With the advent of value-based care and the concomitant rise of consumerism in health care, medical practices face an increasingly challenging business environment, as do the health systems that own and operate them. Many are compelled to explore new ways to ensure the practices survive and thrive, including focusing on process improvements, implementing new technologies, and—in the case of independent practices—seeking a buyout from private equity firms. Practices and their health system owners are discovering that a comprehensive focus on critical revenue cycle processes can help deliver better patient experiences while generating higher revenues and profitable growth.
A medical practice’s ability to achieve these outcomes depends on the extent to which it adopts patient-centric processes, and one effective way it can do so is to use a three-layered strategy focusing on critical processes to address patient concerns while reducing waste. The three layers involve integrating process improvements, behavioral changes, and technology to enhance provider efficiency and reduce costs and thereby improve the patient experience. The primary points of focus for this effort should be on understanding both what patients value and what they ultimately need.
Understanding What Patients Value
This approach requires, first and foremost, a clear understanding of what patients typically value most in their health care. In other industries, consumers tend to value quality, cost, and speed. From a patient’s perspective, these values are reflected in the following:
- High-quality health care at an affordable price
- Service excellence that includes correct and accurate billing, prescription renewals, prompt and helpful answers to healthcare questions, and the ability to see providers when needed, and finally
- Minimal wait times to schedule appointments and see providers after arriving at the office
Waste in a medical practice can be defined as any activities performed or resources consumed that do not add value for the patient. Examples include:
- Long wait times to schedule an appointment
- Inability to locate supplies or information
- Unnecessary steps at check-in, including requests for the same information to be entered repeatedly on documents
- Billing errors
- Patient cancellations or no-shows
- Ordering of unnecessary diagnostic tests
By eliminating such waste, a practice can optimize patient flow to see more patients, increase provider time spent with patients, and optimize patient care.
For medical practices, optimizing patient flow provides an important means to link what patients value to the revenue cycle—that is by improving the patient’s experience from scheduling, through registration and check-in, through the provider encounter and examination, and ending with check-out. The tasks within each of these processes, when optimized and managed correctly, are critical to the effectiveness and efficiency of the practice.
A patient-focused approach to achieving these improvements starts with evaluating the process and addressing questions such as the following:
- Is the scheduling process helping clinicians (i.e., physicians, nurses, and other providers) to maximize their time?
- How effectively does the practice balance provider capacity with patient demand as a means to manage patient access?
- How efficient is the registration check-in process and what impact does the process have on the overall revenue cycle?
- Are there opportunities to reduce the wait times for patients and improve their wait experience?
- How effectively does the check-out process help to minimize call backs and optimize charge capture?
Understanding What Patients Need
Analyzing revenue cycle processes from the patient’s perspective is critical for a medical practice’s success going forward. Traditional techniques, such as patient satisfaction surveys, rely on patient answers to specific questions and are limited in the kinds of insights they can provide. They can help a practice learn about patient reactions to the medical practice’s processes, but they do not help uncover needs that may be difficult for a patient to recognize or express, but that nonetheless influence the patient’s experience.
Therefore, a new emphasis on understanding how and why patients make choices and what shapes their behavior is needed. To gain this understanding, a practice must both engage in direct observation of patients and combine multiple sources of data to map out the patient’s journey.
One of the best tools for better understanding patient needs is called a patient journey map. Through words and imagery, this tool captures a patient’s actions, emotions, concerns, and questions at key points in their interaction with the processes or offerings at the medical practice. It is a graphical representation of the patient experience and the various touchpoints the patient has with the practice along their path.
The start of any patient journey map is deciding on the map’s intended scope. The map should depict an end-to-end patient experience, and the phases can can cover everything from scheduling an appointment to checking out after the exam, or the map can look at just part of this experience. The phases of the patient flow process should be listed across the top.
The map’s middle should depict the patients’ actions. Perhaps most important, it should depict the touch points patients experience and their thoughts and feelings along the journey. For example, in the examination room, while waiting for the physician, a patient may wonder if the physician will be able to address his or her chief complaint and feel anxiety about whether his or her condition is serious. The visual representation is crucial: The basic flow of the process and the touch points should be easily discernable to any reader.
The last part of the diagram should address possible ways the practice can respond to patient concerns (in line with points depicted in the map) and outline related business opportunities for the practice. This characteristic is what differentiates patient journey maps from other kinds of process maps. Contemplating what patients need and how they feel during each phase and at touch point enables medical practices to deliver an exceptional patient experience.
Practices should begin the process of developing a patient journey map by reviewing the patient information they already have. Many already capture an array of data from patient satisfaction surveys, patient portal comments, direct observations and analytics from their practice management systems. The practice can use this information to answer key questions about each step, such as the following:
- What are patients doing at each point in the process, and what would they prefer to be doing?
- What problems might they be experiencing?
- How are the patient’s needs being addressed?
- Do patients have concerns about how the practice is meeting their needs in each step, and if so, what are they?
- How can patient concerns be addressed?
By analyzing these data, medical practices can begin to ensure that patient concerns are addressed at each touch point with the practice. The aim should be to combine these elements to gain a clear picture of what it’s like for a patient to use the practice’s service and to then be able to assess that picture in the broader context of ensuring that the practice is doing all it can do to achieve the desired outcome.
A Comprehensive Approach to Practice Design
Having identified patient values and needs, as well as expectations and experiences during the process, the next step is to address how well the practice is meeting the patients’ needs. One means for translating the information gathered into performance measures is called quality function deployment(QFD). QFD was developed in Japan in the mid-1960s as a means to “deploy” the voice of the customer—in this case, the patient—throughout the process, product, or service design. It is a structured matrix-based approach for designing a practice specifically to meet the wants and needs of its patients. QFD helps accomplish this purpose by linking internal practice requirements to external patient needs and values, establishing a framework for measuring and managing the practice design process, and providing a basis for evaluating the results.
To illustrate, a sample of a QFD framework is shown in the exhibit below—showing customer requirements for the area of scheduling only.
The left side of the matrix, shown in grey, represents patient wants and expectations, which can be gleaned from patient satisfaction surveys, the patient journey map, clinician and staff observations, and other means. These patient wants are assigned an importance rating based on how frequently they have been articulated by patients or observed by the practice.
The critical patient requirements are shown in tan across the top of the matrix. The listed requirements identify how success will be measured in meeting the patients’ overall need, and they are determined for each phase of the process—i.e., scheduling, registration and check-in, examination, and check-out.
Within the actual matrix for evaluating the interrelationships between the identified patient wants and the critical patient requirements, any of three possible scores can be entered: 9 = strong relationship; 3 = moderate relationship; and 1 = weak relationship.
If no relationship exists, the cell is left blank. There should be at least one measure for each patient need, and because none of the measures can address all patient needs, it is common for 50 to 60 percent of the cells to be blank.
The Practice Transformation
At this point, knowing what patients truly value and understanding their feelings throughout the process, it is time to transform the practice, beginning with the critical processes. A process can be identified as a trigger event that leads to a chain of actions that result in something being created for the customer. For a medical practice, the primary customer is the patient, but there also may be internal customers within the practice. For example, the back-office billing personnel are customers of staff who handle the registration and check-in process. These individuals serve the back-office staff by verifying insurance coverage and benefits eligibility and by collecting copayments and performing other financial responsibilities. In short, errors occurring at registration effect the downstream billing department.
Taking into consideration the knowledge about what patients value and how they feel, an organization then can build an enhanced process map, called a value-stream map, which can be used to expose the improvement opportunities within the process. Any activities that do not add value from the patient’s or other customer’s perspective are opportunities for improvement.
In creating a value-stream map, it is crucial to start at a high-level by outlining the four to eight essential steps in the current process, with the goal of simply depicting the process from end to end (e.g., scheduling, registration and check-in, examination, and check-out). Then, more detail can be added below these high-level steps, proceeding from start to finish and identifying the lower level tasks.
The next step is to add information to the value-stream map such as cycle times, wait times, demand, and work-in-progress to help identify where opportunities to reduce or eliminate waste exist. Finally, information flows should be added, including electronic information, the systems used, and paper-based methods, if appropriate. When contemplating how to design the process for the future, the practice should consider four key questions:
- Can non-value-added activity (waste) within the practice be minimized?
- Can processes be made more patient-focused and efficient?
- Can more time be freed up for nurses and physicians?
- Can staff and patient frustration be reduced?
Lean process improvement techniques provide a means for addressing all these questions, helping to identify waste and how it might be reduced. The practice can apply these techniques by evaluating potential areas of waste, such as excessive patient wait times, duplicate entry of information, excess movement by personnel, and processing errors.
Having identified the potential improvement opportunities, the practice can design a new process, which should be tested upon completion to ensure that it satisfies the patient’s requirements.
With the patient-flow process optimized, the next step is to improve the information flow. Many organizations, medical practices included, look to technology as the saving grace for a failing process. However, implementing technology without first redesigning the process simply makes a bad process faster. An important preliminary step practices should take before applying technology is to establish which tasks are better performed by a person and which are better performed through automation. The objective should be to identify the tasks that slow the practice down and automate them for a better patient and employee experience.
For example, the scheduling process is one of the most critical processes within a practice as a key driver of the revenue cycle. Its objective is to maximize patient appointments while matching demand with provider capacity, handling no-shows and last-minute critical appointments. These intricacies make scheduling an excellent candidate for automation. Other technology advancements include patient portals for scheduling appointments and accessing test results, tablets or kiosks for online registering, and billing systems that ensure charge capture accuracy. Ultimately, to make strategic sense, technology must improve the flow of information and provide the right information to the right people at the right time.
Focus on Behavior
Analyzing behavior within a practice is a key consideration in designing a patient-centric medical practice. As a practice develops new processes and implements new technology, changing behaviors will be a necessary—indeed, critical—success factor in transforming the practice. Successfully accomplishing this transformation requires an effective change management program that includes strong and effective executive sponsorship, buy-in from front-line employees, continuous, targeted communications, and a well-planned and organized approach.
Key questions this program should consider include the following:
- What training will be required for those impacted by the change?
- Are the right personnel already on staff or will retraining or a change in hiring practices be required to acquire new characteristics and skills?
- How and when will the changes be communicated?
The goal should be to ensure that, at each touch point where patients interact with the practice, the practice’s personnel are welcoming, enthusiastic, respectful, concerned, accommodating, and fully capable of handling patient complaints as necessary. This goal cannot be accomplished simply through process and technological adjustments, and achieving it may require training or replacement of certain personnel.
A Fundamental Challenge
Driving profitable growth while improving customer satisfaction is a fundamental challenge facing any business. Medical practices and health systems that employ such practices should tackle the challenges the industry presents by focusing on the areas within their control—the internal processes that have the most impact on the ability to drive revenues. By linking those processes to the expectations and experiences of the patient, profitable growth can be achieved while improving both the patient and employee satisfaction.