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Key Lessons Learned When Standardizing and Centralizing Ambulatory Front-Office Functions

Summary 

The COVID-19 pandemic has accelerated the need for healthcare organizations to provide world-class patient acquisition and access experiences. Hospitals and health systems that prioritized such initiatives prior to the pandemic were already organized and able to rapidly adapt to the changing environment while maintaining telephonic and virtual accessibility for their patients and families. Mobilizing an at-home workforce was simple (if not already done). These organizations had the infrastructure in place to create pop-up COVID-19 and related crisis lines and were better positioned to manage and forecast the needs of their population by monitoring incoming contact data.

While healthcare organizations that have yet to launch a comprehensive patient acquisition and access strategy have risen to the unprecedented occasion, leveraging an existing, high-performing patient acquisition and access center would have lightened the operational lift and expedited the ability to maintain customer service standards during this stressful period.

It is no secret that patients are consumers with a growing number of healthcare provider options. Healthcare organizations are investing significant resources into creating a superior patient and family experience to set themselves apart and become the provider of choice in their market and even beyond. Everything from building state-of-the-art facilities to minor process improvements are on the table, but the most successful organizations prioritize creating a consistent and reliable brand that their patients grow to trust.

This patient access opportunity begins at the front door. Can I, as a patient, easily make an appointment for a time that works within my schedule? Was my call answered timely? Better yet, may I schedule an appointment online? Will my referral to a specialist be pre-authorized before my appointment?

Several healthcare organizations have implemented advanced and high-performing, centralized front-office centers that ensure a consistently stellar experience. Others have attempted and fallen short. This whitepaper details the common missteps organizations should avoid in order to develop and sustain transformational change in ambulatory front-office services via standardization and centralization.

Introduction

While centralizing front-office services and establishing a comprehensive patient acquisition and access center can lead to transformational change, five foundational prerequisites must be in place to ensure success and longevity:

  1. Executive and Provider Leadership Support of Standardization and Centralization: The concepts of standardization and centralization must have unwavering support from the highest levels of clinical and administrative leadership, and these efforts must be communicated to all levels of the organization. Patient acquisition and access centers are strategic initiatives, not typical process improvement initiatives!
  2. Guiding Principles: A set of guiding principles that will drive and govern the design of centralized services should be created in a multidisciplinary setting and must be robust enough to uphold the core intentions of the initiative against opposition.
  3. Cultural Change Management Strategy: A comprehensive change management plan tailored to the organization’s level of cultural acceptance should precede implementation of centralized services, and subsequently, work in parallel throughout the implementation period and beyond.
  4. Reporting and Analytics: Measuring and tracking data throughout design and implementation is paramount! Dedicated reporting and analytical support from the beginning of the journey must be in place.
  5. Expect to Invest: While patient acquisition and access centers are traditionally thought of as cost-cutting vehicles, the industry is now recognizing the long-term value that proper investment yields and is willing to wait for efficiencies to materialize.

Services such as registration, appointment scheduling, and referral management can be optimized and consolidated, and thus are typically at the top of the list to address when searching for efficiencies. In his latest book, Prescription for the Future: The Twelve Transformational Practices of Highly Effective Medical Organizations1, Oncologist and Bioethicist, Ezekiel Emanuel, details the benefits of centralizing front-office business services, bringing further confirmation and successful examples of the return-on-investment potential.

Among many, direct benefits of centralizing front-office services include increased operational oversight with a singular point of accountability, consistent pathways for communicating and maintaining a brand experience, and ultimately, cost efficiencies. Indirectly, centralized services also provide an avenue for challenging conversations about provider availability and individualized scheduling rules that tend to limit access to appointments whether intentionally or not.

Common goals of centralizing front-office services include achieving economies of scale and increasing access to appointments and services while decreasing waste.

A prevalent misconception is that creating a centralized patient acquisition and access center will inherently improve patient access. However, simply co-locating existing, often siloed, operations and personnel without foresight and intentional design will never achieve the efficiencies or on-brand experience that organizations seek. In fact, centralizing prior to accomplishing the true work will only amplify existing access and communication issues.

Standardizing and optimizing workflows are the critical actions that will catalyze transformational change and set an organization on the correct path to achieving its access and efficiency goals. This difficult work will also pave the way for enabling a successful and satisfying online scheduling and patient portal experience, which, if leveraged correctly, has the ability to offload incoming call volume, effectively reducing the rate of employee growth in a patient acquisition and access center. Are you seeing dollar signs? You should be!

Executive & Provider Leadership Support of Standardization & Centralization

Just as an organization would not leave branding and patient experience strategies to individual medical offices or departments, a patient acquisition and access center impetus and design will never succeed if it is department-based. A brand and experience strategy must be singular and deliberately driven from the top down, and a patient acquisition and access center requires nothing different. Standardization and centralization discussions are often met with serious opposition from clinical staff. When provider practice and clinic operational differences are streamlined, the perception (and sometimes reality) is loss of control. This is especially true when assessing provider scheduling templates and individualized, complex, symptom-driven scheduling algorithms. Although perhaps ideal from the individual perspective and seemingly easy to maintain in the decentralized clinic setting, most of these customizations are unsustainable in a centralized environment. Why is that the case? Consider a hospital with 10 primary care practices, each employing 10 providers. At the clinic level, it might be reasonable for a front-office employee to manage 10 different ways of scheduling a new patient appointment. In a scaled patient acquisition and access center environment, however, a single agent who is taking calls for those100 providers would never be successful in managing 100 different pathways for a single workflow.

Because a minimum level of standardization must be achieved to effectively centralize services and realize economies of scale (amongst other goals such as patient satisfaction and staff engagement), the concepts of standardization and centralization must have proactive and unwavering support from the highest levels of the organization. Hospital and provider leaders need to be prepared to have crucial conversations, as they will undoubtedly face adverse feedback when these initiatives begin changing current state operations. Most importantly, leaders must proactively communicate their support of centralization to all levels of the organization starting with the “why.” Why is it important to shift to standard processes? Why is it important to develop common workflows? What does each stakeholder stand to gain by doing so? Answers to these questions should remain consistent, and realistically address what individual preferences a centralized center inherently can and cannot accommodate.

The entire effort stands to fail unless establishing a high-functioning patient acquisition and access center is a strategic priority. Early engagement with providers and staff who can help generate early adopters will dramatically improve the likelihood that the effort succeeds. Furthermore, establishing the patient acquisition and access center leader at the Vice President or Executive Director level will demonstrate the level of value placed on the patient acquisition and access center. Because the patient acquisition and access center is a front door to the organization, the patient experience must be superb. For it to be superb, it must be closely monitored and supported by all major departments – ambulatory operations, revenue cycle, IT, human resources, finance, payer relations, and marketing. Creating a dedicated executive leader will promote visibility and proactive coordination to ultimately ensure that the center delivers on its promise.

Finally, leaders should be prepared to enforce adoption of the centralized center rather than allow groups or departments to opt-out at their discretion. A hybrid model of centralized and decentralized processes loses economies of scale and minimizes the gains that these projects can deliver. Additionally, a hybrid model perpetuates an inconsistent patient and brand experience. The ability to measure the centralized center’s effectiveness and return on investment hinges on going all-in.

Guiding Principles Created by a Multidisciplinary Team

Once the concepts of standardization and centralization are endorsed, a set of guiding principles to drive the design of centralized services should be created in a multidisciplinary setting that includes influential provider leaders. The guiding principles will be relied upon when workflow design requests (i.e. scheduling rules and communication pathways between the supported clinics and the patient acquisition and access center) conflict with the project goals. The guiding principles will help to ensure that the final operational design meets the organization’s mission of centralizing services in the first place.

Guiding principles should be detailed enough to assist in decision-making when an impasse is reached and should span from operational workflows to technology use. They should also highlight any deviations from standard work that will be accepted and the rationale for that acceptance. What else should be considered when writing guiding principles? Think about the experience you are trying to create. For example, when a patient calls to schedule an appointment, the agent they speak to should be able to book that appointment at a convenient time and within a timeframe that meets the organization’s access goals. If that is a guiding principle, designing streamlined scheduling rules and removing non-essential barriers to appointments become the tactics to meeting that principle. In other words, standardization becomes the vehicle to opening access and timeliness, and workflows that do not allow for appointments to be booked accordingly will not be endorsed.

Executive leaders should confidently uphold the guiding principles and include them in their broad communication strategy to all relevant stakeholders.

The graphics below showcase an example of a vision statement and guiding principles that were developed by a multidisciplinary team at a large, academic health system. These statements drove the design of a comprehensive, centralized patient acquisition and access center and were pivotal to the long-term success of the program.

Guiding Principles

  • Build a world-class patient acquisition and access center that supports all providers and ambulatory locations within our health system
  • Focus on a consistent, standard service delivery model that provides optimal access for patients and families
  • Create a patient-centric experience that supports and promotes the delivery of high-quality clinical care
  • Build upon the organization’s current capabilities, using and expanding processes already proven to be successful
  • Deliver patient support services in a consistent and seamless way, regardless of the location or specialty
  • Help patients and families navigate all aspects of their care process

Vision Statement

The Patient acquisition and access center will be a patient- and family-focused, world-class center that delivers a consistent and seamless experience across our healthcare organization. It will also provide efficiency and expediency in patient business services, and offload business-related work from the ambulatory practices in order to optimize the on-site care experience.

Cultural Change Management

Centralizing services, and particularly relocating them out of the providers’ offices, is usually an uncomfortable proposition. Although organizations differ in their level of readiness for this effort, many leadership teams utilize the same “get it done” approach, sacrificing critical investment in the time to gather buy-in and understanding from their clinical teams. Entire programs have unwound in several organizations due to lack of engagement and loud dissatisfaction, only resulting in wasted time and resources (not to mention a rocky patient experience as processes flip-flop from old to new and back to old.) The primary tactics for avoiding such failures are to 1) create a comprehensive change management plan, and 2) employ a medical director specifically for the patient acquisition and access center who can champion the plan.

Guided by a strong medical director, a comprehensive change management plan tailored to the organization’s culture and engagement can prevent backlash, and thus should precede implementation of any centralized services. The plan should also act as the platform on which providers and clinical staff participate in the work effort. It is important that the change management plan lives and breathes in parallel with the implementation process, and it must be revisited post-implementation as a mechanism for gathering feedback.

As previously mentioned, centralizing staff and moving to standard workflows are not comfortable changes that healthcare providers quickly adopt. These changes typically involve relinquishing control and placing trust in groups outside daily clinic operations. That is not an easy proposition when providers truly care about their patients and want to do what is best for them. A change management plan should address anticipated pain points – loss of control, shifting from independent to team-based care, adjusting to new visit types, visit type definitions, and scheduling algorithms. It should also offer outlets for discussion and provide an escalation pathway to a multidisciplinary decision-making body that can and will protect provider scope of practice requirements while also confidently upholding the guiding principles when necessary.

This step is one of the hardest and most time-consuming, yet one of the most important to ensuring a smooth implementation and strong program that is supported by all stakeholders. Gathering feedback across the design, implementation, and post-implementation continuum is tedious and will require dedicated support to manage, but the return on investment in the form of provider and staff engagement is well worth the time and resources. The project’s communication plan should dovetail into the change management strategy so that all players are regularly engaged.

Dedicated EHR and Analytical Support

The power is in the data! A significant benefit of patient acquisition and access centers is that they are inherently data rich. In fact, they are so data rich, it is often challenging for organizations to harness the ample information at their disposal and present it in meaningful ways. However, doing so is critical! That said, the most successful patient acquisition and access centers employ a dedicated analytical team, allowing them to stay nimble and adjust to environmental changes in real time.

Dedicated analytical support from the beginning of your patient acquisition and access center journey is the fourth critical element of a standardization and centralization effort. As with most transitional projects, assessing pre- and post-performance against benchmarks is important for creating the project’s initial burning platform, and subsequently measuring progressive change along the journey. Additionally, a return-on-investment analysis may be required because some level of investment in the centralized center will be necessary (as further detailed in the following section.) Employing an analytics manager and report writing staff will allow for continuity across the centralization effort. These team members will also be able to support sensitivity and “what-if” analyses that will surely be requested by the organization’s financial and operational departments as major staffing decisions must be made. For example, what if the target service level is 80% of calls answered within 45 seconds rather than 30 seconds? What impact will those 15 seconds have on agent staffing requirements? Additionally, electronic health record (EHR) data will need to be married to telephony data to appropriately assess the performance of both the patient acquisition and access center and the clinics it supports. For example, how many calls requesting an appointment actually yielded a scheduled visit, and how far into the future was that appointment booked? While far more challenging to quantify in the decentralized environment, insights such as these can catalyze forward movement of the larger, centralized effort.

Access to the appropriate IT systems to garner the data is paramount. As a result, the analytics manager and report writing staff should have direct data access, or at least a single point of contact within the broader IT department, who can quickly assist with data queries. Without dedicated staff and data access, assessing both ad hoc and longitudinal performance is increasingly challenging and time consuming.

Finally, centralizing front-office departments requires full support from the organization’s EHR team. Often, the EHR can support greater automation and functionality than is currently enabled. Solutions and capabilities that were previously unknown also come to light when operational teams can brainstorm an optimal workflow with the EHR team. Throughout the patient acquisition and access center implementation, new system build and adjustments to current system setup will be required. Moreover, as the patient acquisition and access center operation evolves, updates to the EHR will iterate into the future. The most successful centralized centers have dedicated EHR team involvement in the initial workflow design phase and they foster a long-term partnership between IT and the patient acquisition and access center.

All in all, arm your patient acquisition and access center with the ability to manage its own data. You will be grateful that you did!

Expect to Invest

It is certainly true that centralized services can lead to significant operational and staffing efficiencies. However, efficiencies tend to materialize further into the future and only after proper investment is provided on the front-end.

Underinvesting in the patient acquisition and access center is a common mistake that almost always catalyzes the downfall of this transformational effort. Organizations must carefully measure their existing infrastructure against the minimum requirements for launching and maintaining a patient acquisition and access center. Metric goals and Service Level Agreements should also be part of that assessment because the minimum requirements will often not allow for best practice workflows and metric benchmarks to be achieved.

Executive leadership and patient acquisition and access center project sponsors should review the following items and be prepared to dedicate resources to them if not already in place:

Of these ten items, patient acquisition and access center staffing hardly fails to be misunderstood by both project and executive leadership. Staffing a patient acquisition and access center is a unique math problem and is unlike traditional inpatient and clinic staffing calculations or unit of service models. This is why dedicated analytical support and workforce management technology are essential! The goals of your patient acquisition and access center will never be achieved if agents and support FTEs are not prioritized.

Additionally, avoid succumbing to the myth that because phone work is leaving the clinics for the patient acquisition and access center, FTEs from those clinics can be reallocated. Although that might be the case in some instances, shifting staff members does not guarantee that the patient acquisition and access center will be staffed to meet desired service levels. Why, you ask? Most organizations do not truly appreciate or have access to data that demonstrates actual demand for their services. For example, just because a clinic’s main phone number rings 100 times every day does not necessarily mean that only 100 people are trying to reach the office. The phone platform may be dropping calls or governing how many calls can be answered within a given time interval. As a result, the true phone demand is unknown, and staffing the new patient acquisition and access center to that call volume may not provide what is needed to meet call metric benchmarks. Additionally, clinic staff roles are typically comprised of a collection of duties, and if they were staffed appropriately, they would likely be able to answer all calls and potentially render the patient acquisition and access center unnecessary from a phone wait time perspective. Overstaffed clinics, however, are uncommon and staff are already spread thinly across multiple responsibilities. That said, reallocating care team members from the clinics to the patient acquisition and access center without backfilling may leave the clinic with unanticipated operational gaps.

As previously mentioned, patient acquisition and access center support services cannot be underestimated. Dedicated trainers who can build and maintain curriculum are critical to staff performance – remember, patient acquisition and access center agents may be the first of anyone to interact with prospective patients, so they must be proficient and confidently provide top-notch service. Similarly, a quality assurance team must be in place to monitor performance and highlight where workflow improvements can be made to both improve patient satisfaction and operational efficiency. Lastly, a workforce management team to manage both long-term and intra-day staffing will ensure that the patient acquisition and access center is never over- or under-staffed to meet service level goals, effectively managing the budget.

Antiquated technology platforms will also hinder your organization’s ability to realize desired efficiencies via the patient acquisition and access center. Technology should facilitate the most effective and satisfying experience for all stakeholders. The majority of high-performing patient acquisition and access centers have implemented omnichannel solutions that allow for automated calling, texting, chatting, and online scheduling. Although initially expensive, robust technology can mitigate a portion of patient contacts away from human intervention, thus creating a more cost-effective, long-term strategy for managing year-over-year volume growth. Additionally, modern telephony platforms can allow for remote agent work and reduce the cost of physical facility builds and expansions.

While streamlining and centralizing services into a patient acquisition and access center will garner efficiencies, proper investment allows for the foundation to be properly poured and leveled. Without it, progress will be hindered if not reversed.

Conclusion

According to Ezekiel Emanuel, MD, centralizing scheduling is a best practice and thus is cited as one of his twelve researched practices that leads to transformational change in the healthcare system. Centralizing scheduling and other front-office functions can increase access to appointments while also providing more focused care for patients while they are seen in clinic, because in order to be centralized, these areas must undergo significant process and policy changes. Scheduling templates should be adjusted to meet guiding principles and productivity standards, open access to appointments should be established, and simplification of scheduling rules should be achieved so that any scheduler can accurately appoint a patient calling for that service, regardless of the provider and/or location.

Furthermore, this standardization effort will make the implementation of online scheduling simpler and faster. Regardless of the communication channel they choose (e.g. phone call, online portal, online chat), patients and families should have the same experience with the same level of access to appointments and services.

Other services such as registration, insurance eligibility checking and authorization, referral coordination, medication refill coordination, medication insurance authorization, and nurse triage and advice services should also be considered as components of a full-service patient acquisition and access center. These services can create a one-stop shop phone call for patients, effectively decreasing the number of phone interactions made by care team members and instead allowing them to focus on patients physically within in their clinic.

Additionally, clinic staff roles are typically comprised of a collection of duties, so calculating the number of FTEs that correspond to phone calls and other work transitioning to the patient acquisition and access center involves estimating, at best. Overstaffed clinics are uncommon, and staff is already spread thinly across multiple responsibilities. That said, reallocating care team members from the clinics to the patient acquisition and access center may leave the clinic with unanticipated operational gaps.

Many healthcare organizations across the nation have implemented advanced and high-performing centralized front-office centers, and most are willing to share their best practices. Their successes have been achieved and/or sustained by avoiding the common missteps detailed above. While this list is not comprehensive, it should serve as a starting point and overall guide when contemplating how to approach standardizing and centralizing front-office ambulatory services.

References 

1. EMANUEL, E. J. (2018). PRESCRIPTION FOR THE FUTURE: The twelve transformational practices of highly effective medical organizations. S.l.: PUBLIC AFFAIR

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