Practice management principles

Published on 17/03/2015 by admin

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chapter 18 Practice management principles

INTRODUCTION

This chapter provides a checklist of the important factors to consider in establishing and operating an integrative health clinic. It is not a definitive practice management manual. Most of the principles described here are the same as for other medical clinics, but there are some distinctive features.

When considering establishing or changing your practice to an integrative model, you will have a range of options to consider. Your practice might consist of:

• general practitioners (GPs) only, without special CM training, who refer actively to a ‘virtual team’ of CM practitioners outside the clinic
• GPs only, who have an understanding of or special training in one or more CM modalities, which they incorporate into their therapeutics advice to patients
• GPs with or without in-depth knowledge of one or more CM modalities working in a co-located integrated team with CM practitioners, with an in-house inter-referral pattern.

MISSION STATEMENT

An important first step is to know who and what you are, and to be able to articulate this. Writing a mission statement may sound like a simple task, but it can take a significant amount of thought and negotiation to make sure everyone, from the front desk staff to the most senior practitioners, shares the belief described in the mission statement.

Your practice management style will reflect the type of practice, your underpinning philosophy and the mix of practitioners working in your team. Adopting an integrative model of practice should also begin with the practitioners as role models themselves, by incorporating health principles into their own personal beliefs and health habits.

BUSINESS PLAN

Whatever your mission and philosophy, for your practice to survive and thrive, its business fundamentals must be sound. A business strategy needs to be based on the most likely scenario, but it also has to consider the potential ‘worst case’ financial scenarios.

An initial scoping exercise will assess the existing services in your local area and whether there is a demand for the services you are planning to provide. If you provide a largely locally based service then you will need to assess the likely patient demographic and the patients’ special health needs. If your practice is likely to draw from a wider area because it provides more specialised services for which patients are prepared to travel, then that demographic will be different and may only become evident with time as the clinic and its practitioners develop a reputation for expertise in particular areas.

All potential costs need to be factored in, as well as realistic projections of turnover and growth trajectory, including buying or leasing costs of furniture, phone systems, IT, medical equipment, leasing or holding costs of premises, insurances, cleaning, utilities, consumables and staffing.

Material resources need to be planned and discussed with team members and administration staff. Decisions on big-ticket items like computer systems and software need to be made very carefully, with a view to future capacity, not just current need. You also need to decide whether to buy, lease or hire-purchase major equipment.

Staffing levels for administration need to be appropriate to the required skill set and demand due to current and anticipated patient traffic. Staff levels will need to be adjusted as required. The selection of practice manager will be central to your success and your own mental health. This person will need to have the skills to set up and operate the office systems, deal with staff and suppliers, and ensure the smooth running of the business. A mixture of full-time and part-time staff can provide the continuity and flexibility required in a small to medium-sized practice.

Employment contracts that comply with relevant legislation need to be created. It is important to have an occupational health and safety policy and an equal opportunity and anti-discrimination policy in place as an appendix to employment contracts.

Establishing a service-oriented culture from the front desk that pervades your organisation will not only help deliver efficient patient care but also increase the likelihood of profit.

REVOLUTION OR EVOLUTION

Becoming an integrative practice can be a revolution or an evolution. Existing general practices might begin the process by maximising the health promotion opportunities and chronic disease management options offered to patients, as well as encouraging self-care strategies adopted by practitioners and staff.

An existing general practice might also survey its local area for qualified CM practitioners, arrange meetings to discuss practitioners’ areas of expertise and broaden the practice’s referral base beyond the existing list of allied health professionals. For example, an osteopath, an acupuncturist and a chiropractor might be added to the existing referral list where more appropriate than a physiotherapist in some clinical circumstances. The most ‘integrated’ approach is to incorporate CM practices or CM practitioners into an existing GP-only practice, or to establish a planned integrated team de novo.

Your strategic plan ideally will include a statement of goals, objectives, opportunities and potential barriers.

AUDIT THE PRESENT

If you have an existing practice and are planning to move towards an integrative model, you can begin with an audit of the practice’s current performance in this area.

• What does your practice (or practitioners) already offer or provide referrals for in areas such as stress management, dietary advice, exercise advice, risk reduction interventions, community education programs and support groups?
• What are the needs and beliefs of your patients? Rather than taking a wild guess, consider using a carefully constructed patient questionnaire.
• Update your existing referral base to include practitioners who can offer care in a form that your patients would find useful. This would include such things as yoga or Pilates teachers/classes, meditation, t’ai chi, aquafitness, qualified personal trainers, massage therapists, nutrition education classes, counselling services, help lines and so on.

SET UP THE INFRASTRUCTURE

Once you have decided which practices or practitioners you intend to include in your integrative model, you need to adjust your infrastructure to accommodate any changes.

• Are your consulting rooms the appropriate size for the planned activity?
• What is the appropriate duration of consultations?
• Does your practice software have the capacity to accommodate different types of practitioners?
• What equipment is needed? (e.g. massage tables, acupuncture needles)
• Is your communication network (phones, faxes, email) appropriate for your purposes or does it need to be upgraded?
• Staff members need to be educated about the treatments offered by the clinic and the appropriate responses to enquiries from patients and potential patients.
• A website is a useful tool that patients can access for practice details, practitioner profiles and health news and information.

IS YOUR CLINIC AS ‘GREEN’ AS IT COULD BE?

According to the Australian Conservation Foundation,1 saving just one ream of paper will save 20 kg of greenhouse gases and reduce your stationery bill.

• Print on both sides of paper, and use the back of used paper for intra-office memos.
• Aim for a ‘paper-free’ office by moving to computerised records, and arrange for results to be sent online. Ask drug reps to leave only one copy of promotional material, which can then be circulated to all doctors.
• Have a paper shredder to shred privacy-sensitive documents before recycling.
• Buy recycled paper and toilet paper.
• A single incandescent globe switched over to a compact fluorescent globe will save 0.5 tonnes of greenhouse gas and save you $70 in energy costs in its lifetime.
• Installing a $4 tap aerator in the bathroom or kitchen can cut water use there by half. Fix any dripping taps.
• Buy green power for your clinic.
• Turn off computers and appliances when they are not in use, and make sure all lights are switched off out of hours.
• Check that refrigerators are working efficiently and with seals intact.
• Check the cleaning products in your clinic and ensure they are non-toxic.
• Ventilate your clinic with natural air and minimise the use of air conditioning.

REGULATORY CONSIDERATIONS

Specific regulatory requirements will vary from one jurisdiction to another, but practice management requires detailed attention to:

• insurances—professional indemnity, building and contents, public liability, workers’ compensation, key personnel etc
• financial record-keeping and accounting
• staff superannuation
• taxation, including employees’ PAYG withholding
• goods and services tax or other consumption taxes.

OUTSOURCING

Referral to CM practitioners requires some knowledge of the evidence base regarding the safety, efficacy and cost-effectiveness of various modalities for different conditions. It is important to be able to identify the most appropriate therapies for given conditions based on the evidence, and the patient’s needs, previous experiences and personal preferences. For example, there is little point in referring a patient for acupuncture if they have a phobia about needles.

A referral base takes some time and effort to build and will come from a variety of sources including professional recommendations, local networks and patient recommendations.

Practitioners outside the practice could be invited to submit their credentials and references prior to referrals. You will need to know details of the practitioners’ academic qualifications, clinical experience and areas of expertise, registration (if the modality has a register), fee structure, insurance rebates available to patients and professional liability insurance.

IN-HOUSE

If you decide to integrate CM practitioners into an existing general practice, there needs to be consensus on the types of modalities that would be most suitable for inclusion. The type of financial or business arrangement also needs to be considered. This might be in the form of:

• room rental with or without administration services
• contractor on a commission basis
• employee
• associateship
• partnership.

Legal advice should be sought to determine the exact nature of the arrangement and this should be codified and agreed on prior to the commencement of that practitioner. You will need documentation confirming practitioners’ qualifications, references, registration and professional indemnity insurance.

REFERRAL PATTERNS

A general practitioner-centred model of integrative practice has the GP as the initial contact within the practice. The doctor would carry out an assessment of the patient’s health status and their healthcare needs, and then discuss and coordinate the most appropriate strategies to reduce health risk, prevent disease or manage illness.

Referral to practitioners with the appropriate knowledge and skills occurs in the same way as referral to medical specialists, with a requirement for monitoring clinical progress either through an integrated record system or through progress reports being communicated back to the referring doctor. There should also be an agreed time frame for medical re-evaluation of the patient’s progress.

An integrative practice where there is a variety of primary care providers may have either a GP, an allied healthcare or CM practitioner outside the clinic, or another practitioner within the clinic (such as a naturopath, a physiotherapist or a psychologist) as the initial contact. In these cases the non-medical practitioners need to be very clear on when it is appropriate to refer for medical assessment, or to refer back to the referring GP once treatment is concluded or if medical review is required.

Communication protocols between practitioners need to be carefully established and followed.

COMMUNICATION

Communication is an important feature of efficient practice management and team development.

FROM THE PRACTICE TO PATIENTS AND POTENTIAL PATIENTS

A practice brochure in hard copy and on your website should contain, as a minimum, information on your mission statement, practitioners, location, contact details, public transport, directions and parking, how to make appointments, what your after-hours and emergency arrangements are, your billing rates for various practitioners, and forms of payment.

Prior to your launch or relaunch you will need to organise a graphic designer to design a logo and colours for your brochure, letterhead, business cards and other stationery. Patients could be offered the opportunity for email newsletters.

Appointments, particularly for booked long consultations, can be confirmed via bulk email or SMS messaging through practice software.

Patients also need to be informed of the practice’s privacy policy and what happens to their confidential information, and agree to clinically relevant information being transmitted between practitioners involved in their care.

BETWEEN PRACTITIONERS

As in any group practice, group meetings are an essential form of communication for the purpose of exchanging information on practice management matters and improving efficiency. Meetings should be held regularly by agreement at a time suitable for most practitioners and staff. Minutes should be kept and circulated with a note of actions taken or planned, as soon as practicable after the meeting. Practitioners may wish to hold separate clinical meetings to discuss difficult or complex cases, with appropriate measures taken to protect patient confidentiality.

An integrative practice provides the opportunity for joint consultations. For example, a patient wanting to combine medical, herbal and/or acupuncture treatments might benefit from a part of the consultation being conducted with two or more practitioners from different disciplines involved in their care present to discuss their management plan.

Where the integrative practice operates as a ‘virtual’ team, clinical feedback about patient progress ideally needs to be done in writing. Or, if feedback is provided by phone, a contemporaneous record of conversation must be kept in the patient’s records. Significant changes in treatment or the patient’s condition should be communicated with all practitioners involved in the patient’s care.

PATIENT RECORD KEEPING

Medical practitioners are generally well aware of their responsibility to keep contemporaneous and legible records of patient encounters. Confidential patient information must be protected and patients informed if there is a shared record system accessible to other practitioners. These principles must be emphasised for all healthcare practitioners in an integrative clinic.

Some practitioners, such as psychologists, may prefer to maintain their own separate records and communicate patients’ progress back to the referring practitioner by letter rather than shared records.

The clinical record must:

• identify the patient
• be comprehensible to another practitioner
• contain details of the history and examination, clinical opinion and management plan, including medication or supplements prescribed, procedures, counselling and advice.

Records must be kept for at least seven years from the date of the last entry. If the patient is a minor, the record must be kept until the patient turns 25. Within reason, records must be stored so that confidentially is maintained and so that they are not lost, stolen or damaged.

ONGOING EVALUATION

Successful practice management requires an ongoing system of performance assessment. This will include clinical and financial aspects of the practice as well as less tangible outcomes like practitioner and staff satisfaction.

Patient satisfaction can be gauged by surveys designed to assess how happy patients are with the current service and what they would like to see done to improve their experience of the clinic.

RESOURCES

American Medical Association, Solutions for Managing Your Practice. http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice.shtml.

Australian Medical Association Guidelines on Service Contracts between Doctors and Medical Practice Principals. http://www.ama.com.au/node/3760.

The Drs Reference Site, Practice Management. http://www.drsref.com.au/business.html.

REFERENCE

1 The Australian Conservation Foundation’s GreenClinic Guide can be downloaded from the ACF website at http://www.acfonline.org.au/uploads/res/res_greenclinicguide.pdf

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