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Mary Toomey, of PracticeManager.ie looks at how medical professionals can improve the efficiency of their practice, improve the level of care provided to patients and staff and generally increase productivity.
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8th June 2013
PRACTICE MANAGEMENT Tools, Tips & Techniques
8th June 2013
Today’s Talk
Practice Management - Patients First
Risks in General Practices
Measuring Practice Performance
Practical Problems : Debts, Well-Being
8th June 2013
Our Responsibility
To enable our team to provide timely, safe, effective and respectful care - and to ensure this is consistently and compassionately given to all our patients.
8th June 2013
Stafford Hospital Francis Report (Feb 2013)
“put corporate self-interest and cost control ahead of patients and their safety”
- Robert Francis QC
Focus on systems - not outcomes
Focus on data - not people
Lack of listening to patients and families
Lack of risk assessment
Lack of leadership or urgency about decision making
Lack of management and follow up
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Patients “First And Foremost”
8th June 2013
Put the patient’s needs first
Working to agreed standards
Working together
Openness and transparency about matters of concern
All those who provide care for patients – individuals and organisations must be properly accountable
Measure, understand and improve the performance of individuals, teams and your whole clinic
Primum non nocere
“It may seem a strange principle to enunciate as the
very first requirement in a hospital that it should do the
sick no harm”
– Florence Nightingale
8th June 2013
Top Risks – MPS (UK, 2012)
99.1% Communication
95.7% Confidentiality
95.7% Prescribing
95.7% Record keeping
94.0% Health and safety
87.9% Test results
84.5% Infection control
8th June 2013
Communication - Difficulties
Patient / External • Unrealistic / differing
expectations • Rigid beliefs • Personality traits • Chaotic lifestyles • Multiple complaints • Chronic pain • Addictions
Clinic / Internal
• Previous experiences
• Degree of training
• Personality traits
• Time pressures
• Interruptions
• Limited resources
• Third party pressures
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Dealing with Difficult Interactions
Support
• Active listening
• Empathy
• Open approach to problem solving
• Suggest the patient and you might find a mutually acceptable solution
Tension
• Summarise the interaction so far
• Acknowledge the real problem
• State the boundary
• Encourage patient to come up with solution options
8th June 2013
Confidentiality
Overhearing conversations especially at reception
Viewing patient-identifiable information left out at reception
Patient-identifiable information left out on desks in the surgery room
Lost or misplaced post-its and pieces of paper
Interruptions during consultations
Unsecure filing cabinets or unrestricted computer records
8th June 2013
Prescribing
• Have a robust repeat prescribing protocol • Make sure every staff member knows the protocol • Best practice is that only GPs should add medications
to the prescription list • GPs should review medication lists regularly • Be especially vigilant about toxic medications • Ensure patients are uniquely identified to make sure
they are not confused with similarly named others
8th June 2013
Record Keeping
• Ensure contemporaneous notes are kept of all contact including home visits and telephone contact
• Scan all incoming letters / faxes / results
• Use aide-memoirs to follow up test results
• Ensure allergies are accurately recorded on patient files
• Encourage patients to keep their details correct on your files
• MPS recommends keeping files for a minimum 8 years after last treatment or death for adult and longer for maternity records, children’s records, or patients with mental disorders
8th June 2013
Access to Medical Records
Freedom of Information Act (Amendment) 2003 applies to records held by GPs in relation to patients who are medical card holders. It does not apply to the records of private patients. An application for a copy of the records is made to the head of the public body. In the case of FOI, the request for access must be made in writing to the head of the public body concerned which in the case of a GMS medical record is the HSE. The Data Protection Act, 1988 (Amendment Act, 2003) gives a person a right of access and right to correct/delete errors. The current fee that a person can be charged for the provision of a copy of their medical records under the auspices of the Data Protection Act is €6.35. Such records should be provided within 40 days. No medical report or copy records should be provided by the doctor to any third party other than with the consent of the patient or otherwise as required by law or directed by an Order of the Court.
8th June 2013
Health and Safety
• Undertake risk assessments as needed, and prepare or update your practice’s Health and Safety statement annually or more often if needed (see www.hsa.ie and www.besmart.ie for assistance).
• Keep MSDS information, details of all safety checks, drills, and equipment services with the H&S statement.
• Nominate staff safety representative(s).
• Ensure sharps, chemicals, gases and clinical waste are safely used, stored and disposed of.
• Check your security – cctv, panic buttons
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Measuring Practice Performance
Good information is the best management tool.
You can measure almost any aspect of your practice.
Measurements need to be accurate and up to date in order to be most relevant and useful!
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Financial Monitoring Have a proper recording and reporting system for all practice income and expenditure. Use regular, clear reporting to evaluate • Income • Expenditure • GMS claims • Cash flow / bank balance • Drawings Review year to date & compare with target / last year’s figures
Capitation Payments Practice IT and PCRS patient listings (“Blue Books”) match (Use Importer) Newborn babies added to panel and deceased patients removed from panel Private residents in nursing homes (intending to stay periods of greater than 5 weeks) registered and coded correctly (903/906) if over 70 years Temporary Visitors attending > 3 months Visitors with medical cards held by GPs elsewhere in your local area Cards expiring on 16th Birthday
STC / SS / Vaccinations
Ensure claims are completed and claimed for: – Every special service consultation – Every out of hours consultation – Every emergency and temporary visitor – Every NHS / EHIC visitor – Flu and pneumococcal vaccinations
Submit claims online to PCRS – Match claims to payments & follow up all queries
Practice Support Actual GMS Panel must be 100 or more to qualify
Payments increase pro rata in bands of 100 to max. panel size 1200 based on
‘weighted panel’
All patients over 70 are given a weighting of 3:1 when calculating practice support
subsidy entitlement
Staff grade (nurse, practice manager, secretary) and relevant years experience are
taken into consideration
Hours worked and employer PRSI may reduce practice support subsidy payments -
top rate employer PRSI (10.75%) does not affect practice support.
In group practices, practice support may be collectively assessed
To apply for practice support, complete form PSN/1 & submit with copies of relevant
documentation to your local primary care office
Sick Leave
Sick leave allowance is based on a four year rolling period.
Panels of 100 – 700 : full capitation is paid for the first 6 months and half capitation for the next 6 months. Locum is paid based on the GMS doctor’s capitation payment for the month divided by the number of days in the month (up to maximum €213.12 per day) and multiplied by the number of days leave taken.
Panels over 700 : as above, but locum payment is at the maximum €213.12 per day.
Annual Leave
# days annual leave depends on the size of your GMS list
Minimum 100 patients = 14 days annual leave
200 patients = 16 days leave
300 patients = 18 days leave
400 patients = 20 days leave
500 patients = 21 days leave
Every subsequent 100 patients = +1 days leave up to 1400 patients = 32 days leave
1500 patients + = 35 days leave
Study Leave
• Minimum panel size is 100 • Study leave is calculated in half-day
sessions up to a maximum of 10 days • Certificates of attendance must accompany
ALF/1 form along with the name and signature of the locum practitioner
Medical Indemnity Refund Panel must be over 100 to qualify for medical indemnity refund Refund is based on the size of the GPs panel Refund is calculated as a percentage of the net premium paid by the doctor (gross premium less the benefit which the doctor receives as a tax rebate). Forward medical indemnity certificate showing full time work to local primary care office
No. Patients on Panel % Net Re-imbursement 100 – 250 10% 251 – 500 25% 501 – 1,000 50% 1,001 – 1,500 75% 1,501 + and Rural Practice Allowance GPs 95%
Once-Off GMS Grants
Nurse start up grant – to purchase equipment for first nurse employed €3,809
Fridge grant – one per practice €1,270
Computer grant – one per GMS contract up to €2,539
Submit receipts to local primary care office
Maternity Fees First visit & 6 week €41.53
Subsequent visits (incl. special visits) €29.91
Total for first pregnancy €262.52
Total for subsequent pregnancy €292.43
Emergency delivery €249.22
_______________________________________
Make sure all visits are entered on MSC report
Clearly identify any special visits
Check for past EDDs – miscarriages / movers
Childhood Vaccinations - Maximum Fees (per child)
Registration € 37.78 V1, V2, V3 + MMR €125.86 PCV x 3 @ €18.82 € 56.46 Hib Booster € 18.82 Bonus (95% Uptake) € 60.00 Total €298.92 _____________________________________________ Use software reporting to follow up missed / late vaccines & advise LHO of any patients leaving your cohort
Other State Contracts
Palliative care payments (GMS & Private) €212.48
Cervical Check €49.10
Social Welfare Certification Contract
€8.25 per certificate and €44.44 for a detailed report
Socrates : Keeping Tabs on Claims
Claim Tracker
• Child Immunizations
• STCs (if printed)
• Forms (cervical check)
Ante Natal Reports
• Check Boxes in Maternity Protocol
8th June 2013
Tips for Getting Paid On Time Fee schedule and payment policy should be clearly displayed in the surgery & on website
Be consistent - minimise ‘discretionary reductions’
Use practice software to generate invoices, receipts, debtors lists and account statements
Follow up any “left without payment” accounts with a phone call, ideally within 48 hours
Consider pay-on-arrival as an option if bad debts are a significant problem for your practice
Don’t let debts spiral. Take a constructive approach support (e.g. help to apply for a medical card, direction toward MABS services) to patients in difficulty.
Debt Collection by Phone
• Pre-call preparation: have the facts to hand.
• Open strongly: be clear about why you are calling.
• Work through objections and agree a commitment.
• End the call with a clear agreement.
• Follow up : check the agreement is kept, or if not, react quickly with another call.
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Problems with Staff Performance?
Address it directly, objectively, honestly
Meet the employee to discuss it
• Agree that the problem exists
• Identify cause(s) of the issue
• Agree a proposal to solve the problem
• Agree how you will review performance and what will happen if the problem is not resolved
8th June 2013
Personal Well Being
Staying Safe - Crisis
• Avoid escalating anger
• It is safer to leave the room than insist somebody else leaves
• Call for help
• Take time out
• Debrief afterward with a trusted confidante
Daily Grind Stressors
• Separate your emotions from patients’
• Recognise your own emotional responses
• Set realistic expectations of yourself
• Share the load
• Develop and use support systems
8th June 2013
