For six years, Ron Yee’s goal was to turn health care on its head by staking the livelihood of his organization on the quality of its relationships.
Yee, was Chief Medical Officer at United Health Centers in the San Joaquin Valley of central California, and was determined to build an organization where relationships are valued more than anything else, where staff and patients are both cared for, and where the bottom line is healthy. Seem far-fetched and impossible? Read on!
Note: Ron Yee, MD, MBA has since taken on the role of CMO of NACHC the National Association of Community Health Centers. Here is his story of his work at his CHC at his home in the Central Valley of California.
First Things First: Patient Visit Redesign™
The goal of Patient Visit Redesign™ is to make dramatic changes in the patient’s clinic experience. “Redesign gave us new energy and efficiency and helped us to think differently—to break out of our old paradigms,” says Yee. “It broadened our view of our potential and let us build a new vision for our organization.”
Redesign gave us new energy and efficiency and helped us to think differently – to break out of our old paradigms.
Dr. Yee spent nine years at United Health Centers before it was redesigned, just seeing patients. Like many health care organizations, United Health Centers was experiencing a rift between the medical side of the organization and the administration. Goals of the practitioners seemed out of alignment with those of the administrators.
During these dark times, Yee did a patient flow analysis as part of his MBA program. In 1999, when the center was invited to participate in a Coleman Associates Patient Visit Redesign™ collaborative, Yee was an obvious choice for the team. Team Catalyst slashed waiting time from 82 minutes to 37 in just six months. Two months later, Coleman Associates invited Yee to be a member of the Expert Team for another collaborative and to coach several redesign teams.
This experience gave him intimate familiarity with the details of Patient Visit Redesign™. “It’s my life,” Yee says. He has seen what redesign can do—at his center and others—and would never go back to the old way. “I have the huge advantage of having seen the principles of redesign proven over and over again through the years.”
What is Patient Focus?
Yee has come a long way since that first patient visit he tracked as a curious student. His leadership style is characterized by an overriding focus on patients, from billing practices to staff development to facility maintenance.
“Patient focus is not about making money. Providing great health care is the goal,” says Yee. “It’s giving the best care possible to our patients, and I always come back to that.”
In Yee’s mind, everything United Health Centers does should benefit patients in some way. It’s obvious that hiring and retaining the most qualified staff is critical. But other issues are equally important. Will remodeling the facility make the patient more comfortable and improve work flow? Will the patient’s diagnoses be more accurate if a certain piece of equipment is purchased? How can the billing department better serve patients?
“For me, patient focus is a powerful tool, and keeps everything else in the clinic on track,” says Yee. “The things that don’t relate to that focus fall to the wayside.”
So what is it like to work in a patient-focused environment? “It’s actually fun,” says Yee. “Fun and kind of freeing. My goal is to remove obstacles for providers to see patients. Clinicians don’t have to worry about anything but their patients. Physicians coming out of private practice say it’s a night and day difference. It’s refreshing.”
Medicine’s Human Face: Relationships
The dominant feature of a patient-focused health center is the premium it places on relationships. A natural outgrowth of this is that many staff members have forged profound relationships with their patients. “I’ve seen MAs come in on Saturday because their patients are having staples removed after a C-Section,” says Yee. “They come in when they’re not scheduled. They have a real connection with their patients.”
Billing departments have a clear objective: to get payment from patients for their medical care. Yee sees it a little differently. If the billing department can build relationships with patients, the patient experience is further optimized. “You don’t forget about the payment, but you’re reasonable,” says Yee. He says some patients who have hundreds of dollars in medical bills pay five dollars a month because that’s all they can afford.
The Beginning of a Beautiful Friendship: New Staff
How do Yee and others keep the flame of patient focus bright? It’s easy to maintain the furnace and order equipment, but how do you take care of something as intangible as the quality of relationships? Yee says you have to have to look for the right people to work with, regardless of whether they are line staff, clinicians, or top leaders.
For Yee, “your standard twenty questions” interview process just doesn’t cut it anymore.
A candidate may look good on paper but not share the passion for service at the core of a patient-centered practice.
The only way to tell if a candidate will work out, says Yee, is to watch and listen over the course of an entire day.
Yee himself spends much of the day with the candidate, forming his own impressions and gathering impressions from others. When hiring new clinicians, administrative assistants are the first staff people Yee checks in with. “You can learn a lot about a candidate by asking your administrative assistant what the person was like when they thought they weren’t being watched: did they ignore you or just ask for coffee, or did they engage you in conversation and seem interested in the organization?”
Yee says he asks candidates questions about things seemingly unrelated to medical work. “We have an hour or two in the car for conversation while we’re driving between sites. I ask about their experiences and what their life is like and then I just listen.” Yee wants to get a sense of their values—who they are, not just how much they know about making diagnoses.
At the end of the day Yee asks the candidate to have dinner with him and his family. “When the kids were younger it was really telling,” says Yee. “If the candidates tried to play with my kids, it was a good sign. I wanted to see how candidates reacted to them,” says Yee. Since United Health Centers has a family practice model, good interactions with children are critical. After dinner Yee would ask his wife and children what they thought of the candidate, and he would add their impressions to his overall evaluation of the person.
If candidates don’t seem like a good fit, Yee won’t hire them, regardless of their credentials. “I think the chemistry is really key,” says Yee.
Once Yee has found the right candidate, he says it isn’t too hard to get that person on board with the finer points of their redesigned clinic. “If you hire good people, you don’t have to spend much time convincing them about the value of service and relationships. They can focus on making their practice efficient.”
Respecting staff at United Health Centers also means cultivating their skills. Many clinics spend lots of time and money to find and hire the best, but few spend those same resources in retaining them once they’re hired.
“I’m a real believer in growing your own,” says Yee. “We have a number of medical assistants who have gone back to school and either received their LVN or RN degree and have come back to work with us. It’s great.” When Yee decided to get his MBA, the organization split the cost of tuition with him 50/50. “My agreement was that I would stay at least three years after I finished. That was eight years ago,” says Yee, laughing. “They got their money’s worth.”
Staff at the center also feel respect as they see their leaders work side-by-side with them. Yee, an administrator, sees patients 40% of the time and doesn’t shirk the less desirable tasks like call or evening and weekend hours because “my adage has been I’m not going to ask somebody else to do something I wouldn’t do myself,” says Yee. A good manager is “somebody that can get right in there and run with the staff when they’re in the heat of the battle,” says Yee. “I’m not above taking vital signs for a patient, or cleaning up the room.”
“We continuously climb the performance graph every year because we retain good people,” says Yee.
Let’s Talk About Money
“I really believe if you consistently focus on your patients and take care of your staff, the business side will take care of itself,” says Yee. This seems counter intuitive—how can an organization even begin to think about improvements without first having the financing in place? Yee says it takes a little faith, but when you insist on quality in both patient and staff experiences the money will follow. But that’s not to say you stop thinking. Yee has done some pretty creative thinking to make it all work.
Overall, the 25 medical providers at United Health Centers average just under 3.0 patients per hour. The providers who have enthusiastically embraced redesign, however, have practices that run as high as 3.9 patients per provider per hour.
“I wanted to keep the health centers up and running at full capacity,” says Yee, who realized that on average, two providers per week were absent due to vacation or CME. Yee ran an experiment for a couple of months and discovered that the cost of hiring locum tenens to replace the absent providers was more than offset by the revenue that would otherwise have been lost because of the absences. “We had always believed that using locums was financially unfeasible. Managing by fact is key. A lot of people make assumptions without any data whatsoever. We no longer say, ‘we can’t afford this.’ Now we ask, “How can we afford this?—and base our decisions on the facts.”
If you consistently focus on your patients and take care of your staff, the business side will take care of itself.
United Health Centers seems to be doing something right financially. The revenues at United Health Centers have more than doubled in six years, from $10,095,113 before redesign to $21,023,941. They’ve increased their medical and dental visits from 94,700 to 134,397.
They’ve remodeled, expanded, or rebuilt all of their sites within the last two or three years, and they’ve built a brand new site in Kerman, California. They’ve narrowed their focus for grants, only asking for grants that further their mission of family practice. They’ve hired a financial whiz that didn’t come from a health care background because they understood the value of hiring experts regardless of whether they had a health care background. “When you focus on people—both patients and personnel—the by-product is high-quality care, a smoothly running organization, and a solid bottom line,” says Yee.
“People get it backwards—they think, ‘if we make enough money and we make a profit, then we’ll be able to take care of our people and do the things we want to do to improve our organization.’ But it’s exactly the opposite.” Yee learned a lesson from Roger Coleman, General Manager of Coleman Associates: “Don’t go out begging for money,” he remembers Roger saying. “Be recognized for what you do exceptionally well.”
The (Really) Big Picture
For Yee, life at the health center is not unrelated to life everywhere else. He’s thoughtful about the lessons he has learned. Yee tells stories about people he’s known who pursue prestige and fortune single-mindedly only to realize later those things don’t mean anything.
“I would much rather be trusted and respected by staff than have a lot of money. Financial health comes and goes, but if you don’t have respect and trust with staff, they will leave,” says Yee.
Without the loyalty and affection of staff, without enduring regard and concern, the fabric of a health center will begin to unravel, patients will leave and the money will follow them.
Isn’t excellence often surprising? It’s so simple, but oftentimes so unexpected. Incredulous? Yee claims the proof is in the pudding. “Even the most outspoken resistors I’ve known, once they get a taste of what we’re doing, they become great supporters.”
Written by Molly Weisse-Bernstein & Katherine Hickner