Good afternoon, everyone. Thank you so much for joining us and taking time out of your very busy schedules to participate. So we apologize. We've had some last minute changes to the PowerPoint presentation, all my fault. So we're uploading those now. So we are going to be starting off shortly. But just wanted to say hello and let you know that we are ready for all of you and look forward to the active discussion, hopefully. And although I recognize this is a webinar and the two-way conversation is not possible, but we're hoping via the chat function, you guys ask some really great questions. And not only that, because of the specific question we're addressing, you give us solutions, right? You tell us about your experiences that have worked for you guys in the past and currently building. So hopefully between both your solutions and questions, we all walk away from this smarter. So hold just a moment. OK, I guess to best utilize time, I'm going to do my introductions now. This way I can just skip by that slide when we get there. So many thanks to our guests. We have our instigator here, Dr. Dino Reikia from Munson Health Care. As you know, he sparked the original curiosity, right? He sent the original email a little over a month ago that we were amazed at the feedback that we got, right? Lots of questions, lots of people putting in their 2 cents, and a lot of people who had put more questions on top of that. So we're here because of him, so we can thank him. I'm calling him our superhero of the day, rock star, for getting us all together. And again, we're all going to walk away from this smarter. So thank you, Dino, for that. And actually, I also want to thank you for just being an active member of MedAxiom and for participating, because it's questions like yours that really bring us all together and spark curiosity. So thank you. And then we have Tricia Smith, who is the clinical director at Deaconess Heart Group. And she's going to tell us about some of the solutions that she's come up through her experience, right? And then we have Nikki Smith. Nikki is a colleague of mine. She's the director of member services here at MedAxiom. And like all of us at MedAxiom, before we joined the family, we all had previous roles in cardiovascular medicine that we were deeply rooted in the systems, in the processes, and the problems. So we all come with lots of vast experience. So Nikki will share some of the solutions she came up with before she joined us. So with that, again, so this is part two. I'm hoping most of you had an opportunity to join us last week. Ariana, next slide. So really quick, some quick housekeeping. Again, the chat button is your link to presentation slides. And then the green button, most importantly, is your questions. And as I mentioned, I'm hoping it's not just questions, but also solutions, right? Or just tidbits of advice that you have to offer. And we'll take that information together and hopefully walk away, again, smarter. Next slide. So I did the introduction, so we can pass that. Thank you all for participating. And really quick, in case you missed it, last week's presentation I thought was fabulous. That was part one that was also sparked from the original email that Dino sent. So really quick takeaways, at least my takeaways from that presentation, technology, right? There's so much technology and it's always amazing to hear what other people are using. For me, momentum. I hadn't heard about momentum. The folks, the team over at Providence, that's what they use for their physician scheduling. It works wonderful for them, right? It's a web-based app that syncs into their personal calendars and to their outlook, and it keeps all the trains running on time from the physician perspective. So it's always nice to hear about new things. I put on here the PTO request. For the Providence team, it's five months. And I bring this up because, again, it's always amazing to me to hear all the different timeframes that people have created. I recently ran into a member who they request vacation 13 months in advance because the schedules are built out 12 months so that when a patient leaves the clinic, they can schedule their one-year follow-up. That's amazing, right? But that also creates a lot of difficulty, right, in trying to change things. So again, there's no right, there's no wrong. It's what works for your system. That being said, it doesn't work if there aren't consequences for actions and you don't abide by the rules, right? That being said, if a physician consistently cancels, clinic, three weeks in before, right? So again, all the rules don't work if we don't stick to them and have consequences for those. I also learned about the folks over at Spectrum Health, Corwell Health, their early access clinic. So this was very impressive, right? They see all new patient referrals in 72 hours. So let's stop and think about that. 72 hours, I think that's amazing, right? All new patient referrals. You know, most people don't even get back to their new patient, to the referrals that are in the system in 72 hours. So the fact that they see them was quite impressive. Game changer for them, actually, is what they said. Obviously, right, increases revenue. Your no-show rate goes down. Patients are happy. Your primary care, all your referring docs are super ecstatic. It's just a win-win on so many bases. So if people can get to something close to that, that's pretty impressive. So that was amazing to me. And then Danielle and Alan over at Lehigh, sorry, Valley Heart and Vascular, they have an impressive program there too, right? They talked about their care continuum partners. They've been really creative, again, in these new job descriptions, right? Modifying old jobs into new jobs, these care navigation partners and care coordination partners. And they really walk the patient through the system. It's not just one interaction, right? And the one thing that I walked away from them that I hadn't heard of and was incredibly impressed was their welcome video visit, right? So the patient is quickly put into the system. They make them an appointment and then they send them a video visit. So to me, that's brilliant, right? The ROI on that, you capture it. You may not be able to see the patient for a couple months, but if right off the bat, you send them a welcome video visit, guess what? That patient feels welcomed, right? They feel like they're already part of a community. They're not gonna go around looking for four other doctors to figure out who's gonna get them in first and then not cancel the other appointments, right? So obviously their no-show rate has gone down, but that's a little effort upfront, but a long return, a big return on that one, right? So to me, that was impressive. Again, these were just some of my takeaways from last week. I hope you have an opportunity to go back and watch it if you haven't. Next slide. So why are we here? Again, Dino, Dino, Dino. Again, so this question, right? Managing physician APP schedules and optimizing patient care. Seems so simple, but it's incredibly complicated and mainly because there's no one perfect solution. So it was this email that came through on the list over that sparked so many questions, so many emails. So clearly we knew we had to come together to talk about it. Next slide. So air traffic control, right? As Tricia, who you will shortly meet, identified it and it makes perfect sense, right? That's what we all need, right? Air traffic control, the eye up in the sky, right? Someone who's looking over all cardiovascular services, inpatient, outpatient, the procedural areas, right? Looking into the community where you have your doctors to figure out what's happening. And not only what's happening now, but anticipate what we're going to need. That's actually the bigger dilemma that we don't have. We can't anticipate what's coming down the pipeline. You have a doctor going on maternity leave or paternity leave. You have someone retiring in eight months. You have a new fellow you're going to hire on as faculty. These are all variables that are going to change everything. And we constantly need to be modifying our practice to accommodate this. But there's no one person who has their eye on all of it. And I think that's really the big question that we're talking about here. Next slide. So what we do know with all new positions, creating this air traffic control position. Dino and I chatted about this a little bit earlier, right? Budgetary, it's the worst time. We know everyone's having difficulties with the budget. Justifying a new FTE is no easy task, right? These are all the obstacles that we face in trying to do the right thing, right? So you have the budgetary constraints. We have human resources, which to me, that's like the Mount Everest of obstacles, right? It's trying to create a new position that doesn't exist. I have PTSD just thinking about it, right? So because HR has existing job codes, existing salary scales, existing job descriptions from like 20 years ago, and you're trying to build something different, right? You're trying to be innovative. You're trying to shake things up, come up with new solutions, and they keep giving you old situations, right? So that alone takes a lot of time, right? And then obviously you just have the change factor, right? People have trouble with change. You know, you have these preexisting job duties. You create somebody else, you bring somebody else into the system. You're obviously taking bits and pieces of other people's jobs. It makes people nervous. People have a tough time. So these are all obstacles that we face every single day in trying to create new positions. Next slide. So if you make it through all those obstacles and you keep persevering and you're finally ready, just keep in mind that job description matters, right? And in this case, this job that we don't even know what it is yet is actually even harder to create because, you know, the entry-level roles are actually pretty easy, right? They check in the patient, they make a new appointment. It's pretty easy to identify the task. It's these roles that are kind of mid-level that require independent thinking that are actually hard to articulate what they're gonna do, because we don't always know what they're gonna do. We're hiring them because they're gonna be a solution to a problem that we have, but we don't know what the solutions are. So these ones really take more time on our end to create proper job descriptions that set this new employee up for success and creates proper expectations for everyone around them. So job descriptions matter. Just please keep that in mind. Next slide. So I wouldn't be doing my job as a Medi-Axiom team member if I didn't give you another perspective, right? And again, solution is not always hiring people, right? So we're gonna talk about managing your data better, not managing more people. Next slide. So again, our job, we're building the bridge to the future, right? We don't wanna go backwards, we wanna go forward, and we know technology is huge and we need to figure out how to move forward, right? Next slide. So the advantages to data, better data, specifically dashboards, right? We're all fiscally challenged. We know that just the time and energy that goes into creating a new job description, right? It's now eight, nine months later before you get this new position. We also know building a solution around a person is never a good idea. You know, it's all fabulous for a year or two, and then that person leaves because they have a better job opportunity, they get married, God forbid they have a baby, and suddenly, you know, you're in crisis mode, right? So we always know that never works out. The other thing is leveraging existing data to make real-time changes. The data exists, we know it exists, right? And the ability to make change today at the end of the month opposed to six months from now is very competitive, right? It's a rule, it's a game changer. And then obviously, it's living by the rules. When you have people and they all have their very specific job, you know, everyone lives by the rules. So when you change that, it takes a long time to socialize change, right? Next slide. So leveraging data. Again, we all have it, right? And what we're trying to do is to achieve something new, or in this case, better. We're always looking for better, quicker, faster. Next slide. Dashboards. So making them meaningful. So just really quick, the data is there, it's our job to figure it out. We know that right off the bat, IT is gonna say, nope, and shut the door on us, right? Perseverance, right? Working, we're going back and forth with them until we find it, and working with administration, right? Because they're often the ones who control the ability for us to access that data, right? And without their support, we're never gonna get anywhere. We know that data is there, the financial data, the new patient data, the billing data, it's all there. So it's a matter of getting our hands on it. And we all know, we can easily justify to administration, those visuals, they respond to visuals, right? To real data. Everybody responds to the real data. They don't respond to us whining about how broken the system is, or why we need three more new people. You know, that actually shuts the door, right? They don't wanna listen to us. But the data is a quick way to get their attention. So it's our responsibility to monitor the performance, create these reports in order to make informed decisions in real time, but we need the data. Next slide. So quickly, I'm just gonna throw out, there are a couple of examples of dashboard. Our job is to make them meaningful. Often we look at these dashboards that have so much information, and guess what? Month to month, it's always the same. Green is always green, red is always red, yellow is always yellow. That's actually a broken system, right? It's a lot of effort. More specifically, when people are creating Excel spreadsheets, when they're waiting for the data, they're populating the data. First, terrible use of their time, right? And second, it's opportunity for error. That's what we don't want. That's hence why you wanna create dashboards that are derived from the system, right? So that you eliminate that step. So in this case, it's precise, right? There's not a ton of information. We're just looking at new patients. We all know, no new patients is the death of a program. My old chief would always say to me, right? Critical to mission for the ambulatory practice, right? But not necessarily for everyone. So this is an example of that. Next slide. So this one is a more comprehensive dashboard. In fact, close to home, this is what I created back when I was in Boston, working with my group. Originally, it was derived in Excel. Once a year, I would take all the year-end information and drop it into an Excel spreadsheet. The doctors knew that this information was important, and every October, they were looking for this information, right? However, we didn't hit that secret sauce until we purchased a Tableau license and hired an analytics person, right? Eventually, working together closely, we could create meaningful dashboards, right? So together, we were able to pull the financial information, the billing data, the scheduling system, and we could literally report our monthly activity every month, right? So when you look at two, three months, now you know you can identify a trend. You don't have to wait for two quarters of reports to say, huh, we have a problem. What are we gonna do about it, right? Now it's six months, nine months later. We could do this in real time, but I couldn't do it by myself, right? But the information was there. It was us finding the information and then using a sophisticated IT tool to pull that data. And once you build these models, guess what? Then it's a press of a button. It's not easy. It takes time, but once you do it, I promise you, right? It pays off in spades to have this information and you can build it around anything you want. I just happened to build these for physician performance, right? Next slide. So that's my perspective on alternative solutions to hiring more people. The people, sometimes you need people, no doubt, but other times we just need to be more creative about what the solution is. So with that, I'm gonna transfer this over to Dino. And again, thank you, Dino, for so many reasons. Hopefully we can help, we can listen attentively and come up with some solutions for you. Well, great, Anna, thank you. I just wanna share this has been an interesting journey from throwing a question on the MedExium listserv to being a panelist on a webinar post-call, but I'm glad for the opportunity. I also wanna put a plug in. I watched part one of this series just before we got together today. It's excellent. I learned a lot from it. So I would put a plug in as well for those of you to watch part one of this. If you wanna throw up my slide, if you don't mind. Yeah, so this is where it all started, this question. And I'm just gonna give you a little context with a few slides. Again, I am here as the questioner. I do not have the answer to this question looking for that from all of you. So what I'm trying to do, what we're trying to do, our leadership team is to create a position dedicated to solely doing this job. Basically what I'm looking for to create is, what I think I need to create is somebody who spends all their time looking at the physician and APP schedule, figuring out where people should be when, sorting out what adjustments need to be made, et cetera. We do not have that in our practice. We have a physician lead, I'll show you that as we go, and an administrative assistant. So let's go to the next slide, if you don't mind. So this is the growth of our group over time. I've been with the group the longest of the people there now, so way to the far left. When I came, some of you on this call are from the old days like me. I joined one person or we had, we'd make rounds on our own patients first thing in the morning. We'd go to the office, we'd leave the office to go do a stress test. We'd go do a heart catheterization. It was very old school practice and you didn't need anybody to make your schedule because it was always pretty much the same. You did a little bit of everything every day. Our group grew, we became larger. We had someone doing some of this kind of work. Again, we didn't have the dock in the box approach where I did one thing all day. It was still a little bit mixed. And then around 2010 or so, when we became integrated with Munson Healthcare, the group started to get quite a bit larger and now we're gonna be just hired three non-invasive docs to start next year, so we'll be up to 26. But that's the history of sort of our growth. And unfortunately what we've done over the years is just kind of took the little group approach and tried to make it work for a big group. And I think we've reached the end of that run. So if you go to the next slide, please. So this is the way we use our APPs. We have 18 APPs. Our ratio of APPs to docs is 0.7. The MedAxium ratio in the last report was about 0.6. We have our APPs split, meaning we have eight that just do inpatient work and 9.6 FTs that do just outpatient work divided up amongst general EP heart failure and a partial and structural heart. Our inpatient APPs do not see patients independently. Cardiology goes behind them. Our outpatient APPs do see patients independently. So that's kind of the way we use our APPs. Next slide. We cover a large area of Northern Michigan. We're the Red Dots. We're our main flagship hospital and offices. And then we have nine locations of outreach that we go to. Currently we're doing all the outreach physically. We don't really have a good virtual setup for that. And you can see we did about 50,000 visits last year and almost 40% were done in one of our regional clinics. So it's not just who's at home base every day, but it's who's at all of these different places. And then there are restrictions, obviously some of these outreach or regional clinics we can't do on certain days. And there's a lot of moving parts that goes with this. Next slide. Our current approach, we use QGENDA. So the physician champion kind of creates the big schedule, who's making hospital rounds when, that's sort of our big thing that's put in first and then vacation requests, et cetera. Administrative assistant enters that into QGENDA and we kind of backfill with the APPs after the physician schedules are entered. Our baseline assumptions are pretty simple. Basically we have the dock in the box approach. So each one of us does one thing a day, whether you're in the cath lab or reading in the diagnostic lab or seeing patients or at an outreach clinic. We round a week at a time. We cover our procedural and diagnostic areas first because we need to have docs in those spots. We cover our regional clinics basically as second priority because we have certain days we can go there. And then we cover our main clinic with what's left. And we have six months of the schedule in place. And the idea here, and this was a failed idea to be honest, was, oh, a lot of patients get a six month visit. So if we have six months of the schedule in place, if I see my patient today and say, I wanna see you back in six months, or I want you to see an APP in six months, they can leave the office with an appointment. Well, that didn't work for several reasons, probably because a lot of appointments are not six months, they're more than six months. And then we went with the pandemic, we kind of switched to virtual checkout where patients would just leave and the scheduling team would contact them so they weren't leaving with an appointment anyway. So we're at a point, which gets back to my original question, which is this isn't really working. And for whatever reason in my mind, I have this idea that if there was one person whose sole job was to do this, I guess rainbows would come out and the sun would shine and everything would be great. I know that's naive, but I'm interested to hear, especially from Tricia and from other people, sort of, have you done this? Does it work? Would you do it again? What difficulties did you run into? Those are the kinds of things I'm interested in hearing from everybody. So I hope to hear that going forward. Thanks. Oh, I forgot, yeah, my last slide, I apologize. So go back one slide real quick. So just one thing I wanna point out in this, I totally forgot, the middle, the inability to schedule, to change the schedule for six months. This is one thing that we've noticed is because we have six months in, if we find, boy, our TAVR wait time is getting long, we should schedule a few more TAVR days. It can't really happen for six months. And if we do try to do it in short order, it's extremely time consuming for the scheduling team. So these really, the problems we identified, and there's also a lack of integration, as I said on the bottom, between our kind of diagnostic testing, procedural demands. So if we go to a certain regional clinic more for a few months, we're gonna generate more diagnostic testing in that region. But if the diagnostic schedule doesn't match that, then the patients will be frustrated. So those are the big issues we have that I'm hoping to address today. Hi, I'm Tricia Smith. I'm an ambulatory director for Deaconess Heart Group. A little bit about our practice. If you can go to the next slide, because we start with kind of a practice overview and how we got to where we're getting with these roles. So I've been with our health system for 18 years. We're located in Southern Indiana, kind of at that point where Indiana, Illinois, and Kentucky all meet. So our practice size, scope, and operations sound very, very similar to Deno's. We have right now 24 physicians with three additional posted. We have 28 APPs. We have a couple home-based operation locations. So we have five physical locations located in Indiana and Kentucky. And then we do a number of outreach sites. So much like Deno said, we're contracted with these critical access hospitals for space in their facilities. So we're kind of constrained to those days, those times when we can see patients. And we do anywhere from 30 to 40 outreach clinics per month, you know, depending if that month has four to five weeks in there. So when I joined Heart Group, I joined Deaconess Heart Group December of 2019. My background is in clinical laboratory. I know nothing about cardiology service. And three months after I joined the practice, we all learned what COVID was. So this has been an amazing wild roller coaster. And I learned a lot through failure. So as Deno mentioned, one of their projects failed. I fail at something every day and decide what I'm willing to try again and what I'm not. This role is something, hands down, I would try a thousand times over. So prior to having a scheduling coordinator, and you mentioned us, that coordinator title, they're an entry-level supervisor for us, but that was a role the health system was comfortable with us promoting. And this coordinator, when it wasn't the coordinator, it was my role. My role was schedule utilization, schedule management, physician schedule management, physician vacation management on top of all the other director duties with budget growth and strategic plans for our practice. So we identified the amount of time that was taking from my day and what projects that we really needed to move the needle on, that we were not moving the needle on to really kind of put some time to this. Could it be dedicated as a full-time role? So, I mean, we boomed from integration of our group. And when I joined the practice, we went from six APPs to 28 APPs from 2019 to current. We have onboarded 10 physicians from 2019 to current. We have helped five into retirement into a slowdown plan. So, and partial to justify this, what I learned in our system, which I'm wondering if this will help in other systems is we were using MedAxian. We've been MedAxian partners the entirety that I've been with Heart Group, but we tend to think all of us, we think our systems are different. We think we're all unique. So sometimes external benchmarking with the MedAxian data wasn't necessarily what I needed to land my plane. I did a mix of both. Here's internal benchmarking with other specialty practices, even though we know cardiology is a little bit different than GI and oncology, but internal benchmarking of here's what they have in their scope, meaning the number of FTEs in their program, the number of physicians in their program, the RVU production in their program versus our cardiology program. So we then went from there after deciding some internal benchmarking and external benchmarking from the MedAxian data. And I met with our practice manager and we kind of defined the scope of the role. What were things I was doing and the practice manager were doing that we could do our top quality work. If somebody else was watching this, we help set the goals, we check in, we do the audits to make sure that role is still what we need it to be, but they own the day-to-day. They're in the weeds. So we kind of came there. We made them, they're the owner of our physician vacation policy. We have a very liberal vacation policy and it's very well-deserved for our physicians, but it requires a lot of Tetris with the schedules because we're also on a block schedule. Hospital-based services and consult block first. Second, we flip-flop to that. We do our home-based second and then our outreach is a third priority. Many practices have comp models that are a mix of productivity and pooling. So from our perspective, it's very important that we maintain equity. So when we spread out those consult blocks, we want to maintain that it's equitable among all physicians, 52 weeks in a year, two locations divided by the number of cardiologists rounding. And then every other year we lay over. So we're currently tying up our fiscal year. We'll lay over last fiscal year's numbers with our current fiscal year's numbers and make sure they're even because we're aware that one year, Dr. Smith might have an extra consult block week, but we don't want to make sure three years in a row, Dr. Smith has an extra consult block week while Dr. Jones always has one less. So we kind of look year over year and make sure that every two years, our numbers are balancing. This role is also responsible for that. And then they manage our referral and scheduling team. So procedure scheduling and office referrals, outgoing referrals, and our output is now we have one point person for this. Our physicians have loved it. Instead of who does this, who does that, I have to call three different people to make something happen. They email one person, she manages all of it. They're getting consistency in vacation management. They put a request in QGENDA. They have a response within 48 hours. That response follows the vacation policy. We've seen a decrease in physician concerns, which to me is a huge win. Our physicians are happy, we're happy. And then they have been working on streamlining management of our outpatient referral process. And again, then they maintain that block equity. Go to the next slide, please. So some things that they've been able to do, we actually have two scheduling coordinators. We have one for non-invasive and interventional cardiology with most practices, that's the bulk of our practice. But subspecialty in those other procedural areas, we do have an EP and CV surgery scheduling coordinator as well. Some different nuances with those programs. So this was a position we implemented in 2021. They built our holiday call rotation, which was a huge satisfier prior to this. We waited until a month before and tried to take first come first serve or who had it last year, and it just became a last minute frustration for our bellies. They maintain a spreadsheet, which we'll see on a slider to later. This is where we really wanted to open transparency with our physicians and a lot of organizations we've seen and we've heard. Sometimes there's this distrust between administrators and physicians. So our goal is we will lay everything out. We will email it out quarterly. If you have a question, send it publicly. We're here to answer it. We want to make sure that the physicians have comfort that we are fair and equitable, and we want to hear their concerns because it's truly our goal to make their lives better. If we can get them a better balance, they're able to do a little bit more for our patients while they're in here. She's implemented a daily communication with her team of schedulers that we'll see a little bit later as well. And we were able to take the communication and what she was reviewing as far as the schedule utilization, how far out we were, what remained so patients didn't fall through the cracks. And we're able then to set staff bonus goals around that. So as we were working on this, the patient is at the core of what we're doing. So we were able to use this as our annual incentive for our staff to help us work towards certain goals together. We implemented session limits within our EMR and what session limits are, for those who are familiar with Epic, you'll understand this. We have a schedule. We want open scheduling for our patient, not we only take new patients at this time, this time and this time. But we'll take this number of new patients per day, this number of office visits, this number of acute. And it kind of, whenever it works for the patient. So they implemented those and manage those. She has managed to get our schedules 13 months out. We talk about which evil it is. Is it letting a patient walk out the door with an appointment in hand, knowing we might change that pending a physician vacation request and filling a hospital block or something. But which do we want? Our staff scrambling last minute, trying to fill schedules or a few other reschedules. And then we've developed referral tracking dashboards that we actually drill down and report out to our senior administration on a quarterly basis. So we've kind of done all of this with EP surgery and cardiology. Next slide. Can I ask you a question? Yeah, sorry. Help me understand the schedule 13 months out. I'm sure there's people on this webinar who are thinking the same thing I am. Does that mean your docs know 11 months from now on a Wednesday, what they're gonna do? On call and what block they're going to be in. And that's, we have some of our vacation policy built around that. They can still request. We have a certain parameters around what we consider a late notice request in a certain number. They're allowed to request in a year, but they do any of our physicians can pick up their, as they're trying to plan their vacation and say, oh gosh, I'm on consult block that week. So it's gonna be really hard for the Tetris effect of every other provider slash patient that will be provided. So I won't take my vacation the first week of whatever month I'll take it the second because I'm no longer on consult. So it has been a pretty good position satisfied because our on-call is laid out then 13 months as well. Thanks. Mm-hmm. You can go to the next slide. And these are just some examples. So the top image is an example. Our scheduling coordinator sends us out every single day. We have referral work queues built within Epic. We have it broken down by pod of who knows what, you know, we have our staff scheduled or assigned to specific pods that they're working. But she sends an overview to all schedulers and includes a couple administrators on that as well. Again, our transparency is not only with physicians but with our senior administrative team because we want them to, cardiology is a huge service for these hospitals. We want them to know our process every day. So yeah, she lets us know. So our returned referrals, those are referrals that go back to a PCP office or someone for an incomplete referral information that's missing. And then we have guidelines around how many days we'll allow a returned referral to set before we pick up the phone and call that practice and let them know we're going to remove the referral because we're missing information. Recalls, so 13 months out, this is recent for us. We've been really working on that for a while. So what we do is so every patient that we couldn't schedule their one year follow-up, they were going on a recall list. Now we're whittling down that recall list as part of our scheduling team. The two images on the bottom are some things that are very important to us. The one on the left, the lag time to the appointment being scheduled. The top yellow line, that's letting them know how many referrals have we got in that we have contacted that patient and scheduled them in less than five days from the referral hitting us. We do drill that down a little bit more and a different dashboard where we have it broken down. We can see how many referrals we have called and scheduled same day of placement up to two weeks out. So we're trying to get a handle. Our ultimate goal is to have all referrals scheduled, like not maybe physically in the office, but the patient has an appointment in their hand with less than five days from when their primary care or ED or somebody told them they needed to see our practice. Then we also have dashboards around that lag time to encounter because our ultimate goal for access, we're running at 12 days. So that is our average. If you send a PCP routine referral to our practice, we want that patient in our office in less than 12 days. So this here allows us to see where we're at with those. And we can do some drill down of 100% of those referrals. Where are we really getting those patients into our practice? How often are we meeting that 12 day goal? You can go to the next slide. This is that transparency. This is just one now I have it blinded here, but in what our scheduling coordinator sends out, their names are all in there because we know they're all gonna talk about it anyways. So every quarter we send an update on what blocks the physicians all worked in. And we lay that out, but we keep it with the end of the year to show them at the end of the year, how close they are to being within one of each other. And then we lay it out. So the end of our fiscal year is September 30th this year. We will lay over last fiscal year on top of this fiscal year and show the physicians that for their consult weeks, they've balanced out over the course of two years so that we show them we're maintaining that equity for their schedules. And I think this might be the last slide. Nope, here it is. So our impact, we really wanted a couple of goals. We wanted to really put a focus on physician burnout and certain things that were burning them out and stressing them out where their schedules, it's their life. We wanted to increase patient satisfaction. So the top image is where our satisfaction has been going since we've implemented these roles. Again, a lot of it comes down to, we've had the right people in roles to coach our scheduling coordinators, what to say, how to say it, putting the goals around the timeliness of communicating with patients and then walking out of the door with an appointment in hand. And again, we've helped with our physician satisfaction of a centralized point person. We have decreased errors in communication. Sometimes a physician would come to me and request a day off and then it would be a couple hours before I could see somebody and we would forget to close their schedule and then patients would have to be shifted. It has decreased that telephone game and it does also with our outreach locations. We have increased transparency. We've improved our block equity. It was a really hard thing to manage when you're also trying to juggle several things with this person that this is solely what they're responsible for. It has given our physicians that confidence that this is something very important to us. And I think that's all I've got. So I think the handoff is to me, right? Tricia, that was fantastic. So I'll be taking us a step backwards and looking at some of the basics. A couple of years ago, the organization I was working for invested in a new state-of-the-art heart vascular center. The purpose was to increase patient access, exactly what we're talking about, optimize patient care within a large cardiology practice to meet the needs of and also meet the needs of our growing vascular program. As we're ready to move into the new space, there was a large focus on how to expand patient appointments and optimize the utilization of the specialty clinics. And partnering closely with our physicians, it became obvious that we needed to take a step back and first focus on the basics. Next slide. Our physicians were working hard and long hours looking for more time so we could increase their presence in the clinic to provide additional access seemed futile. So how are we gonna optimize our physician time in the clinic? Again, adding physicians and clinical staff is the solution that first comes to mind. However, this was not an option that we could afford. We've been hearing from many physicians that they were using precious hours to perform tasks that weren't valued add to them nor to their patients. Nor did they have the skillset or tools needed to do the work appropriately. For our physicians, one of the first issues brought to light was scheduling. They were spending precious hours manually, monthly, creating their own subspecialty master schedules and then marrying those to create a single practice schedule. So this included clinic, procedural, hospital and on-call coverage. Second was the increasing ask for meeting time for those physicians who were taking on administrative roles across the system. And with more meeting time came the need for additional time to complete the follow-up work. Next slide, please. So these two challenges were creating barriers for our physicians to do what they wanted to do most and what we needed them to do, which was to care for patients. Procedural time was often prioritized and so the clinic time was being crunched. These challenges rolled downhill. We had staff that were working outside their skillset. Clinic managers were helping to manage physician meetings and schedules. Clinical staff and the scheduling team frequently needed to make calls with scheduling changes to patients and late schedules and frequent changes were making everyone's role difficult. The impact of patients was seen through our patient satisfaction surveys and call volume into the clinic was off the charts. So this often led to an all hands on deck mentality where staff was functioning out of their scope and skillset. Next slide. Several projects were started over the course of the next few months to identify root causes and find solutions. We worked to produce a clear schedule for providers and our staff that allowed our patients to be scheduled appropriately. We started with making sure that the correct role was performing the correct duties. Again, basics. We provided clear job descriptions and education to be sure that each person knew how to perform their role and that everyone in the role was functioning in the same manner. And we worked on our phone systems, communications between hospital and clinic and communications with our patients. All of what we've discussed here. Process flows for our patients and providers helped to create fluidity within the clinic and again, between the clinic and hospital. Next slide. So the work to correct roles and responsibilities led to one of the most impactful solutions for everyone. It became evident that we needed to create a position to support our physicians with the basics of their schedules. They needed help with the creation and managing of the subspecialty and group schedules. We hired three program administrative assistants. This team of three assists to create the schedules which are now able to be submitted 90 days out. This team assists with the majority of day-to-day administrative tasks that providers are faced with. Many of them are listed here. They are not routinely patient facing except for out-of-state patients. They each support 10 to 15 physicians depending on specialty. And several of these physicians hold, again, medical director roles that span the health system. They're often called on to help manage physician-led projects, which is some sort of project management. And many of those are listed here. This was not an easy ask, but the time studies that were performed showed the potential time savings for those who provided direct patient care and or value. So this solution greatly helped with physician satisfaction, staff satisfaction, because now they're able to perform in their roles. The addition of this team freed up several hours of patient care time per week. Their work has led to a decrease in schedule changes, which has helped with patient care and flow as well as the service line's access metrics. The most important impact, of course, was to patients. We can now schedule appointments when patients need to have scheduled appointments. I think that's my last slide. Oh, so this is Dino. I got to ask you a question then. Sorry. So in your, different than Tricia, in your schedule, you have three months in the schedule? Three months. So, okay. So after, so if somebody wants to, if I want to see someone in six months, they don't get an appointment, right? For two of the subspecialties, they don't currently. For one of the subspecialties, they do, and that's because of the difference in physician scheduling. But no, they go on a list in Epic and we call them back. Yeah, I think that's an important difference to note here. Each of you is at the opposite end of where I split the middle, right? Where it's six months. And I guess I'm curious, Tricia, in your approach, how do you deal with variations in demand for certain procedural things that need to be done? Let's just take structural heart or EP or something. How do you deal with that if you've got people scheduled 13 months out? So we've done a lot of work with structural heart. When I first joined the team, it was kind of an ad hoc. Okay, we have some patients. Now we need to schedule a structural day, which then required some downstream shift changes, which required a lot of CATH lab coverage if he was in that block. We really sat together at that time, early 2020, and said, what do we want structural heart to be? Let's build it, let's work from there. So we have a dedicated, every Wednesday is a structural heart day to have our ASD, PFO. And then Thursday is our LAAO day because we have two different physicians that do those. So we at that time said, we're gonna make a concentrated effort. We're gonna work with our marketing team. We're gonna make a schedule around this growth that we want. So since 2020, we know every Wednesday is our TAVR day, and we have about five to six patients kind of ready to go, knowing one or two of them might fall off based off labs or whatnot that happens right in there. But we kind of changed our mindset into when we had the patients, then made it happen to we're carving out our schedules that we know this is what we want, and we will build the program around it. So that has caused a complete decrease in our last minute shifts. So let me ask the participants, I know you can only type in the chat box, but if you wouldn't mind typing in there, how many months is in the schedule in your practice? I'm curious to see if you wouldn't, somebody wouldn't mind, or if you wouldn't mind, how many months do you have in the schedule ahead? I'm curious. If I could just ask a question too to Tricia, regarding that vacation. So I know the schedules are built out for 13 months, but you mentioned the doctors have some leeway to put in for vacation time. What's that timeframe? They each get 10 late notice requests per year prior to anything being escalated to our board for approval, because we have a practice management board within our group. So most of our physicians are 12 to 13 months out. We let them know, hey, we're working on this month of this year. If you have any vacation requests, get them in now. If you already know if you're making plans, that has slowed down a lot of our late notice requests. But other than that, we consider anything greater than three months adequate time. Okay. So it's three months vacation notice they have to give you. Okay. All right. And then what was your biggest, I'm curious, Tricia and or Nikki, what was your biggest supporting piece of data to get this position approved? Because we were talking as Anna brought up earlier, you're walking into senior leadership administrative and saying, I need a new job. The position created is very difficult to do in this environment. What was the main driver, do you think? Either one. Nikki, do you want to take a stab at this? Then I can tell him what our biggest piece is. Sure. So for us, it was the time studies that we showed. This is how much physician time is being spent on administrative work. This is how much of our manager's time is being spent on handling physician scheduling issues. So when we're looking at the overall functioning of the practice, we could say our manager doesn't have time to focus on that because of all the administrative work that she was doing. And then our clinical staff, we did the same thing. So it was really the time studies and then being able to say this many patient care hours is being taken by administrative duties. And we really need to start having the right role do the right functions. And from our role was a little bit different. Our physicians weren't managing that. So we couldn't make that case of where we were losing that patient care time. What the biggest impact was, was our internal and external benchmarking. So if your group sends every year that massive spreadsheet to MedAxiom and we get the amazing report back on where are we at, what percentile are we at with our view production with staffing, with clinical staff versus our view production versus physician FTE. There is also a graph in there that talks about your administrative staff per physician FTE and where you kind of rank with that. So some of that external benchmarking that, I mean, we used our MedAxiom graphs for that and then compared it to what we were seeing internally within other specialties. That was a great pickup, Trisha. We actually used that as well. That was a huge help. So Dina, if you look at their responses, they're all over the place, right? The schedule build out from three months, four months, six months, 12 months, and so on, right? Clearly there is no one perfect solution for anybody. I think everyone's trying to figure that one out. Trisha, I have another quick question for you. What was the qualifications of your new coordinator? I saw that and I think I answered one of the questions. We do not require them to be clinical because we also have clinical team leads in place. So if we have an urgent referral and we're doing an overbook, our coordinator, because our scheduling coordinator then references one of our clinical team leads. So they're in staffing, they're immersed within staffing, but they're that clinical point person. We work to get them out of staffing about 30% of the time to help us with that last minute clinical juggling. But so we do a combination of education and experience. One of the coordinators that we have came with a bachelor's degree in business. The other coordinator we have has an associate's degree but has worked in provider office scheduling for 15 years. So we used a bit of kind of a mix there. And then another quick question, you incentivize your staff. So can you tell me more about that? Do they all receive the same incentive? And is it once a year, is it multiple times a year? How does that work? Yeah, our Deaconess, our company has something called staff on target. So it is a once a year bonus structure. And we as directors are able to choose a certain number of goals for our staff. And that breaks down to the percent if they can qualify for X number of dollars and each goal is broken into a certain percent of that dollar. So we, from our practice standpoint, try to have a mix of a clinical goal and a non-clinical goal because we want every single one of our staff members to kind of be rowing in that same direction and feel that they can contribute to their own bonus. So it's a sliding scale. People receive different amounts of money? Mm-hmm. Mm-hmm. Okay. You know, can I ask? Well, no, so sorry, I misspoke on that. No, we hit the goals as a practice. We just try to make sure all areas are covered in that. Sorry. Can I get one clarification? What were the requirements for this role? Remind me. A combination of education and experience is how we wrote it. So either a certain amount of scheduling experience or a bachelor's degree. Okay, so they didn't have to be a clinical person? No, sir. And Nikki, in your organization, they're not clinical people either? These are not clinical people, no. Yeah, that's- So what do you think, Dino? Well, you know, I don't know. I mean, you know, I think it's a metaxiom saying if you've seen one cardiology practice, you've seen one cardiology practice, right? But if you see enough of them, you see things bubble to the surface, right? That sort of come through. And it sounds like neither one of you are using a clinical person to do this. And so that's important to know what kind of background seems to work. But you know, I'll be honest. Part of that is we are all facing that nationwide shortage of our clinical expertise. And we're at a point we need them with the patients that help us guide some of our algorithms. So our non-clinical staff can try to point the patient in the right direction. But we've talked about it back and forth, but I would much rather have a nurse in office with my patient than helping with this. So then let me ask this. What about attrition rates? So when you created this job, did people take the job and say, are you freaking kidding me after six months? Like I'm going back to what I was doing before? Or was it a rewarding experience? Rewarding like this rewarding, you know, that's rewarding to work with cardiologists. In our roles, Nikki might be a little different. In our roles, we have turned over one person. So our cardiology, so for non-invasive and interventional, we've had the same person in the role since we created it in 2021. With the other role, we knew the person we hired, we knew. It was a temporary place for him. He had his master's in healthcare administration. I just really needed help getting that role up and going and policies and procedures written for it. And he was able to transition that he had his own role. Somebody succession planned, somebody trained before he left it. So we were very lucky. So it was the same. We hired three and we've had one person turn over in role. And actually they all reported directly to me as a service line leader. They didn't report to the practice at that point. Now, I believe they do report to the practice, but they, I think, felt highly engaged and appreciated. I know the physicians let them know how appreciated that they were. And I think the practice manager and directors also have done the same thing because they're highly skilled. So we hand selected the people that we hired so that they could fill the roles the way that we needed them to be filled. So it's worked out great. And so, Tricia, one clarification for me, you have not just one person doing this. You have one for general slash intervention, right? Does that remind me of that again? Yes, sir. We have one for general and interventional, and then we have one for EP, CV surgery. Okay. And if you didn't have CT surgery in your practice, because a lot of practices don't, what would the setup be, do you think? I think I would still do, I don't know, maybe 1.8. I would cut that FTE down just slightly. And EP is a little bit of a beast. The number of procedures, while I know there's not near as many EPs in a practice as there are interventionalists or non-invasive, but the number of procedures we're scheduling their proceduralists, all of them, every one of them that walks in the door is that really hands down, we're constantly making sure that we're not only utilizing our practice schedule, but optimizing our lab time, because we don't want to lose that anesthesia resource too, so we want to make sure everything's fully optimized. So their work is just a little more heavy on that lab side too. And what about, someone asked a question about pay grade, which is sort of important. Where does this person fit in your hierarchy? They are an entry level lead role. So like they're paid on the same pay scales or clinical leads. Nikki. Can you give us that scale? I'm going to be honest. I don't have it off the top of my head and I'm not even in my office because my office didn't have a webcam. So I don't have that right now off the top of my head. No, I don't have the exact pay scale either. For us, they were above schedulers, patient schedulers. So it wasn't an entry level position, but it wasn't a lead position. We built the position and then worked with HR to create a pay grade that would be, you know, look enticing to get the right applicants. So all of our applicants had bachelor's degrees and had come from somewhere else, either in event planning or in the health system. Awesome. Well, I'm looking at the clock and we've run out of time. Thank you all for participating. Everybody took time out of their schedule. Dino, thank you for asking the question. Obviously we didn't solve your problem today, but I hope it's given you some food for thought. And for all of you out there, I hope you can join us in Austin in a couple of weeks. We're incredibly excited. We have some exciting topics to discuss. And specifically, we have an amazing, in fact, inspirational keynote speaker that I'm pretty sure will leave half the audience in tears, but in a good way. So I'm hopeful that you guys can participate. Thank you everyone. And if there's any other questions or feedback, feel free to email me and I'm happy to distribute, try to find some answers and get that back out there. Again, Anna Mercario-Pinto for MedAxiom.

physician schedules

patient care

scheduling coordinator

vacation management

referral tracking

clear schedules

physician satisfaction

staff efficiency

data and dashboards

scheduling processes