access alignment project - ucsf academic...

UCSF Medical Group and Medical Center ACCESS ALIGNMENT PROJECT

Phase 2 Medicine Subspecialties and Themes

January 9, 2012

© The Chartis Group, LLC

Topics

I. Phase I: Recap

II. Phase 2: Medicine Subspecialties

III. Common Themes

IV. Challenges and Looking Forward

V. Standard: New Patient Appt within 14 Days

I. Phase I Recap

We launched “Access Alignment” to materially and substantially improve access to adult outpatient services within a defined framework:

Core Patient Population – interventions were geared to patients with UCSF and One Medical Group PCPs;

Clear objectives – simple, efficient referrals for new patients;

Hands on Support - Chartis consultants provided analytic expertise, detailed plans and bodies to help clinics with implementing changes.

I. Phase I Recap

Phase I included Dermatology, Neurology, Orthopedics (Arthroplasty) and Cardiology.

Chief progress:

Auto-acceptance of new core patient referrals;

Direct scheduling option;

New appointment supply;

Enthusiasm and commitment of participants, including Primary Care;

3 month Chartis work supplemented by 6 month longer term action plan in each area.

II. Phase 2: Medicine Subspecialties

“Tipping Point”: There was a desire to expand specialty access as an enterprise-wide endeavor.

Medicine emerged as a strong candidate consistent with original project objectives.

Approach to Medicine – Two Dimensions of Work

Depth: Hands on work with 4 “deep dive” areas (Endocrinology, Gastroenterology, Pulmonary and Rheumatology) similar to Phase I.

Breadth: Plan to spread themes from deep dive divisions across the Department.

GAINING EXPERIENCE EMERGING THEMES

Objective: Core consistency across 35 DOM practices

Test and fine-tune new approach through Division-level pilots

Survey similar organizations for examples of best practice

1. Auto-approve All Core Referrals

2. Align on Consult Expectations

3. “Repatriate” Patients to Primary Care

4. Streamline Appointing Process

5. Optimize Master Schedules

6. Clarify Provider Time Expectations

7. Dedicated Resident Clinics

UCSF Best Practices


III. Common Themes

Pulmonary/ Allergy

Endocrinology Gastroenterology Rheumatology

Key Themes on How to Improve Access Alignment

Cardiology Neurology Dermatology Orthopedics


CAPACITY | Dedicated Resident Clinics

Benefits:

Dermatology and Neurology both dedicated an entire Resident clinic to new consults for Core patients. If slots are unfilled 3-7 days before appointments, they can be used for Core follow-ups or other patient visits.

• Prioritizes slots each week for new, Core patients • Ensures timely access for Core patients while discouraging unused slots

Neurology

Dermatology

Resident Clinic

Note: Requires stable Residents in clinics, unless Faculty members agree to see patients with or without Residents present

• New Core Patients

• Core Follow-up Appointments • Other General Dermatology (or Neurology) Appointments

> 5 Days from Appt1

< 5 Days from Appt1

1 Depends on frequency of Resident Clinic – if once/ week, then 5-7 days is sufficient



BEST PRACTICE: CAPACITY |Optimized Master Schedules

Benefits:

Clinical Commitment

Core Patient Demand

Current Appointment Backlog

Sub-specialty Practice Needs

Practice Objectives

Pulmonary/ Allergy

Pulmonary is reviewing “demand” for new patient slots and creating master templates that better meet the demand now and in a future “steady state” once the demand backlog is met. Cardiology and Orthopedics set minimum numbers of new slots in each session.

• Improves access for core patients • Minimizes gaps in schedule • Reduces congestion in clinic • Creates greater predictability of how the day will unfold

SCHEDULE INPUTS

OPTIMIZED PROVIDER MASTER SCHEDULE

Cardiology

Orthopedics

BEST PRACTICE: CAPACITY | Provider Time Expectations

Benefits:

Orthopedics implemented two key strategies to improve utilization of provider capacity – a time away policy and more leveraged mid-level providers to support additional new slots on physician templates.

Orthopedics

New PTO Policy

Restructured Master

Schedules

Leveraged Mid-level Providers

= Increase of Weekly New Patient Slots

from 18 to 35 + +

NEW Strategies Implemented

Leverage mid-level providers to see more routine follow-up patients, allowing physicians to see more new patients.

New Requirement: For every 2 sessions cancelled, providers “give back” one session within 4 weeks.

Restructuring master schedules of physician providers to increase number of new patient appointment slots each day – from 4 to 7.

• Increases new patient appointment availability • Ensures clinical commitments are met and outpatient clinic time is maximized


CAPACITY | DEFINE Provider Time Expectations (continued) Cardiology has developed a letter to accompany faculty re-appointment letters with explicit guidelines regarding effort allocation and clinical commitments in order to ensure provider capacity is fully utilized.

Cardiology

ROLE % EFFORT COMMENT Administrative* 30% Research/Other Paid Activity** 0% Clinical*** 70%

Contracts/Grants/Faculty Discretionary 0

Medical Center or non-Division Sources 0

Division Sources (including pro-fees, Division discretionary, or other Division resources)

100%

Your RVU productivity (FY11) Comparison Groups Total wRVU Adj wRVU’s* Division Median UHC Median MGMA Median

2581 3687 5996 7120 6849

Expectations for Provider Time Commitments Articulated in Annual Letter

Role

Salary Coverage

Clinical Commitments

Productivity Review

Clinical Area Effort Equiv/Unit^ Scheduled Frequency

Total Units Scheduled %Effort/Unit**

OP Sessions* 1 per session 2 sessions/wk 88 25% CCU 14 per wk 2 wks 28 8% Consults 7.5 per wk 8 wks 60 17% DOW 7.5 per wk 4 wks 30 9% HF Service 10.5 per wk EP Service 3.5 per wk EP Lab 1.5 per day Cath Lab 1.5 per day Echo Reading 2 per day 0.5 days/wk 44 12.5% EKG Reading 0.5 per day TOTAL CLINICAL EFFORT 250 71%


BEST PRACTICE: EFFICIENCY | Auto-Approval of Referrals

Benefits:

Gastroenterology

Pulmonary/ Allergy

Rheumatology

Endocrinology

Auto-approval launched in October

Auto-approval launched in October

Auto-approval under discussion

Eliminates non-value added faculty review time and handoff inefficiency Quicker turnaround to patient appointment made (rather than 2 week delay) Reduces number of patient calls

Teamwork need: Clarity and communication with PCPs on appropriate work-up.

Auto-approval already in place



BEST PRACTICE: EFFICIENCY | Direct Scheduling

Benefits:

Patient identified by PCP for referral

PCP office direct schedules

appointment at time of check-out

New Direct Scheduling Process for Core Patients*

Gastroenterology Dermatology and Neurology worked with UCSF primary care practices to implement direct scheduling for all new consult referrals; GI is next to implement this solution.

• Reduces number of calls into and out of the Specialty clinic, improving overall phone performance

• Satisfies patients tremendously

Neurology

Dermatology

COORDINATION |Clear Consult Expectations Rheumatology and Endocrinology are working with Primary Care to identify ways to

effectively communicate “work up” and referral guidelines for UCSF and One Medical PCP

referrals.

Rheumatology

Benefits: Clarifies service expectations and "who is in the driver's seat"

Endocrinology

Illustrative Referral Management Interface (in Apex)



• 5 Question Survey in each patient sleeve

1

• Specialist completes survey after each patient visit

2 •Identify volume of patients that are ready to return to Primary Care for ongoing follow-up care

3

• Validate findings with Primary Care

4

COORDINATION | “Repatriatism” to Primary Care

Benefits:

Step 1: Identify Magnitude of Opportunity (in process)

Endocrinology and GI providers are completing surveys for each patient to identify potential candidates to repatriate to primary care.

Frees up specialty capacity for new patient appointments

Step 2: Implementation (Winter 2012)

Identify concordance of results between Specialist & PMD

Define communication and operational processes to ensure safe transfer

Begin Repatriation

Endocrinology

Gastroenterology


At 8-8-11 Clinical Chairs, we shared the following vision of spreading consistency:

CURRENT STATE -> NEXT GENERATION -> ENTERPRISE-WIDE FOCUS

Performance Standards

Articulated for a select set of

practices; some monitoring

Centralized monitoring and

reporting on small number

of performance metrics.

Alignment on expected

performance; transparent

reporting on agreed

standards.

Access Strategies

Developed for four pilots

Next Phase to fine tune and

make broader near-term

impact across organization

Centralized resources

available to support

development and execution

Policies

Developed at Departmental

Level

Recommendations

disseminated to all Clinical

Chairs: e.g., definition of

session

Clinical Chairs adopt select

set of “group” policies for all

Departments

Integrated Planning for

Clinical Faculty

Ad hoc rather than based on

shortage

Template, standard process

and consistent expectations

for Clinical Faculty.

Consistent organizational

approach to ensure

appropriate compensation

for performance.


Recurring Challenges 1. Inadequate “general” specialty services supply (now

that we understand core patient population demand). “Losing” outpatient clinic economics, i.e., heavy overhead burden and truncated revenue stream makes expanding supply counterintuitive for a practice in isolation.

2.Need for standard core definitions and foundation. Inconsistencies make data collection and comparisons onerous. No dedicated long-term internal resource.


Recommendation: Internal Spread and solution stabilization until July 2012

1. Medicine is just beginning Dept-wide phase a. Adoption of common practices across Dept; b. Establishing new accountability structure; c. Rolling out additional innovations including e-

consult. 2. “Continued iteration” The two project teams

continue to refine and implement longer-term plans a. The teams meet monthly with PCPs to engage in solution development, testing and feedback.

V. 14 Day New Patient Appointment Metric

Purpose: The election of the 14 Day standard for new patient appointments was based both on Dept of Managed Care regulations effective in 2010 and expectations of PCPs/patients as to what competing specialists could provide in the community. Target: A target set at 80% allowed an overall buffer for pockets that were highly specialized and was considered aspirational. Context: This metric is the most widely applicable measurement with limited automated capability across the organization. This metric does not capture the overall efficiencies gained prior to the appointment being scheduled (i.e., elimination of the cumbersome, time-consuming and ultimately ineffective “screening” process). It also does not speak to the valuable cross-coordination and provider schedule management that will yield improved operations. Performance has many dimensions that current reporting capability does not reflect.

Phase I: Neurology

New Patients Appointments within 14 Days Focus:

Long wait times for general appointments

Convoluted review process

• New slots through Expedited Care Clinic (creative use of residents)

• Number of Patients: 369

• 66% scheduled by Neurology

Capacity

• Direct Scheduling to ECC

• 34% direct scheduled

• CBNS1 Rate = 20% (UCSF practices are typically at 40%)

• Simplified and centralized review process

• Use of ECC to bolster productivity

Efficiency

• Discussion at Primary Care Operations December 2011 Meeting

Communication/Coordination

1CBNS = Cancellations, Bumps, and No Shows

Phase I: Dermatology

New Patients Appointments within 14 Days Focus:

Long wait times and heavy demand

Overwhelming phones

• Dedicated Tuesday PM clinic that was undersubscribed; new providers also geared to core patient population

Capacity

• Direct Scheduling for PCPs

• Direct means for PCPs to refer; outbound call to patients

Efficiency

• Discussion with One Medical Group to extend course offerings/“talks” on managing common dermatologic conditions


Phase I: Orthopedics

New Patient Appointments within 14 Days Focus:

Long wait times due to high bump rates

• Conversion to higher ratio of new patient slots (increased 75%);

• “Give back” policy to stabilize supply and work down back log

Capacity

• Centralized Scheduling Management to minimize gaps in schedule

Efficiency


Phase I: Cardiology

New Patient Appointments within 14 Days Focus:

Long wait times for general appointments

• 4 hour session standard

• “Doc of the Week” to triage urgent requests

Capacity

• Simplified phone tree and “human being” responding to dedicated provider phone line

Efficiency


UCSF Medical Group: New Patients seen within 14 Days by Department

Source: IDX Scheduling arrived new patient visits; six month average July-December 2011

access alignment project - ucsf academic...

Documents