FULL PRACTICE SETUP

BHC has set up a number of new private medical practices on the Central Coast of NSW for both GP and non-GP owners – see examples below:

Practice 1 –

Long term established General Practice in a small village on Brisbane Water, which had been providing services for over 30 years, reluctantly closed its doors in 2014 due to retirement and relocation of the GPs.
A local dentist identified the opportunity to once again provide a medical practice in the area and set about developing a new medical practice with 6 consulting rooms, treatment room and pathology.
The practice opened 1st July 2014 and achieved full accreditation within the first six months.

Practice 2 –

New practice in beachside suburb of Terrigal – completed August 2017.
Two Registered Nurses with extensive hospital and general practice experience identified the need for an addition medical practice and purchased ground floor space in a brand new commercial / residential building. At completion of fit out the practice has 6 consulting rooms, large treatment room with pathology and allied health services onsite.

Practice 3 –

New Skin Cancer and General Practice – completed February 2017.
A local GP with an interest in skin cancer identified the need for further skin cancer services in the Erina area and secured  a large ground floor commercial space with main road frontage. At completion  the practice has 6 consulting rooms, 3 procedure rooms, large treatment room with pathology and allied health services onsite.

BHC was invited to assist the owners of these practices every step of the way, from floor plan stage through to opening date and beyond.
This includes but is not limited to:

  • Advertising and recruitment of GPs, nursing staff and administrative staff
  • All employment documentation and contracts for GPs and staff to ensure all legislative and legal requirements are met
  • Negotiations with allied health providers and pathology to provide onsite services
  • Advice and practical assistance on equipment purchase, medical supplies, IT consultant, fees structure and insurances
  • Writing of policy and procedure manuals and other required manuals
  • Training of staff in practice management system (PMS)
  • Preparation for accreditation and application for PIP
  • Ongoing onsite assistance / training to the owners, GP’s and staff before and after opening date.

INTRODUCING STAFF TRAINING POLICY AND BUDGET

BHC has a strong belief that staff training is not only a benefit to the staff but also a clear benefit to the business. It allows staff to improve on current skills or perhaps gain new skills required for the job. It allows the business to ensure that one of their most important assets (the staff) are always kept up to date with the ever changing environment within the medical industry.

In this instance the practice was fairly accepting of ongoing education and development of their staff, however they wanted to have a more formal & structured approach by introducing a budget line specifically for this purpose.

Our first step was to work out how to develop this budget. How much to allocate? How to implement it? What to do with employees who had been with the practice for 17 years or 25 years compared to employees who have been there for 1 to 5 years? How do we make it equitable for all at the starting point?

Off-Site Training

This budget takes into account:

  • The length of service of current employees
  • Number of hours allocated per year to each employee
  • A qualifying period for new staff
  • A realistic and achievable level of training hours

Allocated Annual Percentage

We looked at the number of employees in the practice, the type of training required and approximate costs of training as a starting point.  Using this information we came up with a percentage against the practices income that we felt was sufficient to generate an equitable training program.

Realistic and Achievable Hours of Training Required

Next step was to work out how many hours or days per year per staff member would be required to attend training. Based on past experience and knowledge of the number of hours that staff may be required to attend training by the employer and allowing for training courses that may be beneficial to the employee over a twelve month period, a nominal number of hours per year per staff member was agreed upon as realistic, within  budget and therefore achievable.

Length of Service of Current Employees

Consideration was given to the number of years of service for current staff members with regard to the initial allocation of hours. Long-term employees were allocated a pro-rata allotment of training hours at commencement of the training program based on every 5 years of service up to 15 years then a set allotment thereafter.

Number of Hours Allocated Per Year

The number of hours allocated to each staff member each year on 1st July was the same. Unused training hours would accrue annually. This allows staff to attend longer training sessions if they arose. July 1st was set as the training anniversary date simply due to to it being the commencement of the financial year.

Qualifying Periods for New Employees

A qualifying period was deemed as the standard probationary period of 3 months. Once a staff member had moved through this period they were then allocated the initial start rate. New employees commencing after 1st January would have their initial start rate allocated on a pro-rata basis.

Reimbursement of Staff Time

Wages are paid at ordinary rate of pay to staff attending courses in their own time. This was set at 4 hours for a half day course and 7.5 hours for a full day course. Courses less than 4 hours would be paid at the same rate according to the number of hours attended. Staff attending courses on their normal working day would be paid at the above rate. Staff would not be paid to attend training that is not relevant to their employment; however, they may choose to do this in their own time and at their own expense.

On-Site Training

Staff were paid on an hourly basis (according to length of training) at the ordinary rate of pay.

Expenses

Expenses were also taken into consideration and were capped for the following: course costs (per course); out of region travel costs (per course); and accommodation (per course) (if applicable). Out of region travel was defined as “not local to the metropolitan area of the practice”


In Summary

The budget was implemented 1st July 2005 and is still in place. Feedback from staff & the Principal has been very positive. All staff have been attending equal amounts of training specifically targeted at enhancing their ability carry out their duties effectively and as yet the Practice has not gone over budget.

INTRODUCTION OF THE FIRST PRACTICE NURSE INTO A LONG TERM EXISTING PRACTICE

This project required BHC to convince a solo principal to employ his very first nurse into the practice. He had been in General Practice for over 25 years and at the time of our involvement had 4 practitioners within his practice. He had argued with colleagues & the local Division of General Practice (of which he was a board member) for sometime against the benefits of a practice nurse. The challenge would be to deliver a sound argument capable of changing long held views.

As a first step BHC provided an outline of the four different nursing roles as defined by the ADGP.  Those roles are:

  1. The Clinical Support Role
  2. The Administrative/Management Role
  3. The EPC/PIP Role
  4. The Enhanced or Primary Care Role

In addition to the roles outlined above we identified a group of services that can be performed by RN’s, they include:

  • Patient monitoring and clinical management
  • Health screening and health promotion services
  • Input into chronic disease management programs
  • Home visits ECG’s, immunisations and wound care.
  • Occupational Health & Safety responsibilities
  • Infection and sterilisation control
  • Ongoing staff education programs of staff
  • Accreditation preparation

BHC identified the following suite of problems the practice faced:

  • The Practice had employed a casual Registered Nurse at $40.00 per hour on an “as needed” basis solely to perform over 75 years of age health assessments.
  • A diabetes trained Registered Nurse was being employed through the Division of General Practice on a 6 monthly basis to run (on-site) diabetic clinics.  At a cost of $50.00 per hour, the cost of engaging this service was more than double the payable rate under the award at the time. (Practice staff were still responsible for recalls, mail outs, making of appointments and co-ordination of the clinics)
  • Reception staff were trying to perform nursing duties as well as reception duties. This confusion of roles was causing considerable disruption at the front desk and also presented significant medico-legal implications.
  • Doctors were unable to meet the ever increasing demand of patient appointments
  • Doctors were working a significant number of hours beyond their normal consulting times to try to meet the demand
  • Patients were forced to wait an unacceptable period of time for appointments
  • Patients were frequently required to wait for extended periods beyond their pre-arranged appointment time. This seemed to be the accepted “norm”, whereas in fact should be the “exception”.

The new practice nurse item numbers had recently been introduced by the government which meant if nurses saw patients on behalf of a doctor for certain procedures (e.g. immunisation), there was now a chargeable item under Medicare.

The proposal BHC put forward highlighted this and showed that nursing staff could certainly generate a revenue stream into the practice. For instance at that time, the monetary difference between a patient being seen for a consult/immunisation by a doctor only,  as opposed to being seen by the nurse first then the doctor was $16.35.

However, more importantly, our proposal demonstrated the total amount of hours per day of GP time freed up equated to approximately 5.5 hours per day.

This extra time could be utilised to allow GP’s:

  • To see extra patients (therefore generating further income-at the time this had the potential to increase total GP daily income by over $1300.00 or
  • To utilise as catch up/free time or report writing etc. or
  • To utilise to increase / expand their corporate medicine.

Statistics provided in the proposal included:

  • Patient practice statistics i.e.: number of patients over 75 yrs. (annual number of Item 702’s),
  • number of patients over 65 yrs. (annual number of patients for flu vaccine – Item 10996),
  • number of patients under 5 yrs. (childhood immunisations – Item 10996) etc

BHC also demonstrated how utilising a Practice Nurse to full capacity (e.g. seeing new patients and taking history) could free even more GP time. The proposal identified achievable monthly targets that could be set as realistic KPI’s for nursing staff.

In summary, BHC’s proposal demonstrated how through employing the right practice nurse the business will:

  • Increase patient access to primary care services,
  • Enhance the range of services available to people attending the practice,
  • Provide collegiate support and assistance to the doctors,
  • Enhance the management of people with chronic conditions,
  • Support, influence and manage change,
  • Promote safety and quality programs and practices,
  • Encourage a team approach to care,
  • Decrease waiting times for appointments,
  • Decrease waiting times for consultation,
  • Increase patient satisfaction,
  • Higher regard in community for the name of the practice,
  • Decrease overload on GP’s,
  • Provide an inducement to recruit new GP’s
  • Increase turnover and profitability.

Project Outcome:

The GP’s practice started with one part-time practice nurse at 3 days per week, and then employed a second nurse approximately 12 months later to job share so the position was covered on a full time basis. He currently employs 3 RNs and often comments “he doesn’t know how he ever coped without a nurse before!”

FINANCIAL AND STAFF REVIEW OF A NOT FOR PROFIT WOMEN’S HEALTH CENTRE

The practice was one of three located in a large metropolitan area providing services such as counselling, consultations and pelvic floor chair and alternative therapies. The practice bulk billed all patients. Their commitment is ‘to work alongside and support women of all ages, backgrounds and cultures in a respectful, friendly and effective way’.

BHC was engaged to review and provide a financial and staff analysis to the board of directors.

Some of the concerns raised included:

  • practitioners paid at an hourly rate (compared to the more common practice of percentage payments for service / management fees);
  • number of patients seen per hour (quite minimal);
  • staffing numbers and remuneration;
  • fee for service.
Initially the project involved meeting with the board, then practitioners and finally staff on an individual basis to obtain feedback. It became apparent very quickly that the organisation was in danger of failing should changes not be implemented rapidly.

A review of financial reports identified:

  1. Debtors showing as $1.1mil in unreconciled income;
  2. Some invalid item numbers still being used;
  3. Incentives for some item numbers not being used;
  4. Pay structure of all doctors was not viable (doctors were classed as employees not contractors). This in itself presented significant complications;
  5. Doctors receiving income from non-income generating activities e.g. meetings with reps, paperwork;
  6. Approximately 23% of patients entitled to be bulk billed therefore leaving over 70% who could potentially be privately charged resulting in a significant increase in practice income;
  7. Significant unnecessary expenditure;
  8. Clinic running at a loss overall.

Additional issues that were identified included:

  • Staff numbers were significantly higher than was needed;
  • Staff were being paid extremely well (well over award) for duties performed;
  • Potential medico-legal issues.
  • Unable to extract useful data from management program, for example:1.The number of specific EPC items billed in a time period;
  • The percentage of HCC / pensioners v private (no concession)Poor succession planning.

BHC provided a comprehensive set of prioritised recommendations that included:

  • Reconciliation of all income received;
  • Pay structure of doctors to be reviewed (employee to contractor status);
  • Management software support be contacted to enable extraction of useful reports for review;
  • Review of item number usage

Project Outcome:

All recommendations were agreed to and adopted by the board.  Over time those recommendations have been implemented through a structured consultation process involving all parties. The consultative process has ensured all recommended changes, while substantial, had minimal impact on the operation of the clinic and its staff.

The clinic is now sitting in a much better financial position overall with the services provided being offered in a more efficient and profitable way.