Exploring Ways to Improve Efficiency in Primary Care

Exploring Ways to Improve Efficiency in Primary Care

CCGC PRACTICE INFORMATION SURVEY

Practice Director (Physician Lead for Practice) and/or Practice Manager (Business Manager for Practice)

I. Introduction

Thank you both very much for taking the time to fill out this information survey. This survey is for research being conducted by the University of Colorado Denver. As you may recall, the Agency for Healthcare Research and Quality (AHRQ) has retained us to explore ways to improve efficiency and assess sources of waste in primary care. We are very interested in your perception of sources of waste and inefficiency in primary care.

Thank you for participating. We will follow up this survey with a telephone call to you to clarify or discuss your responses. The follow-up call should take no longer than 1 hour and will hopefully take much less of your time than that. If you feel the questions are more appropriate for the other person and you need to leave before the end of the call, please, just let me know.

Finally, your participation is voluntary and you may stop participating at any time. Your individual practice will not be identified in any reports related to this study. Practice results will be reported in aggregate, to ensure your privacy in participation.

II. Practice Demographics

First we would like to confirm some basic information about your practice. This will help describe your practice in our study.

1)  Please roster your practices’ employees by job title and percent full time employment (FTE) in the questions below and enter into Appendix A and B.

a)  How many physicians (MD or DO) are in your practice? _____

(1)  Family Medicine? ______

(2)  General Internal Medicine? ______

(3)  Other specialties /Specify______

b)  How many midlevel practitioners are in your practice?

i)  Nurse Practitioners or other advance practice nurses______

ii)  Physician Assistants ______

c)  How many nurses (RN/CRN) are in your practice? ______

d)  How many medical assistants (MA) are in your practice?______

e)  How many non-clinical employees are in your practice? ______

i)  Master’s degree level professionals (e.g. medical rec administrators, accountants)? ______

ii)  Administrative staff (Management, clerical)? ______

iii)  Other/ Specify______

2)  How many total square feet do you have in your practice? ______

a)  How many square feet in your practice related to clerical/office space (including record storage)? ______

b)  How many square feet does your practice have related to patient care including exam rooms (please include total number of patient exam rooms), draw station, x-ray, patient check-in, labs, and bathrooms? ______

c)  How many square feet does your practice have related to other areas (please specify)? ______

3)  Who is the majority owner of your practice?: (Circle one)

a)  Government

b)  Integrated delivery system (IDS/Hospital)

c)  Insurance company or HMO

d)  MSO or PPMC

e)  Physicians

f)  University or Medical School

g)  Other, specify______

4)  What is the population designation that best describes the county, town, or city surrounding your practice? (Circle one)

a)  Nonmetropolitan (<50,000 people)

b)  Metropolitan (50,000 to 250,000 people)

c)  Metropolitan (250,001 to 1,000,000 people)

d)  Metropolitan (> 1,000,000 people)

5)  Estimate the percentage distribution of your patients' ages for your practice.

Infant (under 2 years of age)……………………….._____

Pediatric (between 2 and 12 years of age)………….._____

Adolescent (between 13 and 17 years of age)………_____

Adult (between 18 and 64 years of age)…….………_____

Geriatric (between 65 and 79 years of age)…………_____

Aged (80 years of age and older)……………………_____

TOTAL 100%

III. Characterizing Key Office Processes

Now we’d like information about processes in your office that may relate to inefficiency waste. For the purposes of this survey, “inefficiency waste” is defined as “using more inputs than is necessary to produce a unit of care to benefit patients”.

1)  How does the health/medical records system store information for the majority of patients served by the practice? (Circle one)

a.  Paper medical records/charts in record cabinet

b.  Computer-based system in which paper records are scanned and scanned documents are filed electronically (Document Imaging System)

c.  An electronic health record (EHR) system that stores patient medical and demographic information in a computer database accessed by computer terminals or other electronic means.

d.  Hybrid Inception (a cross between paper and electronic records)

e.  Other, specify ______

2)  If you have used an EHR, please indicate how many years. ______

3)  Does your practice utilize a Computer Physician Order Entry (if Yes, the document for each)

a)  Prescriptions ______

b)  Ordering Lab Tests ______

c)  Order Radiology ______

d)  Other ______

4)  Does your practice use formal and standard clinical practice guidelines for

a.  Diabetes YES NO

b.  Hypertension YES NO

c.  Depression YES NO

d.  Asthma YES NO

e.  Other (please specify)

5)  Does your practice use process flow sheets (if so, for what procedures or conditions) to gather patient data, and to keep track progress over time (either manually or by populating electronic registries)? Are these standardized in your practice, or does each practitioner have their own?

______Does your practice use group visits for certain chronic diseases (e.g. Diabetes)? YES NO

6)  Does your practice use electronic communication? (Check all that apply)

Email / Website / Text Messaging
Intra-office
External
Patients
Other Physicians/practices
Laboratories
Hospital
Other

7)  Does your practice have routine and structured meetings on patient care and/or quality improvement?

a.  If so which staff is involved? (Circle all that apply)

i.  Physicians (MD/DO)

ii.  Midlevel providers (PA)

iii.  Nurses (NP,RN,CRN)

iv.  Administrative staff

v.  Probe: Does the team make-up vary by type of meeting?

b.  How often do you meet? (Circle one)

i.  Weekly

ii.  Monthly

iii.  Quarterly

iv.  Other, specify______

8)  Is your practice structured with interdisciplinary teams for patient care? If so are there are formal roles for the non-physician members of the practices for these visits – and what are the roles?

a.  Chronic Diseases

i.  Diabetes

______

ii.  Cardiovascular

______

iii.  Asthma

______

iv.  Depression

______

b.  Well Care and Sick Care

______

c.  Other??

______

9)  How does your office schedule majority of appointments? (Circle one)

a.  Open Access

b.  Traditional scheduling and open access

c.  Traditional scheduling (via telephone/in person) only

IV. Financial Profile of Practice

1)  Does your practice do its own billing, or do you use a service?

a.  How do you assure that procedures and/or E and M codes are billing at the appropriate level to maximize revenue yet be justifiable, if audited?

b.  Do you have the documentation in place to help you do that? YES NO

2)  Do you feel your practice bills at the appropriate level? YES NO

3)  Does your practice accept any capitation or risk contracts? YES NO

a.  If yes, please explain

______

4)  What types of ancillary/supplementary services does your practice provide? (Circle all that apply)

a.  General Radiology

b.  Radiation therapy

c.  Clinical laboratory services (complex under CLIA)

d.  Health education

e.  Complementary alternative medicine

f.  Other?

5)  Estimate the percentage of your practice's “total gross charges" by type of payer.

Medicare……………………………………_____

Medicaid……………………………………_____

Commercial fee-for-service…………………_____

Commercial capitated………………………_____

Workers' compensation……………………._____

Charity and uncompensated care ………….._____

Self pay…………………………………….._____

Other……………………………………….._____

TOTAL 100%

6)  Please list the practice’s total medical revenue after operating costs (e.g., after paying all of your bills, how much is left over)?______

IV. Characterizing Efficiency improvement activities

1)  Do you have any awareness of industry-based methods for reduction waste such as: (Circle all that apply)

a.  LEAN Manufacturing (a.k.a Toyota Production System)

b.  Six Sigma

c.  Total Quality Management

d.  Other?______

2)  Do you know of any other practices using these techniques? If so, what do you know of the technique?

______

3)  Do you use any efficiency improvement techniques in your practice? YES NO

a.  If so, what types of efficiency improvement techniques do you have underway in your practice? (probes to include redesign of practice flow or patient flow, implantation of EHR, use of electronic communication technology, coding accuracy/maximization, etc.)

______

b.  How are you using these techniques?

______

c.  Has it been useful to you and your practice? If so, how?

______

d.  What sorts of costs have been involved for your practice in implementing these efficiency techniques?

______

e.  Who is involved, and how much time do they usually spend on this?

______

f.  What are some of the benefits (financial, efficiency, or otherwise) that you have seen in your practice as a result of implementing these efficiency improvement techniques? How do you assess costs and benefits?

______

g.  How did you make the decision to implement efficiency improvement techniques in your practice? Who made the decision? What were the factors that you considered in making the decision? ______

h.  If your practice has not implemented efficiency improvement techniques, please tell us how much of a barrier each of the below was.

Major barrier / Minor barrier / Not a barrier
Financial Barriers
The amount of capital needed to invest in change (technology, staff training, and time) / q / q / q
Uncertainty about the return on investment (ROI) from an efficiency improvement methods / q / q / q
Organizational Barriers
Resistance to adoption from practice physicians / q / q / q
Concern about loss of productivity during implementation/No time to consider these things / q / q / q
Capacity to install and implement industry methods / q / q / q
Ongoing training and maintenance costs / q / q / q
Legal or Regulatory Barriers
Concerns about inappropriate disclosure of patient information (i.e. breaches of confidentiality). / q / q / q
Concerns about the legality of accepting EHR functions (such as e-prescribing) that are donated from a hospital / q / q / q
Are there other barriers to add?? Please do so!

Is there anything specific that you have identified that would help you to improve efficiency in any areas of your practice?

______

10) Does your practice collect performance measures data (such as Medicare PQRI, reports to other insurance companies, or to an IPA)? YES NO

a.  If YES, specify.

______

b.  If NO, has your practice considered whether it should be gathering and using performance measure data?

______

i.  How did your practice make the decision not to collect and report the performance measure data?

______

ii.  Who made the decision?

______

iii.  What were the factors that were considered in making the decision? (Probe motivators and barriers that were considered)

______Are there things that might make your practice reconsider your decision and begin collecting and reporting performance measure data?

______

IV. Perceived Sources of Waste and Inefficiency within the Practice

1)  What are work flow issues that cause the greatest problems in your office? (circle all that apply)

a.  Having your practice’s medical records unavailable at the time of the office visit

b.  Poor legibility of records

c.  Chart Chasing

d.  Installing an EHR

e.  Using an EHR

f.  Inability to consistently see patients at their scheduled appointment time

g.  Patients unable to access physician when they need

h.  Handling patient phone calls

i.  Appointments unavailable for necessary patient visits

j.  Verifying insurance eligibility

k.  Scheduling/No shows

l.  Long patient waiting times during visits

m.  Inefficient use of resources (please specify)______

n.  Results (labs, x-rays) tracking and follow-up

o.  Acquiring outside information (consultant notes, hospital discharge summaries, ED reports at the time of care)

p.  Medication refills

2)  Please explain further any above circled work flow issues.

______

______

______

______

______

______

Are there any processes or work flow issues not listed above that you feel are a great source of inefficiency and waste within your practice?

______

______

______

______

3)  Do you feel any of the processes you have identified above would be appropriate for our research team to observe as part of our on-site data collection on waste and inefficiency? YES NO

a.  If so please specify if there are certain days of the week, times of the day, or certain staff that this/these process/es would best be observed.

______

______

______

______

Thank you very much for your time today, we really appreciate your help with this.

FTE Report

Sequence
(Example: MD1, PA2, DO3) / FTE / Number of half-days seeing patients / Rounds in hospital (Y/N)? / Role
(MD/DO/
NP/PA) / Specialty (FP, GIM, Other)

Staff Report

Roles: Check all that apply
Roster of office staff / FTE / Practice Manager / Front Desk / Medical Assistant / Billing / Medical Records / Triage /Refill Nurse / IT Support / Other (specify below)

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