Creating a Cohesive Physician Culture: Action Plans for Accountability

Creating A Cohesive Physician Culture: Action Plans for AccountabilityAmerican College of Physician ExecutivesApril 25, 2014

1

Steven P. Keuer, M.D.President, Chief Medical OfficerTrinity Mother Frances Health System

Andy Ziskind, M.D. Managing Director, Clinical SolutionsHuron Healthcare

2

Agenda

I. Three Keys To A Cohesive Physician Culture1) Clear work expectations2) Process for monitoring performance3) Action plans to increase accountability and productivity

II. Trinity Mother Frances Health System Case StudyIII. Commentary IV. Questions and Discussion

Organization Tools for Change

3Source: Forbes Steve Denning – Leadership 7/2011

Keys to Successful Culture Change DO introduce and consistently reinforce the

values of radical transparency and continuous improvement.

DO communicate horizontally in conversations and stories, not through top-down commands.

x DON’T start by reorganizing. First clarify the vision and put in place the management roles and systems that will reinforce the vision.

x DON’T parachute in a new team of top managers. Work with the existing managers and draw on people who share your vision.

4Source: Forbes Steve Denning – Leadership 7/2011

DO come with a clear vision of where you want the organization to go and promulgate that vision rapidly and forcefully with leadership storytelling.

DO identify the core stakeholders of the new vision and drive the organization to be continuously and systematically responsive to those stakeholders.

DO define the role of managers as enablers of self-organizing teams and draw on the full capabilities of the talented staff.

DO quickly develop and put in place new systems and processes that support and reinforce this vision of the future, drawing on the practices of dynamic linking.

Critical Elements to Support Change• Clear & Timely Communication

– You can’t over communicate!– Listen too!

• Strong Engagement Models– Give physicians opportunity to have direct input and responsibility for clinical and

administrative results– Inclusion and shared decision-making improve satisfaction

• Flexible Participation Models– Balance structure and hierarchy vs. agility – Make sure contract structure and financial incentives align individual goals with the

organizational goals – and be prepared to adjust as the market changes

• Be Supportive of Taking Risk and Making Mistakes– Recognize mistakes quickly and resolve them in a respectful and supportive manner– Implement change quickly, but also to monitor and adapt quickly as mistakes are

recognized and resolved

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© 2014 Huron Consulting Group Inc. All Rights Reserved. Proprietary & Confidential.

Trinity Mother Frances Health System Case Study

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Profile of Trinity Clinic – 2012

• Multispecialty clinic, 250 physicians / 100 APP’s in East Texas, part of Trinity Mother Frances Health System

• Governed by a 501(a) all-physician board, clinical leadership led by system wide Chiefs of Service who lead eight Institutes

• Culture characterized by group loyalty, passion for quality, physician-centric focus, ambivalence to service and access issues, variable productivity, with few practice standards

• New President and new Chief Administrative Officer in 2012• Clinic losses were covered by a System mission grant

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Climate for Change – 2012

• Financial crisis late 2012, caused by declining volumes, EHR implementation, opening of new Heart Hospital

• Comprehensive System cost reduction strategies implemented, including Trinity Clinic

• Intense focus on Clinic operations, productivity, financial improvement

• Private discussions began about sustainability of our integrated model

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Setting the Stage• “Never waste the opportunities offered by a good crisis” The

Prince, Machiavelli, 1532• Clinic leadership created a new vision for change, a

commitment to not only clinical but also financial and operational excellence

• Consensus developed among Clinic Board Executive Committee

• Restructured physician leadership to effectively lead new initiatives

• Executed a new management structure to support action plans (including data analytic support)

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Action Plans• Analysis revealed significant performance gaps in physician

productivity and access• Created physician-led multidisciplinary teams to lead each project• Clinic Board (1) approved a target of 65-75% specialty-specific

MGMA WRVU’s for physician productivity, (2) approved centralized scheduling for the entire Clinic, and (3) mandated that all Clinic physicians would see new patients

• Data analytics developed individual physician productivity reports produced monthly

• Chiefs of Service and administrative leaders met with small groups of physicians initially, then individually with low performers

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Productivity Approach: Throughput Analysis

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Physician Productivity Policy - 12/4/12• WHEREAS, the Trinity Clinic is a not-for-profit, physician corporation and an affiliate of Trinity Mother

Frances Hospitals and Clinics, an integrated health care delivery system consisting of, among others, acute care facilities, outpatient facilities, community practices and critical access hospitals (the “System”);

• WHEREAS, the Trinity Clinic desires to create fair and reasonable productivity targets that take into account: (1) physician work effort measured predominantly by a metric know as a work relative value unit (“WRVU”); as well as, (2) the System and Clinic’s overarching strategic vision and goal of improving quality and efficiency through innovation, integration and coordination of care; and

• WHEREAS, the Trinity Clinic further desires to create and maintain a provider workforce that is predictable and financially sustainable and yet flexible enough to meet the upcoming federal health care overhaul measures which will include provider accountability for quality, efficiency and outcomes;

• ACCORDINGLY, the Trinity Clinic Board hereby adopts the following as its Physician Productivity Policy effective December 4, 2012.

• The minimum target range for physician productivity for a full time Trinity Clinic physician shall be between the 65th and 75th percentile WRVUs, based on the most recent Medical Group Management Association (“MGMA”) data.

• The Board authorizes management to use appropriate actions to assist physicians in reaching this target range.

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Action Plans• 30, 60, 90 day meetings with providers to promote accountability, with

focused meetings as needed thereafter• Improved physician effort, re-locating providers, improving office

efficiency, marketing certain services lines, and in rare cases elimination of positions were required to right size each site

• Access dashboards were produced weekly, physician scheduling templates were simplified

• Centralized scheduling has been implemented in over 50% of clinics, with anticipation of 100% of clinics completed by calendar year end

• Significant returns in service, access, productivity, compensation, and financial performance have resulted

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Provider Capacity Tracking Report (WRVUs)

Internal Medicine

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Fam

ily M

edic

ine

Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun0

100

200

300

400

500

600

700

800

900

2012-20132013-201465th %tile75th %tile

Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun0

100

200

300

400

500

600

2012-20132013-201465th %tile75th %tile

Provider Capacity Tracking Report (cont)

15

Car

diol

ogy

Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun0

200

400

600

800

1,000

1,200

1,400

1,600

2012-20132013-201465th %tile75th %tile

Operating Revenues

16

Jan-1

2

Feb-1

2

Mar

-12

Apr-12

May

-12

Jun-1

2

Jul-1

2

Aug-12

Sep-1

2

Oct-1

2

Nov-12

Dec-1

2

Jan-1

3

Feb-1

3

Mar

-13

Apr-13

May

-13

Jun-1

3

Jul-1

3

Aug-13

Sep-1

3

Oct-1

3

Nov-13

Dec-1

3

Jan-1

4

System Consolidated Financials Operating Revenues

(In Thousands)

Net Oper. Rev.

Productivity Project Started

Trinity Clinic WRVU Trend

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Hospitalists are excluded in this data

37,000

39,000

41,000

43,000

45,000

47,000

49,000

51,000

53,000

PRIMARY CARE - PHYS. & APPMONTHLY WRVUs

PCP WRVU - ACTUAL MGMA 65%ile 2013 Report MGMA 75%ile 2013 Report

Data excludes Hospital based physicians such as Anesthesia, ER, Critical Care, etc

55,000

60,000

65,000

70,000

75,000

80,000

85,000

90,000

95,000

100,000

SPECIALIST PHYSICIANS(EXCLUDES HOSPITAL BASED PROVIDERS)

MONTHLY WRVUs

WRVU - Actual MGMA 65%ile 2013 Report MGMA 75%ile 2013 Report

Access Improvements: Clinical Call Volume

Goal:• Improve response time to patients on clinical

questions and inquires• Mitigate incoming call volume related to clinical

questions and inquires to improve overall customer experience for patients at POS

Tactic:• Utilize centralized call center management to

filter all front end telephony and isolate clinical calls and inquiries

• Use of EMR In-basket messaging to allow for instant visibility to clinical question and inquires by type and improve response time in hierarchy of clinical importance

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Result:• 25% reduction in front end clinic call volume• 89% reduction in response time to patients

Access Improvements: Centralized Scheduling Customer Experience

Goal:• Improve overall customer experience rating for

Centralized Scheduling, Insurance Verification, and Pre-Registration components of the system

• Achieve Service Industry best-in-class rating of 92% or better

Tactic:• Comprehensive SWOT analysis of all aspects of

provisioning and general telephony customer experience skills

• Comprehensive tailored training program isolated by functionality by business unit

• Comprehensive ongoing Quality Assurance process inclusive of measurement, management, and training by representative

• Calibration and On-going Secret Shop Evaluations

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Result:• Customer Experience Scores improved from

baseline of 71.5% to 93.1%• Improved Access Experience and Efficiencies

Lessons Learned• A crisis provides a unique opportunity to create transformative

change in your organization• Using existing governance of Clinic Board and Chiefs of Service

created project champions, and greatly facilitated cultural change and project success

• Changing Clinic culture from a physician-centric to a patient-centric focus, with clinical, operational, and financial excellence requires vision, planning, and clear accountabilities. For leaders it requires courage, for resistance to change will be great.

• A key to our project was accurate data in a user-friendly format consistently presented to physicians in a small group setting

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Summary• Changing performance requires diligent attention to changing

the culture• Three keys to developing a cohesive physician culture– Clear work expectations– Processes for monitoring performance– Action plans to increase accountability and productivity

• Pay close attention to– Communication– Engagement and meaningful physician participation– Using data well– Aligning incentives– Taking risks and celebrating successes!

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© 2014 Huron Consulting Group Inc. All Rights Reserved. Proprietary & Confidential.

Questions?

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Presenter Contact Information

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Steven P. Keuer, M.D.

President, Chief Medical Officer

Trinity Mother Frances Health System

[email protected]

903-531-4445

Andy Ziskind, M.D.

Managing Director

Huron Healthcare

[email protected]

312-405-7298