Leadership Prescription Project

Healthcare is a complex field where clinicians and non-clinicians collaborate to provide care for patients. Healthcare is undergoing a significant evolution from volume- to value-based care, resulting in an increasing need for physician-leaders to lead the change. Typically physician-leaders receive little or no formal preparation for leadership roles.(1) However, some organizations. such as the Mayo Clinic, invest in the professional growth and development of their current and future leaders by offering leadership development programs.

Leadership Prescription Project

The Leadership Prescription is an action-learning program to further develop the skills of Mayo Clinic leaders and their project teams by focusing on solving real-world business challenges. Physician-leaders are expected to lead and leverage the diverse skills of multidisciplinary team members, and other colleagues, in order to advance strategic priorities and practice outcomes. Teamwork is more than a value of the Mayo Clinic: it is a hallmark of the institution’s past, current, and future success. In fact, many of other clinic’s values—including excellence, innovation, and stewardship—are manifested largely through successful teamwork.

The Leadership Prescription is a three-month project for department and division chairs and includes a half-day workshop focusing on the principles of leadership and teamwork. “Teaming” is a core learning principle of the workshop. Teaming is about understanding the reciprocal, dynamic interdependence and real-time learning that occurs between team members and their organizing systems.(2) Teaming includes specific behaviors for the leader and the individual team members. Following the initial workshop, the physician and his or her administrative partner lead the team in planning and implementation over the subsequent three months. The teams analyze and develop recommendations, concluding with a 90-day report on the implementation experience and project outcomes. The team is assigned a coach to help focus on the teaming process and professional development goals of the leader and team members.

The Business Challenge

Proper assignment of billing codes to reflect the work performed during patient encounters has been a universal opportunity for improvement in all healthcare arenas. The Mayo Clinic Hospital Internal Medicine (HIM) Specialty Council identified variable practice patterns in clinical documentation, coding, and E/M billing for complex patient encounters. The HIM Specialty Council believed that there was an opportunity to enhance revenue by standardizing clinical documentation and accurate coding/capture for the E/M professional fee charges.

In 2016, fewer than 5% of hospitalists met the 40th percentile for relative value units (RVUs). E/M charges often are “down-coded” not because of medical complexity, but because of inadequate documentation. These lost opportunities contribute to a suboptimal ratio of total RVUs/total volumes, which varies across sites in a range between 2.51 and 3.38. Pilot projects conducted in the Mayo Clinic Florida and the Mayo Clinic Health System La Crosse, Wisconsin, demonstrated appropriate capture of E/M charges by standardizing accurate documentation and coding. At the Mayo Clinic Florida, comparison of gross revenue of Q1 2016 to Q1 2017 saw an increase of $446,180, with 50% increase in gross revenue and 40% increase in billing critical care time. Conservative review of the La Crosse HIM E/M charges, when compared with national benchmarks, revealed a potential opportunity of $600,000.

As a response to a rapidly changing reimbursement environment, the HIM practice wanted to create a standard for provider documentation and billing to optimize revenue and support the level of care rendered.

Because the Mayo Clinic’s revenue cycle department did not have the consistent bandwidth to audit and provide feedback to the HIM practice, an outside vendor was selected to help assess the current state of professional E/M billing across our enterprise HIM practice, identify opportunities for improvement, and help create an education support system to improve the billing practice.

As part of the professional revenue improvement project, it was decided to conduct a site-based pilot, which included external vendors reviewing and auditing the professional revenue capture practices at the site, and providing feedback to the leadership group.

Project Overview

The overall process is explained as a flowchart in Figure 1. The project began in September 2018 with an initial one-hour meeting that included introduction of the team, discussion of roles, agreed-on end goals, metrics, and resources needed. Biweekly team meetings were conducted to review progress and maintain forward momentum. Biweekly one-on-one coaching between the leader and assigned coach was set up.

Figure 1. Leadership Prescription Project. ADKAR, Awareness, Desire, Knowledge, Ability, and Reinforcement.

Site Pilot with a Non-Mayo Vendor

The practice site was selected based on interest from local providers. A proof-of-concept pilot was developed with an outside vendor to audit more than 50 records. The vendor’s physician advisor rounded with hospitalists providers, covering 19 patients. More than 50 charts reviewed for documentation accuracy, professional billing, and findings were compared with final professional billing by the Mayo Clinic’s revenue cycle department. Results were vetted through revenue integrity and the compliance team.

Change Readiness Assessment

Integrating the Prosci ADKAR (Awareness, Desire, Knowledge, Ability, and Reinforcement) model for change into the project management process provides synergy in managing both the people side of change and the business side of change.(3) The ADKAR model was used as a framework to assess pre-pilot readiness.

Project Team Assessment

Project team members received pre- and post-surveys three months apart to assess for various aspects of team member and leader dynamics. This was an integral part of the team coaching experience.

Results and Metrics

Revenue Integrity: Report, Goal, Metrics

The revenue cycle department identified and held 400 provider charge records for the audit to be completed by the vendor. The vendor reviewed the charts for documentation accuracy and billing. The findings were then compared with the final charge selected by the HIM provider for professional billing. The detailed findings by the vendor were presented to the Mayo Clinic’s legal and compliance department. Any discrepancies that required internal review and auditing prior to billing were reviewed by the coding operations team and discussed with the vendor to determine the most appropriate professional billing charge. Any changes that needed to be addressed were completed prior to the release of the charge for billing.

Change management: As a result of the survey assessment findings, the pilot site staff received education during department meetings and through e-mails to ensure an understanding of pilot objectives. All communication included the rationale for change, the urgency needed, and the implications if change did not occur. During these meetings, the providers were eager to understand their coding deficiencies and asked for more education and training. Figure 2 shows the Readiness for Change assessment survey. Figure 3 shows the corresponding median scores based on a 1–5 Likert scale, with 1 being low and 5 high:

• Awareness—3.0;

• Desire—5.0;

• Knowledge—3.0;

• Ability—4.5; and

• Reinforcement—2.0.

Figure 2. Change Readiness Assessment Survey. HIM, Hospital Internal Medicine; RVU, relative value unit.

Figure 3. Prosci ADKAR (Awareness, Desire, Knowledge, Ability, and Reinforcement) model scores.

ADKAR survey: Awareness about the current state of professional billing including the process, training, and support post-EPIC implementations was assessed. Awareness about the lack of back-end revenue analyst post-EPIC, EPIC training manual, training and reinforcement for support and maintaining change was low. The desire for change was high. Along with the quantitative findings, the providers also were given an opportunity to offer qualitative feedback on their readiness for this change. The common themes were a lack of formal training and education, lack of clarity on the billing process, and lack of adequate time to document their cases.

Site pilot findings: The pilot study revealed a documentation–professional billing accuracy as follows:

• Documentation = charge code selected— 63%;

• Not enough documentation (documentation < charge selected)—24%;

• Lower charge (documentation > charge selected)—6%; and

• No charges selected—7%.

• Pre- and post-program assessment surveys showed improvements in team dynamics for most questions for the team members (Figure 4) and the team leader (Figure 5).

Figure 4. Team assessment. Mean ratings: 1= strongly disagree to 5= strongly agree.

Figure 5. Leader assessment. Mean ratings: 1= strongly disagree to 5= strongly agree.

Discussion: Lessons, Challenges, and Strategies

Post-Pilot Findings

Mismatch between documentation and billing exposes a practice to two potential challenges:

1. Lost revenue results when professional charges are lower than that supported by documentation; and

2. Compliance risk may become an issue when professional charges are higher than that supported by documentation.

Because missed charges also represent a revenue capture opportunity, it was felt that providers need training or coaching on professional revenue capture. Professional revenue capture includes the total time spent on patient care, including face-to-face time, floor time, and communication with family and caregivers and other providers.

After a post-pilot discussion with the HIM Specialty Council, it was decided that a second pilot study with a larger sample size (200 charts) should be conducted at a larger academic community practice site, which would help validate the findings of the first pilot. The project helped to identify potential future challenges for multisite implementation, including the need for RVU improvement champions; remote site electronic medical record access for the vendor to access records; and continued revenue cycle and compliance team engagement.

Change Management

A successful project starts with assembling a diverse team with complementary skill sets that are directed toward a shared goal. Our multidisciplinary team included hospitalists and finance, project management, and administrative staff. These stakeholders possessed the key skills to navigate through the system and clinical practice challenges. In addition, support and problem-solving assistance was sought throughout the project from additional groups, including revenue cycle, compliance/legal, and the enterprise specialty practice council.

The project team was able to understand the individual experience for change transition through the five stages of ADKAR and intervene as appropriate in each stage by focusing conversations and identifying gaps in the process.

Leader and Team Learning Experience

The assigned leadership coach focused on professional development goals for the leader and team members and provided “in the moment” coaching during the meeting to highlight learning opportunities. Leading a team toward successful project completion has highlighted several key lessons:

• Start with an end goal in mind—the leader must engage the team in creating the overall vision.

• Establish a roadmap of critical milestones so the team sees the path toward success.

• Provide the “why” behind the project and relate the sense of urgency for change.

• Engage all stakeholders in the rationale for change using readiness assessment results.

• Establish clear role expectations for team members and leverage their unique talents.

• Engage a team coach to challenge assumptions and beliefs and guide in-the-moment action learning.

• Manage internal and external team and leader expectations on project timelines.

• Establish open and regular team communication to address challenges along the way.

• Recognize that patience is required, especially when working with members outside of your regular sphere of influence or those outside the organization.

Conclusion: The Value of Developing Leaders

Even though large U.S. companies and multinational corporations invest close to $14 billion annually in leadership development, 53% of healthcare organizations lack dedicated physician leadership development programs.(4,5) Physician-leaders with the right management skills have a distinct advantage over other business professionals in steering organizations toward providing high-quality yet cost-effective care, an idea that is supported by the fact that the best-performing hospitals, such as the Mayo Clinic, are largely physician driven.(1,6)

Successful physician-leaders need expertise in key competencies, including technical knowledge and skills, industry knowledge, problem-solving skills, emotional intelligence, communication, and a commitment to lifelong learning.(7)

Most physician-leadership programs typically involve only physicians and do not include other professional groups in the healthcare organization. These programs focus mainly on skills training and conceptual and technical knowledge and pay less attention to personal growth and awareness.(4)

The Mayo Clinic has always been a physician-led organization, allowing it to invest in and nurture programs that promote leadership skills among young physician-leaders. The Leadership Prescription project is one such real-world action learning project that not only offers innovative solutions to difficult real world organizational or patient care problems, but also teaches leaders to function and manage teams across disciplines, thereby guaranteeing return on investment—sometimes of up to 5 or 10 times the cost of the program itself.

Investing in leadership development within the organization paves the way to reduce costs, explore new lines of revenue, and improve patient experience as well as satisfaction. Effective leadership at an organization invariably improves employee engagement and staff retention, allowing strategic and cultural alignment of its workforce with the goals of the organization and thereby setting it up for success. Organizations with robust leadership development programs and effective leaders can be more resilient in response to unpredictable or unfavorable changes in the business environment, such as reducing reimbursements in the healthcare industry, and more likely to outperform their competitors. Thus, investing in future leadership through pragmatic programs such as the Leadership Prescription not only help develop a rich pool of talent but may also be vital to the long-term growth and survival of large healthcare organizations.(1,8)

Teaming is a core skill in today’s healthcare environment, especially when people are juggling multiple responsibilities with minimal oversight and are expected to shift quickly from one priority to another while still maintaining excellent communication. Every team member brings a unique skill set and perspective to the table. The leader plays an essential role in knowing when and how to leverage those skills.

Learning organizations such as the Mayo Clinic provide a creative and powerful action-learning development program in which department and division leaders and teams will be stretched by working on real-time strategic challenges—not case studies or simulations, but business problems that affect daily work. The efforts of action-learning teams bring measurable business value and return on investment to their departments. These projects help a leader increase knowledge and understanding of team dynamics, formulate strategies for managing change, and incorporate various methods to enhance team performance. These projects are an investment in a leader’s capacity to build strategy, execution, and innovation competencies of the extended leadership team. They can help address a key business challenge and produce a set of recommendations that, upon execution, will create real and lasting business value to organizations such as the Mayo Clinic.

Acknowledgment: The authors thank Mayo Clinic Workforce Learning for the leadership development resources and guidance that helped make this project a success.

References

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2. Edmondson AC. Teaming. How Organizations Learn, Innovate, and Compete in the Knowledge Economy. San Francisco: Jossey-Bass, 2012.

3. Hiatt JM, Creasey TJ. Change Management. The People Side of Change. Loveland, CO: Prosci, Inc., 2012.

4. Frich JC, Brewster AL, Cherlin EJ, Bradley EH. Leadership development programs for physicians: a systematic review. J Gen Intern Med. 2014;30:656-674. DOI:10.1007/s11606-014-3141-1.

5. Steinert Y, Naismith L, Mann K. Faculty development initiatives designed to promote leadership in medical education. A BEME systematic review: BEME Guide No. 19. Med Teach. 2012;34:483-503. DOI: 10.3109/0142159X.2012.680937.

6. Goodall AH. Physician-leaders and hospital performance: is there an association? Soc Sci Med. 2011;73:535-539. DOI: 10.1016/j.socscimed.2011.06.025.

7. Stoller JK. Developing physician-leaders: a call to action. J Gen Intern Med. 2009; 24:876–878. DOI:10.1007/s11606-009-1007-8.

8. Vimr MA, Thompson GG. Building physician capacity for transformational leadership. Healthc Manage Forum. 2011;24(1_suppl), S49-S54. DOI: 10.1016/j.hcmf.2011.01.004.