Consistent Care, Productive Practice

The benefits of getting everyone “on the same page.”

BY LESLIE GOLDBERG, ASSOCIATE EDITOR

As eye care practices grow in size and complexity, ophthalmologists will increasingly need to confront the logistical, and sometimes philosophical, issues that arise when several physicians work under the same roof. Should treatment protocols be set by the practice owner(s) for all to follow, or is it preferable to take a more “federalist” approach in which the individual doctors retain autonomy in their clinical decisions? To improve practice efficiency and avoid medicolegal risk, the case for standardization is compelling.

A comprehensive policies manual is part and parcel of any successful high-volume medical practice. “We have established protocols for virtually everything,” says James Dawes, chief administrative officer at Center for Sight in Sarasota, Fla. “We perform 14,000 surgical operations a year in our ASC and have 100,000 patient visits. If you don't have systematic ways of doing things, it is just a mess.”

The challenge is to establish policies that are formal and detailed enough to address most everyday concerns without stifling the creativity and unique personal touch that each physician brings to the “art” of medicine. Below, administrators of large group practices provide insights, suggestions and lessons learned.

Putting it in Practice

Even though practices surely have numerous policies and standards already in place, a periodic reassessment to uncover areas in need of update is a worthwhile endeavor.

Unless you happen to have someone on staff with a flexible enough workload to take on the project, it's probably best to bring in outside assistance. Mr. Dawes hired a technical writer, provided all existing written procedures, and directed her to look for inconsistencies and ambiguities. In addition, the writer shadowed several staff members to glean the day-to-day issues that arise. The writer and the practice owners methodically reviewed and updated two to three procedures per day, ultimately creating manuals and employee handbooks attuned to the needs of the practice.

“It took six months, but was absolutely worth it — the staff would never have had the time to do it alone,” says Mr. Dawes. “We can now train correctly, giving the staff the resources they need.” Indeed, the Center for Sight also developed a training system for employees that requires testing of their proficiency in the practice's policies. The training period takes 30 days and the tests are ongoing to ensure staff are up to date.

Amir Arbisser, MD, says that similar rigor is used for training the staff of Eye Surgeons Associates, a large practice with 14 ophthalmologists and six optometrists practicing in five offices spread across two states (Iowa and Illinois). His staff must undergo a formal in-house training program that takes over six months to complete. Training and testing are done under the auspices of Certified Ophthalmic Medical Technologists employed at the practice.

The program greatly reduces staff attrition, he says. “People who go through testing are almost exclusively staff members who have been in the practice for a number of years. They need to apply for the training program, and it is competitive,” Dr. Arbisser says. “It is an excellent incentive because it means there is upward mobility.” The practice considers the training so valuable, in fact, that trainees are required to sign a contract. If the staff member leaves shortly after completing training, they must reimburse the practice.

Once procedures are in place and staff up to speed, department heads are responsible for approving and disseminating updates. At the Center for Sight's eight locations, all staff members access policies and procedures via a company-wide Intranet. Whenever a policy must be updated, those staff members impacted by the change are sent a communication alerting them to review the new information. For example, if the fee for corneal topography has changed, the appropriate staff members are sent an email.

Clinical policies and procedures updated in the same way. “If we change a drug or the frequency of a drug's use, it is updated on the Intranet and a communication is set out to let people know this has occurred,” says Mr. Dawes. “If you put a manual on a shelf, it will collect dust — our staff is on computers every day.”

Relevant staff members who are impacted by a change in policy should receive written a notification that requires a signature indicating their awareness of the revision, says Hildy Abel, general manager at Vitreous-Retina-Macula Consultants of New York. “Everything is put in writing,” she says. “We have a reception protocol, a biller's manual, a front desk manual, a master billing guide, a service contract binder, even an injection protocol. I don't leave anything to memory.”

In managing a practice with a staff of 56, Ms. Abel is by necessity a proponent of standardized protocols and procedures. She began the task of organizing the 15,000-square foot office by creating distinct job descriptions and performance appraisals for each position. The practice also brought in a clinical educator to assist in creating standard operating procedures (SOPs) for patient care services, as well as staff training to ensure proficiency.

Physicians in the practice use identical forms to document the patient encounter, and generally speaking the same clinical protocols, aside from minor variations in the preparation of intravitreal injections and instrument set-up — but this information is also in a manual. “Other than that, everything is standardized,” says Ms. Abel. The practice also has one patient service liaison per pod who follows up at the conclusion of the exam on any physician instructions for additional services, such as imaging, by ensuring that the appropriate tech is informed. This liaison person is also responsible for seeing that exam rooms are flagged for restocking and disinfection at the end of the day.

Enabling Self-Assessment

Once your practice has set up its policies, you’ll be able to identify deviations and correct them when needed. Dr. Arbisser's practice has a compliance nurse on staff who reviews charts to ensure that patients are getting the appropriate care. “Everyone has to deal with the consequences of poor care,” says Dr. Arbisser. “You have a responsibility to monitor your level of care.”

Doctors' charts are reviewed at a different frequency based on their track record. For instance, one doctor may be on a quarterly review if they are found to undercode or over-code their records, while other docs may be down to once a year.

“One positive outcome of the compliance nurse is that our staff feels more comfortable voicing concerns about matters dealing with a doctor,” says Dr. Arbisser. “If that happens, the compliance nurse pulls a number of charts on that doctor and reviews them. She will then talk to me about what she found. If there is an issue, we can privately review and fix it.”

Dr. Arbisser considers this a job of opportunity. “She can tell us if we are not ordering visual fields or OCTs — which helps improve our patients' care, and the bottom line. She has added six figures to the bottom line by teaching us to properly code. We are enhanced by her presence.”

The Center for Sight keeps a firm on retainer for billing and coding. “The firm gives us consulting advice on how to train our staff and audit our charts,” says Mr. Dawes. “Based on those audits, we educate our staff on improvements and more appropriate documentation that needs to be made.”

EMR Implementation

One might think that standardized office protocols and EMR would go hand in hand, but that's not always the case. “We do not have an EMR system in place,” says Mr. Dawes of Center for Sight. “We have investigated various systems but have chosen not to make that investment yet.” Uncertainty over the nature of and requirements for the federal incentive program has prompted them to delay adoption of EMR.

Mr. Dawes, who has implemented EMR systems in other practices, says that productivity suffers for approximately six months; at 12 months, productivity should rebound to its level prior to adoption.

Dr. Arbisser's practice has not implemented EMR either. Some are strong advocates for it, he says, but due to the number and diversity of sub-specialties in the practice, they have not found the system that fits everyone's needs. “A system may help some doctors, but do a great disservice to another doctor. From an administrative standpoint, EMR has very clear advantages also some immense hurdles,” says Dr. Arbisser.

Other practices, however, have found that the rigor of digital record-keeping aids their efforts to standardize their office policies. “EMR makes things more consistent within our practice,” says Rik Phillips, practice administrator for Hudson Eye Physicians & Surgeons in New Jersey. It has made it easier to standardize the coding, he says. “The system actually makes it impossible for you to move on” unless the record is filled out correctly and completely.

Hudson Eye uses customized templates in their system, but they are the same across offices and linked to the same server. “I don't have to track down a chart,” says Mr. Phillips. “I can pull up a chart from any office and view it from any computer.”

Mr. Phillips says that overall, the standardization of care is becoming more important and EMR can definitely assist in that venture. “Doctors originally viewed EMR as a way to streamline processes and make them a standard of care once they started to expand. Their biggest apprehension is how much they are going to spend and how much time it is going to take to learn the system, but it is becoming essential to growing practices,” he concludes.

Potential Challenges

“I think standardizing what we do every day is pretty easy,” says Mr. Dawes. “What's tough is trying to standardize customer service. We want to provide the same level of service across the board at all locations. As we expand, how do we standardize the experience?” To that end, the practice has identified the 12 characteristics that all employees should be delivering to their patients (see sidebar at above). Their customer service program is built around these characteristics.

Dr. Arbisser thinks that standardizing what happens in the operating room is the most challenging.

“There is a definite difference in the level of how a doctor works in the OR,” he says. “Right now, we look at complication rates. If you have a technically proficient surgeon, he is in the OR a shorter period of time, he has fewer reoperation rates, a more predictable refraction outcome, fewer disposable materials are used and there are fewer lens remakes in your optical shop. The OR is the toughest place to standardize care.”

Another downside of standardization is the potential for individual doctors in the practice to feel straight-jacketed if everything must be done “by the book.”

“We have some general standards in place, particularly with chronic diseases like glaucoma, macular degeneration, diabetes and dry eye,” says Amir Arbisser, MD, of the approach at his comprehensive practice. “We start by looking at the AAO's preferred practice patterns, then edit those with our individual subspecialists.”

His practice's doctors have a medical evening conference every two months to review the clinical protocols. “Several of the doctors will make presentations on topics of interest, and this helps to keep everyone informed and interested,” says Dr. Arbisser.

He adds that for chronic conditions, “there is a good medical and economic advantage for the general ophthalmologist to pay attention to those standards.” Committing to a select group of products, for instance, gives the practice greater purchasing power with vendors while also standardizing some aspects of the care provided.

Still, building in some flexibility and diversity among the clinical staff is essential. For instance, the approach to premium IOLs — on which opinions and philosophies vary widely — can be tricky to standardize. “We have four surgeons doing premium lenses and we perform about 2,500 implants a year — so about 40% of our patients get premium lenses,” says Mr. Dawes of the experience at Center for Sight. “With premium lenses, it is about patient selection and what the patient needs. There is constant communication among the surgeons about which lenses are best for which patient types, but surgeons don't necessarily make the same lens choices.”

Cataract surgeons are not required to recommend the same lenses at Dr. Arbisser's Eye Surgeons Associates either. For instance, only two of their six surgeons are at ease with use of multifocal IOLs.

However, the practice feels an obligation to educate patients about premium lenses, so they are currently developing a phone script that can be used throughout the practice to make sure the message delivered to patients is consistent. The practice created a cataract informational video that covers all the options, and every cataract patient sees that film. The staff documents with a checklist that they have reviewed the options. They also include a list of the names of people who are in the room when this information is given.

In retina practices, variability may manifest in doctors' preferences for Avastin or Lucentis, each of which has its proponents. Mr. Dawes says his practice primarily uses Avastin, although some patients will come in and demand Lucentis, prompted by Genentech's direct-to-patient marketing. He says that to a patient with insurance, the increase in cost is almost imperceptible. “We have found Avastin to be equally as good a drug as Lucentis and it is much better for us not to maintain a large inventory of an expensive medication,” he says.

Robert Mittra, MD, a retina specialist based in St. Paul, Minn., says his practice prefers Avastin as the anti-VEGF of choice for intravitreal injections. “ We find Avastin easier to use because it comes in pre-filled syringes that are very convenient. Also, though we do use some Lucentis, at our practice it's about 85% Avastin and 15% Lucentis. It is very costly to maintain a substantial Lucentis inventory because of the high cost of the drug. If you lose a vial or break a vial of Lucentis, that's a significant loss in dollars.”

All For One, One For All

Mr. Dawes says that maintaining consistency in such an inherently dynamic and variable process like ophthalmic care requires a daily commitment to strive for improvement. “Every time we encounter a problem, we ask, ‘What do we need to do procedurally to prevent this from happening again? Let's put in place a long-term systematic solution that we can document so it does not happen again.’” He says that while there will always be things that fall through the cracks, he needs to make sure they are not repeated.

“The bottom line in running a successful practice is that someone at the helm has to have a vision of how they want the practice to run,” says Ms. Abel of Vitreous-Retina-Macula Consultants, “and the physicians need to buy into that vision. If the physician is resistant to change at any step, you will not be successful.” OM