Reworking its process for getting physicians credentialed, insured, and approved to see patients was time-consuming, but it yielded a "gigantic payoff" for Dayton Children's Hospital.
Hiring physicians is difficult enough. But once you find them and bring them and their families to town, paying them while they can't see patients is a serious problem.
This is especially so when many of the physicians are specialists. When they can't see patients, they're a drag on revenues; they grow quickly dissatisfied, and it might eventually be tough to retain them.
The process of onboarding—getting hospital privileges, state licenses, background checks, malpractice insurance and payer credentialing, not to mention a host of other tasks that need to be completed before a new physician can begin seeing patients—can cost hospitals and health systems big money.
In a time where much of their business is being disrupted, for hospitals, any opportunity to shorten a process that dissatisfies while it siphons precious resources away from other important tasks can yield a big payoff.
Lisa Coffey |
Physician onboarding has become a key strategic priority for the senior leadership team at Dayton Children's Hospital, says Lisa Coffey, vice president of physician services at the Ohio-based organization. The physician onboarding process revision came as part of a revamp of the hospital's strategic plan, which is internally referred to as Destination 2020.
Among the strategic priorities are an extensive re-evaluation of the services the hospital should be offering, as well as physician integration, which includes improving access, meeting referring physician expectations, and partnering with physicians. All of those priorities were challenged in the old physician onboarding process, says Coffey, which meant that it was an area where the hospital wanted immediate focus. The revamp began in 2014.
Many Stakeholders
One big problem with the onboarding process that can't easily be rectified is the huge number of stakeholders involved with the separate processes involved in getting the physicians to the point of being able to see patients, Coffey says. But while the number of processes can't easily be changed, they don't have to happen in succession. They can happen mostly simultaneously.
Another tactic is to educate all the stakeholders together so that each understands how critical their role is to that goal, and the ultimate goal: getting physicians ready to see patients more quickly. A single cog's role is not simply completing a bureaucratic task, in other words.
"Silos are alive and well in most organizations," says Tammy Tiller-Hewitt, CEO of Tiller-Hewitt Healthcare Strategies, who helped Coffey and Dayton Children's with the onboarding process redesign. "Everyone's juggling so much and they're trying to get their part done, but it's up to us to help them understand the critical opportunity to win big or lose huge if we don't do onboarding effectively."
In physician onboarding, any part of the process that's not done quickly is a barrier.
The organization has always spent lots of time and effort making decisions about how many physicians it needs and in what specialties, "but that's where it fell apart for Dayton Children's," says Coffey. "We had all the placement stuff well thought out, which often meant the physician was ready to go. But [they] couldn't see any patients because other work wasn't done yet."
Being unable to quickly accommodate referrals, is what really started the hospital down this road, says Coffey. In order to remain competitive with other children's hospitals, and there are several in relatively close proximity to Dayton, Children's needed immediate access for referred patients. With an institutional physician shortage to start with, and an unacceptable six- to eight-month lag before access started to improve, the team focused on reducing onboarding time.
"Before I had this role, I was director of our clinics, so I saw firsthand operationally what was happening when we brought these physicians in," Coffey says. "Often they would have to sit there for several weeks while they waited to be able to see patients…We have recruited 21 physicians over the past two years, and a lot in key specialties, so there's a lot of money wrapped up in those recruits. That's a big deal in this world."
Identifying Delays and Duplication
Having had some Lean training, Coffey and her team value stream-mapped everything that happens in the onboarding process, looking for ways to shave time and effort off a laborious and Byzantine process.
"We had rolls of paper in the conference room taped up to the wall after we met with each of the 20 members of the onboarding team separately and asked for all their steps to get their part done. Then went back and found delays, duplication, and where the process breaks down."
Another discovery was that the organization was not starting its marketing campaigns for new physicians until months after they arrived because they didn't want to release the marketing information before the physician could take the referral.
That was a dissatisfier for physicians. "Now that we fixed credentialing we can actually get the marketing out when they first start," says Coffey.
Since the redesign began in early 2014, the onboarding process has been reduced to as little as 90 days from six to eight months. The norm is about 120 days, according to Coffey. Time-to-credential and time-to-reach-full-productivity for physicians overall have been reduced from 322 days and 14 months, respectively, to 84 days and five months.
They've also reduced the amount of paperwork physicians need to complete to start the process from 30 pages to about 16.
Coffey says CEO Deborah Feldman was key to providing proper focus and a sense of urgency to the onboarding redesign.
"First you need that senior leader champion," she says. "But breaking it into individual groups and value mapping helped manage the information and the process. Dedicate the time to it, because it is time-consuming, but the payoff is gigantic."
Philip Betbeze is the senior leadership editor at HealthLeaders.