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Organization and
Operations of Medical
Group Practice
By Stephen L. Wagner, PhD, FACMPE
Our Age of Anxiety is, in great part, the result of trying to do today’s jobs with yesterday’s tools.
—Marshall McLuhan
This chapter is divided into two parts. Part I covers the
organization of medical group practice and deals with the
various structures, characteristics, methods of governance, and other important issues related to the many
forms of medical group practice. Part II discusses the
operations of medical group practices and how these operations are organized into functional departments, or
divisions in the case of large groups. The issue of quality
and the management implications of quality are also
Part I: Organization
When Home State Mining Company opened the first medical practice in 1870 to care for their growing workforce
in the remote parts of the West, it could not have been
predicted that medical groups would become such a significant modality for physician practice in the delivery of
medical care in the United States. Although over 130 years
have passed, consolidation of group practices has been
slow, and group practice size on average has remained
The answer to this, very likely, lies in the nature of
medical practice itself and the nature of technological uncertainty as described by James Thompson. Thompson
classified technologies as being either long-linked, mediated, or intensive. Medical practice is an example of an
intensive technology where a “customized response” is
necessary to a given set of circumstances or contingencies,2 as shown in Figure 2-1.
In addition, Robbins discusses the concept of
decision-maker divergence as a significant reason why
organizations and decision makers’ interests do not coincide. In this construct, the ability of an organization
to grow and become efficient is directly related to the divergence of the interests of the decision makers,3 as shown
in Figure 2-2.
Regardless of the organizational challenges facing
medical groups, many variant structures have been developed. In its simplest form, a medical practice can exist as a solo proprietorship with no formal organizational
structure at all; a simple general partnership is the next
step in the development of a group practice.
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Chapter 2: Organization and Operations of Medical Group Practice
Multiple Inputs
Figure 2-1 Aligned Interest Model
Taxonomy of Medical Groups
By definition, medical groups must contain at least three
practitioners working within a common organizational
structure. Groups share expenses and services and almost
always bill under a single tax identification number. Special
requirements for designation as a group practice are also
defined by the Department of Health and Human Services
Office of the Inspector General and will be discussed later
in this chapter.4 Furthermore, one can think of groups as
being either confederate models, in which the practices
tend to be loosely affiliated, or centralized models, in
which the practices tend to be closely affiliated.
Figure 2-3 shows a taxonomy of medical groups and
the relationship of the different forms. There are many
variations in the structure of a group practice, but all typically fit into one of these categories.
Of course, this taxonomy is incomplete. Groups are
also organized by single- or multispecialty status. Singlespecialty groups are common in cardiology, surgical specialty, OB-GYN, pediatrics, orthopedics, behavioral
medicine, rehabilitative specialties, internal medicine,
neurology, and many others. The more divergent the specialties in terms of their economics and the nature of practice, the more difficult they can be to bring together under
one structure.
The many organizational forms of medical groups
have evolved in response to the needs and interests of
medical practitioners as they have sought to adapt to a
changing environment and to overcome the inherent
nature of practices to stay small. In this sense, the medical group practice is a pragmatic entity. The definitions
of each form are constantly varying and assuming characteristics of several forms.
One question needing to be answered when considering which group practice structure to use is, “How will
the structure influence the culture of the group and the
governance system that the group envisions?” As illustrated in Figure 2-4, the governance structure of a group
affects the culture, which ultimately influences the operational nature of the group. For example, if there is not
a centralized governance system and the culture of the
group is biased toward significant physician autonomy,
then operations will likely be variable with standardization lacking.
The degree of integration varies widely according to
design and group type. Solo practices obviously have no
integration with other practices, while in confederate
models such as independent practice associations (IPAs)
and management service organizations (MSOs), some
services, identified in Figure 2-5 as “soft resources,” are
shared and integrated by the organization. In the fully
integrated centralized group, all resources are shared.
Consideration for Structuring Practices
The choice of practice form has a number of points to
consider. In general, organizational forms offer different
advantages and disadvantages to the physician and patients. They are generally related to:
The ability to move forward
Figure 2-2 Thompson’s Intensive Technology Model
Liability of owners
Continuity of the business entity
Transferability of assets and ownership
Capital formation
Benefit plans
Virtually every state has adopted statutes that govern
the formation and operation of corporations, partnerships, and other forms of commercial ventures. Since
1961, most states have special statues specifically related
to the organization of professional organizations. In some
states, these are referred to as “Service Corporations,” signified by the designation “S.C.” In other states, the designation “P.A.” is used, which stands for “Professional
Association.” The principal distinguishing feature of these
organizations from other incorporated entities is that med-
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Part I: Organization
Practice Forms
Joint Ventures
Figure 2-3 Taxonomy of Medical Groups
ical professionals are not protected by malpractice liabilities in an incorporated medical practice. A malpractice claim can and does pierce the corporate veil, and
the physician is held liable individually for any acts of
The other major difference in the treatment of P.A.s
and S.C.s is in the area of taxation. These entities are essentially treated as individual taxpayers. They are taxed
at the highest individual tax rates and are required to have
a calendar year for their fiscal year for tax purposes. This
was a response by the IRS to the use of the professional
corporation by small practices to defer income between
tax years.
In addition, centralized practice structures and confederate forms have different attributes that determine
the level of satisfaction of the physician with the practice
form. Figure 2-6 shows a list of several attributes that
have been identified by physicians as being important to
their satisfaction with practice. Centralized forms have a
tendency toward certain attributes and confederate forms
tend to move in the opposite direction.
Operational Form
Organizational Form
with the Reality
Figure 2- 4 Governance
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Chapter 2: Organization and Operations of Medical Group Practice
Centralized Group
Solo Practice
Confederate Models
* Management
* Marketing
Assets and
* Management
* Marketing
* Contracting
of Assets
and All
Figure 2- 5 Integration Spectrum
Group Practice
Organizational Forms
There are a large number of practice structures and variations of those structures that are possible for the medical
practice. Although clear distinctions are sometimes made
between these forms, they often have much in common
and in some cases, vary more by name than function.
General partnerships (see Figure 2-7) are the simplest
form of group-practice organization. Partnerships are created by a contract commonly referred to as a partnership
agreement, which specifies the terms of the partnership.
These entities are characterized by:
1. An agreement on the nature of the enterprise. Two
or more individuals (remember that a corporation
is an artificial person in the eyes of the law; and therefore, may form partnerships) agree to work together
by contributing their assets, skills, and efforts in
whole or part in the pursuit of the practice activity.
2. Partnerships are pass-through entities for taxation.
Profits or losses are divided in accordance with the
partnership agreement, and the partners then declare those profits as income on their personal tax
3. General partners have unlimited liability for
the debts and torts of the partnership and their
4. Upon the death of a general partner, the partnership ceases to exit.
Personal Physician Autonomy
Personal Flexibility
Services Offered
Capital Formation
Easy Patient Access
Professional Interaction
Shared Call
Operational Reporting
Decision Making Process
Less Likely (decrease)
More Likely (increase)
No Inherent Tendency
Figure 2-6 Relative Influence of Practice Structure on Practice
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Part I: Organization
Professional Associations (P.A.s)
Service Corporations (S.C.s)
C-Corp Section of Laws
S-Corp Section of Laws
Limited Liability Corporation
Figure 2-7 Partnership (straight partnership or limited liability
partnership, LLPS)
The greatest advantage of the partnership is that it is
easily formed. They are generally controlled by the owners, and decision making is usually by consensus.
Unlike the partnership, a corporation (see Figure
2-8) is an “artificial person created by the law.” However,
state legislators have placed a number of limits on what
a corporation can do and what their legal rights are. First,
corporations have a right to buy and own assets, borrow
money, enter into contracts, sell interests or shares in the
ownership of the corporation, commit torts, commit
crimes, and make income. They can be taxable or tax exempt, but are taxed under the corporate tax provision of
the Internal Revenue Code. Ownership of the corporation is seen as having some level of independence from
the corporation. Individuals that have an interest in the
corporation are called shareholders. An important distinction between corporations and partnerships is that
corporations and their shareholders can easily exchange
their ownership interests without dissolution of the corporation. This allows the medical group practice to add
shareholders and remove shareholders as needed while
the integrity of the organization remains.
Although they are seen as a person under the law, a
corporation does not have all the rights of a living person. A corporation may not vote and has no Fourteenth
Amendment rights; so, states may tax and impose fees on
corporations for the privilege of doing business in a particular state.
Figure 2-8 Corporate Forms
Corporations are created by filing articles of incorporation in accordance with state law. A charter is then
granted for the corporation to operate and engage in the
lawful activities it was created to do. It is important to
note that corporations may not practice medicine and
may not be licensed to practice medicine. Furthermore,
corporations, being constructs of legislation and having
no free will, are required by law to operate according to
their charter or bylaws. It is, therefore, essential that the
group practice carefully consider the operating parameters established in its organizing documents.
Most large medical groups operate as corporations.
Physicians typically join the practice under an employment agreement. Unlike publicly traded companies, becoming a shareholder in a group practice is usually not
automatic and often requires more than the simple purchase of the stock. The incoming shareholder purchases
the stock in the medical group in accordance with the stock
purchase agreement. These agreements specify the terms
for the purchase and sell of group stock and any restrictions related to its sale. One common restriction, for example, is that the stock must be sold back to the corporation
upon death or departure from the practice for any reason.
The use of a stock restriction agreement is extremely important, because, although states have statutes that require
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Chapter 2: Organization and Operations of Medical Group Practice
Department Communications
Figure 2-9 Group-Practice Organizational Chart
all members of a professional corporation to be licensed
professionals, the state does not require that stock be sold
to members of the existing corporation or to the corporation in the absence of a stock restriction agreement.4
Figure 2-9 shows the organization of a typical group
Hybrid Corporate and Partnership Forms
Although the corporate form is the dominant practice organizational form for medical groups today, they can take
some variation in form.
The limited liability partnership, or LLP, is a variation
in the partnership form that has some characteristics of a
corporation in the area of taxation and extends liability protection to its partners. Similarly, limited liability corporations, LLC, and the S-Corp, are variations of the corporate
form and have some characteristics of the partnership. SCorps, for example, are pass-through entities for taxation
much like a partnership, but still have the corporate veil for
protection from nonprofessional liability. A more detailed
discussion of this can be found in J. Stuart Showalter’s book,
Southwick’s The Law of Health Care Administration.5
Physician Hospital Organization (PHO)
One form of group practice that combines the hospital
and the physician group or groups into a single organizational structure is the PHO (see Figure 2-10). This form
usually occurs when a hospital or its parent company acquires the medical group through the purchase of the
group practice’s assets and the employment of the physicians directly by the hospital corporation or through a
medical services agreement executed by the corporation.
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Part I: Organization
Can be 501(c) 3 Corporation or a
C-Corp, Individual Hospital, IDS
or Multihospital System
Parent Health Care
For Profit
Foundation 501(c)3
Physician Organization
For Profit
Physician Organization
Figure 2-10 Physician Hospital Organization (PHO)
This form offers some clear potential advantages. Many
arrangements, which would be prohibited or very difficult
and complex, can be accomplished in the routine course of
business for the PHO. This includes such things as joint
marketing, contract negotiation for professional services
contracts, managed-care contracts, purchasing, and the sharing of such assets as information technology. Another advantage is the access to capital for the purchase of increasingly
expensive new technologies and practice development.
The major potential disadvantage is the loss of control over decision making and potential inflexibility of a
larger organization.
Management Service Organization (MSO)
Management service organizations are not actually medical
groups at all in the sense that the MSO and the medical practice are usually two distinct organizations (see Figure 2-11).
MSOs are entities that provide management service support to practices through a contract relationship. The MSO
generally contracts with several practices to provide similar services. These contracts specify the nature of this relationship, which generally involve billing and collection of
practice accounts receivable, personnel management contract administration, and most of the administrative functions of any medical practice. The advantage of this
arrangement is the potential for having higher-quality management and administrative service at a lower cost.
A large MSO has the ability to employ more highly
skilled and, consequently, more expensive people in the
organization and leverage more expensive technologies
for more efficient operations because these costs can be
spread over a larger number of physicians. In most cases,
MSOs often are capitalized by outside investors and are
managed independently of the medical group.
The disadvantages are largely related to the difficulty
of separating out these essential functions from the practice should the relationship with the MSO prove to be unsatisfactory. Once the arrangement is in place, it is
extremely difficult to undo, rehire staff, and rebuild the
necessary aspects of the practice operation. It is essential
that practices contemplating such an arrangement do so
with great care and due diligence. Performance benchmarks in the contract with procedures for resolving problems and potential compensation for fee relief for poor
performance is advisable.
Practice A
Practice B
Practice C
Practice D
Practice E
Figure 2-11 Management Service Organization (MSO)
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Chapter 2: Organization and Operations of Medical Group Practice
Practice Management Company (PMC)
Practice management companies (see Figure 2-12) have
fallen largely out of favor with some notable exceptions.
These entities essentially took the MSO concept a step
further by serving as a vehicle to amalgamate practices
under one corporation. Many of these organizations were
able to tap large amounts of capital for acquisitions by
becoming publicly traded companies. The advantage of
this practice form is its ability to raise capital in the financial markets, but that has turned out to be as much a
problem as an advantage.
The need to generate profits from aggregated businesses accustomed to distributing 100% of the income to
the physicians as income, seemed to be a clear problem
with the model. PMCs simply could not live up to their
promise of increasing income to physicians, improving
group performance, and providing an acceptable return
to public shareholders. PhyCor, one of the largest and
oldest of the PMCs, was delisted by the NASD in November
of 2000 after posting over a $400 million loss.6
Pediatrix is a publicly traded medical group that has
met with great success, even though its business model
is similar to the PMC. The PMC is not a complete relic of
the past, and as with many medical business models, it
requires a careful examination of asset acquisition cost
and operations to produce an optimum outcome.
Independent Practice Association (IPA)
These are loosely affiliated entities and are not as
widely employed today as in the recent past. Many IPAs
formed when managed-care plans were seeking to con-
tract with a smaller number of providers at discounted
fees with the promise to direct larger numbers of patients
to those providers. The IPAs often share risks with the
managed-care plans and accept a defined number of patients while agreeing to provide care at a fixed price or
capitated fee (see figure 2-13).
IPAs are usually operated by a board or management
committee derived from the practice participants and a
professional staff.
The popularity of IPAs has demised as capitation and
risk-sharing arrangements with physicians has declined.
IPAs that experienced difficulties did so because it was often difficult to properly evaluate risk for the patient population being serviced. Managed-care organizations also
had difficulty in providing enough patients to an IPA so
that the risk associated with the contract was predictable
in actuarial terms.
IPAs may also function similarly to MSOs by providing management services and a way for many practices
to share resources. In the case of the IPA, however, such
relationships tend to be partnerships between the practices, and the IPA agreement is actually a partnership
Typical Activities of Service Organizations
(MSOs and IPAs)
MSOs and IPAs serve a variety of different functions for
the practices they support and in many respects, can replace some or all of the administrative functions that are
traditionally contained within the medical group. These
services typically include:
Public or Private
Corporation (PMC)
Operates as a
division of the
Figure 2-12 Practice Management Company (PMC)
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Part I: Organization
Practice or
Figure 2-13 Independent Practice Association (IPA)
Assessing and developing local market plans
Providing practice management support through
the employment of professional managers
Increasing coding expertise
Developing a compliance plan
Developing and complying an OSHA plan
MSOs and IPAs also offer:
Faculty practice plans and medical foundation models offer several advantages to the physician practice.
Practice assessment
Billing assistance or provide the billing function
Wage and hour administration
Practice positioning, by serving as a clearing house
for managed-care contracts
Promotion and other marketing activities
Continuing medical education
Quality initiatives
Vendor leverage and other economies of scale
Access to capital
Data collection and management
Contract administration
Faculty Practice Plans—Medical Foundation Model
Faculty practice plans are group practices within a university setting or integrated delivery system (IDS). They
have sometimes been referred to as “clinics without walls.”
These organizations are mechanisms by which the medical school faculty or physicians servicing the IDS can
operate as a single large group practice (see Figure 2-14).
These structures may be tax exempt under 501(c)3 of the
Internal Revenue Code.
1. They allow several independent practices to come
together and contract as a single entity, which may
offer strength in numbers to the managed-care
2. Because the organization is tax exempt in most
cases, more flexibility is available to the physicians
for certain employee benefits such as nonqualified
deferred compensation plans.
3. The legal barrier to joint activities with the parent
organizations is greatly reduced because they are
a single organization.
4. In the case of a physician with a faculty appointment
at a medical school, it simplifies the ability of the
practice to provide teaching services and maintain a
private practice at the same time, with less legal concerns and barriers as these activities are coordinated
by one administrative organization.
The greatest potential disadvantage concerns the
complexity of the organization and some of the unique
regulatory challenges of working within a tax-exempt
environment. Many medical groups distribute all or most
of the organization’s income to the physician owners. IRS
regulations have standards on reasonable compensation
for employees of tax-exempt organizations, so care must
be taken to properly implement compensation plans to
avoid private inurnment.
Medical School
or Hospital
or Administration
Practice Plan
Figure 2-14 Faculty Practice Plan—Foundation Models
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Chapter 2: Organization and Operations of Medical Group Practice
Joint Venture (JV) Relationship
These are special partnerships. They are usually entered
into for a specific project or service. They can be between
the medical groups, between hospitals and a medical
group, or other entities (see Figure 2-15). These entities
are highly regulated by the Office of the Inspector General
(OIG) of both the federal and state governments because
of the potential for fraud and abuse. JVs are often permissible when there is a low potential for abuse or the
potential for community good exceeds the potential for
harm to the Medicare or Medicaid program.
Most JVs attempt to comply with the various regulatory requirements by fitting into one of a number of safe
Investments in Group Practices
Physicians are protected when they invest in their
own practice if the practice meets the physician
self-referral (Stark) law definition of group practice. This does not apply to physician or grouppractice investments in ancillary services joint
ventures, but those ventures may qualify under
other safe harbors.
Investments in Ambulatory Surgical Centers
Certain investment interests in four categories of
freestanding, Medicare-certified ASCs are protected: surgeon-owned, single-specialty, multispecialty, and hospital–physician owned. The ASC
must be an extension of a physician’s office practice
for the physician to be protected as an investor.
Specialty Referral Arrangements
A physician or entity is protected when referring a
patient to another provider with the understanding
that the patient will be referred back to that physician or entity at a certain time or under certain circumstances. Referrals must be clinically appropriate.
Parent Entity
Parent Entity
Group Practice
In addition, there are five standards of the group practice safe harbor:
Committee or
Joint Venture Operation
Figure 2-15 Joint Venture (JV) Relationship
Cooperative Hospital Services Organizations
CHSOs are relations between two or more taxexempt hospitals to provide specific services, such
as purchasing, billing, and clinical services, solely
for the use of the patron hospitals. The CHSO can
be supported through operational costs and payments from a CHSO to a patron hospital.
Joint Ventures in Underserved Areas
Raises the limit on investments in a venture in an
underserved area by “tainted” investors—those
who refer to or provide services to the entity—from
40–50% and allows unlimited revenues from
referral source investors.
Practitioner Recruitment in Underserved Areas
Protects recruitment payments made by entities to
attract needed physicians and other health care
professionals to areas in need of health professionals. Places certain restrictions on patient percentages and payment time limits.
Sales of Physician Practices to Hospitals in
Underserved Areas
Allows hospitals in underserved areas to buy practices of retiring physicians for the purpose of holding them until the hospital can find a new physician
buyer. The sale must occur within three years.
Subsidies for Obstetrical Malpractice Insurance
in Underserved Areas
Protects entities that pay malpractice insurance
premiums for practitioners engaging in obstetrical
services in areas in need of health professionals.7
Equity interests must be held by licensed professionals who practice in the group or by solo professional corporations owned by individuals who
practice in the group.
The equity interest must be in the group itself, not
a subdivision of the group.
The practice must meet the definition of a “bona
fide group practice under the Stark law and implementing regulations.”
The practice must be a “unified business” with centralized decision making, pooling of expenses and
revenues, and a compensation–profit distribution
system that is not based on satellite offices operating
as if they were separate enterprises or profit centers.
Ancillary revenues must be derived from services
that meet the Stark law and implement the regulations’ definition of “in-office ancillary services.”8
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Part I: Organization
1. It becomes more difficult for members of the group
to find time and to get adequate numbers of the
group together to make policies.
2. Information disequilibrium increases. Some people are aware of and understand the issues, and
some do not. This may be due to poor communication or the lack of time to understand the issue
or to be informed.
3. The geographic limitations of attendance at meetings, calls, and other necessary absences from
meetings makes it difficult to deal with important
4. There is a lack of interest in topics for discussion.
5. There is a sense that members do not understand
the issues or that their participation is not needed
or welcomed.
The complexity and extent of the various legal restrictions on JVs has made them less attractive as possible business models for group practice. The penalties can be so
onerous that, frequently, JVs will not service patients with
Medicare or Medicaid because the JV cannot qualify for
harbor status. The most serious economic penalty for the
medical group and its physicians is exclusion from the
Medicare and Medicaid program.
One of the most significant issues for medical group practice today is the issue of governance. What makes a group
practice a focused and effective organization has much
more to do with how the governance structure is organized than the practice’s legal structure. As Figures 2-16
and 2-17 illustrate, the effective interaction of governance
and operational activities are essential for the execution
of the group’s mission. Such interaction also ensures
through monitoring operational and governing activities
that the organization’s mission is advanced.
Medical groups are traditionally viewed as professional collegial organizations. They have many unique
features, but some that affect governance: the primary
producers are all the owners (in many cases); the governed are also the governors (which leads to many policy quandaries); and the notion that “My view should be
considered above all else.”
This issue becomes more difficult, as well as more
important, the larger and more diverse the group gets. As
groups grow, the need for a more centralized form of governance becomes important for many reasons:
The Role of the Governing Body
The governing body of the medical group must deal with
a number of stakeholders in its quest to provide effective
governance of the group, such as:
Physicians in the practice
Other physicians in the community
Patients and families
Federal, state, and local government
Communities at large
There is widespread agreement that the principle role
of the board is to:
Has to
Start Here
Define Mission
Figure 2-16 Group-Practice Governance
Benchmarks, Statistics,
1. Develop the organizational mission.
2. Provide institutional goals and target (monitor).
3. Hire, evaluate, compensate, and interact with senior management (CEO).
4. Be responsible for providing quality of care.
5. Deal with external constituents (media, community, and government).
6. Monitor the organization.
7. Develop plans (financial and other).
8. Evaluate its own performance as a body.
In medical groups, most members of the board are
physicians; although their duty is to the group as a whole,
they may find it hard from time to time letting their own
interests or the interests of their specialty take a back seat
for the good of the whole. Much of this may be a matter
of experience on a governing body, adequate structure in
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Chapter 2: Organization and Operations of Medical Group Practice
–Understandable (adoption)
Governance and
Plant and
Mediated by Technology
Policy and Procedure
Figure 2-17 Operations of Medical Group Practice
the group for operational concerns that address individual and specialty needs, and education. Members that
value the group tend to have a much easier time serving
in a nonparochial manner.
One of the most important but often most neglected aspects of a group-practice organization is the lack of a clear
mission statement that is consistent with the values of
the organization’s members. Here is an example of a mission statement:
The Good Clinic will provide care of the highest
quality to our patients within an environment
that is compassionate, ethical, and economically
sound. We will accomplish this by:
1. Always putting patients first, maintaining clinical
excellence, and seeking to improve care through
research, system enhancement, innovation, and
continuing education.
2. Being ethical in all of our dealings with patients,
colleagues, employees, our hospitals, third-party
payers, vendors, and our community.
3. Providing value to our patients, insurance carriers, and hospitals, and being seen as an asset to our
4. Having an effective organization that provides quality care, efficient service, effective communication,
cost-effective treatment, and a competent and positive work force.
5. Recognizing the value of the group—that we are
greater than the sum of our parts.
6. Being focused on the creation of a positive environment that shows compassion and caring for our
patients and our staff members.
7. Providing attractive salary and benefit packages
that are competitive with all national standards allowing the Good Clinic to attract and keep the
most talented physicians and employees.
A Board Job Description
It is very important that every potential member of the
board understand his or her role and the expectations of
the job. As an example, the following is what a board
prospect sheet might look like.
Member of the Board
Job Description and Expectations
To advise, govern, oversee policy and direction, and to assist with the leadership
and general promotion of the clinic so as to
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Part I: Organization
Specify the number of members. The typical number is between 5 and 11, depending on the size of the group.
• Organizational leadership and advisement
• Organization of the executive committee officers and committees
• Formulation oversight of policy and
• Financial management (to be defined)
• Review and adopt budget for the organization; to review quarterly financial reports, and to assist administration with
budgetary issues as necessary
• Oversight of program planning and
• Hiring, evaluation, and compensation
of senior administrative staff
• Review of organizational and programmatic reports
• Promotion of the organization
• Strategic planning and implementation
Length of
Specify length of term, which may be
and Time
Commitment: Specify the time and location of meetings
such as, “The executive committee will
meet every other Friday commencing
at 7:30 a.m. and meetings will typically
last one (1) hour (this may need to
be revised). An alternative is to have
monthly meetings (2–3 hours) in the
afternoon or evening (consider payment
to participants).”
Expectation of
Board Members:
• Attend and participate in meetings on
a regular basis and special events as possible.
• Participate in standing committees of
the board and serve on ad hoc committees as necessary.
• Help communicate and promote mission and programs of the clinic.
• Become familiar with the finances and
resources of the clinic as well as financial and resource needs.
• Understand the policies and procedures
of the clinic.
support the organization’s mission and needs
and to work closely with the administration of the clinic in order to achieve its goals.
Number of
Board and Committee Structure
Committees: It shall be the responsibility of the executive committee to establish ad hoc and permanent standing committees as necessary
to assist in the functioning of the clinic.
Whenever possible, these committees
should contain a representative of the executive committee to provide a proper liaison as well as an administrative staff
Committees: Include finance, personnel, marketing,
quality care, and technology. In an area
where managed-care risk contracting is
a significant part of the business environment, a utilization management committee is common to oversee the risk
management of such contracts.
Board Selection
Board members are typically selected by election. Election
rules are specified in the bylaws of the organization. It is
extremely important that the bylaws be properly adopted
and that the procedures adopted by the bylaws be adhered
to carefully. Failure to follow an organizational process
correctly could result in a challenge to the legitimacy of
the process and invalidation under state law.
Board Retreats
An essential element of group planning and strategic activity is the board retreat. This event combines educational time, by internal and external speakers, with time
to consider issues that are of strategic interest to the group.
These issues are often:
Related to growth
Change in or development of new services
Examination of future scenarios and how they will
play out: What their effect will or will not be on
the organization
5. A reexamination or development of a mission statement
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Chapter 2: Organization and Operations of Medical Group Practice
Outside Board Members
Physician Survey
Increasingly groups are beginning to behave more like
traditional business corporations. As part of this change,
groups are adding outside persons to the board to improve the governance process and to bring new ideas and
perspectives to the board. These individuals must be chosen carefully with consideration to a number of important criteria.
An example of these selection criteria for a clinic’s
outside board member might be:
At the physician retreat, we agreed to examine the issue
of group governance for the Good Clinic. This survey is
intended to provide input to the committee to help guide
the process.
Please rate the following statements based on how
strongly you agree or disagree with each of these issues
in your association with the Good Clinic.
1. Has a general understanding of the region, its business climate, political environment, and some of
the key community drivers; has some perspective
on health care and what is happening in the broad
2. A strategic thinker
3. Willing and able to attend meetings
4. Able to treat information discreetly
5. Some experience as a member of a board
6. No conflicts of interest or its appearance (not someone looking to do business with the clinic)
7. General business acumen
8. Someone who can contribute but not dominate the
9. Someone who has a history of working well in a
group setting—a good fit
10. Willing to sign a confidentiality agreement
11. Willing to accept fair compensation
The Process of Governance Change
Many groups have boards that consist of all of the physicians or all of the physicians that have reached full shareholder or partnership status. Although this method may
address the perennial question of autonomy and control,
it does little to improve decision making or the speed at
which decisions are made. To improve the speed of decision making, many large boards elect an executive committee that has the ability to make certain decisions on
behalf of the organization without the vote of the full
board. For other decisions, typically those that are significant in magnitude, the executive committee develops
preliminary information about a matter and makes recommendations to the board for voting.
Changing governance and modifying the manner in
which the board operates is assessed through observations about the effectiveness of the board. Such assessments can be gained by using a survey instrument similar
to the following:
Strongly Strongly
Agree Disagree
1. The current governance practices 5
of the clinic needs to be changed.
2. I feel the executive committee
could handle many issues without
full board approval as long as I
was kept informed of the process
(e.g., last year’s malpractice issue).
3. I feel the full board should meet 5
less often.
4. I would be willing to allow a
smaller group of physicians to
make major clinical decisions so
long as they are held accountable for their actions.
5. I would be willing to allow our 5
clinic management greater
autonomy in decision making for
the clinic so long as they are held
accountable for their actions.
6. We attend too many meetings
on a regular basis.
7. There are too many physicians
involved in the clinic decisionmaking processes.
8. The three divisions of the Good 5
Clinic should be more coordinated in terms of their
decision making, not less.
9. I would be willing to have less
personal autonomy to expedite
decision making in the group.
10. I would be willing to devote
significant time to the governance of the clinic.
1. The Good Clinic should offer
comprehensive care to the region
even if that occasionally means
4 3
2 1
4 3
2 1
4 3
2 1
4 3
2 1
4 3
2 1
4 3
2 1
4 3
2 1
4 3
2 1
4 3
2 1
4 3
2 1
4 3
2 1
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Part II: Operations
investing in technologies or staffing that may not be profitable.
2. I would be willing to make less 5 4 3 2 1
money to preserve lifestyle
issues such as time off.
3. In a few sentences, please describe your view on
the mission of the Good Clinic.
1. Size matters. Larger groups often have more departments headed by professional managers that
require less supervision and management by administration. In small groups, functions such as
human resources (HR), marketing, and finance
may be combined under the title of administration. In the context of this chapter, administration
is synonymous with executive management.
2. How involved are the physicians in the management structure of the clinic? The physician administrator team has been recognized as an
important success factor for groups.
3. The skill and education of the administrative group.
It is important to develop a series of benchmarks that can
be tracked by the board over time to monitor the progress
and status of the group’s performance. This includes quality indicators, such as results of quality initiatives, comparisons with peer databases, and financial indicators
such as:
Gross revenue/per RVU
Collections/per RVU
Profit/net income/per RVU
RVU per MD
Operating cost/per RVU
Employee salary/per RVU
Relative value units (RVUs) make excellent measurement tools because they have become a standard part of
group-practice management and reimbursement systems.9
Benchmarks need to be understandable and communicate a clear message as to their meaning, be reproducible over time, and be timely (old news is no news,
and it is not helpful for quickly reacting to changing situations). Benchmarks also need to measure a key competency or key success indicator for the practice. A
complete discussion of benchmarking will be found in
another section of this text.
Part II: Operations
Having discussed the structural aspects of group practice, Part II explores the functional and operational components found in most physician practices.
Nonphysician leadership and implementation of board
policies is the principle role of medical group administration. This is accomplished by a coordination of the
group’s departmental functions to produce the desired
outcome. One of the most critical activities is the translation of policy to procedure (see Figure 2-18).
Policies must be stated in terms of actionable steps
and procedures that can be communicated to employees.
Policies should be documented in a way that allows for
consistent application of policy in a reproducible way.
The function of administration varies in groups depending on a number of issues:
Monitoring by the Board
Administration generally falls into three board domains of group-practice administration:
1. The strategic, which can be either mission oriented
or competitive in nature
2. The adaptive, reactive, or proactive
3. The operative, maintenance, or implementation
Strategic planning and marketing are major functions
found in the strategic domain. Michael E. Porter talks
about three general strategic aspects of strategy:
Cost leadership
The medical reimbursement system does not provide
a mechanism for strategies based on price. In our system,
pricing has very little to do with what is actually paid for
a service, and price elasticity is not as relevant a concept as in most industries. Differentiation and focus have
been the dominant strategies for medical groups. Group
differentiators are becoming an increasingly important
concern. Chief among these are quality and customer satisfaction. Focus is another widely used strategy. The singlespecialty group and the specialty hospital are clear
examples of focus strategies.
The American College of Medical Practice Executives
(ACMPE) has developed an extensive document, which
seeks to define all of the critical areas of knowledge and
skill necessary for an individual to be a successful administrator of a medical group practice.
The ACMPE Body of Knowledge defines five general
areas of competency for the group-practice administrator.11
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Chapter 2: Organization and Operations of Medical Group Practice
Has to Start Here
Define Mission
Produce Policies
Benchmarks, Statistics,
Produce Procedures
Figure 2-18 Policy and Procedure Development Cycle
Five General Competencies for
Medical Practice Management
1. Professionalism: Achieving and preserving professional standards
2. Leadership: Supporting the organization’s strategic direction
3. Communication skills: Interacting and presenting
information clearly and concisely
4. Organizational and analytical skills: Solving problems, making decisions, and developing systems
5. Technical and professional knowledge and skills:
Developing the knowledge base and skill set necessary to perform activities unique to the job, role,
or task within the eight performance domains or
areas of responsibility:
Financial management
Human resource management
Planning and marketing
Information management
Risk management
Governance and organizational dynamics
Business and clinical operations
Professional responsibility
Best Practices
A significant body of research exists on medical group
practices and the traits that distinguish better performing organizations. According to data published by Medical
Group Management Association,12 better performing
groups have the following characteristics:
Physician compensation usually rewards productivity.
There is excellent communication between physicians and administrative staff.
There is a productivity-oriented culture in the
An emphasis is placed on quality care, reputation,
and patient satisfaction.
There is a physician administrative leadership team
in place.
A good relationship exists with referral physicians.
Excellent control systems and budgets are used.
Cost structures are known and understood.
Central organization (delegation of decision making as opposed to consensus) is key.
The entire staff focuses on customer service.
New physicians are recruited to fit with the group
and its culture.
Management is delegated to administration.
Administration is seen as professional colleagues
and specialists in business.
A culture of respect is in place.
The Legal Environment and Risk
Another important function for medical group administration is in the area of risk management. In very large
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Part II: Operations
groups, this may be contained in a separate legal department, but typically this is a function of administration.
Groups need an active risk management program.
The mitigation of risk is the purpose of risk management and may be organized as a department within
the organization, as a part of the legal department, or it
may be part of administration. Risk management activities involve:
1. The purchase of insurance for physical assets and
liability (fiduciary liability directors and officers,
malpractice, and bonds); however, these activities
are certainly not limited to those that can be insured against
2. Antitrust, fraud and abuse, criminal acts of all kinds,
HIPPA violations, unfair trade practices, contract
disputes, private inurnment issues, and Stark I and
II, all issues that have the potential to cause considerable harm to the practice, even as much as
malpractice suits can
3. The development of an effective quality assurance
program as described later in this chapter
4. Contract administration, which includes a number of documents common to all medical groups
Contracts and other legal considerations These are another major concern for administration. Health care, including the medical group practice, is one of the most
highly regulated industries in the United States. It is essential that the well-managed medical group consider this
and be familiar with this enormous body of law and how
it applies to the practice. This information is also critical
in the proper development of policies and procedures to
ensure compliance and legal operation.
Although malpractice is the first subject to come to
mind in a discussion of legal matters that affect medical
group operations, it is by no means the only issue. These
issues can be generally divided into:
Patient care issues Standards of care, informed consent, medical records, advance directives, malpractice,
and reporting requirements
Business issues Reimbursement, Medicare and
Medicaid; Stark and anti-kickback rules, credit and collection; contracts with payers and vendors
Employment contracts A host of law devoted to human resource issues
Licensure issues Regards physicians, physicians’ assistants, nurses, nurse practitioners, clinical laboratory,
nuclear medicine, radiology, and cytology technicians are
a key management concern for the medical group.
Corporations and partnerships are also required to main-
tain business licenses, which requires filing with states
in which the organization has been incorporated, and in
which it operates.
Credentialing Thousands of applications and renewals
must be handled by this functional unit of the practice
on an annual basis. Managed-care companies, hospitals,
insurance companies, state regulators, and federal programs such as Medicare and Medicaid, require an application for provider status and maintenance of pertinent
records on a regular basis. Unfortunately, this activity
varies dramatically from state to state and from company
to company. A practice of 50 physicians could easily have
over 2000 pieces of credentialing that must be handled
each year.
A medical license is required for each state in which
the physician or other licensed professional practices.
Medicare provider number
Medicaid provider number
Provider number for managed-care organizations
and insurance companies such as Aetna, CIGNA,
United, Blue Cross and Blue Shield (several across
the country)
Contract negotiations The complexity of contracts and
the significant consequences of signing a “bad” contract
make this a significant duty for administration to either
carry out this function or manage the process if it is delegated to a law firm or in-house counsel.
Patient Flow
Effective group-practice operations begin with a wellorganized and managed patient flow system.
Front office activities include the scheduling of patients and preparation for their visit to the clinic as shown
in Figure 2-19. These systems are usually integrated with
the information technology systems of the organization
and may be divided into smaller department functions,
Appointment scheduling
Patient arrival and check in
Patient management during their visit
Patient exit
The physical layout of the practice is also critical for
efficient patient flow. The steps that patients need to follow in preparing for and receiving their services should
be logical, communicated carefully to the patient (verbally and through well-written information), prompted
by well-done and informative signage, and by the careful
observation of a staff that is well trained in customer ser-
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Chapter 2: Organization and Operations of Medical Group Practice
vice and the hospitality arts. Employees for a wellmanaged medical group should always be selected for
their ability to interact well with patients and visitors and
not just for technical skill. It is often possible to teach
technical information, but many times more difficult to
train for customer service attributes.
Because patient waiting is one of the most frequent
sources of dissatisfaction, waiting areas should be comfortable, with plenty of reading material or other activities such as patient education, either in written form or
as video material.
Billing, Credit and Collections, Insurance
Managing the revenue cycle is an essential function for
the successful medical group. This is a very dynamic
process that is constantly changing because of revisions
in billing requirements by payers and as information technology continues to improve. Most medical groups use
medical-practice software packages that contain all of the
subsystems necessary for the effective documentation of
service, entry of patient information, and service information. Almost all systems include:
Documentation to
Follow-up established
as needed
Patient Arrives
Key Documents
Charge Ticket – Routine Ticket
Registration Form
Update Material
Documentation of Service
Figure 2-19 Patient Flow
Verification and Internal Audit
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Part II: Operations
Scheduling and registration of patients and verification of services and payer information
Patient information
Billing functions, which include multiple-fee
schedules and billing requirements for each payer
Managed-care requirements and procedures
Reporting of billing and service information
Multiple data entry options such as scanning, key
entry, and downloading of wireless devices
Accounts receivable and collections information
and reporting
Electronic claims submission and remittance of
payments through electronic data interchanges
These systems then provide for the creation of claims
for reimbursement to Medicare, Medicaid, and all commercial insurance payers, as well as the creation of patient bills.
Although attempts have been made to standardize
claims processing, almost no standardization of billing
and payment processes exists among the more than 1000
health insurers in the United States.13 Among the areas
of variability are:
Patient eligibility verification procedures14
Payer documentation requirements for certain procedures
Bundling policies
Modifiers and formats for explanations of benefits
The failure of our health care system to standardize
the billing process has led to high error rates, denial of
payments, and difficulty for everyone involved—the patient, the practice, and the payers.
The billing and collection process is covered by a significant number of rules and a large body of law. In addition, the billing process is very complex and varies
greatly among payers. In an article published in the New
England Journal of Medicine, authors Steffie Woolhandler
et al. found that the cost of administration in the United
States was $1059 per person in 1999, compared to $307
in Canada.
Although some are critical of the study and felt it overestimated the cost of the administrative burden of the
American health system (some $300 billion annually),
no one doubts that the administration of our health care
system is fragmented and cumbersome.15
Because these systems vary by their specific functionality, each system requires a significant amount of
training by the medical group for all employees that will
use the system. Many groups maintain training facilities
for this purpose because the cost to the practice for having poorly trained employees can be substantial in terms
of revenue loss and potential penalties by payers, not to
mention the delay in receiving payment.
Figure 2-20 outlines the revenue cycle for most medical groups from the entry of patient service information
until the claim is paid and the cycle is completed.
Medical records The maintenance and safekeeping of
a patient’s medical record is the principal function of the
medical records unit. These records contain the proof of
what was done, who did it, how it was done, why it was
necessary to be done, where it was done; and in addition,
it contains a plan for future care. One could argue with
great success that this is the most valuable and important
document within the medical practice.
Most group-practice records contain:
Physician notes including a treatment plan and
treatments provided
Operative notes
Laboratory test results and orders
X-ray tests results and orders
All other ancillary services that may be applicable
to the patient
Communication from other providers in the form
of letters or other forms of communication, such as
copies of records
Hospital records, such as discharge summaries, operative notes, and copies of test results from the
Consultative reports
Treatment plan
Demographic information about the patient
Identification of the patient within the last provider
Details of the admitting or receiving clerk
Patient demographics
Insurance or health plan information
Relevant appointments
Medication list
Physician orders
Anticipated goals (care plan), including rehabilitation plans
Home health or hospice information
Nurse detail
Self-care status
Disabilities and impairments
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Chapter 2: Organization and Operations of Medical Group Practice
Service Delivery
of Services
Entered in Billing
Insurance or Other
Third-Party Claim
Requires careful coordination between front-end
Patient Billing
operations, coding, billing, and A/R management.
Figure 2-20 Revenue Cycle
Equipment requirements
Nutrition details
Therapist details
Social service detail
One of the great challenges of medical records management is one of completeness. Patient records come
from so many sources, as shown in Figure 2-21.
The new emphasis on patient privacy has also led to
new challenges. The Healthcare Insurance Portability and
Privacy Act of 1996 (HIPPA), is a very pervasive law that
affects many aspects of group practice. The law deals with:
Privacy of patient information
Security of patient information
Transaction and coding standards
Patient identifiers16
It is essential that all employees are properly trained
regarding HIPPA, and that all systems within the organization, including physical space, is vetted for HIPPA
Electronic medical records (EMRs) One of the most dynamic areas of the medical group practice has been, and
continues to be, the electronic patient record. After many
years of development, however, electronic records are beginning to fulfill their promise of creating a reduced
amount of paper records in the office. Although there
have been electronic records systems for a number of years
and many of them have been capable systems, adaptations have been very slow, principally because innovation can be adopted only so quickly (see Figure 2-22).
This fact can largely be attributed to the inherent difficulty of getting 100% adoption of the innovation, which
is necessary to prevent the need to maintain multiple
records systems.
Another problem is the multiple systems of medical
records material; often there is a plethora of technological platforms and media formats. It is frequently impossible to find compatible ways to integrate the records, and
these different medical records formats produce a regression to the lowest technological denominator. In many
cases, it is paper. Scanning technology and the develop-
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Part II: Operations
(e.g., MRI)
Other Physicians
Health Department
Figure 2-21 Sources of Medical Records Information
ment of e-interfaces with computer systems, making them
easier to use, have overcome these issues. In addition, developers of systems are creating the ability to provide
more linkages, either through using common computer
code or by using common interface engines. One of the
positive forces in the electronic records area is the precipitous drop in prices of storage media.
In spite of the inherent difficulties in the move to the
electronic medical record, this is a trend that will continue for many reasons. In a survey of providers conducted by the Medical Records Institute, the driving force
for implementation continues to show an upward trend,
as shown in Table 2-1.
The financial structure of medical groups is not substantially different, or at least should not be substantially dif■
Slow Adopters
Average Adopters
ferent, from other organizations. One significant exception to this operation is the fact that most medical groups
still maintain their financial records on a cash basis accounting system as contrasted to an accrual system. Cash
basis systems recognize expenses when they are paid and
income when it is received. Accrual systems recognize
expenses when incurred and income when it is earned.
Cash basis systems are analogous to the way our income
tax system works and is undoubtedly a remnant of proprietorship, which must operate in this way. Other reasons such a system has endured is at least in part the
propriety in nature of medical receivables, which at times
can be difficult to determine. In addition, the reversion
to an accrual system once a cash system has been in place
represents a formidable challenge as it requires the recognition of receivables as income. In addition, most medical groups are privately held, where a strict adherence to
generally accepted accounting principles (GAAP) is not
Financial systems typically maintained by a medical
group are:
Early Adopters
Accounts receivable
Billing systems
• Insurance
• Government third party
• Self-pay
Employee benefits
Accounts payable
Financial reporting
• Balance sheet
• Profit/loss statements (income statements)
• Budgets
• Variance analysis
• Service and receipt (and its various forms)
Financial control and audit functions
• Internal
• External
Maintenance of fee schedules and charge masters
Chart of accounts
Adoption Rate
Human Resources
The human resources department is responsible for the
orderly management of the most important resource in
the medical group practice, its people. As shown in Figure
2-23, this involves a large number of functions:
Willingness to adopt innovation
Figure 2-22 Adoptors
Evaluation of positions needed by the organization
Creation of position-control procedures
Table 2-1
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Chapter 2: Organization and Operations of Medical Group Practice
Improve the ability to share patient record information among health care
practitioners and professionals within the enterprise
Improve quality of care
Improve clinical processes or work flow efficiency
Improve clinical data capture
Reduce medical errors (improve patient safety)
Provide access to patient records at remote locations
Facilitate clinical decision support
Improve employee/physician satisfaction
Improve patient satisfaction
Improve efficiency via previsit health assessments and postvisit patient education
Support and integrate patient health care information from Web-based personal
health records
Retain health plan membership
Responses to these questions
Establishing and preparation of job descriptions
Salary administration, which includes the establishing of pay ranges
Recruiting, which includes seeking candidates, interviewing, and testing
Credential evaluation and verification
Selection of applicants
Hiring and the required statutory and organizational documentation
Evaluation of performance
Documentation of work to payroll
In addition, administration of employee benefits is a
vital function. Some of the benefits plans include:
1. Paid time off or PTO: This is sick leave and vacation or personal time off
2. Statutory benefits: FICA, Medicare, FUTA, and
state unemployment benefits
3. Pensions
4. Insurance benefits: Health, dental, life, and
5. Section 125 plans: These are special employee
reimbursement plans that allow pre-tax reimbursement of certain expenses, such as noninsured medical expenses, co-pays, deductibles,
and child care; they are so named because they
are enabled by Section 125 of the Internal Revenue
Another critical function of the human resources department is development and management of personnel
policies, which cover a vast number and variety of issues
beyond the scope of this book. However, a typical personnel manual, which contains an extensive list of issues
that must be addressed by the human resources department, might look something like this:
Welcome . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Introductory Statement . . . . . . . . . . . . . . . . .2
History of Clinic . . . . . . . . . . . . . . . . . . . . . .3
Mission Statement . . . . . . . . . . . . . . . . . . . . .4
Employee Acknowledgment . . . . . . . . . . . .5
Customer Relations . . . . . . . . . . . . . . . . . . . .6
Contributions and Solicitations . . . . . . . . . .9
Donations . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Equal Employment Opportunity . . . . . . . . .9
Business Ethics and Conduct . . . . . . . . . . . .9
Gifts/Gratuities . . . . . . . . . . . . . . . . . . . . . .10
Conflicts of Interest . . . . . . . . . . . . . . . . . .10
Security and Privacy . . . . . . . . . . . . . . . . . .11
Hiring Relatives . . . . . . . . . . . . . . . . . . . . . .11
Immigration Law Compliance . . . . . . . . . .11
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Part II: Operations
Establish Pay Range
to P/R
Establish Job
Position Control
(Authorization for Hire)
If Needed
Pay Cycle
Performance of
Selected Applicants
Personal Records
Figure 2-23 Human Resources
Outside Work . . . . . . . . . . . . . . . . . . . . . . .12
Job Posting . . . . . . . . . . . . . . . . . . . . . . . . . .12
Identification Badges . . . . . . . . . . . . . . . . .12
Employment Status & Records
Employment Categories . . . . . . . . . . . . . . .14
Access to Personnel Files . . . . . . . . . . . . . .14
Employment Reference Checks . . . . . . . . .14
Personnel Data Changes . . . . . . . . . . . . . . .15
Introductory Period . . . . . . . . . . . . . . . . . .15
Employment Applications . . . . . . . . . . . . .15
Performance Evaluations . . . . . . . . . . . . . .15
Employee Benefit Programs
Paid Time Off (PTO) . . . . . . . . . . . . . . . . . .19
Sell Back PTO . . . . . . . . . . . . . . . . . . . . . . .19
Service Years . . . . . . . . . . . . . . . . . . . . . . . .19
Holidays . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Bereavement . . . . . . . . . . . . . . . . . . . . . . . .20
Uniform Allowance . . . . . . . . . . . . . . . . . . .20
Jury Duty . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Workers‚ Compensation . . . . . . . . . . . . . . .21
Health Insurance . . . . . . . . . . . . . . . . . . . . .21
Dental . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Change of Status . . . . . . . . . . . . . . . . . . . . .21
Short-Term Disability . . . . . . . . . . . . . . . . .22
Long-Term Disability . . . . . . . . . . . . . . . . .22
Life Insurance . . . . . . . . . . . . . . . . . . . . . . .22
Retirement . . . . . . . . . . . . . . . . . . . . . . . . . .22
401(k) and Profit Sharing Plans . . . . . . . . .23
Continuing Education . . . . . . . . . . . . . . . .23
Family Medical Leave Act (FMLA) . . . . . .23
Educational or Personal Leave . . . . . . . . . .24
Military Leave . . . . . . . . . . . . . . . . . . . . . . .25
Parental Involvement Leave . . . . . . . . . . .25
Timekeeping . . . . . . . . . . . . . . . . . . . . . . . .27
Paydays . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
Administrative Pay Corrections . . . . . . . . .27
Pay Deductions and Garnishments . . . . . .27
Overtime . . . . . . . . . . . . . . . . . . . . . . . . . . .27
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Chapter 2: Organization and Operations of Medical Group Practice
Work Conditions & Hours
Safety/Reporting Injuries . . . . . . . . . . . . . .29
Work Schedules . . . . . . . . . . . . . . . . . . . . . .29
Use of Phone and Mail Systems . . . . . . . . .29
Business Use of Personal Auto . . . . . . . . . .29
Parking . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Media Inquiries . . . . . . . . . . . . . . . . . . . . . .30
Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Rest and Meal Periods . . . . . . . . . . . . . . . . .30
Use of Equipment and Vehicles . . . . . . . . .30
Employer–Employee Communication . . .30
Emergency . . . . . . . . . . . . . . . . . . . . . . . . . .30
Business Travel . . . . . . . . . . . . . . . . . . . . . .31
Computer and E-mail Usage . . . . . . . . . . .31
Workplace Inspection/Monitoring . . . . . .31
Workplace Violence . . . . . . . . . . . . . . . . . .32
Employee Conduct and Work Rules . . . . .32
Drug and Alcohol Use . . . . . . . . . . . . . . . . .33
Sexual and Other Unlawful Harassment . .33
Attendance and Punctuality . . . . . . . . . . . .34
Unexcused Absences . . . . . . . . . . . . . . . . . .34
Personal Appearance . . . . . . . . . . . . . . . . . .34
Resignation . . . . . . . . . . . . . . . . . . . . . . . . .34
Progressive Discipline . . . . . . . . . . . . . . . . .35
Problem Resolution . . . . . . . . . . . . . . . . . .35
Corporate Compliance . . . . . . . . . . . .36–41
Patient Care
Management of Prescription Medications 43
Inventory of Medications . . . . . . . . . . . . . .44
Labeling of Medication . . . . . . . . . . . . . . . .44
Administration of Medication and
Employee Training . . . . . . . . . . . . . . . . . . .44
Safety and OSHA
CPR Instruction . . . . . . . . . . . . . . . . . . . . .45
Fire Safety . . . . . . . . . . . . . . . . . . . . . . . . . .45
Fire Extinguishers . . . . . . . . . . . . . . . . . . . .47
Bloodborne Infection Issues . . . . . . . . .48–50
Infection Control/Employee
Health Test . . . . . . . . . . . . . . . . . . . . . . .52–53
Information Technology
Information technology (IT) is widely used for many of
the functions found in medical group practices. Most
larger medical group practices have now developed integrated networks to provide ready access to information
and the ability to instantly update records and information related to various activities within the practice.
The IT department touches virtually every department in the clinic and provides the opportunity to share
data and information and to easily access information for
management and clinical use.
Often these networks include many subsystems that
carry out a specific function. This includes accounting,
financial management, personnel and file maintenance,
accounts receivable, accounts payable, billing, medical
records, clinical reporting, quality assurance, and training. Figure 2-24 shows a simplified schematic of a grouppractice information system.
Increasingly, systems between organizations are being linked through network interfaces. In some cases,
these networks become quite extensive and encompass
many aspects of the medical community. Such systems
are known as community health information networks
(CHINs). A typical system includes:
Patient portals
Web sites
Clinical portals
HIPAA compliance
Easily exchanged information to authorized parties
Links between different providers to share the patient’s longitudinal care record
As the Internet has become faster and more available,
especially high-speed access, the interaction of the medical group practice with all of its stakeholders has become
increasingly possible.
The Internet has begun to significantly change how
the group practice operates. Both clinical and business
operations are involved in this revolution. The World
Wide Web is cost-effective, makes possible ready access
to information for review, and is a vehicle for updating
Web portals have become the key to an effective
Internet strategy. The key element is the practice Web
site. Frequently, a practice’s Web site becomes the portal
of entry to the practice, and serves not only as a vehicle
for the prospective patient to obtain information about
the practice, but increasingly it is becoming a method of
two-way communication.
Web sites should:
Be easy to navigate
Be updated frequently
Contain accurate and relevant information, including such topics as services, directions, physician information, specialized care and services,
policies, community activities, and research being
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External Interface to
Hospitals, Insurance
Carrier and Community
Health Information
Clinical Information
Systems (EMR)
IT Network
Figure 2-24 Information Management Systems
In addition to the availability of records, the notion
that organizations can be connected to better service the
patient is a concept that has been developing over the
years. These CHINs will likely gain additional vigor as
more emphasis is placed on patient-centered care.
The specialist referral process can create significant
frustration for both referring physicians and patients. In
interviews with physicians, here are some of the most
common statements and findings:
Referral coordinators are often on the phone 20 to
30 minutes to get an appointment.
Managed-care influences access and administrative
Appointments are difficult to get in timely fashion.
Despite the proliferation of information technology,
the referral process continues to lack sophistication,
clear customer interfaces, and information flow.
Specialist feedback, when provided, is written and
sent through the mail.
Patient records are often misplaced.
Patient Communication and Access
Some 25% of patients use the Internet for health information.18 The Internet is becoming the great “democratizer” of health care information. Patients, however, want
that information to come from their physicians. In a re-
cent survey of 400 patients with an average age of 59.1
years, 44.1% indicated they had access to e-mail, and of
those, 58.6% said they would like to communicate with
their physician in this manner. Certainly this data supports the idea that health care is becoming a more collaborative venture between the physician and the patient.
Facilities Management
For smaller practices with a single location, facilities
management may be a function within administration.
The function of facilities management is to acquire and
maintain the physical facilities of the organization. This
1. Leasing or purchase of the space
2. Construction management of building or renovation projects
3. Acquisition of fixtures, such as office furniture and
4. Maintaining the property and equipment to ensure
that the clinic is able to function at all times
These activities may also be done through a series of
outsourcing and maintenance arrangements, such as maintenance contracts, but the coordination and supervision
of this function cannot be overlooked. Facilities that are
in poor condition or not functioning are not only ineffective, but can be a considerable liability to the practice.
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Chapter 2: Organization and Operations of Medical Group Practice
Purchasing and Supply Management
The purchase of supplies and other necessary items for
the practice requires special attention to the following
Discounts for bulk orders
Price and quality
Relationship with current vendors
Market exclusivity
Delivery schedules
Safety for the purchasing agent
The current state of the art in medical group management uses computerized systems to purchase supplies
and equipment for the organization and to manage the
supply chain for the practice. The characteristics of these
systems are:
1. A common catalogue (used to control items that
are ordered. Many groups with automated systems
have a difficult time controlling the number of
sources and the scope of the items purchased. This
is especially true in groups with a number of offices in different geographic areas.)
2. A rule-based per established ordering program
which requires authorization of purchases from
the approved catalogue
3. A system to control and document receipt of goods
and the accuracy of the ordered items, which provides an effective method to verify delivery of products and establish if the order is correct in terms
of quantity and price
Important software features included in many of the
newer software products include:
Online requisitioning (electronic catalogs
Transaction based audit trails
Online approvals and purchasing
Automated faxing
Internal messaging
Request for quotation
Electronic ordering capabilities
Standing orders
Freeform orders
Rule builder
Transaction-based reporting
Predictive reporting
Multiuser defined pick lists
In/out status tracking
Purchase order attachments
Real-time status updates
Purchase order consolidation
In addition to control, automated procurement provides the practice with better opportunities for inventory
control and taking advantage of economies of scale when
Clinical Activities and Departments
Medical group practice provides a large variety of patient
services in addition to the physician visit. Physician services are often loosely divided into office-based services
and hospital-based services, but the line is rapidly beginning to blur. Group clinic operations often include:
Clinical laboratory services
Radiology services
Nuclear medicine
Computerized axial tomography
Nuclear magnetic resonance imaging
Outpatient surgery, sometimes within the context
of the ambulatory surgery center
Dietary counseling services
Other clinical services such as preventive care is
often organized into a unique department of the group
The organization of each medical service department
requires careful attention to a host of legal, licensing, and
regulatory requirements. It also may be necessary in many
states to obtain a Certificate of Need (CON) or other regulatory approval for certain services depending on cost
of the service and the compliance of the service with community standards of care and state health plans.
Clinical service must be organized and managed by
properly licensed and knowledgeable professionals. Such
services also require adherence to standards that are established by various professional society and credentialing bodies. Often approval and certification of operations
are required by state departments of health and by major
payers before payments are be made on behalf of covered
Quality Assessment an Important Focus
A major barrier to change and improvement activities in
medical groups is the problem of variation. Variation
equals cost. This variation, as noted earlier, is one inherent reason for the slow growth of group medical practice.
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In addition, the variability in the delivery of care has been
associated with the fragmentation of quality and the inability to leverage economies of scale to any great degree
in physician practice.
This has become one of the most important areas of
concern for the medical group. The Institute of Medicine
(IOM) released a report “To Err is Human,”19 which has
been a hotly debated topic, but nonetheless has strong
support from the social science and economics disciplines.
These are issues that everyone in group management
needs to understand, and these issues should be the basis for quality assurance and risk management activities.
Regardless of our feelings on the matter, there are
many critics of the health care system and all of its components. These voices are increasingly being heard and
simply cannot and should not be ignored. The medical
group is a quasi-public organization, although most groups
are privately owned. To illustrate this point, consider that:
Vendors typically know more about the strengths
and weaknesses of their products than do purchasers.
Employees typically know more about their health
problems than do human resource or health plan
Subordinates typically know more about the effort
that they have put into assignments than do their
Providers typically know more about the treatment
options than do their patients.
Another widely discussed concern by critics of the
medical industry is that physicians and other health care
providers have the unique ability to create supplierinduced demand (SID). SID is characterized by a change
in demand for medical care services associated with the
discretionary influence of providers, especially physicians, over their patients. This is demand that provides
for the self-interests of providers rather than solely for
the patients’ interests.
In addition, critics of the health care system and physicians in general have often pointed to small area variations (SAV) as evidence of a physician’s ability to increase
the use of services. SAV was documented by John Wennberg20, 21 and defined as large variations in the per capita
rates of utilization across small, homogenous areas for
many medical and surgical procedures.
The Social Concerns for Health Care Delivery
The detractors of our health care system do not stop with
Wennberg and, in fact, go much further.
Ivan Illich in his book, Medical Nemesis, delivers a
stinging indictment of the health care system. He says,
The major threat to health in the world is modern medicine. The medical community has actually become a great threat to people. Doctors and
others (pharmaceutical industry) serve their own
interests first. People become consumers and
1. Sixty percent of all health care in the United States
is paid for by government entities.
2. Public scrutiny of health care and its regulations
is increasing.
Medical groups will continue to be a source of public interest and debate.
It is important to have some background on the nature of quality improvement and its critical need in the
medical group. Unlike most other industries, quality is
difficult to define and measure for the typical consumer/patient. First, consider the great asymmetric nature of health care, which is characterized by situations
in which the parties on the opposite side of a transaction
have differing amounts of relevant information. Examples
of asymmetric knowledge are:
He identifies three levels of damage:
1. Clinical treatment actually often harms people.
Patient safety has not been a high priority.
2. More and more problems are seen as amenable to
medical intervention. Pharmaceutical companies
develop expensive treatments for nondiseases.
3. Over 100,000 people a year die from adverse drug
People Are Consumers and Objects
It is a new idea that everything, including labor and culture, can be assigned a market value. Such a practice destroys traditional ways of dealing with death, pain, and
Thomas McKeown, a leading expert on social medicine and another prominent critic of our health care system, in his book, The Role of Medicine, asserts the role of
medicine and doctors in improving human health has been
greatly overstated. Disease is basically addressed through
prevention and only secondarily through treatment.
Longevity of life has increased through factors
such as:
Reduction in infectious diseases because of genetic
Better nutrition
Elimination of infanticide
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Chapter 2: Organization and Operations of Medical Group Practice
McKeown goes on to say medical research is of limited value and researchers too often focus on “basic research” at the expense of socially useful research.23
It is essential that we have programs to demonstrate
quality care that is appropriate, cost-effective, and in the
best interest of patients. We need to understand our outcomes and our process so we can better explain away the
“blackbox” nature of the profession to our detractors.
Quality Improvement and
the Effective Medical Group
The issue of quality in the service provided by group
practices is paramount to group-practice operations and
the future of health care. In addition to the critics of our
services, paying for performance is becoming a reality. It
starts with understanding what the medical group is really about. The first section of this chapter discusses the
many structures and lists attributes of group practice.
Organizing for delivery of quality has not been a central
theme in group practices because many structural and
operational considerations have been focused on issues
other than the quality of care. The lack of standardization, the absence of any formal adherence to best practices, and lack of formalized quality improvement for
programs all contribute to a lack of progress in deliverying quality service.
This is not to say that financial issues are not important. Medical group structures are not designed, or in
some cases are antithetically designed, to invest in quality initiatives. The extreme short-term focus of financial
performance is a chief culprit. Groups do not invest either financially or in the training needed to carry out
large-scale improvement initiatives. Investment dollars
can only come from the shareholders’ pockets, a prospect
that has long curtailed the development of modern medical groups.
In Dr. Deming’s book, Out of the Crisis, he asks a question that should serve as the cornerstone of any group’s
quality initiative:
What are you doing about the quality that you
hope to provide to your customers four years from
The issue of quality in the American health care system is an increasingly important one as we begin to better understand the issue of quality. For most of history,
quality has been virtually undefined. As Voltaire would
have said, it is indeed “in the eye of the beholder.” However,
that is changing dramatically as the ability to measure
quality evolves and expectations of the quality of health
services become higher.
Variation, or put another way, lack of standardization, is a central theme throughout group practices. We
know our health care system produces superior outcomes
usually, so why the variation? There are many potential
causes of variation.
So what do we do about it? Quality must be a core
value of medical group practice and that value must be
expressed by having a systematic way of monitoring and
improving quality in the medical group practice.
Identifying Issues That Require Examination
and Correction
There are many opportunities to evaluate the practice.
Some of the most fruitful areas to find projects for quality improvement activities are:
Patient satisfaction surveys
Malpractice claims review
Benchmarking clinical and nonclinical data
Standards established by specialty societies
Review and understanding of national data such
as all of the departments of the National Institutes
of Health (see and the
Agency for Health Research and Quality (see
Initiatives on quality require a systematic approach
to reduce the influence of bias and emotions on the process.
Many techniques have been used, including:
Total Quality Management or TQM25
Continuous Quality Improvement or CQI26
Six Sigma27,28,29
All of these processes use statistical measure to evaluate an identified process to determine the source of error and variation in outcome. There are many resources
on the actual technique, and the reader is referred to these
sources for more complete information.
However, all of these techniques have the same fundamental premise. They all involve the following steps:
1. Plan and determine the process to be examined
and a clear delineation of the process.
2. Measure the process activities.
3. Analyze using various statistical techniques. This
can involve one or more of the tools shown in Table
All of these techniques seek to identify the variation
in outcomes and then assign the nature of the cause of
variation or error. These are often referred to as special
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Part II: Operations
causes, such as human error, or common cause, which
are the results of the process itself. An example of this
might be billing error due to improper coding. Run charts
are very commonly used to evaluate data for common and
special causes, as shown in Figure 2-25.
Variation is depicted as upper- and lower-control limits once the data is plotted. The run chart then shows the
natural variation in the system, or the areas between the
upper- and lower-control limit. Special causes can then
be said to be those that fall outside these limits.
These quality assurance (QA) processes depend heavily on virtually everyone involved in the activity being
trained to use the measurement tools needed to evaluate
the process. The time and expense involved in doing this
is one of the major difficulties in having an effective
process-improvement program.
One of the more popular systems being used in process
improvement today is Six Sigma. It is interesting considering the level of performance that Six Sigma implies and
what users of the system are able to achieve.30 Six Sigma
takes the absolute number of unacceptable outcomes as
a percentage of all outcomes to determine the sigma level
as shown in Table 2-3.
American industry is seeking the Six Sigma level of
performance as a quality standard. It is realistic to achieve
this in group-practice activities. Can many medical groups
produce an error rate less than 3.4 per million appointments, transaction postings, or filed claims? How about
diagnostic or treatment errors? The usefulness of Six
Sigma in the medical group practice remains to be seen;
even if sigma level six is not achievable, improvement is
certainly possible.
Another important issue is the concept of the Type I
and Type II error. Type I errors in process improvement
occur when the evaluator concludes incorrectly that the
observed outcome is caused by the data point being considered. Figures 2-26, 2-27, and 2-28 show examples of
a potential Type I error.31
Table 2-2
It might be logical to conclude that group size would
influence total medical revenue per FTE physician; but
when regression analysis is carried out, R-squared is only
.0001, meaning that this has almost no effect on the outcome. Recall that R-squared is a measure of the percentage of cause that can be accounted for by the variable
under analysis while holding all other variables consistent. Figure 2-27 shows a similar analysis for cardiology
groups who accept Medicare. Logic might say that groups
with high percentages also have lower total incomes; but
this is not true according to these data.
And a final example of Type I errors, as seen in Figure
2-28, shows the effect of commercial insurance on total
income. The conclusion must mean that other factors are
more responsible for effects on total income than those
When action is taken to correct an erroneous cause
of an effect, tampering occurs and then systems may actually become more variable.
Type II errors result from situations where the cause
is not recognized as being produced by the variable being analyzed. This is most likely caused by a failure in the
process, improper data collection, or improper analysis.
In some cases the system may be so complex that it defies the use of these techniques. The results would be affected by the tendency to undercontrol the process. This
is the inherent nature of health care, and Type II errors
are probable.
It is impossible to monitor all activities of the practice continuously in real time. Consider, for example, that
in a large practice with 100 physicians, depending on the
specialty, there can be as many a 1000 visits a day, with
other services adding thousands of additional transactions to the system, all of which have a “customized” feature. Control charts, the patient satisfaction survey, and
the other techniques available to the practice are essential to help identify areas of the clinic that need to be examined in a systematic way.
Methods for measuring/monitoring quality
Frequency plot
Process maps
Pareto chart
Time series plot or run chart
Scatter plot
Shows the range and depth of variation in a group of continuous data
Displays discrete “count”data (number of defects)
Charts a series of tasks (rectangles) and decisions/reviews (diamonds), connected by arrows to show
the flow of work
Stratifies data into groups from largest to smallest
Chart show how things change from moment to moment, day to day, etc. (see Figure 2-25 as an example)
Shows the correlation between two factors that vary by count or on a continuum
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Chapter 2: Organization and Operations of Medical Group Practice
ing ways of trying to most appropriately manage that risk.32
The key players in the research department are:
Special Cause
Upper-Control Limit (UCL)
Desired Outcome
Common Cause
Lower-Control Limit (LCL)
The greater the distance between UCL and LCL,
the greater the variation due to systemic causes.
Figure 2-25 Chart control
Many medical groups are engaged in significant research
as part of the clinical activity of the group. This is almost
always clinical research as opposed to basic research,
which is usually divided into two general categories:
1. Premarket research
2. Postmarket research
This research is regulated by the FDA. As the name
implies, premarket research is conducted prior to the approval by the FDA to market the device or medication,
and postmarket research is conducted to “monitor the ongoing safety of marketed products.” This is accomplished
by reassessing drug and device risks based on new data
learned after the product is marketed, and recommend-
Table 2-3
1. The Principle Investigator (PI): Usually this is a
physician, and the PI is responsible for conducting the clinical research
2. The Director: Responsible for the administration
of the project and often involved in the acquisition
of projects
3. Research Nurses: Conduct research, collect data,
and manage the research information as well as reporting
4. Support Staff: Assists the nurses and direct in their
5. The Institutional Review Board (IRB): An independent body responsible for reviewing and approving proposed research involving human
subjects; the role of the IRB is principally to help
ensure that research is as safe as possible and that
the potential benefits of the research outweigh any
possible harm that could be caused to the experimental subjects.
6. The Protocol: The written procedures and processes
required by the project. It indicates which patients
are eligible to participate in the research, what the
endpoints of the research are to be, what measurements and data are needed, and what must be
reported. Follow-up care of the subjects is also typically specified.
Figure 2-29 illustrates the process of medical research
in the practice environment. As more new drugs and devices are discovered, research opportunities will continue
Sigma level determination
The absolute number of unacceptable
outcomes per million observations
The percentage of unacceptable
The Six Sigma level
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Part II: Operations
Single-Specialty Cardiology Groups
Total medical revenue after operating cost
Total Physician FTE
Figure 2-26 Revenue by Number of FTE Physicians
Single-Specialty Cardiology Groups
Total medical revenue after operating cost
per FTE physician
Figure 2-27 Revenue by Percent of Charges from Medicare
Medicare Fee for Service
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Chapter 2: Organization and Operations of Medical Group Practice
Single-Specialty Cardiology Groups
Total medical revenue after operating cost
per FTE physician
20% 30% 40% 50% 60% 70%
Commercial FFS (all sources)
Figure 2-28 Revenue by Percent of Charges from Commercial Insurance
to increase and become an increasingly important part of
the medical group. Research also offers the advantage of
intellectual challenge, and interest can be a source of great
professional satisfaction.
1. Havlicek, P.L. 1999. Medical Group Practices in the U.S.—A Survey
of Practice Characteristics. American Medical Association, Chicago.
2. Thompson, J.D. 1967. Organizations & Action, New York: McGrawHill.
3. Robbins, S.P. 1990. Organizational Theory Structure Design &
Applications, 3rd ed. Upper Saddle River, NJ: Prentice Hall. 191,
4. Showalter, J.S. 1999. Southwick’s The Law of Health Care Administration, 3rd ed. Chicago: The Health Administration Press.
81–89, 119, 251.
5. Showalter. 251.
6. Nashville Business Journal,
7. Redling, R. 1 March 2000. New Anti-Kickback Safe Harbor Rules
or Mixed Bag for Medical Practices. MGM Update; 39, 5.
8. Federal Registry, Washington, DC.: National Archives and Records
Administration. 1999.
9. Glass, K. 2003. RVUs Applications for Medical Practice Success.
Dubuque, IA: MGMA, Kendall/Hunt Publishing Co.
10. Porter, M.E. 1980. Competitive Strategy: Techniques for Analyzing
Industries & Competitors. New York: The Free Press.
11. Body of Knowledge, 2001. Denver, CO: American College of Medical
Practice Executives.
12. Performance and Practices of Successful Medical Groups, 2003. Denver,
13. The Center for Medicare and Medicaid Services (CMS) has created
the standardized 1500 claim form, and The HealthCare Portability
and Accountability Act (HIPAA) has mandated some standardization of coding and submission of claims.
14., United States Government Department of Health and Human Services.
15. Woolhandler, S., Campbell, T., and Himmelstein, D.U. 2003. Costs
of Health Care Administration in the United States and Canada.
New England Journal of Medicine; 349:768–775.
16., United States
Government Department of Health and Human Services.
17. Waegemann, P. EHR vs CCR: What Is the Difference Between the
Electronic Health Record and the Continuity of Care Record? Medical
Records Institute.
18. Patient Satisfaction Survey of 4000 Patients at The Sanger Clinic,
P.A., 2003.
19. Kohn, L.T., J.M. Corrigan, and M.S. Donaldson. 2000. To Err Is
Human: Building a Safer Health System, Washington, DC: National
Academies of Science, The Institute of Medicine.
20. Wennberg, J. 1973. Small Area Variations in Health Care Delivery.
Science; 182: 1102–1108.
21. Wennberg, J. 1984. Dealing with Medical Practice Variation: A
Proposal for Action. Health Aff; Summer 1984, 3:6–32.
22. Illich, I. 1976. Medical Nemesis: The Exploration of Health. New
York: Random House.
23. McKeown, T. 1980. The Role of Medicine: Dream, Mirage or Nemesis.
Princeton, NJ: Princeton University Press.
24. Deming, W.E. 1990. Out of the Crisis. Cambridge, MA: Massachusetts
Institute of Technology, Center for Advanced Engineering Studies;
25. Turzillo, S. 1992. Total Quality Management in the Medical Practice.
The Road Seldom Traveled. Denver: ACMPE.
26. Juran, J.M. June 2001. Innovative Designs for Six Sigma.
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Device or
Project Ends
Agreement to
Contract Terms
Patient Identified
& Enrolled
Data Gathered
Figure 2-29 Research Project
27. Pande, P., R. Neuman, and R. Cavanagh. 2000. The Six Sigma Way—
How GE, Motorola and Other Top Companies Are Honing Their
Performance. New York: McGraw-Hill. pp. 23–24.
28. Chowdhury, W. 2000. The Power of Six Sigma. Chicago: Dearborn
Trade. p. 29.
29. “Six Sigma Systems,” June 2001. http://www.sixsigmasystems.
30. Carey, R.G., and R.C. Lloyd. 1995. Measuring Quality Improvement
in Health Care: A Guide to Statistical Process Control Applications.
New York: Quality Resources, a Division of the Kraus Organization
31. Acknowledged that charts in Figures 2-27, 2-28, and 2-29 were
prepared with assistance from David N. Gans, MSHA, CMPE,
MGMA Practice Management Resources Director, Denver, CO.
32. The Code of Federal Regulations (CFR), Federal Food Drug &
Cosmetic Act, Section 21 of CFR Part 314.
General References
Shewhart, W.A. 1986. Statistical Methods from the Viewpoint of Quality
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Wagner, S.F. 1991. Introduction to Statistics. New York: Harper Perennial.
Burney, R. 2001. The JCAHO Approach to Medical Errors. American
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Galbraith, J. 1995. Designing Organizations. San Francisco: Jossey-Bass.
“PHYCOR Sells 5 Clinics for $38 Million,” American City Business Journals
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Gans, D. 2003. Following a Road Map to Success. MGMA Connections;
July 2003: 26–27.

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