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2013 Model Practices (Public)

Practice Title
Provider Productivity Analysis Team
Submitting LHD/Agency/Organization
Volusia County Health Department
City
Daytona Beach
State
FL
Submitting LHD/Agency/Organization Web Address (if applicable)
www.volusiahealth.com

Provide a brief summary of the practice in this section. This overview will be used to introduce the model or promising practice in the Model Practices Database. Although this section is not judged, the judges use it to get an overall idea about your practice. You must include answers to the following questions in your response:

• Size of population in your health department’s jurisdiction
• Who is your target population/audience, what is the size of your intended population/audience for this practice and what percent of your target population did you reach?
•Provide the demographics of your target population (i.e. age, gender, race/ethnicity, socio-economic status) 
• Describe the nature and gravity of the public health issue addressed
• List the goal’s and objective(s) of the practice and clearly link them to the problem or issue the practice is addressing.
• Describe the potential public health impact of the practice, and the likely effectiveness of the practice being implemented as intended, and the ease of adoption of the practice by other LHDs.

In your description, also address the following
• When (month and year) the practice was implemented.
• Briefly describe how the practice was implemented, what were major activities, and any start-up and in-kind costs and funding services.
• Outcomes of practice (list process milestones and intended/actual outcomes and impacts.
• Were all of the objectives met? 
• What specific factors led to the success of this practice?

Volusia County, Florida has an approximate population of 495,890 residents. Volusia County Health Department serves as the safety net for residents who do not have a medical home and as a leader in the community for public health issues. Volusia County Health Department's clinic consists of four clinical sites; two Dental offices located though out our county and conduct outreach within our community. Historically, accessing productivity across operational sites was tedious, inconsistent and unreliable. This proved to be true for Volusia County Health Department. The VCHD experienced a ten percent reduction in state and federal funding this year. In July 2011, in an effort to have an effective system in place to measure productivity, we organized a multi-disciplinary functional team to build a consensus around our core functions and identify the most valid and reliable measures to report and monitor productivity. This team was comprised of Senior Leaders, Clinical Managers, Clerical Supervisors, Finance and Accounting and Information Technology. The team developed a reporting mechanism to provide pertinent information on the overall health and productivity of the Volusia County Health Department. This team met to evaluate the productivity and efficiency of our clinics and providers. With the continuous financial constraints that we as a state agency face, it is imperative that all resources are utilized for maximum benefit to the Volusia County Health Department. The team developed monthly productivity reports, which are generated and analyzed by clinic site, program and provider. The team then enhanced the reports by adding a RVU (Relative Value Unit) to each service provided. The team based the RVU’S on the standard Medicare RBRVS (Resource-Based Relative Value Scale) which assigns a RVU to a CPT (Current Procedural Terminology) Code to each service. Since there are many services that County Health Departments are mandated to provide, the team had to develop an RVU table for all services that did not have a standard CPT associated with it. A draft of the RVU report was given to the providers for review to ensure that there was buy-in. The providers agreed on the time that was associated with each service. The total days that a provider worked were also included and time is based on an average 8-hour day using 480 minutes. These reports indicate what clinics and providers are more productive; and those areas that need improvement and allow leaders and managers to access consist, reliable, meaningful information resulting in “managing by fact.” Our goal was to assess our productivity and identify opportunities for improvement - allowing us to work more efficiently and effectively while providing services to our community. The team analyzed and stratified current operational processes within the clinics and applied these processes to a productivity model.

Overflow: Please finish the response to the question above by using this text area.  Please be mindful of the word limits.

n/a
You may provide no more than two supplement materials to support your application. These may include but are not limited to graphs, images, photos, newspaper articles, etc.
Describe the public health issue that this practice addresses. (350 word limit)
The Volusia County Health Department (VCHD) is a governmental subdivision of the Florida Department of Health, one of 67 county partnerships between the State and County governments to provide health services to the people of Florida. Volusia County, Florida has an approximate population of 494,593 residents. Florida county health departments have experienced several reductions in funding over the past five years. The VCHD experienced a ten percent reduction in state and federal funding this year. VCHD did not have a mechanism to evaluate efficiencies and effectiveness of clinical operations in all sites. This resulted in inconsistencies in operational functions and delivery of services within VCHD. Uniform processes were developed and agreed upon by the team and key productivity and operational indicators were established.
What process was used to determine the relevancy of the public health issue to the community? (350 word limit)
As we serve as a safety net for health in our community, it is vital to ensure a consistent level of quality of service delivery throughout VCHD. The State of Florida has a number of performance standards and processes that require and define such accountability as expected by the taxpayers of Florida. This necessitated a hard look at clinical operations to determine what our core functions are and what our most valid and reliable measures to report and monitor these functions. Valid and reliable information is needed to facilitate the strategic plan process, allowing the most effective and efficient use of our resources to meet community needs. Key clinical indicators are identified as measurements for productivity. All provider levels are provided an outline of this new mythology for evaluating clinic productivity as well as their productivity. This process was done to ensure buy in from all staff and allowed them the opportunity to agree with the established time and RVU’S assigned and make adjustments. We continue to use the Plan-Do-Check-Act (PDCA) mechanism for process management on the analysis of the provider productivity reports allowing us to monitor and manage our daily operations.
How does the practice address the issue? (350 word limit)
This innovated process ensures the information needed to make data driven decisions. We serve as a safety net health in our community; it is a vital to ensure a consistent level of quality of service delivery. These productivity reports show the providers real time face-to-face daily services and allow the Volusia County Health Departments to better manage and target its limited resources to services most needed in the community. The focus of these productivity reports is to look at the feasibility of utilization of existing data, reporting tools and delivery mechanisms and incorporate the RVU’S, CPT codes and hours worked by providers to analyze the provider productivity, clinic productivity and that of supporting staff.
Does this practice address any of the CDC Winnable Battles? If yes, select from the following
Please list any evidence based strategies used in developing this practice. (Provide links or other materials for support)
The development of these reports indicate what clinics and providers are more productive; and areas that need improvement. The reports allow management to analyze the data and to make fact-based decisions. Some of the decisions resulting from the development and utilization of these reports are: 1) To assign providers, nurses and support staff to different clinics based on the number services provided and the enhancement of the client schedules to “same day next day” appointments. 2) To develop best practices by comparing the services and the productivity at the same provider level in order to streamline procedures and enhance efficiency. Senior leadership felt that this was a valuable tool to assist in the allocation of resources.
Is the practice new to the field of public health? If so, answer the following questions.
Yes

What process was used to determine that the practice is new to the field of public health? Please provide any supporting evidence you may have, e.g. literature review.

Medicare RBRVS The Physician’s Guide distributed by the AMA. The Medicare RBRVS is a result of the American Medical Association to provide physicians a fair and equitable system for physician payment. The RVRVS is based on the principle that payment for physician service should vary with the resource costs for providing those services, improving and stabilizing the payment system. The Volusia County Health Department(VCHD) took that basic premise and created the Provider Productivity Report with CPT (Current Procedural Terminology) and RVU (Resource-Based Relative Value Scale) assigning a time value to the services that our provided to our clients. The team then enhanced the reports and incorporated the provider’s time and days worked into the report. This resulted in a method to evaluate the productivity of our providers, our clinics and the services provided. To the VCHD knowledge there are no other county health department using this analysis.
How does this practice differ from other approaches used to address the public health issue?
At this time, the majority of the County Health Departments are using reports developed at the agency level. Although these reports are useful, they do not allow timely response and tend not to meet specific data analysis and requirements for local counties and communities.
Is the practice a creative use of an existing tool or practice? If so, answer the following questions.
No
What process was used to determine that the practice is a creative use of an existing tool or practice?  Please provide any supporting evidence you may have, for example, literature review.
NO

What tool or practice (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, etc.); did you use in a creative way to create your practice?  (if applicable) (300 word limit total)
a. Is it in NACCHO’s Toolbox; (if not, have you uploaded it in the Toolbox)?
b. If you used a tool or practice to implement your practice, how was your approach to implementing the tool unique and innovative for your target area/population?

The Quality Improvement Toolkit was use for our processes. In an effort to standardize clinical decision-making, we evaluated existing processes, identified key clinical data for measurement. The team stratified organizational reporting needs to make data driven decisions and for strategic planning. Enhance the productivity of the clinics as well as the providers and support staff to maximize current resources.

How does this practice differ from other approaches used to address the public health issue? 

At this time, the majority of the County Health Departments are using reports developed at the agency level. Although these reports are useful, they do not analyze Provider Productivity based on the same elements of RVU’S, CPT Codes, provider time and days worked. Without all of these elements reports would tend not to meet specific data analysis and requirements for local counties and communities.
If this practice is similar to an existing model practice in NACCHO’s Model Practices Database (www.naccho.org/topics/modelpractices/database), how does your practice differ? (if, applicable)
NO
Who were the primary stakeholders in the practice?
VCHD approach to the utilization of this new productivity reporting was a joint effort by staff at all levels it required by-in from providers, nurses, supporting staff, clinic management, finance and accounting and senior management as well as the clients we serve. All VCHD levels agreed that these reports would be the bases that data driven decisions would be made. The reallocation of resources such has reassignment of staff and services would be decided based on the needs of the clients. These reports provide valuable information of the financial health of VCHD my maximizing our resources we ensure that VCHD utilizes the taxpayers’ funds to serve our community.
What is the LHD's role in this practice?
VCHD's initial development of the productivity reports was an effort to improve the management of our local resources and improve efficiency. Our Senior Leadership staff was very impressed with the outcome of our project - it is simple and easy to use
What is the role of stakeholders/partners in the planning and implementation of the practice?
The development of Provider Productivity team was to create an effective system to measure productivity, we organized a multi-disciplinary functional team to build a consensus around our core functions and identify the most valid and reliable measures to report and monitor productivity. This team was comprised of Senior Leaders, Clinical Managers, Clerical Supervisors, Finance and Accounting and Information Technology. The team developed a reporting mechanism to provide pertinent information on the overall health and productivity of the Volusia County Health Department. This team met to evaluate the productivity and efficiency of our clinics and providers. With the continuous financial constraints that we as a state agency face, it is imperative that all resources are utilized for maximum benefit to the Volusia County Health Department. The team developed monthly productivity reports, which are generated and analyzed by clinic site, program and provider. The team then enhanced the reports by adding a RVU (Relative Value Unit) to each service provided. The team based the RVU’S on the standard Medicare RBRVS (Resource-Based Relative Value Scale) which assigns a RVU to a CPT (Current Procedural Terminology) Code to each service. Since there are many services that County Health Departments are mandated to provide, the team had to develop an RVU table for all services that did not have a standard CPT associated with it. A template of the RVU report was given to the providers for review to ensure that there was buy-in. The providers had agreed on the time that was associated with each service. All staff from senior management to frontline staff was aware of the measurement of productivity of providers as well as clinics and the need to make decisions based on the analysis of these reports.

What does the LHD do to foster collaboration with community shareholders?
Describe the relationship(s) and how it furthers the practice's goals.

Although VCHD initially developed the Provider Productivity reports as an internal mechanism for evaluating the productivity of providers and clinics members of this team have also participated and attended a statewide Practice Management Institute (PMI). The focus of PMI is to improve the efficiency, productivity and financial sustainability of CHD clinic operations. This Boot Camp training has had several different sessions in which members of the development of the Provider Productivity Reports team have attended along with cohorts from various CHD throughout the state. The networking and marketing of this methodology of these reporting features with other CHD’s cohorts, who show interest in evaluating their clinics and providers on the same or similar bases.
Describe lessons learned and barriers to developing collaborations.
The implementation and development of these productivity reports must have the by- in from all staff to be successful. It is necessary to ensure that all staff is fully aware of what the measurements and goals of the department are. It is imperative that the providers have input to the review process in the assignment of time for procedures that they perform in doing so these eliminates discrepancies after the reports are analyzed and decisions made. Another benefit was the development of best practice for the delivery of service by same level providers. Upon review of the monthly reports, it was clear to see the number of services that were performed by each provider. Decisions on what changes might need to be made to achieve similar percentages for face-to-face time by all same level providers. In some cases, providers became completive and in other cases, changes in clinic flow and procedures were evaluated and updated to improve productivity. One of the barriers is while other CHDS may be able to utilize VCHD’S RVU and CPT template for the assignment of time for services would need to be done by each CHD. CHD would have to adjust the template to the services that they provide and meet with their staff to ensure the same buy-in.

Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improves practice.


Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).

List up to three primary objectives for the practice. For each objective, provide the following information:  (750 word limit per objective)

• Performance measures used to evaluate the practice: List the performance measures used in your evaluation. Depending on the type of evaluation conducted, these might be measures of processes (e.g., number of meetings held, number of partners contacted), program outputs (e.g., number of clients served, number of informational flyers distributed), or program outcomes (e.g., policy change, change in knowledge or attitude, change in a health indicator)
• Data: List secondary and primary data sources used for the evaluation.  Describe what primary data, if any were collected for each performance measure, who collected them, and how.
• Evaluation results: Summarize what the LHD learned from the process and/or outcome evaluation. To what extent did the LHD successfully implement the activities that supported that objective? To what extent was the objective achieved?
• Feedback:  List who received the evaluation results, what lessons were learned, and what modifications, if any, were made to the practice as a result of the data findings.


 

VCHD need an improve methodology to evaluate clinic and provider productivity the development of the Provider Productivity Reports with RVU and CPT value allows management to analyze the data and make fact based decisions. Objective1: Maximize VCHD resources. Objective 2: Increase the productivity of our clinic and providers. Objective 3: Develop best practices and streamline procedures.

Objective 1:

Objective 1: By strategizing and assessing our current processes, we were able to identify and improve the efficiency of our providers and our clinics. We investigated best practices, implemented and monitored change. Because of our endeavors, we have greatly improved outcomes as well as increased revenue with the number of clients that can be scheduled and seen. Providers and staff are reassigned to maximize resources. Services are enhanced and clients are seen “same day next day” due to the reallocation of staff. The reallocation of resources has eliminated the possible need for work force reduction.

Overflow (Objective 1): Please finish the response to the question above by using this text area.  Please be mindful of the word limits.

Objective 2:

Overflow (Objective 2): Please finish the response to the question above by using this text area.  Please be mindful of the word limits.

Objective 2: To evaluate the productivity and efficiency of our clinics and providers. The wait time for clients to schedule an appointment has decreased and the availability of services was improved. Open access, same day next day, which also decreased the “no show” rates. This also increases the productivity of the providers and the clinics. Staff is reassigned to high volume clinics, which increases the amount of revenue generated by clinic services.
Objective 3:
Objective 3: The development of the Provider Productivity Reports with RVU’S and CPT codes has measurably improved service delivery and/or internal operations. We have been able to offset salary dollars for our staff members. These offset salary dollars are reallocated to our County Health Department’s budget. The development and utilization of the Provider Productivity Reports with the evaluation of the Relative Value Unit has allowed us to balance efficiency and improves our customer service experiences.

Overflow (Objective 3): Please finish the response to the question above by using this text area.  Please be mindful of the word limits.

What are the specific tasks taken that achieve each goal and objective of the practice?
By strategizing and assessing our current processes, we were able to identify and improve the efficiency of our providers and our clinics. We investigated best practices, implemented and monitored change. Because of our endeavors, we have greatly improved outcomes as well as increased revenue with the number of clients that can be scheduled and seen. Providers and staff are reassigned to maximize resources. Services were enhanced and clients were seen “same day next day” due to the reallocation of staff. The development and utilization of these Provider Productivity reports have had a positive impact on our clients. The wait time for clients to schedulable, an appointment has decreased and the availability of services was improved. Open access, same day next day, which also decreased the “no show” rates. . These reports have measurably improved service delivery and/or internal operations. We have been able to offset salary dollars for our staff members. These offset salary dollars are reallocated to our County Health Department’s budget. The development and utilization of the Provider Productivity Reports with the added evaluation of the Relative Value Unit allows us to balance efficiency and improves our customer service experiences
What was the timeframe for carrying out these tasks?
The original development of these reports were approximately 6 months from start to implementation it required developing a basic template for the RVU’S, CPT codes and time associated with services. Reports had to be development to generate all required information, a methodology for verifying the days worked by providers was created. The templates then were distributed to appropriate staff for review and approval. Changes were made and reports are now produced monthly several levels at the CHD review the outcomes and if necessary new procedures are implemented. These monthly report remain an ongoing review process and continues to improve the productivity of clinics and providers.
Please provide a succinct outline of some basic steps taken in implementing your practice.
The development and implementation of this Provider Productivity Analysis Reports with the Relative Value Unit allows for monthly review of provider and clinic productivity. The Relative Value Units assigned shows the number of minutes per day a provider is providing services. It illustrates the need for improvement and reallocation of resources. This innovative tool establishes the best practice productivity of clinics and allows providers to compare the delivery of services among themselves and make improvements. The team creatively researched and identified a solution for our needs to improve clinic productivity and increase services. It was identified by analyzing these reports the need to make enhancements to clinics and reassign staff based on the services provided in all clinics. Additionally, the nominees were proactive in identifying areas of improvement. The nominees were able to collaborate with others to provide services and increase revenue. The team created a process that maximizes time; increases productivity; and generates additional revenue. These data driven decisions based on the development of these reports also helped in the prevention of a work-force reduction. These clinic productivity reports have played a major role in our strategic planning and budgeting process by providing key measures and indicators. These measures assist us to utilize our limited resources to serve the health needs of the community. The development of added feature of a Relative Value assigned to all services increased the number of services scheduled, improved the utilization of staff to reassign them to the clinics that were in need of additional staff. Implemented best practices for the delivery of services by comparing the services and the productivity of the same provider level in order to streamline procedures and enhance efficiency. Senior leadership felt that this was a valuable tool to assist in the allocation of resources. This achievement resulted in a cost savings of approximately $214,399.60.

What were some lessons learned as a part of your program's implementation process?

The implementation and development of these productivity reports requires the by- in from all staff to be successful from front line staff to senior management. It is necessary to ensure that all staff is fully aware of what are the measurements and goals of the department. It is imperative that the providers have input to the review process and the assignment of time for they perform in doing so these eliminates discrepancies when reports are analyzed and decisions made. Other lessons learned are the development of best practice for the delivery of service by same level providers. Upon review of the monthly reports, it was clear to see the number of services that were performed by each provider. Decisions to changes in processes need to be made to achieve similar percentages for face-to-face time by all same level providers. In some cases, providers became completive and in other cases, changes in clinic flow and procedures were evaluated and updated to improve productivity.
Provide a breakdown of the overall cost of implementation, including start-up and in-kind costs and funding services.
The development of the Provider Productivity Report with the added RVU (Relative Value Unit) value allows management the capability to review the efficiencies of the clinics by site and provider. The utilization of these reports assisted in the reallocation of staff to clinic where the services provided were at a higher level. This reallocation has a two-part advantage. First, this allowed for the clinics with a higher volume to benefit with additional staff without the need to hire additional staff. Advanced Registered Nurse Practitioners and Registered Nurses were reassigned to other sites two days a week. The reassignment saved the department the additional expenditure of hiring new staff. Salary and Benefits for Advanced Register Nurse Practitioner = $77,785.00 Salary and Benefits for Register Nurse Practitioner = $56,084.00 Total savings =$133,869.00 The second cost savings was the reallocation of support staff from unproductive clinics since there was not enough client volume to support them. The clinic schedules for these two clinics were evaluated and patients were seen in three days instead of being spread out for five days. Additional support staff was also reassigned. This also prevented the possibility of work-force reduction. Salary and Benefits for two Senior clerks =$ 84, 526.00 Total expenditures for the development of the reports were =$ 3,995.40 60 hours for two team members to create the process at a combined total of $3,995.40 Grand Total Savings to the department: $ 214, 399.60
Is there sufficient stakeholder commitment to sustain the practice?  Describe how this commitment is ensured.
The development of the Provider Productivity Report with the added RVU (Relative Value Unit) value allows management to make necessary changes to provider and clinic productivity on monthly bases therefore VCHD is able to maximize its limited resources relativity quickly. The reallocation of staff to other clinic sites continues to be cost effective and enables VCHD to continue to provide essential health services to all residents.
Describe plans to sustain the practice over time and leverage resources.
Since these reports are generated and analyzed monthly allows for immediate adjustment to clinic and provider schedules. Staff can easily be reassigned to “high” volume clinics. Management can improve process flow and update procedures to ensure that best practices are put in place. This reallocation of resources helps VCHD avoid the need for work-force reduction and ensures that all resources
Practice Category Choice 1:
Organizational Practices
Practice Category Choice 2:
Quality Improvement
Practice Category Choice 3:
Access to Care
Other?
No

Please Describe:

NO