Clinics improve customer satisfaction rates
Management styles support staff performance
Health care systems with academic affiliations are busily reshaping their traditionally mediocre customer service images. Among the most potent incentives are the realities of capitation and consumer choice.
"Academic medical centers can no longer afford the luxury of being laissez faire," says Paul Etre, administrator of the Department of Orthopaedic Surgery at the University of Iowa Hospitals and Clinics in Iowa City. "We have to do things on a par or a level above other systems."
Both Etre’s clinic and the Internal Medicine Group (IMG) of Lexington, KY, please their customers with such regularity that both earned Better Performers status in a recent Ambulatory Clinics Benchmarking Study by University HealthSystem Consortium, based in Oak Brook, IL. Some of the enablers of operational excellence are worth a second look by ambulatory clinics of any stripe.
IMG: Measure every commitment
This primary care center, unlike many university clinics, is a non-teaching facility based on a private practice model. Clinic manager Kathleen Greene explains that it serves the population insured by the University of Kentucky’s HMO. Its mission is to build a strong primary care referral base for the university’s other clinics.
Internal Medicine Group, formed in 1996, has one distinct advantage over other clinics, Greene concedes. "When we were pulled out from the university’s larger clinic, we got to handpick employees who would fit into a center of excellence and its philosophy."
The clinic staff has the support of managers who immerse themselves in the daily operations. "Our medical director and business manager set the tone. They’re approachable, and they listen to people," Greene says. Of herself, she says, "If the staff needs help, I pitch in. We set our standards, and we monitor everything we say we’ll do."
In its short history, IMG has more than lived up to these promises of excellence:
- Standard wait times one to four minutes.
While the staff’s goal is 15-minute waits, most days are better than that. IMG also sees new patients within one to two days.
"It’s a little booking trick we use," Greene explains. Schedulers make three appointments an hour, for example, 8:00 a.m., 8:15 a.m., and 8:30 a.m.; the 8:45 a.m. slot remains open. Physicians may use it for same-day patients or to catch up on longer visits. Each day they provide the support staff a list of open times in which they could see extra patients.
- No-show rate 8%.
While appointment reminder cards help, the most significant factor in minimizing no-shows is a two-day pre-appointment reminder call. The IMG hires a college student to make evening calls.
"We know it works because when the student is sick, we see the rates go up," notes Greene. The reminder calls also provide the invaluable function of updating patient contact information. When the student gets a recorded message of a new forwarding number, a notation goes on the patient’s record.
When the patient comes in, the front desk staff verify the new mailing address and any other information changes. "We’re stringent about checking phone numbers, addresses, and emergency contacts every visit to keep our records current," she explains.
IMG drops habitual no-shows. After four or five no-shows in a row, a patient gets two warning letters. Finally, a certified letter explains that IMG will no longer provide care.
An example of interdependency at its best is Orthopaedic Surgery, a teaching clinic at the University of Iowa’s Hospitals and Clinics that operates in a largely rural state of 3 million people whom Etre describes as intelligent and independent. "We’re fortunate in Iowa because the penetration of HMOs is not that great. Our communities have shunned managed care, and a lot of the local doctors have refused to do business with managed care plans."
Though Iowa doctors are fiercely independent in their rejection of managed care, they are clearly interdependent with the university’s hospitals and clinics, the state’s only tertiary medical center.
As a mentor of sorts to Iowa’s private practitioners, Orthopaedic Surgery reflects the tradition of the university’s larger medical program. It feeds new knowledge back into the local communities through consultation, publication of research journals, leadership in professional societies, and continuing medical education offerings. "We also are careful to show community physicians that we will not steal their patients when they make referrals to us," Etre explains.
Complete list of caregivers
To keep the guarantee of returning patients to their primary providers, the clinic asks them to complete a caregiver list for their charts. They name their primary care physicians, local specialists, home care agency, social worker, etc., who receive immediate feedback on the patient’s care and follow-up needs.
The clinic’s management philosophy is to foster staff loyalty, skills, and longevity. The department selects employees carefully and compensates them with a work environment they’re loathe to leave. Competitive salaries are one part of it, but the physicians also design their own offices.
One nurse is permanently assigned to each surgeon, enabling them to grow as a team. Obviously, it works. In the past 12 years, only one surgeon has taken a job elsewhere. The schedulers have worked in the department for over 10 years each.
Some of Orthopaedic Surgery’s performance features are:
* 99% availability of X-rays and patient charts before clinic appointments.
One of the ways the clinic’s state-of-the art computer technology enhances productivity is through a bar-code tracking system for each X-ray and medical chart. The system’s network makes patient information available to assist clinicians from any department.
* 18 permanent clinic staff balance education, patient care, and research.
"Surgeons are very competitive people," observes Etre, so they constantly seek to exceed the standards they set as a group. For example:
— patient care requirements: 104 half-day clinics per year (25 appointments per clinic, eight of whom must be new patients);
— actual averages: 150 half-day clinics per year (30 appointments per clinic).
But doesn’t the brisk pace compromise patient care? Not in the least, Etre says. "Our schedulers choose which patients to put into each time slot. They know who will take two minutes for a cast check, for example." In many visits, the surgeon makes a quick assessment of post-surgery progress, and the nurse provides teaching or other care as needed.
Besides productivity levels, the physicians are expected to support timely information flow to other clinicians and to billing by promptly dictating their operating room notes and signing clinical notes.
The department has a 2% to 4% annual increase in patient population. These recent ratings show that patients are as satisfied with their care as the staff are with their work environment:
• access to care — 99% rated fair to excellent;
• choice/continuity of care — 96% fair to excellent;
• technical quality — 94% fair to excellent;
• time spent — 95% fair to excellent;
• outcomes — 92% fair to excellent;
• would probably or definitely recommend clinic to others — 93.9%.
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