Roll the DICE: Streamline the workflow in your pain practice
Dear Arizona Pain Specialists,
My partner and I run a growing interventional pain practice. During the last three months, we hired a new physician and are opening a new location soon. During this time of rapid growth, our staff has become increasingly overwhelmed. Despite their hard work, their ability to handle the ancillary elements of patient care has suffered. I’m worried as we continue to grow; we will not be able to provide the same level of care for our patients. Do you have any suggestions that can help us continue to provide top quality patient care while increasing our patient volume?
Dear Growing Pains,
This issue affects all growing pain management practices nation-wide. One of the solutions involves a process called “streamlining”. Your workflow needs to be examined and re-evaluated as your practice grows.
Growing practices often find that employees become inefficient as they perform many tasks that are unnecessary and/or redundant. One method to avoid this, and create a scalable system for growth is called the DICE process. The DICE process includes the following components:
Identify key steps
These elements should be guided by one principle tenant: to funnel all critical thinking to a single entity. To help illustrate, I’ll describe how Arizona Pain Specialists (APS) has changed their workflow for obtaining procedure authorizations based on the DICE method.
Define current workflow: The first step in streamlining workflow is to Define a practice’s current workflow. Oftentimes this step is skipped, and a utopian workflow is simply forced upon staff. Current workflow needs to be assessed so employees can be given clear instruction on how to transition the work they’re doing now into a different model, and still feel comfortable and secure that all aspects of their responsibilities will continue to be handled. Pain management clinics tend to have complicated processes completed by individuals who do a vast amount of critical thinking to determine the appropriate course of action. For example, ordering a radiofrequency ablation (RFA) procedure might include this workflow:
- Document a successful trial with medial branch blocks
- Educate the patient about RFA
- Order the RFA procedure
- Schedule the patient for the procedure if authorization not required
- Obtain authorization if required
- If authorization is required and is obtained, call and schedule the patient
In smaller pain clinics, this can be managed by one or only a few employees, who all are capable of completing the required ancillary tasks at each stage required for a patient’s plan of care to continue. As a practice grows, however, this becomes increasing difficult and inefficient. With each stage of the patient’s care the staff member must switch everything he/she is doing, begin a new train of thought, and start a different set of steps. Handling patient calls, calling insurances to follow up on authorizations, and calling patients to get more information are all very different processes; when handling all at once there are constant interruptions, distractions, and tangents that occur. Focusing on one part of this process and working it consistently without distraction will ensure maximum quality, consistency and efficiency in completing the task.
Identify key steps: This is an important step that occurs from the time an order for a procedure is written to when the patient is scheduled for that procedure. In this case the key steps are:
- Obtaining authorization
- Obtaining clearance
- Scheduling the patient
Because these can occur in almost any order, we need to identify a fourth step:
- Determining the order of operations
The process has now been distilled to four key components. Each of these is a complicated endeavor; however, we have broken the larger nebulous process of scheduling patients for procedures into more manageable steps. This is important for designing an improved workflow, and an excellent way to discover unnecessary steps in current workflow.
Consolidate tasks: In order to Consolidate each of the key steps, roles for each department must be identified. Departments required to complete the process for this example include: provider, authorizations, clearance, scheduler and the front desk. Each of these departments has a clearly defined role within the process of scheduling a procedure. When an order for a radiofrequency ablation is written in clinic, a defined set of processes must occur every time for a patient is to be scheduled. First, the front desk staff must determine if a patient needs authorization, clearance, or is ready to schedule immediately; this department is critical in directing the process. Front desk staff must create a marker to track a patient’s authorization process. A marker can be something as simple as a piece of paper, and is used to track the process from when an item is ordered (e.g., a procedure) to when it is scheduled and completed. At APS, we use a task message in our electronic medical record (EMR). The initial information recorded in a task message for an RFA are a patient’s name, insurance, relevant blood thinner information, procedure, side, levels, quantity, prescribing doctor, and clinic location. As this information will be used by many different people in multiple departments, it is very important to establish a rigid format for how this should be written so that interpretation from person to person does not vary. An example of a message at APS would look like this:
Doe, John MED *BT* RFA LT L2-L5 PL SC
This tells us that patient “John Doe” has Medicare, is on a blood thinner, and has been written for a left L2-L5 RFA by Dr. Paul Lynch at the Scottsdale location. The task message should also be used as a log on which any work that is done on a task is recorded. This ensures the task has a history; whoever is working on it can follow a patient’s scheduling progress. For example, if the patient called to check on the status of the authorization, the staff member who took the call would document this interaction in the task. Additionally, if an authorization team member contacted the clinic to ensure a peer-to-peer was completed, this information would also go into the task message. This becomes particularly important for the scheduler, who needs to make sense of each stage of the task’s history. When the task arrives in the authorization department, it is imperative that staff know the task cannot leave the department until the procedure has been either authorized or denied. Similarly with the clearance department, the task is not to leave the department until blood thinner clearance for a patient has been obtained or denied. The clearance department would then send the task to scheduling to complete the final stages of the process. Now, the marker details the task’s entire history including all necessary information for scheduling. This will include answers to questions such as: Did the patient want to schedule their procedure? Did the patient obtain authorization? Were they denied clearance? Now, all critical thinking required to successfully resolve the authorization process has been funneled to scheduling. Their main responsibility is to establish patient contact and move forward with scheduling.
Execution: This last stage in streamlining may be the most difficult because it requires transitioning from the status quo. The transition to a new workflow is typically a challenge, and simply defining each department’s roles and responsibilities is not enough. One individual should be designated as project manager for execution of the change. This person, more than departmental managers, should act as the ultimate authority on “correct practice” in the new workflow. During the transition, many employees will make mistakes; the expectation that this will occur should be communicated. Nevertheless, the project manager must be meticulous about following up on each step of the revised workflow and notifying staff members of inconsistencies when they happen. Repetition builds habit, and after enough time and practice, the responsibilities for ensuring that correct workflow are being followed can be offloaded from the project manager back to the departmental managers. During the transition period, however, the guidelines for “correct practice” should stem from a single source. When a plan is drafted, often the wording is not as well written and is subject to interpretation. As long as one person has a vision of correct practice, documentation can be revised during transition so that no misunderstanding is possible and all employees are following a single set of guidelines.
CROSS TRAINING & CRITICAL THINKING
Smaller practices that handle patients on a case-by-case basis tend to produce valuable employees who have been cross-trained in many departments and are capable of handling many situations. Shifting these employees into a single and isolated area can be a frightening prospect for a smaller practice that relies on such employees’ flexibility and skill. The fear is twofold: a decrease in the capabilities of future employees and the development of disconnect between staff and patients that decreases quality of patient care and satisfaction.
The fear that employees may become less capable of handling duties outside of their departmental responsibilities is reasonable. However, compartmentalizing departments and funneling critical thinking should not discourage cross-training of employees. Cross-training is incredibly useful and an important practice for employees working in a complicated and multifaceted environment like pain management. Such employee training can also benefit the DICE process.
The most obvious benefit is apparent when an employee is absent from work. If an another employee is cross-trained in the absent employee’s role, work will not be missed during the absence. Secondly, during unexpected employee turnover, multiple knowledgeable staff will expedite on-boarding of a new employee, with significantly less of a negative impact to your organization’s daily workflow.
The indirect benefit to cross-training employees in a compartmentalized organization is an increase in an employee’s ability to think critically. It becomes easy when repeatedly performing the same task to lose sight of the bigger picture — quality patient care — and not understand how actions at point A affect actions at point Z in an organization. Having employees cross-train, or at least shadow those with whom they cannot cross-train, helps provide context to their work and ensures that when something unexpected occurs during the course of patient care, appropriate action is taken within each department. This should lead all staff to be aware of how their work is part of the organization’s ultimate goal: excellent patient care.
The second fear is that patient satisfaction and care will decrease with compartmentalization due to disconnect between patients and staff. Although this is reasonable, it is one that an EMR has the capacity to handle. The nation is rapidly transitioning to more frequent use of EMRs on the wave of federal incentives and the ability for them to provide improved healthcare are being observed. For example, since the implementation of an EMR at APS, we have developed a patient concierge group (PCG) – a team exclusively dedicated to interacting with patients regarding treatments, procedures, appointments, as well as non-medical issues or emergencies. APS uses task messaging to record all of the various processes that occur related to a patient. This allows the PCG to answer patient questions accurately, and in real-time, while avoiding the disruption of workflow in other operational departments, like authorization, billing, or the clinic. Now, when a patient calls into our clinic, they no longer need to speak with an authorization specialist to determine their authorization status. This information is listed in the patient’s chart and is immediately accessible to members of the PCG and other departments.
In January 2011, APS used the DICE process to streamline the workflow of our authorization process. We began with MRI authorizations, followed by procedure authorizations. Productivity has increased dramatically since then and more authorizations are being submitted and obtained per month than ever before. Streamlining workflow is tough but necessary for growth. The DICE process provides a framework for how an organization can accomplish shifts in workflow while minimizing negative consequences and maximizing positive outcomes. If done properly, the DICE process will also help pain practices achieve two important goals: 1) increase the quality of patient care, and 2) increase practice profitability.
Dr. Tory McJunkin and Dr. Paul Lynch founded Arizona Pain Specialists, a comprehensive pain management practice with three locations, seven pain physicians, ten midlevel providers, three chiropractors, on-site research, and behavioral therapy. They teach nationally and are consultants for St. Jude Medical and Stryker Interventional Spine. Through their partner company, Boost Medical, they provide practice management and consulting services to other pain doctors throughout the country. For more information, visit ArizonaPain.com and BoostMedical.com.