No business is immune to ups and downs. And countless books have been written on companies that not only survive challenging times, but come through those times stronger, more nimble and ahead of their competitors.
We predict the urgent care industry will face some fairly strong headwinds over the next five years. And by the time those headwinds die down, some players will end up on top and others will fall to the bottom, or worse, no longer exist.
In a future article, we may write about those companies that come out ahead. No doubt there will be a number of characteristics that stand out about those players: use of technology, financial sophistication, strict attention to key performance indicators and strong marketing. But one characteristic will stand out more than others: culture.
In any business, culture is important. But in walk-in healthcare, culture is what drives retention. Retention is what drives consistency. Consistency is what drives productivity. Productivity is what drives speed. Speed is what drives customer satisfaction. And customer satisfaction is what will drive patient volume. On the expense side, there are only incremental changes we can make. But on the top line, patient volume will be the key to success.
You could argue that this set of logic applies to all of healthcare, or go even further to say that there is a culture crisis in healthcare. After all, if you believe the logic that there is a link between culture and productivity, there is no shortage of articles suggesting there is a productivity problem in the healthcare industry like no other industry.
This article looks at the intricate link between productivity and team culture. This link may well be the most important factor in helping your business weather any storms on the urgent care horizon.
Productivity in Healthcare
There have been many articles written about productivity in the U.S. healthcare industry. On the one hand, many argue that measured productivity growth in the healthcare industry has generally been well below that of the economy as a whole because it has little incentive to focus on productivity improvement. Conversely, others argue that most of the productivity growth in healthcare has come in the form of improved quality rather than lower cost and that many of the innovations that have reduced costs and increased productivity—such as moving from inpatient to outpatient care—are not captured in the standard measures. This latter argument is weak at best, and comes largely from defenders of hospital approaches to care, where change and innovation come about at a snail’s pace.
But whichever argument you believe, the U.S. healthcare industry in general and the urgent care industry in particular are facing a wakeup call. In the broader ambulatory care sector, new entrants, fueled with private equity investment, are bringing greater sophistication and productivity methods to such specialties as orthopedics, rehabilitation and physical therapy, radiology, ophthalmology, oncology, outpatient surgery and a host of others. These specialties and subspecialties are critical to the future of health systems. Yet health systems are not nearly as nimble as these private-equity-backed disruptors.
And when it comes to urgent care, private equity investment is well ahead of those other parts of ambulatory care. Health systems who are just now waking up to the potential for urgent care to feed new lives into their system are probably too late to the party.
An article earlier this month in the New York Times called “The Disappearing Doctor: How
Mega-Mergers Are Changing the Business of Medical Care,” makes this point abundantly clear.
Most healthcare entities today are large entities. Scale in healthcare means line managers and those working the floor of any healthcare setting are more removed from decision making. Processes and procedures are dictated from on high from leaders who want to be great at everything. Burnout is rampant. Turnover percentages are well into double digits. In her book “Uncommon Service,” Francis Frei calls this “exhaustive mediocrity,” and urgent care could not be more vulnerable to this phenomenon.
Productivity in Urgent Care
Urgent care is an on-demand business. Things can be coasting along at one moment and in a matter of a few minutes, 10 people can descend upon your front desk seeking care as if a bus just dropped them off. Some may have gotten into queue online while others may have just walked in. You have a group of people who see each other arriving at the same time, stressing over having no control or predictive information about how the next minutes or hours will transpire. How you interact with those patients and how you get them in and out in a reasonable amount of time will determine whether they become loyal customers or a single blip in your patient history.
But more important, this is a team business. When those 10 people arrive simultaneously at your center at 6 p.m., how does your team react? Do they immediately fret that there’s no way they will be leaving on time tonight? Or do they see that as part of a typical evening routine, knowing everyone on the shift works well together, enjoys the work and had a say in how each day is constructed (and deconstructed for productivity improvement), and thus a 10-person onslaught is just a routine occurrence?
With urgent care becoming more competitive, payers no longer need to pay a premium for urgent care services over primary care services. So reimbursement is leveling off or even dropping. At the same time the scarcity not only for providers, but for the entire support staff, is causing labor costs to increase. Productivity in urgent care is important because these two factors add up to a potentially unsustainable path going forward. It is unsustainable unless you are able to unleash the potential of your team to reach much higher levels of productivity.
As any urgent care operator knows, there is a formula for the team members that make up a given shift, assuming a certain level or range of patient volume. And most typically, this team is geared around the number of providers required to meet that volume. “Single-provider coverage” means there is one doctor or advanced practice provider (APP), along with a clinical support team and patient service representatives, i.e. front desk staff. Because these teams are constructed around the number of providers on any given shift, and since providers are the most expensive members of the labor team, we use a base productivity measure of patients per provider hour.
What you might typically hear anecdotally from many in the urgent care industry is, “We see around 3.5 patients per hour.” But here is the dark secret in urgent care. Operators typically don’t include in that statement how many providers on average are needed to produce that 3.5 patients per hour. In the research we have done, the industry average is more like 2.5 patients per provider hour. Sometimes is it well below that, resulting in a surprisingly wide productivity range, from under 2 to more than 4 hours.
On hearing that a single provider could see more than four patients per hour you might think clinical quality must be suffering. In many cases that is true, along with the possibility that more than four patients per provider hour is not sustainable. However, there are cases where these productivity levels not only are sustainable, but clinical quality is equal to or better than those centers with much lower productivity levels. And we have found this to be the case with organizations that have a bottom-up culture that drives productivity.
In other words, there are many urgent care centers that could safely double their productivity. And when you double your productivity, you are likely decreasing your door-to-door times, increasing your patient satisfaction scores, lowering your costs and achieving a higher operating contribution. And more importantly, with all of these factors you can weather the ups and downs that are inevitable in any industry.
“A culture has to be designed by the participants,” says Charlie Ireland, D.O., medical director at Advocate Medical Group’s 12 Immediate Care Centers (ICCs) in greater Chicago. “It also has to be measurable and transparent.”
The Advocate ICCs are one of those urgent care operations we referenced that has very high productivity combined with very high clinical quality and patient satisfaction. And Ireland attributes this success to an intentional culture that came about as a result of a very dark time for many of the members of his current team.
“There was a time about 14 years ago when we were all ready to quit,” he says. “The processes we were using didn’t work, the tools we had didn’t work, and although we liked each other, we didn’t always work well together.”
Ireland will go into more detail on the Advocate Urgent Care story as a speaker at our next Strategy Symposium, January 21-23, 2019, in Fort Lauderdale. He had an interest in organizational development and had attended some Disney sessions on service, team building and the development of a corporate culture. But his knowledge was largely theoretical. So he decided to take a risk and turn that theoretical knowledge into hands-on experience. He called an all-hands meeting for anyone willing to participate from any of the three urgent care clinics under his leadership at the time. The meeting would take place on a Saturday without pay. He and his wife would pay for the food and meeting room. Much to their surprise, more than 80 people agreed to show up.
Out of that meeting came an airing of tremendous frustration. But also out of that meeting came concrete suggestions for designing new ways of thinking, acting and leading. In other words, it turned out not to be a session on designing workflow or choosing new tools and technology. It was a session to design a new culture, an intentional, detail-oriented and measurable culture.
More specifically, the resulting elements of the Advocate Urgent Care culture were the following:
- A common purpose: “World-class medicine fast.”
- A common understanding that the team must decrease variation in order to improve safety, workflow, employee experience and patient experience.
- Six key metrics: employee engagement, provider engagement, wait times, patient satisfaction scores, LTR (likelihood to recommend scores) and revenue.
- Four activities are to be “over managed:” selection, training, communication and care.
When reading these four elements of the Advocate ICC culture, you may be tempted to question what some words or concepts really mean. But what you read is not important. It is what those words mean to the Advocate team member that developed them. And every line has meaning.
Decreased variation means, for example, that there are certain standing orders that triage nurses implement given certain chief complaints. Some providers might prefer to do it another way, but would be quickly admonished or shown the door.
Employee engagement means, for example, providers are given 360-degree evaluations by the clinic support team each year. Those evaluations are fully transparent; they are posted for all to see.
While on our site visit, a provider was telling us that if he has to go into an exam room to see a patient more than one time, it’s a fail.
“You need to move,” said one of the nurses, interrupting our conversation with the provider. “You have patients in rooms 1, 3 and 4.”
This interruption demonstrated one example of over-management of communication: how leadership works on the floor. Leadership at these urgent care centers is provided largely by the nursing staff, not by the providers. And it is strong, fearless leadership. To have world-class medicine fast, you have to have great providers, but you also need great leadership by the ones who can see the whole floor at any given time. And that visibility comes not from providers but from nurses and medical assistants. This leadership is not only intentional but embraced by all team members.
The result is they know how to step up when it seems like a bus load of people just got dropped off in the waiting room. They have designed systems that include an ingenious mix of high-tech and low-tech methods to move patients through the system quickly and safely. They have a team that manages the measurement and communication of patient satisfaction scores. They have a detailed approach to triage management. And they never hesitate to ask why some things could be done differently.
“The providers know our people, the ICC team, are our most valuable asset,” says Ireland. “We make sure our behavior reflects that every day.”
Turnover in the last 10 years is virtually non-existent. Throughput is off the charts, typically 140 patients per day with two providers. Patients know they can go to any Advocate ICC site and have predictable wait times no matter how many people are in queue: they are in and out in less than an hour. And most importantly, the team knows the doors are locked at closing time (8:30 p.m.) and they are heading home by no later than 9 p.m.
Why Culture Matters Today
This used to be an industry that once prided itself on being capable of handling a fairly wide scope of care and acuity, which meant that a patient could walk into most centers and they would be taken care of. But with payers no longer increasing reimbursement at the same pace as provider costs, we are seeing cracks in scope of care. Urgent care operators are getting desperate, hiring more advanced practice providers (APPs) out of school who don’t feel comfortable suturing or reading films. More patients are being referred out, creating leakage to the competition.
“If you have high turnover you have a poor culture,” says Ireland. “And if you have poor culture you have low throughput.”
Ireland says high turnover is the death knell of any walk-in operation.
“High provider turnover means you end up using lots of Locums,” he says. “How can you reduce variability when you have different providers coming in every day or every week? And if the support staff is turning over you have no support because you are constantly retraining, things slow down and the team starts to lose energy. You can’t provide great care fast if your team isn’t wanting to come to work and be part of the culture that they had a say in designing.”
Imagine creating an environment that is a great place to work. Word travels fast among the provider community. Money only goes so far. Advocate ICCs have providers knocking on the door wondering when there might be openings. The openings are few and far between.
“When you avoid engaging, speaking into your work, managing it, then you see things as happening to you, not for you,” says Ireland. “You see problems, not opportunities. I use to be one of those doctors. It takes a great team. So now, as challenging as this business is, I look forward to going to work and managing the practice with my team."