At Vantage Clinical Solutions, we recently published a number of free practice management tools intended for use by private practice owners and managers. 

The tools are simplified for quick and easy use and focus on 5 areas of practice management that we commonly address with our clients: the startup process, budgeting, productivity, breakeven analysis, and strategy. 

More detailed versions of the tools are available for purchase and Vantage offers a selection of consulting and management services that work hand-in-hand with the online toolbox in order to help private practices navigate our healthcare economy both efficiently and profitably.

So, check ‘em out and let us know what you think!

Introduction by Tannus Quatre PT, MBA

I’d like to take this opportunity to introduce Dr. Richard Schoor to The Healthcare Entrepreneur.  Dr. Schoor is a urologist from Smithtown, NY, and author of The Independent Urologist blog.  Dr. Schoor typifies what we are about at The Healthcare Entrepreneur - entrepreneurial spirit within the healthcare industry, and an active voice that believes in sharing with others.  Some of my favorite posts from The Independent Urologist include, “What happens when physicians leave?” (Feb 2008), “My high tech snow day” (Feb 2008), and “E-Rx: A good use for an i-Phone.”

In this post, Dr. Schoor shares with The Healthcare Entrepreneur some tips on how to avoid a lawsuit in private practice.  Thanks Dr. Schoor - and happy blogging!

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Some Tips on How to Avoid a Lawsuit - by Dr. Richard Schoor, The Independent Urologist

Lawsuits are a fact of practice, and tort reform will continue to be hotly debated in all 50 states.  I believe that all of us can agree that the root causes for lawsuits should be minimized though I don’t think we can agree exactly on what those “root” causes are.  In general, bad outcomes result in lawsuits, not good ones.  Since opening on my own in 2006, I have become somewhat risk obsessed and risk averse.  Here are some of the steps I have taken to prevent the initiation of a lawsuit and to enable the successful defense should one occur despite my efforts.

These are some of the mechanisms I’ve put into place to minimize risk.

• Quality Assurance: I have a written QA plan that I follow on a monthly basis.  QA activities include random chart audits for appropriate documentation, process evaluations, disaster plans, data-back-up and recovery plans, patient complain t processes and laboratory complaint processes, etc.
• Lab and Study Tracking: all ordered labs and studies are logged on my PM software and checked off when completed.  Non-compliant patients are contacted and the outcomes are documented in the medical record.
• Specimen Handling: I have written protocols for specimen handling that eliminate misidentification errors.
• Patient No-Shows: Patient no-show activity is noted in the computer system and letters are automatically generated. The letters are retained in the medical record and the letter is sent certified to the patient.  The certification receipt is retained in the medical record.
• EMR: I have an EMR and a 100% paperless office.  All documentation is done in type-set with essentially no handwriting.  All paper, such as consents and hand-written diagrams, are scanned into the record.
• Templates and Macros: I utilize templates and macros liberally.  I believe this assists in enabling me to hit key features in the history and physical exam routinely.  It also makes for good documentation.
• E-Prescribing: I e-prescribe and this has eliminated prescription errors and pharmacy call-backs.
• Automation: I use automated urine and semen analyzers and perform daily quality control per CLIA requirements.  All QC activity is documented.
• In-Office Lab Accreditation: My office lab is accredited through COLA.  Many of the processes required for lab accreditation are analogous to good practice management and have been adopted as such. 
• Infection Control: I follow the strictest infection control policies and use single-use-only equipment where ever possible.  Scopes are sterilized exactly per manufacturer specifications with no deviation from protocol. 
• Correspondence Management Processes: all correspondence with providers are done via fax and ALL fax confirmations are saved in the medical record.
• Informed Consent: informed consent is a process.  All informed consent discussions are documented and the actual consents (the paper forms) are taken by me, rather than staff.  Informed consent discussions take place on multiple occasions.
• Time-Outs: prior to vasectomies, I do a “time-out” and make the patient state what they are having and why.
• Document Management: all labs and studies results come in via fax and are saved in PDF format in the medical record.  Results are electronically signed and time-stamped by me.
• Call: after hours patients can reach me directly by calling the office phone.  The phone is forwarded to my cell-phone and a second line in my house for redundancy.  I answer all phones personally after hours.  The phone system logs all incoming and outgoing phone calls.  I take call 24/7 for my own patients.  I purposely place no barriers between my patients and me and request that they contact me by phone without hesitation.  When I am not in town, I have a call arrangement with 2 local urologists that I know well.
• Emergency Management: all emergency visit request are accommodated same-day, 7 days per week (yes, even Sundays). 
• Patient Selection: patients at high risk for adverse outcomes, such as ASA class 2 or above, are referred to tertiary care centers.  I no longer perform any laparoscopy, hand-assisted laparoscopy, percutaneous stone surgery or open renal or prostate surgery.  
• Patient Intake Forms: I have none.  I take all patient histories myself.  As an expert reviewer, I have seen on numerous instances, lawsuits that have been made more difficult to defend because of discrepancies between patient-completed forms and physician-completed histories. 
• Limited English Proficiency: Spanish is the only 2nd language that I see, and am proficient in it.   I also utilize translators when needed.

These are some of the mechanisms I have put into place to minimize risk.

It’s an interesting dilemma that we often see new practice owners face.  That is, they want to keep their expenses low and end up tackling every business-related task that there is, and at the same time want to see as many patients as possible to get cash flowing as rapidly as possible.  What usually happens is that the business-related tasks begin to eat away at time that the provider should be in front of patients.  Patient time = cash flow.  Less patient time = less cash flow.  One hour with patient = more money made than it costs to have someone else perform business-related tasks.

A key challenge to handling business growth is whether you are able, and willing, to give up control and delegate certain business tasks to others who are:

• More skilled at the task
• Able to complete the task at a lower hourly rate than you
• Easily trainable to do the jobs that you dislike or are no good at

Here is a quick down-and-dirty to figure out your own “hourly rate”.

Let’s imagine you want your business to gross $300,000 in 2008. And you plan to work a 40-hour week (good luck if you can get away with this!) for 48 weeks in the year.

Your hourly rate is $300,000 ÷ 48 = $6250, and $6250 ÷ 40 = $156.25. In order to make $300,000 in a year, you need to be bringing about $156 an hour in revenue. That means that when you are answering your own emails, you are costing your business roughly $156 an hour to do so.

In her recent post, Kennealy tells us the four tasks that MUST be delegated to someone else, either in-house or to an outsourced company: 1) Housekeeping, 2) Bookkeeping, 3) Administrative support, and 4) Managing technology.  These are tasks that you can find someone that will cost less than your time to do the same job and perhaps a better, more effecient job.

Kennealy goes on to discuss three things that the owning provider MUST hold on to: 1) Strategy development and business planning, 2) Marketing, and 3) Content creation or program development.  These things are critically linked to the owner’s vision, goals and selling efforts.  This doesn’t mean that outside help can not be employed to assist with these things (i.e. consultants, branding companies), but the provider definitely needs to sacrifice some patient time to focus on these elements…these are the elements that get more patients in the door.

It’s easy to be productive with a full schedule.  As long as your office is booked solid and patients are showing up for appointments, there’s never a trouble when it comes to staying busy.  Just buckle up and get busy.

It’s trickier though when the schedule lightens up a bit.  Many aspects of healthcare are cyclical, and while it’s easy to for a caseload to diminish a bit here and there, it’s not as easy to flex your schedule so that you and your staff remain busy (er, “productive”)…that is, if productivity is measured solely on the number of patients seen.

Though revenues wane when there are less patients walking through the door, remember that the growth of a practice takes work, and the mental energy that it applied to patients on a busy day can (and should) be applied toward your practice on a lighter day.  Having a plan for slow days is important, and will allow you to quickly make the adaptation when dictated by your schedule.

This post by Dr. Schoor at the Independent Urologist Blog makes important mention of this, as well as a number of tasks to perform during your slower days.

While busy is great, an occasional slow is ok too; as long as it is only every so often. Here’s what to do on a slow day so that you can stay productive and proactive.

More and more I’m seeing healthcare practices (medical, dental, physical therapy, optometry, etc.) getting really entrepreneurial about their business models.  Most of this is born out of necessity in order to find ways to stay profitable, but some of it comes from clinicians making the decision to run their practices in a way consistent with their passions, interests, and lifestyle.

There is a lot to be learned from a client of mine who is starting up a practice.  She is really doing things right.  When developing her business concept she knew early on that she wanted her practice to be different, and truly wanted to enjoy the way she spent her time each and every day.  She began with a mission and vision for her practice model, and has crafted everything else around it.  From brand position, to information systems, to software selection, to interior design, to financial modeling, she has built a practice that all ties back to her mission and vision.  This is the first step in creating a business that lasts.

There are some very practical things she is doing right as well.  She is putting a great team of business advisors and experts around her and has allowed us all to provide her with direction and guidance.  She realizes that this is a team effort, and the better the team, the better the end result.  Financially she is sound, and has secured the necessary operating capital to get her through several months of operations based on “worst-case” scenarios.  And regarding her patient clientele, she is pounding the pavement in order to build up her caseload months before the doors even open.  She will be successful for the long term, and it’s because she’s acting not only like a clinician, but also like an entrepreneur.

I read an article today that started me thinking about the client above, and it was about an entrepreneurship forum in Kansas in which business owners were learning about how to plan for success for the long haul.  Interestingly, one of the speakers at the entrepreneurship forum was a founder of a medical group.  This is exciting to me, as I believe that entrepreneurship within healthcare is the answer to many the problems that befall us in this industry.  Private practice owners need to become entrepreneurial in their approach to business practices in order to make significant shifts in payment models, service offerings, and cost reduction.  I’m really glad to see that entrepreneurship in healthcare is being used to educate others through this healthcare panelist, and I especially love to see it within the clients I work with day to day.

Three successful Wichita service-based entrepreneurs told a story of faith Thursday at Wichita State University’s Center for Entrepreneurship.

Have a business idea, believe in it, find people who complement your talents and establish a brand, said business owners in medicine, advertising and investment.

Joseph Galichia, founder of Galichia Medical Group; Sonia Greteman, chief executive of Greteman Group; and Corporate Lodging Consultants founder Barry Downing were the speakers at WSU’s final spring entrepreneurship forum.

The advice-oriented session focused on what makes a service-based business go, something the three panelists largely agreed on.

More and more medical practices are turning to strategies utilized by large national and international corporations to eliminate waste, streamline processes and systems in the workplace, and ultimately improve the financial bottom line.  In this 20-minute podcast interview, Donna Weinstock of Office Management Solutions discusses the Toyota Production Systems method for doing so and how this system can be applied directly to your medical practice.

It’s not rare to have a cancellation policy that requires (err…requests) a $25 payment for missed doctor, dentist, or physical therapy appointments.  It’s pretty standard and I see it all the time.  I haven’t heard too many complaints about this type of policy from patients, and I believe that for the most part it’s a widely accepted practice.  In fact, I don’t mind the policy myself.

I think the reason there isn’t too much ruckus over this policy is that there is really no obligation to pay it if you miss the appointment.  Sure, the provider might not allow you to reschedule if you don’t pay, but how often is that really going to happen?  Physicians and dentists have reputations to protect, and I don’t know many that are going to risk it over a $25 no-show charge.

So, if a no-show charge doesn’t incentivize patients to show for appointments then how do you keep your no-show rate down (as if good healthcare isn’t enough by itself)?  In this post from the Musings of a Dinosaur blog, we learn about a specialist that charges $75 IN ADVANCE to hold an appointment. 

Show up ready for your appointment?  Get your check back.

No show? No refund.

Not sure if I like it or not, but I bet it works.

The specialist’s first available appointment was April 22 (six weeks out.) That’s par for the course around here, but what floored me was the demand to send a $75 check along with the required pre-visit paperwork, along with a deadline after which the appointment would be canceled if not received. The check would be returned to the patient at the time of the visit, and would only be cashed if she failed to keep the appointment.

I’m a runner.  I’ve had plenty of periods where I don’t run for a while, but I always come back to it, and it’s always for the same reasons. 

Nothing makes me feel quite the same as I do after putting in a 5 miler.  I breathe deeper, get good time alone with my thoughts, feel better during the day, and on and on.  At the same time, nothing is quite as difficult to stay consistent with as running 5 days a week. 

As I was running the other morning, I began thinking about some of my private practice clients, and how in many ways they face a similar challenge.  Just as I always feels good when I’m done running, I’ve found that many private practice owners have the same feeling when they’re “done” with a big project, “done” with the startup phase of their practice and finally have the doors open, and “done” with getting a big bank loan finalized. 

Being “done” always feels good, whether running the streets, or running a practice, but the process of reaching that end goal isn’t always a whole lot of fun.  As much as I love running, it’s not really the feeling of being out of breath, the constant pounding that I feel with each step, or the burning in my legs that makes it worthwhile.  It’s the feeling of accomplishment that is achieved when I put each of those tiny steps, deep breaths, and aches and pains together over a period of months and years to achieve personal accomplishments that can be obtained in no other way.

When I work with a client, I spend a lot of time discussing vision, personality, lifestyle, values, and a lot of other stuff that doesn’t have an immediate tie to the bottom line.  The reason for this is that running a private practice, like a 5am running routine, is only going to be successful if it lasts for a really long time, and the only way to achieve this by tapping in to motivation, experience, and vision.  To do this, I use the same techniques to keep myself running that I do with my private practice clients: Stay focused on the end objective, always be prepared for bad weather, break each session (project) up into bite-sized milestones, enjoy the journey, and don’t go it alone.

I’ve found that when these elements are taken into account along the way, the bottom line usually falls right into place.

In any aspect of healthcare, clinical excellence is necessary in order to provide patients with the information and intervention necessary to keep them healthy and return them from illness.  Clinical excellence by itself though, still requires intelligent administrative and organizational delivery in order for patients to receive good care.  In this article from Net News, this point is made as relates to the dental profession.  Schools focus on the education of clinical skill, but still lack in terms of the business education required to keep the doors open to dental practices.

“Dental schools might be great, but they’re notoriously bad at addressing business issues,” said Jim Du Molin, dental management consultant and founder of The Wealthy Dentist. “Students learn lots of science and very little about practice management. But how can graduates expect to practice dentistry if they can’t run a dental practice?”

We all realize that our medical practices should have risk-management programs in place, however, taking the time to develop a solid program is often put aside due to other operational components of our business.  Without proper procedures in place that are documented and abided by, we place our businesses in potentially precarious positions.  Here are a few tips from MGMA when reviewing your risk-management program.

Everyone in a medical group practice benefits from an effective risk-management program. A strong program helps identify problem areas and enables clinicians to reduce patient errors and poor outcomes. To accomplish this, leaders — including the practice administrator — must constantly gather pertinent information. This allows you to develop policies and procedures that promote quality health care and a safe environment.

The basic components of a risk management program are a source document to report incidents, staff education and a quality-improvement team.