Why Do High Volume Practices Not Work Well For So Many?

[Guest guest]

I have seen quite a few high volume practices not work well from both

the patient and physician vantage points. We know the typical

scenarios all too well; long wait times, different docs on different

days, delays in access, incorrect care, physician burnout and

dissatisfaction amongst staff, and so on.

However, there are also practices with multiple docs who are doing

quite well. They offer group visits, extended hours, open access,

patient portals, good P4P numbers, happy staff and physicians, etc.

What might explain this difference? Some of my observations are that

the practices that are " failing " the patients and the docs are lacking

in organizational systems. There typically is a lack of a mission

statement, no direction, no measurement of progress, no benchmarking,

and no milestones. The " successful " practices tend to have these

things in place.

Perhaps one of the reasons is that the " successful " practices are run

by people trained to run a medical business. Perhaps the lack of this

sort of training at any level in our medical education sets us up for

businesses that are unfocused be it for patients or doctors.

This is one of the reasons I like P4P and the registry functionality

of EMRs. It forces us to see our practices globally and from a systems

perspective. The global view allows us to realize that in order to

address our population of patients we need systems in place that allow

us to act globally.

I think group visits are a case in point. Using my EMR we pulled up

patients with out of range A1c's. With that list in hand, we hired a

health educator and invited the patients on the list to an 8 session

series of group visits.

I think that all of this applies to a practice be it a small or large

IMP or a volume based practice.

Lowell

[Guest guest]

I agree with what you have said. Case in point is that in the

90's we sold our practice to the local hospital and we were seen as a through

put exactly as you described. They had 2 MBA's running our practice and it was

the perfect recipe for disaster. I lasted one year in that environment.

What I was describing in my original post was not an MBA run

group. Rather, a stakeholder run group that has a manager or point person

(might be a doc) who has ongoing training on how to run a successful office.

I think a mission statement that grows with the practice, that

is created by all of the practice's stakeholders (staff/docs/sometimes

patients) is the compass that sets True North. P4P, registries, portals, etc. are

the tools that allow you to know if you are headed in the right direction and

tell you when you need to make adjustments. For example, having a hurdle in the

AM, or a weekly/monthly meeting is a compass thing. Using a registry to set up

a diabetes group visit is a tool thing. Getting a P4P report tells you if your

compass is working well.

Lastly, I am thinking that running the practice like a BUSINESS

can result in overemphasizing the profit incentive. It does not capture what

many of us are trying to create However, we can't ignore business tactics.

Lowell Kleinman, MD

5601 Norris Canyon Rd.

Suite 340

San Ramon, CA 94583

www.drkleinman.com

drk@...

From:

[mailto: ] On Behalf Of magnetdoctor@...

Sent: Tuesday, April 15, 2008 7:16 AM

To:

Subject: Re: Why Do High Volume Practices Not

Work Well For So Many?

Having worked for at least 3 practices with multiple

doctors, mission statements, and benchmarking, meetings ad nausea, all run by

people with MBA's but no medical training, I couldn't agree less with

you. All of these practices were failing in the monetary sense, and

failing for patients, they were a collection of individuals, trying to get

through the day, and the abyss of rules, forms, and goals, to their families,

and their lives. I still am seeing doctors join, burn out in 7-10 years,

and move on. These practices had one thing in common, they were run as

business' to supply through put for a larger organization. That is, labs,

XR, referrals, and admissions to the hospital, or organization owning the

practice. I feel that until doctors are the ones running the practices,

with or without MBA's, or mission statements nothing will change. I also

see doctor run small to medium groups, that function very well, and I believe

it has more to do w ith group purpose, and treating the employee's well, than a

mission statement or P4P.

Cote' MD

Maple Valley, WA

-------------- Original message --------------

I have seen quite a few high volume practices

not work well from both

the patient and physician vantage points. We know the typical

scenarios all too well; long wait times, different docs on different

days, delays in access, incorrect care, physician burnout and

dissatisfaction amongst staff, and so on.

However, there are also practices with multiple docs who are doing

quite well. They offer group visits, extended hours, open access,

patient portals, good P4P numbers, happy staff and physicians, etc.

What might explain this difference? Some of my observations are that

the practices that are " failing " the patients and the docs are

lacking

in organizational systems. There typically is a lack of a mission

statement, no direction, no measurement of progress, no benchmarking,

and no milestones. The " successful " practices tend to have these

things in place.

Perhaps one of the reasons is that the " successful " practices are run

by people trained to run a medical business. Perhaps the lack of this

sort of training at any level in our medical education sets us up for

businesses that are unfocused be it for patients or doctors.

This is one of the reasons I like P4P and the registry functionality

of EMRs. It forces us to see our practices globally and from a systems

perspective. The global view allows us to realize that in order to

address our population of patients we need systems in place that allow

us to act globally.

I think group visits are a case in point. Using my EMR we pulled up

patients with out of range A1c's. With that list in hand, we hired a

health educator and invited the patients on the list to an 8 session

series of group visits.

I think that all of this applies to a practice be it a small or large

IMP or a volume based practice.

Lowell

[Guest guest]

Although in general I agree with what is said below, I would put a

slightly different spin on things. I think the traditional model of

running medical offices has failed. That is, the traditional

business model used in medicine has not held up to the new reality.

The new business model is certainly predicated on systems thinking,

effectiveness and efficiency as well as a new extreme form of

teamwork. As I said before, I'm not bashful about saying that I use

the Toyota production system as the paradigm for this new model with

a few extra ingredients added in specifically for family medicine.

It is a system that one needs to think about for years, continually

work at implementing,and values consistency of team members.

Also, no business model at all will hold up when the external system

becomes so hostile that it is difficult to survive. (Read the

present state of the United States healthcare system)

>

> > I have seen quite a few high volume practices not work well

from both

> > the patient and physician vantage points. We know the typical

> > scenarios all too well; long wait times, different docs on

different

> > days, delays in access, incorrect care, physician burnout and

> > dissatisfaction amongst staff, and so on.

> >

> > However, there are also practices with multiple docs who are

doing

> > quite well. They offer group visits, extended hours, open access,

> > patient portals, good P4P numbers, happy staff and physicians,

etc.

> >

> > What might explain this difference? Some of my observations are

that

> > the practices that are " failing " the patients and the docs are

lacking

> > in organizational systems. There typically is a lack of a mission

> > statement, no direction, no measurement of progress, no

benchmarking,

> > and no milestones. The " successful " practices tend to have these

> > things in place.

> >

> > Perhaps one of the reasons is that the " successful " practices

are run

> > by people trained to run a medical business. Perhaps the lack of

this

> > sort of training at any level in our medical education sets us

up for

> > businesses that are unfocused be it for patients or doctors.

> >

> > This is one of the reasons I like P4P and the registry

functionality

> > of EMRs. It forces us to see our practices globally and from a

systems

> > perspective. The global view allows us to realize that in order

to

> > address our population of patients we need systems in place that

allow

> > us to act globally.

> >

> > I think group visits are a case in point. Using my EMR we pulled

up

> > patients with out of range A1c's. With that list in hand, we

hired a

> > health educator and invited the patients on the list to an 8

session

> > series of group visits.

> >

> > I think that all of this applies to a practice be it a small or

large

> > IMP or a volume based practice.

> >

> > Lowell

> >

> >

> >

>

>

>

> --

> If you are a patient please allow up to 4-8 hours for a reply by

email/

> please note the new email address/

> e mail may not be entirely secure/

> MD

>

>

> ph fax

>

[Guest guest]

My

nurse (LPN) is like that. She is off every Wednesday and my wife fills in.

Repeatedly, there are people who call and ask for Jeannie. When my wife tells

the patient she is off for the day, they say they will call back. I have also

tracked how busy we are when she goes on vacation and the number of patients we

see drops by about 1/3. No question she is quite valuable to the practice.

Re: Why Do High Volume Practices Not Work Well For So Many?

Has anybody ever had an assistant that was so good you felt like

the patients were really coming in to see that person more than

you as a physician? I've had maybe 4 of those during 30 years.

Somebody who could empathize with the patients at the same time

they could cut to the quick and get the important information from

them for you, so you could do the physician stuff so much easier?

Keep all the office flow going, while monitoring your every mood and

need, while at the same time taking care of their own families, and

yet they actually seem to enjoy the whole mess. The ones like that

I've had mostly had no formal training nor any degrees. How do you

find people with those kinds of qualities?

>

> > I have seen quite a few high volume practices not work well

from both

> > the patient and physician vantage points. We know the typical

> > scenarios all too well; long wait times, different docs on

different

> > days, delays in access, incorrect care, physician burnout and

> > dissatisfaction amongst staff, and so on.

> >

> > However, there are also practices with multiple docs who are doing

> > quite well. They offer group visits, extended hours, open access,

> > patient portals, good P4P numbers, happy staff and physicians,

etc.

> >

> > What might explain this difference? Some of my observations are

that

> > the practices that are " failing " the patients and the docs

are

lacking

> > in organizational systems. There typically is a lack of a mission

> > statement, no direction, no measurement of progress, no

benchmarking,

> > and no milestones. The " successful " practices tend to have

these

> > things in place.

> >

> > Perhaps one of the reasons is that the " successful "

practices are

run

> > by people trained to run a medical business. Perhaps the lack of

this

> > sort of training at any level in our medical education sets us up

for

> > businesses that are unfocused be it for patients or doctors.

> >

> > This is one of the reasons I like P4P and the registry

functionality

> > of EMRs. It forces us to see our practices globally and from a

systems

> > perspective. The global view allows us to realize that in order to

> > address our population of patients we need systems in place that

allow

> > us to act globally.

> >

> > I think group visits are a case in point. Using my EMR we pulled

up

> > patients with out of range A1c's. With that list in hand, we

hired a

> > health educator and invited the patients on the list to an 8

session

> > series of group visits.

> >

> > I think that all of this applies to a practice be it a small or

large

> > IMP or a volume based practice.

> >

> > Lowell

> >

> >

> >

>

>

>

> --

> If you are a patient please allow up to 4-8 hours for a reply by

email/

> please note the new email address/

> e mail may not be entirely secure/

> MD

>

>

> ph fax

>