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By Jennifer Pendleton, MS, MGMA member
Studies of occupational stress pay little attention to features of the physical environment in which the actual work is performed. Yet evidence is accumulating that the physical environment of work affects both job performance and job satisfaction.1
Provider burnout shows consistent negative relationships with perceived quality (including patient satisfaction), quality indicators and perceptions of safety.2 Conversely, nurses who perceive their work units are patient-centered were significantly more satisfied with their jobs than those who do not.3
All of these factors led to the creation of more collaborative workspaces at Concord Surgical Associates, Concord, N.H., for clinical support staff in the outpatient medical practice setting.
Press Ganey surveys all of the clinical providers and staff at Concord Surgical Associates on a biannual basis to determine the level of engagement of the overall institution and each department. The survey results to the question, “My job makes good use of my skills and abilities,” was identified as an area needing improvement in the general surgery department, which included eight surgeons, 11 advanced practitioners (APRN, PA-C), three medical assistants (MAs), three registered nurses (RNs) and five patient care coordinators (PCCs). In response, this department redesigned clinical area workstations to create a more collaborative workspace for clinical support staff and thereby improve employee engagement.
Before the office redesign, the workspace setup was not ideal for the specialized care of patients requiring clinical assessment and guidance, and was not patient-centric for care delivery (see Figure 1). The close proximity between the clinical and administrative staff led to blurred role definitions, in that MAs often provided backup to the administrative team by doing tasks that did not require clinical competency or medical decision-making: faxing documents, handling medical record requests and leave of absence paperwork, covering the check-in and checkout processes, and scanning documents into the patient medical record.
Due to their close proximity, many MAs also performed duties of a PCC, which were more administrative than clinical.
In June 2015, the office was redesigned to increase efficiency and clinical workflows (see Figure 2). As part of this process, RNs, MAs and PCCs worked with practice leadership to review the details of their job descriptions and expectations, and redefine the clinical roles of the team with more clarity. Tasks that were administrative and did not require clinical expertise were better performed by front-end users. Those tasks were systematically identified and reassigned to PCCs. MAs continued to room patients but eliminated the administrative responsibilities of scanning, answering calls and scheduling appointments, which were shifted back to the PCCs.
Workstations were renovated so that each MA was placed with an RN in the central area of the office. This workspace, referred to as the “clinical fishbowl,” has been identified as “one-stop shopping” for physicians and advanced providers looking for RN or MA help, making workflows more efficient. Clinical staff members were empowered to refer administrative responsibilities to PCCs in the front office. This change provided more time for clinical support staff to complete tasks that were within their scope and that were more professionally satisfying. For example, nurses provided pre-operative patient education and nurse office visits, which resulted in increased patient volume and revenue. This also allocated time to complete classes and required competencies for their clinical practice and development.
When expectations are clear, responsible parties are held to duties required by their certification or license, and roles are physically arranged in a space that encourages collaborative learning, coaching and mentoring. The result is an increase in employee engagement scores and increased patient volume and revenue.
Shane served for six years in the Marine Corps, three providing security for the communications of the President of the United States and three as an operator within a Recon unit. With degrees in Business Administration and Health Sciences as well as an MBA in Operations Management and Strategic Planning, Shane has spent almost 15 years in healthcare management, both in large systems as well as private clinics. Currently Shane is the Administrator of Klasinski Clinic Orthopaedics, a division of Orthopaedic Centers of Wisconsin.
Join us June 12 for a Newsmaker Event with Mayo Clinic Vice President Dr. Bobbie Gostout. As the leader of Mayo Clinic Health System, Gostout oversees the organization’s hospitals in Wisconsin, Minnesota and Iowa.
11:45 a.m. -1:00 p.m.
Wisconsin continues to grapple with the opioid epidemic. Emergency departments in the state saw suspected opioid overdoses more than double between July 2016 and last September, according to recent federal data. While Wisconsin has taken steps to fight the crisis, more work remains. A Wisconsin Health News panel will take a closer look at the challenges facing those seeking treatment and how to boost access.
Submitted by Tom Ludwig, RN, FACMPE, WMGMA ACMPE Forum Rep
Congratulations to Larry Sobal from Menasha – Wisconsin’s newest FACMPE!
Congratulations to the following MGMA members from Wisconsin who recently attained Certified status:
New Certification Requirements!
The requirements for becoming certified are changing next year. Current requirements that carry over are that you must have two years of healthcare experience and be a MGMA member. As of January 1, 2019, you must also hold a bachelor’s degree or have 120 hours of college credit. Once you apply for certification, you will have THREE years from your application date to become certified.
If you are already certified, or if you become certified by December 31, 2018, you will NOT be required to have the degree or the college credits. If that is your situation, there is still time! First, if you are not already a national MGMA member, you can purchase MGMA membership plus the board certification application (MMBCMPE) in one bundle and save $50!
Certification Study Group
A national live web-based study group is scheduled to begin in May. You can register for this free webinar series through the MGMA Store at MGMA.org.
Upcoming Exam Dates:
June 9-23, 2018: Exam Registration Apr. 23- May 7, 2018
Sept. 8-22, 2018: Exam Registration July 23- Aug. 7, 2018
Dec. 1-15, 2018: Exam Registration Oct. 22- Nov. 6, 2018
Fellowship Program Enhancements
There will be several enhancements to the Fellowship program effective January 2019. These enhancements affect the following areas:
Information on the changes can be found on the MGMA web site at https://www.mgma.com/2019-fellowship-program-enhancements.
Mark your calendars for April 26th and May 17th for the Fellowship Workshop Series presented by Lee Ann H. Webster, FACMPE and Nina Chavez, FACMPE. Registration will open soon for the live webinars.
Session 1 – ACMPE Fellowship: Requirements and the Submission Process
Session 2 – Developing a Fellowship Manuscript or Business Plan
If you have any questions, please feel free to contact me at firstname.lastname@example.org.
Submitted by Dean Cravillion, Payer Committee Co-Chair
On March 19, the WMGMA held its first quarterly Payer Forum meeting of 2018 at UW Health in Madison. Attendees of the meeting included payers and WMGMA members. This meeting was the first with a new format that changed to include all payers to meet in-person in the morning session for Q&A, and payers were welcomed to stay for lunch.
Submit questions for the June meeting and register to attend here.
Submitted by Brandy Boone, JD, Director, Education & Client Guidance, Risk Resources, ProAssurance
WMGMA Affiliate Member
Animals are rarely seen in physician offices, so it may take patients and staff by surprise when a person walks in with an animal. Many physicians and their staff actively discourage the presence of animals within the office for cleanliness and hygiene reasons—as well as the potential safety threat from an uncontrollable animal. However, medical practices that prohibit all animals from their premises under any circumstances risk facing allegations that they have violated the Americans with Disabilities Act (ADA).
Since medical offices or clinics are defined as “places of public accommodation” by Title III of the ADA, they are prohibited from discriminating against individuals on the basis of disability; they must make policy, practice, and procedure accommodations for service animals of people with disabilities.1
The U.S. Department of Justice defines a service animal under the ADA as a dog that is individually trained to do work or perform tasks for a person with a disability—although as of 2010, miniature horses have been included as an exception to dogs in that definition.2 The Department of Justice has also issued guidance on the use of service animals in places of public accommodation, which includes the following elements:
In 2011, a physician’s office in Florida reached a settlement agreement with the Department of Justice following a complaint; an individual stated he was treated inappropriately at the office because of his service animal. The individual in question was not asked to leave or remove his service dog from the premises. His complaint was based on comments by the office staff about the dog’s presence and inquiries about the dog’s training or certification. Under the settlement, the physician’s office was required to establish a service animal policy, provide effective notice of the new policy, retrain office staff, and pay the complainant $500.00.5
Physicians or medical office staff may access the Department of Justice’s resources on service animals at https://www.ada.gov/service_animals_2010.htm and https://www.ada.gov/regs2010/service_animal_qa.pdf.
Submitted by Mallory Earley, JD, Senior Risk Resource Advisor, ProAssurance
WMGMA Affiliate member
To ensure an effective physician-patient relationship and provide quality care, you must be able to communicate with your patients.
Physicians may encounter difficulties in three situations: when a patient is hard of hearing, has limited English proficiency, or is illiterate. Federal law requires physicians to make reasonable accommodations for hard of hearing and Limited English Proficiency (LEP) patients. If proper accommodations are not afforded to these individuals, serious consequences, including medical professional liability lawsuits, can occur. Here are some risk management strategies which can be applied to reduce miscommunication with hard of hearing, LEP, and illiterate patients.
Hard of Hearing Patients
The Americans with Disabilities Act (ADA) strictly prohibits any discrimination against individuals who are hard of hearing in places of public accommodation. Under Title III of the Act, a physician’s office is defined as a place of public accommodation.1 As such, it is required to make reasonable accommodations for hard of hearing patients. Since the standard is reasonable accommodation, there is not a bright-line rule which states what each practice must do for each patient. Appropriate accommodations will vary based on the circumstances of each patient’s case and his or her needs. For example, one patient may want to write notes to facilitate communication with the provider while another may require a qualified sign-language interpreter for every visit.
Discuss communication preferences with hard of hearing patients in advance. Their options can include: a qualified interpreter on site, note taking, computer-aided transcription services, or devices such as telephone handset amplifiers and Telecommunications Devices for the Deaf (TDDs). If you have a large number of hard of hearing patients it may be effective to hire an interpreter. Then set aside a block of time when the interpreter will be present to accommodate these patients.
Regardless of the method of assistance your patient chooses, ensure the type of aid to facilitate communication is accurate, effectively conveys medical terminology, and maintains the patient’s confidentiality of protected health information.
Limited English Proficiency (LEP) Patients
Another breakdown in communication can occur with LEP patients. Title VI of the Civil Rights Act prohibits discrimination on the basis of race, color, or national origin. This Act requires physicians to ensure that non-English speaking patients have equal access to healthcare.2 You and your office staff need to take reasonable steps to make sure LEP patients have meaningful access to care.
Once you determine your office’s need for language or interpreting services, choose the services that best meet your patient’s needs and office’s resources. Your practice may also want to include a preferred language section on office intake forms so patients can tell your practice if they require accommodation.
Your options for communicating with LEP patients can include: hiring bilingual staff if English is not the dominate language in your area; using a telephone or video conferencing interpretation service; contracting with companies to provide qualified interpreters who will come to your office; or written translation services.
Some patients ask their family or friends to translate which can be helpful. However, it remains the physician’s responsibility to ensure that the communication is accurate and effective. For example, if minor children translate for a parent, they may lack the knowledge or maturity to effectively convey the medical information. An adult family member or friend may not be comfortable telling the patient certain information or could fail to tell the patient important items. In certain circumstances, referring the patient to a physician better suited to communicate with the LEP patient could be an option. However, this does not need to be the sole method for accommodating LEP patients in your practice.
As with any patient, the doctor must ensure accurate communication of any medical terminology. When using an interpreter, the physician should stress the importance of confidentiality and document in the medical record the type of interpretive services used.
Minimally Literate Patients
Minimally literate patients may be difficult to identify in your practice.
One article defines health literacy as “the degree to which individuals can obtain, process, and understand the basic health information and services they need to make appropriate health decisions.”3 If patients cannot understand their medical information, they may be unable to follow their treatment plans, take medications as prescribed, or make educated decisions about their care. Some may turn to litigation to resolve their issues.
According to one estimate, nearly half of Americans have some type of limited ability to understand medical terminology and have difficulty understanding and acting on health information. Nearly forty million Americans cannot read complex medical texts, and ninety million have difficulty understanding them.4 With training, your front office staff may be able to help identify and assist minimally literate patients at check-in. Patients who avoid filling out new patient information, miss appointments, or mishandle medications may have literacy challenges. They also may bring a family member along to read their paperwork, or say they have poor eye sight and forgot their glasses.
There are a few risk management tips when caring for minimally literate patients. Physicians and medical staff should avoid using complex medical terms. Instead of assuming a patient understands what has been said, physicians can ask questions and have the patient explain the instructions or care plan. Physicians can help minimally literate patients by using pictures or illustrations to assist patients in understanding treatment plans. If a patient brings a family member or friend to the appointment, enlist the help of the other person to aid in the patient’s comprehension. As with any patient, ask if he or she has questions at the end of the appointment. A little bit of extra time during the appointment could help prevent follow-up appointments or subsequent treatments and improve the health of the patient. Ensure that your educational materials and forms are easy to read and understand. Use plain language in short sentences and avoid medical jargon.
Noncompliant patients also can pose a risk management risk to a physician practice. These patients may miss scheduled appointments, not follow treatment guidelines, or ignore medical recommendations for further testing or scans. Although there can be many reasons for noncompliance, open and honest communications with the patient may help you reach a compromise.
Some patients may not follow through due to financial limitations.5 Others may not understand the importance of compliance in their treatment goals. Regardless of the reasons, physicians and office staff must document any noncompliance in the medical record. Proper tracking and follow up procedures for missed appointments will indicate a potential problem with a patient that must be addressed. If the patient continues to be noncompliant with appointments or treatment options, the practice may consider dismissing the patient.
Join us for lunch and discussion with Sen. Leah Vukmir, who chairs the Senate Committee on Health and Human Services. The Brookfield Republican will talk about the past session's major health-related initiatives and what's next for healthcare in the state.
Wisconsin Medical Management Group Association563 Carter Court, Suite B, Kimberly, WI 54136920-560-5621 / 800-762-8968WMGMA@Badgerbay.co
MissionTo be a resource for information, education, networking, and advocacy opportunities for all medical group management professionals.