The Physician Advisor as a “Quarterback” in Managing Silos
There are silos in all aspects of life but most of the time we associate them with farming as the classic pictures are of grain silos. The term is often used in the business world, but “silo” is not really an exclusively business or project management term. Yet it is often used. For example, “when you say that the teams on a project work in silos, … it means that each and every individual team works independently of the other team, and the teams don’t know anything about each other’s work.” The use of the term even extends into the healthcare industry in many aspects such as their departments and even physicians. Department silos will be discussed further on, but I suspect that one never thought of physician practice as silos. Yet if you look again at the quote above, it may apply. There are many specialties in the practice of medicine such as cardiology, GI, GU, infectious disease, and many more. Why do hospitalists, internists, and other general practice physicians get consults, sometimes numerous during a single admission? Because they need the expertise of that specialty as they really don’t know in detail about each other’s area of practice or specialty. As a matter of fact, it has pretty much become the standard of care to get these consults, but does it contribute to the efficiency of care delivery? Most of the time, it may not.
Where does silo thinking originate?
The reality is that silos are everywhere, and they are not necessarily totally bad, but where does that silo mentality come from? Surprisingly, the silo concept gets implanted in our minds very early on in life which may be a surprise to most of us. It was to me. Remembering back to our childhood days, grammar school tended to be one teacher, multiple subjects, all in the same classroom. The silo process starts in the upper grades with each subject having its own teacher, with different styles, different rooms, homework assignments, and allotted times. In addition, most of the time each student had their own desk, their own locker, books, and equipment. This was the beginning of compartmentalization or, more simply stated, silos. Each subject was independent of all the others. This concept is subliminally implanted in our minds, so why would we not carry it through to our work environment including healthcare.
What exactly is subliminal? It has been defined as “existing or operating below the threshold of consciousness; being or employing stimuli insufficiently intense to produce a discrete sensation but often being or designed to be intense enough to influence the mental processes or the behavior of the individual.”
Utilization Management 360
There tend to be numerous silos in healthcare but let’s focus on the Clinical Revenue Cycle (CRC) area from a holistic point of view and the concept of Utilization Management 360, UM360. UM360 is a revolutionary concept that takes a holistic approach to the components of utilization review (UR), case management (CM), clinical documentation integrity (CDI), the Physician Advisor (PA), and coding as they all funnel into CRC. The holistic approach basically states that no one component is more important than the whole. There is a common link between all of these components and that is they are all looking at the same documentation, the medical record, but through their own lens. Hence they tend to function as a collection of sealed off departments with few perceived links between them where critical information may be trapped, inaccessible, or sequestered. There may actually be a sixth component to UM360 – revenue integrity, but is it a silo or a solution? To learn more about this component please refer to the following article:
The PA may not actually be a silo, but a “quarterback”, as they tend to work with the other components, UR, CM, CDI, but not that often with coding. With this unintentional silo concept each of these components generally work independently, and each really doesn’t know much about the other’s work or role. Working in silos can obstruct communication, hinder productivity, lead to resentment and animosity, and generally just makes work a lot more painful than it needs to be.
Types of Business Silos
According to Corey Moseley there are three types of silos he discusses:
1. Organizational – this is division within the department according to different types of people and skill sets often making them operationally autonomous entities focusing on specific goals leading to little interaction and information sharing.
2. Information – this can be secondary to #1 where information remains trapped within the department
3. Silos of the mind – these are ingrained thought patterns that influence everyday decision-making within teams. They’re the result of departmental biases and information hoarding
These are all found in clinical revenue cycle.
What is a Physician Advisor?
There really are no exact definitions of a PA. They can be onsite or there are remote services and are typically associated with second level medical necessity reviews in the UR arena. As this specialty has progressed and grown, the functions have increased to many different areas including, but not exclusive of, appeal of denials with peer to peers, length of stay management, participation in the UR committee, physician education including physician documentation improvement, collaboration with UR, CDI, case management, and maybe even coding. Many times, PA’s are considered the liaison between physicians and leadership and in essence, they must primarily integrate with the utilization staff, physicians, and executive level. They become regulatory and subject matter experts. There are probably many other roles that have not been included here but they will appropriately vary from facility to facility.
Since physician advisors are a key component of clinical revenue cycle and, using the holistic approach where no one part is more important than the whole, the effect to be achieved in managing those silos is collaboration and knowledge sharing. The PA is perfectly positioned to play a major role in helping this to occur as “boots on the ground” along with executive levels. In order to accomplish it is important to understand how these silos originate in the business world. There are overall common etiologies and there will be some specific to the healthcare organization.
How do silos originate in business?
It’s already been stated that silos are subliminally implanted in our behavior from childhood. It becomes part of adult behavior as it is already quite prevalent in nature. Take for example the male lion that has his own “pride”, group of females, and a male comes along challenging that position. It can lead to a battle to the death. Luckily, that shouldn’t happen in the human environment. Silos are not necessarily bad, intentional, nor the work of any one person but they must be managed appropriately. You may have seen some examples of that behavior when it gets carried to an extreme on an individual basis in the form of territorialism. It’s like “marking my territory”:
• “That’s my chair”
• Hiding stuff so no one else can use it
• “That’s my staff, they only work for me”
That type of individual thinking and behavior taken to the departmental level can be so destructive especially by making decisions on what’s best for them, not the overall goal or vision, not the overall team. In the business and healthcare world there is a tendency to cluster expertise into specific departments by functions and employees tend to mimic what they see in management. One can recognize that a silo has or is developing when information or other business resources that would be beneficial to the organization are being kept by an individual or specific group.
What role can the PA play?
Once again, the onsite PA interacts with many of the components of UM360 on a daily basis. Can the PA play a role in managing these silos? Here is a list of several suggested areas that can be addressed by PA’s as they may have detailed knowledge of each component’s processes:
Learn what are common goals and visions and educate all involved
The PA should have the advantage of knowing and understanding what the common goals and visions are for their institution. Increasing revenue is certainly number one but it needs to be sustainable revenue. The PA should meet with management to learn and validate what these goals and visions are. Once that is established, and since the PA would have working knowledge of each component, there needs to be inter-compartmental education at a high level. Team empowerment will play a significant role as they are the ones in the trenches, not management. Management needs to reduce bottlenecks and constraints to make the teams successful. The PA can be the liaison between the teams and management.
With team empowerment the IKEA effect can be utilized. “The IKEA effect is a cognitive bias in which consumers place a disproportionately high value on products they partially created. The name refers to Swedish manufacturer and furniture retailer IKEA, which sells many items of furniture that require assembly.” As you may know, many IKEA products require some degree of assembly. The basic theory is that people place more value, ownership, in something that they have participated in building and/or creating. It goes back to the old question, as a child, what bike did you treat better, the one someone bought for you or the one you paid for? One must be careful that the value or ownership does not turn into hoarding and non-sharing. Product development is a perfect example, as they create a new product or service, but they must eventually “let go” of the ownership and relinquish it out to sales and implementation.
Help to build the puzzle
Look at where your components of CRC are and know where you want them to be. This is different than vision and goals but has to deal with knowing what is the proper process and functions of each component. One might consider this a gap analysis analogy, and this is where the puzzle concept comes into play. One knows what the completed puzzle should look like based on the picture on the box or an enlarged provided picture but starts with a bunch of pieces. There are a couple of ways to build a puzzle:
1. Build the edges first and then fill in the inside – edges are identified easily but filling in can be a daunting task
2. Lay out all the pieces and start looking for those that match
a. This can be very challenging with a high number of pieces
3. Build smaller sections of the puzzle, get them into their right places, and then fill in the connecting sections, the rest
Even though management should know what the proper function of a department/team should be, they are not in the trenches. The PA knows what the functions, roles, and team members are for each of the components. Without being intimately involved in the details of daily functions, they can provide the needed education of regulations, standards, and compliant practices to all components and physicians. Following #3 building technique above, the PA can help them fit into the overall picture while leadership and management fills in to connect the sections. There may be meetings, conferences, such as multi-disciplinary rounds where the PA can serve as a facilitator for all components.
All five components of Utilization Management 360 are dealing in some manner with the patient story and the care in order to facilitate proper level of care placement, proper treatment and care transition, proper documentation, and compliant billing. Think about it this way: there is a football team whose players never block, won’t tackle unless it is the man they are covering, receivers that run out for a reception only when it will be to them, and focus only on actions that will run up their statistics. This is another form of silos and the chances of this team winning are next to nil. This can and does occur in individual healthcare teams and overall clinical revenue cycle and resentment and disgruntlement will start to build. In reality, there is a huddle before each play, that is run by the quarterback who lays out the play and options. This is a great form of “communication”. Everyone on the team knows what the intended play is and the options for change. The PA can serve as a “quarterback”
Just as a few examples, do the team members, components, know:
• The financial consequences to the beneficiary for being in the wrong level of care
• The challenges of getting a patient transferred to a SNF
• The extent of documentation that doesn’t support the acuity of the patient
• Trying to get a physician to change the level of care order
• What are the processes and consequences of condition code 44 and trying to notify the patient, the physician, and the facility
• What are the consequences of up coding
• Why are there so many denials and how do you appeal them
• And so much more?
One may say why does each member and component need to know this? Well, they don’t need to know the intimate details, but an overall knowledge base can provide some insight to getting the right results and outcomes for the patient and the facility resulting in sustainable revenue and maintaining hospital existence. Therefore, that’s where communication and education plays a role, a role that the PA can be part of in managing silos. The physician advisor can provide this communication on a one on one basis or overall education.
The role that the Physician Advisor provides as communicator, facilitator, subject matter expert, and “quarterback” is invaluable. In just performing their intended duties, working with teams and management, managing the silos within Clinical Revenue Cycle can occur.