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On April 29, 2019, WTH commented on Patient flow from ER to the wards does not flow :

This is very very common. We have hospitals with bed managers and those that do not have bed managers. I agree with the comment above about discharges being around noon, that seems late. We have been able to help reduce LOS in our hospitals by doing lean process improvement projects. Analyzing the process for discharges, admissions, transfers, and surge capacity can really be eye opening to the problems in the system. The key to these projects is getting front line champions (from specific departments) and someone from senior leadership involved in the project. Starting with a smaller project, registration for example, then building to the larger projects was helpful.

We also use wRVUs as a part of compensation but we were also concerned that this would lead to over billing. What we found was that having ~15% of the compensation be tied to wRVUs was enough to motivate people to be productive and chart appropriately but not enough to game the system. The other thing that we did was provide data to the clinicians that showed where they stood in the group in many quality areas. This helped to keep everyone focused on quality and allowed for conversation about why someone might be very successful with a specific diagnosis vs someone else.

On April 15, 2019, WTH commented on Electronic Health Record Implementation :

We have done this several times with different hospitals. We have seen bad implementations and good ones. The good ones have seen heavy engagement with front line leaders and did the roll out systematically, and not all at once. They started with a few specialties ( primary care, peds, ect) and then did the roll out at the hospitals after. Engagement was key, so they identified “champions” from each specialty and had regular meetings. Even the “good” roll outs had issues, but with the systematic roll-outs it allowed them to identify issues early on and make changes before the next specialty go live. Communicating the issues seen in the primary care helped the other front line leaders understand what they may see when it rolls out in their specialty.

Breaking down barriers and silos is a very difficult thing. These silos create a sense of mistrust within any organization, and it is extremely difficult to change that mistrust. The only way we have been successful is to foster better communication and transparency. It has been a difficult road for my organization and there is still some mistrust, but we continue to build back the trust by communicating regularly about the decisions that are being made by senior leadership. To change things you must begin somewhere and know that it is a long road. Celebrate the small wins and keep it going.

You are not alone in having a difficult time delegating, especially when you are able to see the solutions quickly. Leaders are not just born, they are created through education. If your organization is looking to decentralize decision making, then they should invest in the education of the lower level leaders that they are trusting to make changes.

Communication and relationship building is also key in decentralizing the decision making. You need to be able to trust those leaders below you and give them autonomy. The only way that they will be successful with that sudden autonomy is to have a clear mission and for them to understand your expectations. Trust is only achieved between members of a team when they get to know each other. I know your time is valuable, but intentionally make time to get to know your people. Grab a coffee together, have a regular check in meeting, or doing something social will help to build the necessary relationships to make this change. Build the trust, develop the relationships, clearly communicate the goals/mission, give them the power to make change happen, and most importantly celebrate the wins.

The best way to change the minds of the “bean counters” is to educate yourself on how coding actually works, and what things your physicians can be doing to get the appropriate reimbursement for their work. Many times physicians are not putting the appropriate documentation into their charts, largely because of time issues and number of clicks it takes. Scribes have worked in our practices to improve productivity, reduce documentation errors, and increase reimbursement. I understand wanting to move away from RVUs but showing a willingness to try and solve the current problem will help you with the next suggestion: moving away from RVUs and focusing more on value. Focusing on value is very important, especially if your organization is contracting with ACOs. Again, this is where you will need to educate yourself and ask questions about what those value based contracts entail. There are many opportunities in the shared saving or value based contracts that you and your fellow physicians can take advantage of, you just need to understand the measures and get buy-in.

In the negotiation for a new pay structure, I would suggest asking them to lower the $/RVU rate, increase the base amount, and begin shifting more compensation to value based measures over a period of time (years). Not many administrators would make the quick leap away from RVU, so a gradual change would likely be more palatable.

Understanding what measures would be acceptable from the administrative point of view is key. Patient satisfaction would be acceptable to administrators, but is most often attacked by physicians. Again, the measures in value based contracts and MIPS/MACRA are the easiest way that administrators can measure their ROI in changing the reimbursement structure. These measures are already put in place and do not require you or admins to reinvent the wheel.