Strategy & Executive Leadership

Leverage MACRA to Support Long-Term Strategic Goals

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Patient Access Throughput: The Strategy to Success

In today’s healthcare world, health systems experience constant change and at times, a state of the unknown. Patient care is the business of the hospital and when processes are inefficient, business is inefficient.  Medical groups and hospital systems are focused on reducing costs and consequences to patients, staff and the organization as a whole.  However, the overall goal is to improve the ability to optimize how efficiently the processes and operations are managed.

Opportunities for Improvement

  1. Lengthy admissions/outpatient wait times continue to be a major area for improvement
    1. Cross-training scheduling staff to create accounts, schedule, and begin the pre-certification process will reduce the number of calls to the patient prior to the date of service (DOS)
    2. Assign verifiers to “physician teams”
    3. Manage block schedules
    4. Provide the benefit of obtaining co-pay, deductibles, and (out-of-pocket) OOP during the pre-registration process to minimize intake process at the time of arrival
  2. Engagement
    1. Minimize patient complaints through service recovery methods
    2. Open communication with physicians/departmental leaders (i.e., office visits/monthly meetings)
    3. Educate and engage employees to increase customer service
  3. QA, QA, QA! – Accountability is KEY!
    1. “On Your Mark” accountability will minimize errors, denials, rebills, wait times, and patient complaints


As organizations strive to exceed the patient’s expectations, they must continue to explore new ways of streamlining the patient access processes to improve the patient experience. Today’s consumer is a savvy, educated consumer and they anticipate exceptional service.  The following patient access initiatives can benefit organizations in serving their patients:

  • Pre-registration – Online access, patient portals, etc.
  • Patient access advisors
  • Customer service training
  • Discovering strengths by utilizing the Lean Process, Six Sigma, Eagle Wings, etc.
  • Leadership development (placing the patient’s needs first)

Ongoing Initiatives

Health systems have an interesting road ahead of them, but one thing is certain – the patients come first. Staying abreast of updates on the national and local level is essential to implementation of any strategic initiatives moving forward.  Organizations must continue to make their experience the best, and exceed the goals of stakeholders while doing so.  Communication, education, exploring options and listening to the “customers” will help healthcare providers reach those successful practices.







Access to Care ….or Lack Thereof

Long Appointment Wait Time, Your Horrible Parking Lot and Your Mediocre Front Desk: Your New Patients’ Experience

I am back on my “Patient Access” soapbox as a result of a recent visit to your private practice in the suburbs of Philadelphia. I had a fairly significant medical concern and wanted to get to a specialist as quickly as possible in the event I needed treatment.  Knowing that I was seeking an appointment as a new patient in a high demand medical specialty area, I figured it would be weeks or even a month or more before I would secure an appointment, so I got to work right away.  Like most patients, I got on the Internet and started to review specialists in my area; trying to find a physician that was well qualified, accepted my health insurance and would minimize my drive time so that I didn’t have be away from the office for hours.  I chose you, a qualified physician that had a new patient appointment available in twenty-seven days.  Twenty-seven days.  I was actually delighted that I was going to be examined by a high demand specialist in under a month. Delighted! What does this say about physician access for some specialists?  Have we lowered our expectations so much that getting an appointment four weeks from the date of request is considered acceptable? It’s a question that won’t be solved as I write this blog, but it is food for thought.

Twenty-seven days later, I arrived for my 10am appointment. It was 9:30am when I arrived and your parking lot was completely full.  Cars were double parked, and your underground lot was impossible to navigate with a Mini-Cooper, let alone the Chevy Tahoe I was driving.  I had to park across the street and up two blocks risking a ticket as I was not doing business at this location.  I was frustrated and five minutes late for my visit when I opened the door to your office.  When I approached the front desk to provide my name and an apology for being late; I was greeted with silence.  Not a “Good Morning”, not a “What is Your Name”, not a word.  I wondered if I chose not to say anything upon arrival if the sour woman at the window would have acknowledged me at all.  She proceeded to have conversations with her equally sour colleagues behind the window while she grabbed my insurance card and personal identification.  The only words spoken to me were to ask for my $40 dollar copay.  Not even a “Thank You” upon payment, was uttered.  I was completely unsatisfied, to say the least and was silently hoping to receive a patient satisfaction survey in the mail.

To be completely objective, I was pleasantly surprised that I waited only five minutes before being escorted to an exam room and even more pleased when you arrived to see me less than five minutes later. Your exam was thorough and you were on your game. What a shame that so many barriers were put up before I even had the chance to meet you.

Now here’s the question. Was the wait, aggravation and less than courteous support staff worth it?  Would speaking to the specialist about her access problems help?  Would anything actually change?  Should I start again with a new provider that has better access to care and a friendlier staff?  Should I drive further away and wait longer to have a better experience?  The answers to these questions are very personal and real for patients.  Access to care is a serious issue that can and will determine the success of your practice.  Look at the little things.  They are larger than life for the patients on the other side of the window.

Transforming Access Through Scheduling Redesign

Long wait times can be a symptom of scheduling and access problems. When new providers join a practice, significant time and effort is put forth to “create” the schedule and the scheduling guidelines.  Rarely is any effort spent reviewing the schedule once the on-boarding phase is completed.

Providers may be satisfied from the perspective of their practice when their schedule is full. However, this is not always a win-win if patients are complaining about the schedule. Delays in care can result in unnecessary costs and less revenue.

There are a variety of strategies which can be utilized to improve patient access. Some practices use team medicine such as the pairing of providers with Nurse Practitioners or Physician Assistants. When care is presented as a unit or a team (and in a positive light by the provider), patients are more likely to see an advance practice clinician when a provider is full.  Practices with significant capitated or bundled income may find it helpful to build the access infrastructure by adding non-provider touches to patient care such as dieticians, nurses or health coaches.  Another option is cutting edge methods such as mobile apps, social media, shared medical appointments, outreach through a patient portal, texting or telephone calls, or virtual care visits.

It can be helpful to review triage protocols to be sure they encourage patients to be seen when new acute conditions arise or established chronic conditions are worsen. Often times patients can be managed by a staff member and providers may miss important signs of a problem.  Determine if refill protocols include standards for visit frequency and ongoing surveillance with diagnostic testing such as lab or radiology.

Ensure the practice has optimized the clinical workflow to be efficient. This includes standardizing rooms and staff duties, co-locating providers near staff to enhance communication, adding huddles to the day to discuss potential issues/concerns and decreasing patient wait time for ancillaries which are ordered at the time of service or in advance by primary care physicians prior to referral to the specialists.

Governance can play an important role when it comes to managing access. Jointly develop standards and guidelines between providers, administrators and staff. Requests to change templates should run through the operations team in order to ensure the schedule is not compromised.  Review schedules in a meaningful way once or twice yearly; confirm a provider does in fact have the required number of patient care hours available and the designated number of new patient appointment slots each day.  Ask questions to understand the reason for blocked or appointment slots on hold. Scheduling protocols can erode over time with meetings and non-work responsibilities which can reduce productivity.   Employ use of automation features and ensure they are hard wired to allow for search optimization and same day visit access.

The “third next available appointment “ represents a nationally reported measure against which practices can monitor their performance with a goal of seeing patients when clinically indicated and when they desire to be seen. Offering this type of data to providers, managers and staff can help to engage them in solving the access puzzle together.  Given the complexity of scheduling, it may be necessary to utilize one or more interventions on a regular basis.

Jill Berger-Fiffy , MHA, FACMPE Senior Consultant

Jill Berger-Fiffy , MHA, FACMPE
Senior Consultant

Improving Patient Access: What’s Your 3rd Next Available Appointment?

In continuing the quest to ensure that my colleagues are seeking ways to improve patients access to care; I thought a discussion regarding the 3rd Next Available Appointment would be beneficial.  The 3rd Next Available Appointment metric is often misunderstood, and as a result, not utilized. I would venture to say, if this metric is not one of your top three Patient Access Key Performance Indicators (KPI’s), you need to make it so.  Some might say, “why not measure the calendar days between the day a patient makes a new patient appointment with a physician and the next available appointment? What makes the 3rd available appointment a better indicator of access to care?”

The 3rd Next Available Appointment is preferable to the next available appointment because it is a better reflection of slot availability within your scheduling system.  Given that patients cancel appointments at the last minute, reporting the first available appointment may give a physician practice manager a false sense of timely access.  For example, you are the manager of a busy orthopedic practice.  You are measuring the next available appointment time by physician in an effort to provide patients with a new patient appointment in under three days.  Despite the fact that you confirmed your appointments for the day, a new patient calls to cancel her visit for this afternoon.  Moments later, another patient calls to cancel his new patient appointment for tomorrow with the same orthopedic surgeon.

If you were to report on this surgeon’s Next Available Appointment, and you ran this report from your scheduling system right now, your next available appointment for Dr. Smith would be this afternoon. As a manager, I would assume this means Dr. Smith’s new patient availability is under the three day threshold and my patients are receiving timely access to care.

Now let’s run the third next available appointment for Dr. Smith. In doing so, you find that the 3rd next available appointment for a new patient is 19 days.  The two cancellations received today, while providing an open slot for another new patient to fill, is not a true reflection of Dr. Smiths’ patient availability and as such, intervention should be initiated.

Most scheduling systems include this report as part of their standard package. If you have access to it, run it for every physician in your practice.  Run it often and act on any adverse results.  You’ll find a significant increase in patient satisfaction as well as a positive boost in revenue will be your reward.

MIR_3944-Johanna Epstein

The CIO of the Future- Long Live the CIO

There are many articles out there that focus on the death of the CIO as a strategic position in the executive management landscape. Many pundits have suggested that today’s CIO (especially in healthcare) is mired in the technical underpinnings and has lost his/her position as a true business leader. Healthcare especially in its fast-growth, heavily regulated world has caused its CIO’s to be focused on implementation and support of costly, poorly integrated systems that don’t scale well or play well with others.

So, what does the CIO of 2020 need to be thinking about today in order to improve the impression of what the CIO is these days? What do CIO’s need to do to move healthcare to a higher state of technological maturity?

We all know the big Healthcare vendors need to come together and establish a standard framework, but while we are waiting for that to begin to take shape, we as CIO’s can drive a more flexible, scalable and cost-effective technological infrastructure and prepare for that future. Today’s infrastructure for running a modern hospital or clinic is really 5 key platforms: Voice, Data, End-user compute, your application stack, and mobile platforms.

There has been a lot of talk around cloud computing and things like IAAS, and SAAS and PAAS, but how does these play in Healthcare? Many CIO’s are apprehensive and rightfully so – there is risk. But, forward-thinking CIO’s should be looking out to 2020 and thinking more about how their patients and clinicians can interact with their organization electronically. In order to do this there will have to be a massive build-up of back-end infrastructure to support those mobile-enabled apps. With that said, the CIOs of 2020 should be thinking they need to partner with hosting and managed services providers that can bring infrastructure that is highly scalable and highly flexible to the table now.

So, why not move to the cloud? Blue sky here, think about this… Healthcare IT could be run by 3-4 key leaders who are responsible to organize 20-25 managed services contracts into a truly flexible technology framework for the organization. So let’s take a look at the 5 key technology platforms and what you can do to virtualize and commoditize these platforms and ready your organization for 2020+. Oh, and by the way, all of this is available today.

The voice and data networks are vital to any business, especially healthcare. Now that voice and data have converged, our lives have gotten easier. Gone are the days when a PBX the size of a small garage or an army of network engineers is needed to run voice and data. There are new businesses that allow you to run your voice service in the cloud, and many network VAR’s have very mature managed services organizations that can design, build, and manage your network infrastructure without having a small army of engineers on your payroll. BYOD has also changed this landscape as well, but we’ll touch on that below in the mobile platforms section.

End-User Compute (PC’s, Laptops, Printers) – In 2020, traditional PC’s and laptops may be a thing of the past (or at least on their way out). Thinking about the BYOD mentality, your employees may just bring their own tablets and smartphones to work and they join the domain and off they go. But even if you still have traditional end-user computing in 2020, there are vendors today who will design, provision to your spec, deliver to your desk, and support your end-user computing in your building.

The application stack – all of the big players offer a hosted option including Epic. Cerner has been offering this service since their days of the mainframe and Epic has just recently completed a massive Tier 3 data center to offer hosted solutions. Even if you decide not to use the app vendor as your hosting partner, you can still go to Amazon, Google, or many regional players to run your apps on their infrastructure. Even if you find an app that has to be run on your own infrastructure, your hosting partner(s) can offer up an IAAS platform that is highly scalable and flexible.

Mobile platforms are here, let’s deal with them. As everybody knows, the smartphone has become so powerful and flexible that it has completely changed the technology landscape. Everybody has one and wants to use it, but is Healthcare ready to support it – I would say a resounding “NO”. Again, the application vendors have a lot to do with it as they haven’t really embraced the small screen, but again we need to prepare for the inevitability. Other industries have come to grips with the small screen revolution and we should also for our employees and our customers.

The bottom line – there is no longer a need for massive data centers and armies of technical engineers. Remote hosting, managed services and virtualization are here now. So what does this mean for the CIO of the future? We CIO’s should be positioning healthcare IT for that future now. Remember, we are behind and it’s not just the end-user community, but the vendors in the healthcare space who haven’t moved the ball. CIO’s of the future need to be solely focused on the business. Remember those 3-4 key leaders I was talking about earlier? We are managing our services contracts with our vendors and offering highly flexible and scalable technology to our ever-changing and fast growing businesses. The CIO of the future now can focus on how technology interacts with the business and position IT for the future.



Patient Wait Times Should Be Your Priority

The firestorm over the comments made by VA Secretary Bob McDonald regarding the length of time veterans wait for healthcare has gotten me on my soapbox. By stating that Disney doesn’t measure wait times for guests’ queueing up for Space Mountain, McDonald was trying to point out that the VA should focus on the veteran’s overall healthcare experience when trying to quantify satisfaction.  I have spent years working on ways to improve patient satisfaction in the large, academic physician practices where I have been fortunate enough to have been employed.  I have conducted focus groups, spoken to patients one on one, sent surveys and read countless studies about how to positively impact the patient experience.  I have found that asking patients to wait what a patient perceives is too long for care is the single biggest driver in patient dissatisfaction. I have also found that wait times for care (otherwise known as access to care) is the single biggest reason patients leave health systems to seek care from your competitor.

Evaluating the patients’ overall experience is indeed important. Effective clinical care, responsiveness to patients’ questions, a pleasant staff and appropriate follow up are obviously critical to the continuum of care.  However, if a patient has had to wait weeks or months to receive an appointment, coupled with waiting far too long in a waiting room and examination room, the memory of the care quality is overshadowed by the often times tortuous wait.

Too many patients decide the wait is too long and choose another healthcare provider that is accessible. Unfortunately for our Veterans they have no choice.  They are forced to utilize a healthcare system that is steeped in bureaucratic and antiquated processes.  Waiting too long in the case of a chronically ill veteran could have serious health implications.

I urge my colleagues at the VA and elsewhere who are responsible for patient access to look at your patient wait times. If you think they are too long, your patients think they are an eternity.  Dig deep to find the root causes of your access problems and solve them.  Your patients and most certainly our Veterans will thank you for it. MIR_3944-Johanna Epstein

Installing Effective Change Management in Healthcare

Read Johanna Epstein’s article  in

Physicians Practice

Installing Effective Change Management in Healthcare–     link here

Physician Quality Reporting (PQRS)

Jill Berger-Fiffy, MHA, FACMPE, Senior Consultant, Management Consulting Team

Physician Quality Reporting (PQRS)

PQRS was envisioned to be a driver to improve the quality of care provided to Medicare patients and was initially an “incentive program” focused around achieving evidence based goals.  With the “incentive” or pay-for-reporting stage now complete, medical groups and individual providers (defined by CMS as “Eligible Professionals) who have not met the reporting criteria in 2015 are faced with a -2% Medicare reimbursement “penalty”  effective January 1, 2017. Medical groups or Eligible Professionals who reported in 2013 or 2014 and received an incentive payment avoided any penalties in 2015 (-1.5%) or 2016 (-2%).

If your medical group or practice is now in the PQRS “penalty box” now time to prepare 2016 reporting. To achieve compliance, a threshold of at least 50% of the eligible instances (referred to as the numerator) of all Medicare patients (referred to as the denominator) must meet the criteria. There are four National Quality Strategy (NQS) domains which are categorized as Effective Clinical Care, Patient Safety, Communication and Care Coordination, and Community Population Health. Compliance must include at least nine measures; inclusive of one cross cutting measure for providers who have face to face encounters with patients.

What Can Practices Do to Prepare?


  • Determine the participants. Review your types of providers, roles and responsibilities. Confirm which EPs are eligible to participate and are billable providers such as primary care physicians, specialists, advanced practice providers, and some allied health providers.
  • Verify the workflows in the practice. Compare the care provided in the practice to the list of 2016 measures and determine which measures overlap with the current workflow and identify other measures which could easily be integrated.
  • Select the measures. Practices may consider reporting up to twelve measures to ensure compliance with the minimum of nine measures. Choose the measures most relevant to the specialty, the patients and the providers.
  • Initiate a discussion. Speak with medical and administrative leadership of the practice to offer recommendations on the suggested approach to comply with the program.
  • Prepare the team. Develop an implementation and training plan for the practice. Determine if the practice will build automated prompts in your electronic medical record or use questionnaires. Confirm which providers will be responsible for inputting this important data. Licensed or registered staff; such as Nurses or Medical Assistants can input some of the information saving time for EPs to attend to tasks at the top of their license.
  • Training. Data integrity is integral to meeting the requirements. Consider the team and determine what methods of training will be most effective. Choose from a variety of training methods such as hands on learning, train the trainer, posters, written reference materials, checklists and screen shots which describe the steps in detail.
  • Documentation. It is understandable that some Medicare patients will not meet the expected criteria. Prepare the team to document exceptions such as those which are medical, patient or system related. Proper documentation will exclude these patients from the denominator and will not affect your overall score. Consider on the spot observation, data extraction and shadowing as helpful methods to train and monitor registered medical assistants or nurses; as well as other billable providers.
  • Differentiate the reporting method. Select which of the three methods (i.e., Group Practice Reporting Option [GPRO], Claims Based, or through Certified Technology) is best suited for the practice. Be aware of the required timelines. For example, between now and June 30th, practices should self-nominate for the GPRO option. Practices will need to identify the reporting method (Registry, EHR Interface or certified survey vendor).

Benefits and Challenges

Practices are incentivized to participate in PQRS now that the penalty stage has begun. This penalty will continue in perpetuity with funds being shifted to practices complying with the program.  This reduction may be additive to other potential reductions in payments for the Meaningful Use (MU) and Value Based Modifier (VBM) programs.  The coupling of these programs can add substantial reimbursement penalties to practices  – potentially a 9% reduction in Medicare fee-for-service payments.

It is essential to understand the reporting capabilities of your Electronic Health Record. PQRS reporting capability provides an automated way to assess the current status and if the practice is meeting/exceeding the measures.  If you do not have a certified EHR product, a web based registry may be an option. These programs are widely available and easy to use.  These involve an upload of the data to the reporting registry.

Whether or not these measures do in fact improve care, remains to be seen. Some worry that the PQRS initiative is onerous and detracts from the work at hand which is diagnosing and treating health conditions.  Compliance with the measures may require additional data entry, staff, and may have little or no relevance to outcomes.   Providers may need to focus on other metrics due state and local health plan requirements. Research published in Health Affairs in March 2016 found that Medical Group Management Association (MGMA) practices spent 785 hours per physician and more than $15.4 billion on quality measure reporting programs. The study found that majority of time spent on quality reporting consists of “entering information into the medical record ONLY for the purpose of reporting for quality measures from external entities,” and nearly three-quarters of practices stated that their group was being evaluated on quality measures that are not clinically relevant.[1]

National outcry from the MGMA and various medical societies has been strong. As a result, there is an effort underway to combine Meaningful Use (MU) and PQRS in 2017.  These will evolve into the Merit Based Incentive System (MIPS).  The standards; not yet available, proclaim to measure quality, resource use, clinical practice improvement and meaningful use of Electronic Medical Record Technology.

In the interim, much preparation and planning are needed to avert payment reductions. Begin planning today. Time is of the essence!



Jill Berger-Fiffy , MHA, FACMPE Senior Consultant

Jill Berger-Fiffy , MHA, FACMPE
Senior Consultant


resource found here

Mixed Use Patient Access Centers Improve the Patient Experience

Lisa Monteleone

Lisa Monteleone

By Lisa E Monteleone, RN-BC, BSN, MHA

Mixed use centralized patient access centers are an important investment for medical groups and health systems as they provide an access point for current and prospective patients. A decentralized or splintered patient access design or a poorly performing centralized center can result in patient frustration and lost revenue.

Patient Access

Effective implementation and management of a mixed use centralized patient access center is key to attracting and retaining patients. What is “patient access?” It’s everything that affects a patient’s ability to get to the right care, at the right time, for the right reasons, at the right location. Patient access most often includes the operational functions of referrals, scheduling, insurance, registration and payment collections.  It also includes IT systems, facility and workflow design, staff training and management, the right mix and number of providers, as well as the coordination of care and services between multiple sites across the full continuum of care.

When it goes wrong

In the recent past you have likely been subject to a poorly performing patient access workflow that resulted in multiple calls, repetitive requests for information, long hold times and inadvertent disconnects. It’s likely this experience left you frustrated and questioning your choice in care provider.  In today’s healthcare environment this experience can be detrimental to the success of the healthcare provider.  To be successful, providers must focus their patient access efforts on the complete patient experience. Overlooking steps adds to the risk of losing the patient to another group or system or generating a less than desirable patient outcome.

When it goes right

I had a recent experience during peak hours with a patient-centered provider of health care services. During the call the representative was alerted via their IT system that there was a financial hold on my account.  The hold did not allow the appointment to be scheduled. I thought to myself, here we go, this is going to take FOREVER!  Boy was I surprised!  In one call that lasted less than 15 minutes, touched three departments, and had minimal repetition of patient information:

  • An outstanding payment – rectified
  • An appointment – scheduled
  • A non-urgent medical request – triaged by a nurse

Positive Outcomes

Mixed use centralized patient access centers accomplish many things for a medical group or health system, not the least of which is call demand management and appropriate routing. In addition to improved efficiencies and operational savings the centers create multi-practice, provider, and service line visibility.  The centers reduce voicemail and email related frustration and eliminate the need for multiple calls.  Mixed use centralized patient access centers are a one-stop-shop for the patient and a command center for the provider:

  • Appointment scheduling & reminders
  • Physician & service referrals
  • Pre-registration functions
  • Follow-up calls / patient outreach
  • Prescription refills
  • Test result communication
  • Symptom based nurse triage
  • Revenue cycle management

Which shape and size fits your need?

Mixed use patient access centers come in all shapes and sizes. The centers can be centralized in a single location or virtually though IT applications and systems.  They can be operational during business hours or 24-hours a day 7 days a week.  The centers can be staffed in-house by the medical group or health system or they can be outsourced to regional or national call centers.  And lastly, the centers can be brick and mortar based or deployed remotely.  Larger medical groups and health systems are likely to use more than one of these models to effectively manage the needs of the patient population and their providers.

Meeting the challenge head on

Health care providers are faced with several challenges at once: an aging and more consumer-oriented patient population alongside reduced payments and a more competitive marketplace. Investing in top notch people, policies, and processes are key to health care provider survival.  Mixed use centralized patient access centers allow medical group and hospital based staff to focus on face-to-face patient management needs at their facilities and offices and as a result improve operational efficiencies, patient satisfaction, and patient outcomes. How does your patient access measure up?