After the practice manager reoriented staff according to Hertz’s recommendations and used his feedback about the overall patient experience to tweak processes, the throughput for scheduled and “same-day” patients increased. The attention to utilizing space more effectively and schedul-ing care teams also increased patient throughput while providing improved care. And the con-sistent program of patient reminder calls meant fewer missed patient appointments.

Hertz wrapped up with a final written report he provided to this administrator, who then took charge of the actual implementation of the transition.

It worked, too, slashing the practice’s ED utilization with its Medicaid population. The practice far outpaced its 5 percent reduction goal — cutting utilization by 37 percent, ultimately saving tens of thousands of dollars in ED utilization costs.

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