Addressing Physician Burnout-It’s Not Just the EHR

Tactics for addressing Physician Burnout http://bit.ly/2xJOzX4

MGMA 2017- Presentation : Optimizing Health Information Management

Another outstanding MGMA conference in Anaheim CA.   Proud of our speakers Elizabeth Morgenroth, CPC and Randy Jones, DHA, FACHE,FACMPE who presented:

“The Data Integrity Department: Optimizing Health Information Management”

Looking forward to MGMA 2018 in Boston!

Selecting and Mentoring your Physician Champions for Organizational Change

Healthcare executives know that physician champions are critical to achieve successful change within their organization for many projects. However, merely selecting a physician to function as the champion for an organizational change project, is often insufficient. Things don’t always turn out as envisioned.   The physician may not be effective as hoped due to lack of credibility, inability to obtain buy-in, or inadequate communication skills.    It is not only important to select the right physician champion, but also to provide guidance and mentoring to maximize their effectiveness.

What is a physician champion? The physician champion functions as an important liaison between project leadership and the physician community.   It is important that they represent the physician’s voice, not just their own, and can “speak” to physician’s interests broadly.   In addition, they are an important communicator back to the physicians.  They need to be able to speak directly to the physicians and focus on the most relevant issues.  Physician champions should help identify important stakeholders, both advocates and naysayers, and communicate effectively with these important groups in order to maximize buy in for successful change.

Selection of physician champions.  Obviously, selecting the best person for the role is critical.  You should not assume that your CMIO or CMO is the right physician champion for every project within your organization.   It certainly makes sense for them to be aware and support change projects, but they may not always be the best person to function as physician champion.  Are they viewed as “a suit” and not clearly a physician voice? Are they stretched too thin for a time-consuming change project?  Do they lack credibility, due to limited clinical or operational experience, to represent physician’s interests on a given project?  The organization may be better suited by a physician more closely aligned with the physicians and/or the project subject matter.

Clinical credibility is often very important when selecting a physician champion.  You may have physicians interested in leadership roles because they are IT gurus, but they aren’t viewed as walking in their colleague’s shoes.   Or you might have physicians who view their role to be the voice of the physicians… “against any change that might ever impact the physicians.”

Supporting the role of the physician leader.   Physicians tend to be independent by nature.   Training has taught us to make and own important life and death decisions.   Although todays medicine often focuses on team care, it doesn’t come easily to physicians nor do the leadership skills required to achieve consensus and deal with conflict.   It is important to not assume that by simply identifying a good physician champion they will be successful   Identify a mentor who can guide them through the core responsibilities of a good physician champion.

Core responsibilities of a physician champion:

  1. Develop an effective process to gather broad based physician input
  2. Effectively represent physician interests in governance and design meetings
  3. Stakeholder management through development of a stakeholder list and action plan
  4. Develop and implement a communication plan
  5. Effective dealing with naysayers, conflict, and setbacks within a project.


Selecting the right physician champion for organizational change project is only one important strategic step.  It is equally as important for the champion to understand the expectations of the role.   Providing the champion with appropriate mentoring and guidance will help assure success.


Crossroads Between Physician Productivity & Burnout


Deconstructing the Construction of a New Facility

The success of building a new clinical location is dependent on many factors and people working collaboratively and in sync.  Some tips for a successful outcome include:

Time – One can never start planning too early.  Prior to construction and during construction, take time to understand and document wants vs. needs vs. must haves.  You can narrow and prioritize the list at a later date.  Changes to the design during construction can result in additional costs.

People – Consult the users of the space.  This includes all stakeholders including providers, front desk, billing, clinical staff, ancillary services and your administrative team.  Observe the work in the current space and verify all of the key workflows.  Ensure barriers to productivity are resolved.  As you design the new space, consider opportunities to enhance efficiency, patient and staff and physician satisfaction.

Communication – Consider building “touchdown space” in the clinical area and optimize your flow.  Many designs now have co-located shared space with providers and support staff, which is known to improve communication and teamwork.

Voice of the Patient – The voice of the patient is key when constructing and problem solving; not to mention when creating a patient centered environment.  Interview patients to obtain their input.  Consider surveys, on-site interviews, focus groups and outreach calls to gather information.

Practice – Test out the new workflows and create a mock-up of the exam room.  Map out your table, stools, cabinets, sharps boxes, locations for disposable supplies such as gloves, door, curtain, etc. Simulate how the team members and patients will move within the space.  A fun and effective exercise in the initial planning stage is to put together a cross functional team to create the ideal layout using post-its!  This helps to surface workflows but can also point out differences in opinion among the team.

Team Meetings – Consider if you will need space for teaching or team meetings.  With the implementation of value-based care, a shared administrative space may prove to be essential for your PCMH.  Don’t forget about staff meetings or educational programming, which is required by licensure or recommended by leadership.  If you are a teaching program, consider the needs of students, fellows, residents and instructors.

Technology – Consider your current level of technology.  Will the construction include new features of your current software or upgrades or a completely new system?  This is a good time to review your Electronic Health Record (EHR) and Practice Management System (PM) or Radiology PACS, and identify change opportunities to allow time to plan.  For example, my current client is using it as a vehicle to redesign and optimize their clinical capabilities.  Instead of assigning each student a designated workspace (i.e., Exam rooms 1 and 2), they are using the rooms as resources, which will allow for other users to utilize the exam room when the Monday and Wednesday provider is on vacation.  This change will allow a 36% opportunity to increase production.

Construction is exciting, but identifying a lead project manager can be essential to a successful outcome.

Jill Berger-Fiffy , MHA, FACMPE
Senior Consultant

CMS Quality Payment Program – APM Path- part 3 of a 3 part Series on MACRA

What is an Alternative Payment Model (APM)?

In part two of this specific blog series on MACRA, I emphasized the CMS QPP decision tree and covered the MIPS path.  In part three, we will discuss the APM path.

Alternative Payment Models (APMs) are new approaches to paying for care through Medicare that incentivize quality and value.  The CMS Innovation Center develops new payment and service delivery models.  Additionally, Congress has defined—both through the Affordable Care Act and other legislation—a number of demonstrations that CMS conducts.

APM entities must meet one of two thresholds each year for their physicians to be considered qualified participants: the Payment Amount threshold or the Patient Count threshold

Using the Payment Amount threshold, APM entities must receive a minimum percentage of Medicare Part B payments through the APM each performance year, with the percentage rising through 2022.




  • A payment approach that provides added incentives to clinicians to provide high-quality and cost-efficient care.
  • Can apply to a specific condition, care episode or population.
  • May offer significant opportunities for eligible clinicians who are not ready to participate in Advanced APMs.


Advanced Alternative Payment Models (AAPMs)

Advanced APMs are a subset of APMs and enable practices to earn more rewards for taking on some risk related to patients’ outcomes and cost of care

Under the Quality Payment Program, clinicians who participate to a sufficient degree in Advanced APMs are excluded from MIPS and earn a 5% lump sum incentive payment based on their Part B professional services for a given year, and also receive greater rewards for taking on some risk related to patient outcomes.

Advanced APMs must meet the following three requirements:

  1. At least 50% of the clinicians in each APM Entity use certified EHR technology to document and communicate clinical care information with patients and other healthcare professionals.
  2. Bases payments on quality measures that are comparable to those used in the MIPS quality performance category.
  3. Be a Medical Home Model expanded under CMS Innovation Center authority or:
    1. Meet a revenue-based standard of financial risk that averages at least 8% of revenues at-risk for participating APMs
    2. Meet a benchmark-based standard of financial risk in which the maximum possible loss must be at least 3% of the spending target

In 2017, the following models are Advanced APMs:

  • Comprehensive ESRD Care (CEC) – Two-sided Risk Arrangements
  • Comprehensive Primary Care Plus (CPC+)
  • Next Generation ACO Model
  • Shared Savings Program – Track 2
  • Shared Savings Program – Track 3
  • Oncology Care Model (OCM) – Two-sided Risk Arrangement

In future performance years, we anticipate that the following models will be Advanced APMs:

  • Comprehensive Care for Joint Replacement (CJR) Payment Model (Track 1- CEHRT)
  • New Voluntary Bundled Payment Model
  • Advancing Care Coordination through Episode Payment Models Track 1 (CEHRT)
  • Vermont Medicare ACO Initiative (as part of the Vermont All-Payer ACO Model)
  • ACO Track 1+

Under the AAPM path, clinicians will receive an annual 5% lump-sum bonus between 2019 and 2024, with a 0.75% increase to their Medicare physician fee schedule beginning in 2026.  While the AAPM track does not carry the penalty risks present in the MIPS track, APM entities must have a risk-based payment model for clinicians to qualify for AAPM.

While Advanced APMs have a fixed bonus incentive of 5% through 2024, it is important to understand that the Quality Payment Program does not change the design of any particular APM.  Instead, it creates extra incentives for a sufficient degree of participation in Advanced APMs.

How Do Eligible Clinicians Become a Qualifying APM Participant (QP)?

APM entities must meet one of two thresholds each year for their physicians to be considered qualified participants.  CMS will calculate a percentage “Threshold Score” for each Advanced APM Entity using two methods:

  1. The Payment Amount threshold and the Patient Count threshold.
  2. Using the Payment Amount threshold, APM entities must receive a minimum percentage of Medicare Part B payments through the APM each performance year, with the percentage rising through 2022.

Using the Patient Count Method, APM entities must see a minimum percentage of Medicare patients through the APM each performance year, with the percentage rising through 2022.

  • Methods are based on Medicare Part B professional services and beneficiaries attributed to Advanced APM.
  • CMS will use the method that results in a more favorable QP determination for each Advanced APM Entity.
  • The Threshold Score for each method is compared to the corresponding QP threshold table and CMS takes the better result.
  • The QP Performance Period for each payment year will be from January 1—August 31 of the calendar year that is two years prior to the payment year.

Beginning in 2021, this threshold percentage may be reached through a combination of Medicare and other non-Medicare payer arrangements, such as private payers and Medicaid.









What is a Partial Qualifying APM?

Clinicians are considered Partial Qualifying APM participants if their APM entities participate in an Advanced APM, but meet a slightly lower threshold outlined by CMS.

Clinicians participating in the Partial Qualifying APM track will not receive AAPM’s 5% incentive payment, but they can opt into the MIPS path if they can meet its reporting requirements.

In Summary

The shift from the Sustainable Growth Rate formula’s “fee-for-service” payment model to MACRA’s value-based payment model should ultimately help to preserve Medicare funds in the long-term while incentivizing ongoing initiatives that could make a positive impact on population health in the U.S.  The Advanced APM track and the QP status may be desirable for many MIPS eligible providers.  Due to the inherent financial risks involved in any AAPM, an organization should evaluate these programs with care and consideration.



Senior Consultant -Culbert Healthcare Solutions

Admissions/Registration: Helping to Improve Accounts Receivable

One of the most important ways to improve A/R is the admissions/registration areas of any healthcare organization.

Many facilities band-aid issues within the admission/registration areas by correcting errors in billings, which is not effective nor is it cost efficient.  It is estimated that it costs healthcare facilities $15 per visit to track and collect co-payments and deductibles after the fact.  For many healthcare organizations, such as physician offices, this practice could result in a zero net revenue gain.  Additionally, it costs healthcare facilities approximately $15 – $25 per visit for billing staff to correct registration errors and approximately $15 per statement sent to patients for co-pays, deductibles and co-insurances that could have been collected upfront.

So what steps can a healthcare facility take to remove the admissions/registration area band -aids and ultimately improve their A/R?

Step 1:  Management should be open to change

Most admission/registration managers have vast experience in their field and want nothing but a well-run department.  However, for many managers the stress of running a high-volume department that can potentially be open 24 hours a day does not allow them the luxury of thinking outside the box.  Staff may not be willing to discuss issues with management, some applications do not provide error reports to managers, and some applications do not record who made the error(s) so they cannot be addressed with that individual.  For improvement and changes within the admission/registration areas, management must be open to change, permit their staff to assist in recognizing issues and require their application(s) or MIS department to provide error reports.

Step 2:  Assign an impartial third party

The first step in this process is to assign the task of meeting with the admission/registration areas to an impartial third party.  This is the most important step in this process as admissions/registration needs to feel comfortable in discussing all issues they face daily without fear of retribution or criticism.  The impartial third party should not only meet with management of these areas, but with 75% of the staff covering all shifts.

 Step Three:  Logging issues

This is not the time to address or correct issues that are discovered.  Although issues presented need to be clear and concise, they should not be demonstrated or dissected as this is purely a fact finding process.  All issues discussed are to be logged no matter how insufficient they may appear.

Step Four:  Organization

Issues need to be organized into categories such as process, system, staffing, training and education.  Once this is accomplished a meeting should be held with management to determine what issues are the priorities and can be addressed immediately versus issues that may take time to resolve (such as lack of staff).

Step Five:  Resolving issues

Process issues:  It is imperative that management and staff be open to resolving processing issues.  A process should not be kept in place because it has “always been done this way” but because it enhances the admission/registration process.  An impartial third party can assist management in looking at the processes, determining if they are assisting or hindering the workflow and changing what does not work.

System issues:  Are the admission/registration pathways specific to your site or are they generic?  Does the application provide “help” screens or pathways that are easy to maneuver and are they specific to your site?  Are required billing fields designated as “must enter” and won’t allow staff to bypass?  Is your IT staff knowledgeable of your environment and application?  Is your application vendor directly involved with improving your application pathways?  Can your staff search for a patient’s prior admission/visits within the application?

Staffing:  Are the errors the result of under or overstaffing?  Both can be issues for admission/registration areas as too much work per staff member can cause a hurried approach whereas too many staff can cause disruptions in daily work.  When are most of your admissions/registrations?  Can your facility add or deduct staff according to daily needs?  Are pre-admissions/registration the practice of your department so that most of the information can be input prior to the patient’s visit?

Training:  Has your staff been properly trained in the workflows of the department and admission/registration pathways within the application?  Does staff understand what fields are required and why?  Does your staff update prior admission/registration information or just process the data?

Education:  Correction of errors must be done by the admission staff and not billing.  This is very important because they need to understand what constitutes an error and why.  Some applications only record the last person who worked on the admission/registration versus who made the error.  This limitation should not stop management from requiring error correction.  Although the last person who touched the admission/registration may not have made the error it is the responsibility of anyone who touches the admission/registration to ensure all information is correct.

Holding registration responsible for errors is a proven tool that will assist staff in knowing what an error is, assist management in recognizing what staff training needs are and allows billing to concentrate on their job responsibilities.  As registration is made aware of their errors, it is imperative to teach them how to perform registrations and keep them from repeating the same errors over and over.  Correction of their own errors will assist in staff in adhering to policy, train them in proper registration processes, and will ultimately decrease billing errors and free up billing to perform their job responsibilities.

Do You Have a “Culture of Safety” in your Ambulatory Setting?

Safety is no longer a problem just for executives. Much is said at conferences by health organizations and is in the literature about having a “culture of safety.”  This term embodies the application of safety and quality as a primary and overarching goal in the medical practice.  Safety becomes part of the daily work in which leaders and staff proactively solve problems, reduce risk and improve care.  Organizations turn to the safety tools from the “culture of safety” movement.  Using these and other tools, team members of all levels communicate about safety, ask questions and learn without the barriers of title, status or a fear of retribution. In this setting, leaders, physicians and staff are equally empowered to make changes during the course of their work.

One might be surprised to learn that there is a greater risk for harm in a routine office visit than some inpatient admissions. With the number of outpatient encounters significantly growing the risk becomes even more pronounced.  This blog provides guidance to leadership regarding strategies to reduce risk in the medical office by having clearly defined care guidelines and using the tools and tones of the culture of safety.

As you begin thinking about your environment, consider the overall approach to staff training. Review your on-boarding process and consider how you introduce safety principles in your culture.  Practices need to outline expectations early to avoid issues at a later date. Too many offices make the mistake of not having designated staff trainers which leads to inconsistency.  Ensuring physician and staff training is adequate, reduces the likelihood of performance improvement issues, stress from being understaffed, improves quality, as well as staff and provider satisfaction.

Next, consider the value of pre-visit work. Staff should learn a standardized pre-visit preparation process to identify gaps in care.  This will help staff to close all gaps during the office visit.  Ensure staff and providers know and understand the expected testing, the referral circle (internal vs. external) and the process for ordering required studies.  The employee probation period should provide support, coaching and instruction in the employee’s clinical setting.  Augment this training with online and classroom training.  Leaders can review paid claims and use business intelligence tools to analyze the cost and services provided, conduct audits and intervene when care is provided outside of the protocol.

Diagnostic errors can include missed care opportunities, delays in care, or more seriously, an incorrect diagnosis. Patient care should be consistent with evidence-based care guidelines.  A variety of approaches such as, decision support tools, order sets, electronic tasking, pop up messages, care coordination staff and evidence-based protocols, can reduce errors. Certified medical assistants can alert a provider to sign off on a pending order created by them, help to monitor the test that has been performed and the result delivered to the patient.   Encourage staff to use the culture of safety tools to ask clarifying questions to validate the follow-up plan when there is a deviation from the protocol.

Once diagnostic testing is ordered, it is important to provide clear information to the patient regarding the delivery of the result. The follow-up plan should be consistent as expressed by providers, staff and even the ancillary service.  Patients should either have a scheduled follow-up appointment to review the findings, be told they will receive a call or they should expect a letter within a number of pre-defined days.  It’s important to avoid saying to the patient, “if you don’t hear from us, then everything is okay.”

This type of discharge planning can result in miscommunication and delays in care.  Staff could use the culture of safety technique of “STAR” technique (Stop, Think, Act and Pause) to confirm they understand the follow-up plan for each patient and confirm it is consistent with office protocol.

Staff not updating the family history section in the patient record during the history taking can contribute to an important detail being missed. Staff learn differently and training materials may need to be in multiple languages or in various formats such as a written article, a checklist, or a routing slip. Encourage staff to utilize the culture of safety technique of validation and verification to ensure they understand what is required for each patient.

Communication errors may occur if an electronic system is not being used effectively to communicate or if active listening is not occurring, such as when a staff member is rushed or when a practice is chronically understaffed. Best practice includes future appointments being noted on the routing slip or a workflow which includes electronic orders being entered prior to the patient reaching check-out.  Consider if “pod” check-outs would help to ensure the discharge plan is reviewed/activated in the exam room, thus reducing hand-offs.

Errors or delays can inadvertently occur if a specific diagnosis is lacking or an incorrect diagnosis is entered. Using the culture of safety tool, such as practicing with a questioning attitude, staff can help to eliminate/reduce these errors.

With value-based care, the emphasis is on improving quality, safety and patient satisfaction. Practice leadership should continuously review their internal workflows and processes to shine a light on potential quality and safety issues from a variety of perspectives.  Consider holding a daily huddle with your team or identifying a safety coach in the practice to increase recognition, decrease harm to patients and employees while improving care.

Jill Berger-Fiffy , MHA, FACMPE
Senior Consultant

Consultants as Mentors?

Working in any industry, you encounter people with various backgrounds and degrees with little or no knowledge of the business. You run into the young graduate who just entered the workforce, the established employee who is set to retire or the ambitious employee who is thirsty for more knowledge. In a hustle and flow environment, where do you find time to encourage your employees to master their skills, prepare them for management level or assist in adapting to a new environment when the industry changes around them?

Consultants continuously walk into organizations where change is in the midst, an established business is not working as efficiently as it could, or an open position needs an interim replacement. We observe as an outside party and want to help to create efficiency, structure and indicate where we identify the gaps, but we also know we are there for a specific task.  During engagements, it isn’t uncommon to form relationships with the company staff – listening to their concerns, providing limited feedback if necessary and amusing the ones that just want to complain, even when there isn’t anything to complain about.  Many times, we are perceived as a wealth of knowledge – a golden ticket to show them what they want to learn or to help do some of the work no one else has time for.  When we as consultants have the time to share that knowledge and mentor the existing client staff, success is exponential.

In a recent article with Fortune.Com, CEO and Co-founder of AirBNB, Brian Chesky, explains “you’re the average of the five people you surround yourself with. So the question is, how mature are the people you surround yourself with?  If you surround yourself with the right people, you can grow up pretty quickly.”  Imagine making a decision based on just your thoughts rather than thoughts that are inspired by interactions with insightful individuals or groups.  That could heavily impact a place of business, how you interact with staff, and your own psyche.

Consultants that have the skill of mentoring or coaching are able to provide more of a service to the client rather than just the task at hand. This type of consultant will flourish, as they build a rapport with the client which could allow future interaction together, providing knowledge transfer, understanding the client outside of the assigned task, and creates an abundance of new relationships.  Mentoring is a silent skill – some people have it and others don’t, which is perfectly fine.  Consultants are there to provide a service and this is just an added bonus during a client engagement.



Jim Lachner joins Culbert as Regional Executive -Advisory Services

Culbert Healthcare Solutions is pleased to welcome Jim Lachner as the newest member of our business development team. Jim will serve as Regional Executive – Advisory Services, where he will be responsible for supporting clients located on the west coast.

For the past 30 years, Jim has delivered software and service solutions to medical groups, hospitals, integrated delivery networks, and academic medical centers. Prior to joining Culbert, he held senior sales executive roles at Cerner, First Consulting Group and KPMG.