As the building took shape, so, too, did the pediatric group, merging cultures and organizations, and settling differences, to create a faculty practice plan that allowed for the delivery of clinical care while safeguarding academic research and teaching commitments. The staff accomplished much, clearing operational, academic and administrative hurdles to plan and open the new facility. Yet, they fell short in the area of practice infrastructure - a carefully thought-out system of protocols to efficiently and profitably manage the day-to-day business of what would soon amount to more than 65,000 patient visits a year.

After the first six months, the CCMC FPP was facing projected annual losses in excess of $5 million. Under siege and hemorrhaging badly, the new group had little choice: take quick and drastic action, or risk going out of business altogether. Committed to the mission of a children's hospital and determined to set about erasing the deficit and putting the practice on solid ground by the end of the first full fiscal year, which was only 18 months after

Accomplishing this turnaround meant challenging age-old assumptions about faculty practice plans and their three-fold mission of research, teaching and clinical care. It took a tremendous amount of effort and planning, prioritizing goals, and hitting key objectives at timed intervals. Most notably, it required a new perspective on the value of clinical care.

CCMC FPP pediatricians agreed to value clinical care in its own right, as a means of generating revenue to safeguard research/ teaching time, as well as their livelihood and the practice and hospital's shared non-profit mission. Indeed, putting clinical, ambulatory care on the same footing with research and teaching is a complete reversal of the cultural underpinnings of FPPs, a boat-rocking concept for the majority of plans across the country.

Every faculty practice plan today faces the same challenge: how to finance operations in an environment of decreasing teaching and research revenue. Dollars have become more and more scarce, and affiliated institutions and medical schools, under unprecedented fiscal pressure, are less enthusiastic about funding sustained losses. Plans must rely increasingly on the clinical enterprise to generate revenue. Delivering efficient and productive clinical care, while serving up a healthy bottom line, are not things faculty practice plans historically do well. But the CCMC FPP is proof that generating clinical revenue is the surest way to protect research and teaching time.

Staff devised a short-term approach to problem solving, to deal with the unfolding crisis and address the symptoms. A

CCMC FPP accomplished what many faculty practice plans find elusive, if not downright impossible: to break-even while still respecting the delivery of quality care, and allowing for research efforts and teaching time. While every faculty plan faces its own set of unique challenges, there are seven key lessons learned at CCMC FPP that can be applied to faculty practice plans anywhere.

1. Watch the Money

It is a universal problem: Collection rates in faculty practice plans are notoriously low due to faulty front-end billing processes. Unlike so many long-tenured faculty practice plans, CCMC got to start on the ground floor, systematically, "doing things right," by correcting processes step by step. It was a painstaking process. The revenue cycle for the new pediatric practice was in complete disarray - not because it had fallen apart, but because it had evolved haphazardly as the practice took shape. There was no standard superbill in place, no understanding of what charges were billable nor how to capture them, and no clarity around the rules and regulations for individual insurance carriers, including how to properly enroll providers. Staff needed training and tools - worksheets, procedures and protocols - to capture charges accurately, to reconcile that the work done was indeed accounted for and coded properly, and to track that the charges forwarded to the billing vendor were swiftly processed. The pediatric group selected a new billing service with whom

The practice next quickly moved to bring in staff to provide in-house financial leadership, hiring a Controller, developing financial statements and revenue tracking so as to chart and manage its progress to goals. Without a highly competent financial staff, there could be no way to measure financial progress objectively.

On a grand scale, the practice needed new registration software better suited for an office-based, physician-practice setting, but that long-term fix was put on hold until the group could implement these short-term solutions to survive the immediate crisis. As they started to clean up the front-end billing cycle, collections began to improve.

2. Value Clinical Care

Today, faculty practice plans cannot afford to view clinical care as anything other than an equal partner alongside teaching and research. Dollars generated by funded research in a practice are clearly insufficient, and without a healthy clinical revenue stream, research and teaching in a faculty practice plan are in grave jeopardy. In fact, not only does clinical care have to be a priority culturally, but from a financial perspective, the practice must understand what it needs to generate in its budget to make the organization a going concern.

CCMC FPP pediatricians first defined the amount of time they would spend in the exam room - assigning 70 percent of the faculty practice plan time to clinical care and 30 percent to research and teaching. In many faculty practice plans, the actual time dedicated to clinical care may be arbitrary or undefined. Interestingly, many pediatricians in the plan welcomed the quantitative guidelines. They understood their research and teaching commitments, but wanted clarity around patient care. Young physicians were especially vocal about the need for clear guidelines and expectations.

Having valued and quantified clinical care, the faculty practice plan, after careful analysis, then determined it needed to generate approximately 85 percent of its operating budget through clinical care. That objective required a complete change

3. Aim for the Top

Success is possible if faculty practice plans make clinical care a priority, infuse the culture with the thought process, understand the business from a profit and loss perspective and what level of volume and resulting revenue needs to be generated, and then benchmark performance. CCMC FPP pediatricians agreed that during the 70 percent of time they were in the exam room, they would go head-to-head with private practice colleagues. They looked at private practice industry standards for productivity, access and efficiency, and committed to hitting the 90th percentile. They started tracking benchmarks such as patients seen per year, dollars generated by physician, and amount of charges logged by specialty. Each department committed to performance and access standards, including reducing wait time for appointments and time sitting in the office. Although the plan was committed to teaching and research, it expected pediatricians in the exam room to operate as if they were in private practice.

4. Structure for High Volume

The CCMC FPP needed an operational overhaul to not only reach high-volume clinical care benchmarks, but better accommodate the patient-teaching experience. For example, the pediatric primary care group initially delivered teaching and non-teaching care simultaneously, in the same office space. As patients arrived for appointments, staff would determine on a case-by-case basis whether patients would see physicians or nurse practitioners, who were not scheduled to teach, or whether patients would be assigned to residents and preceptors who were scheduled to teach. Even though the floor space was adequate, the result was bedlam for patients and staff alike. Patient wait lines overflowed the waiting area as staff wrestled with decisions. It was difficult to track the delivery of care. Other issues added to the confusion. Translation services, for example, were not coordinated to serve the

In short, moving high-volume patient care through the practice - 60 percent of which was same-day requests for appointments - required careful pre-visit planning. Staff needed to be sure resources were identified, coordinated and in place when the patient arrived. In some cases staff conducted phone assessments of patient need before the visit to determine scheduling requirements, length of visit, and other resources that might be necessary. The practice set up a telephone triage system to screen requests for same-day appointments.

In addition, in this and all CCMC FPP areas, a great deal of time was devoted to preparing clinical scheduling templates that met both the established clinical volume and efficiency goals, without being unrealistic.

Along with pre-visit planning came space planning. The practice divided the office space, 28 exam rooms, into a teaching and non-teaching unit, and then funneled patients to the appropriate unit depending upon who they were booked to see that day. Patients assigned to primary care physicians who were teaching that day headed to the teaching unit. On another visit, that same patient and provider might interact on the non-teaching unit, if that physician was not scheduled to teach. Staff tried to maintain the integrity and continuity of the patient-provider relationship, so patients saw their primary doctors.

Each unit, teaching and non-teaching, was assigned different support staff to manage their respective patient flow. The high-volume, non-teaching unit had more support staff, for example, to keep patients moving and boost provider efficiency. The practice also assigned ward clerks to both units, who interfaced between the front desk and the exam rooms to be sure patients didn't get lost in the shuffle. Keeping a close eye on patient traffic, the ward clerks made sure patient flow was always moving at a consistent, high-volume rate.

5. Prevent Provider Overcapacity

Faculty practice plans tend to hire a large number of the residents they train, rewarding those students who have excelled academically by giving them a chance to succeed in the organization. This approach can feed inefficiency if not keyed to patient volume demand or patient volume gets spread over more and more providers. Top heavy and bloated, faculty practice plans soon end up supporting provider practice instead of efficient patient volume.

The CCMC FPP took a different view, streamlining efficiency and boosting productivity to handle maximum patient volume with the fewest number of providers possible. The goal was to work smarter, not harder, eliminating duplicate effort, and working in a systematic way to maximize patient volume.

As CCMC FPP staff started smoothing patient flow, increasing productivity, and driving performance, they found in some areas that they had too much physician capacity to the number of patients served. As a result, some physicians did leave. But their departure made an enormous difference, bringing budgets into balance.

6. Assign P&L's to MD's

The kind of sweeping change the CCMC FPP implemented - broad-based and cultural - is only possible with strong physician leadership, and providers' willingness to assume financial accountability for clinical departments. Physicians in private-practice have always understood that they alone drive their organization's performance. It's a lesson faculty practice plans must adopt if they are to survive and thrive in today's marketplace.

When the CCMC FPP first came together, physicians were inundated with distractions related to the merger. They did an excellent job of building a hospital relationship and their own internal relationship - all for the benefit of the state's children. But the bottom line is that physicians have to run the operation, and when the patient queue is an hour long,

In order to achieve the ambitious clinical goals CCMC FPP had set for itself, decisions needed to occur much closer to the front line. The practice set about to hire Practice Directors, carefully selecting from candidates those who could work in partnership with several Division Chiefs. The Practice Directors provided a key link between practice management needs and exigencies of front line patient care. They worked with Division Chiefs to support or lead, as necessary, clinical operations management of the divisions they represented. The practice put the Chiefs and their Practice Director administrative partners in charge of ensuring front-line performance, driving productivity, working out teaching, research and clinical care ratios, and balancing budgets.

This added responsibility for day-to-day operations came easily for some pediatricians, but others found it more challenging. Mentoring can make a key difference. Faculty practice plans would do well to follow CCMC FPP's example of supporting those physicians who are tackling front-end operations for the first time. Physicians in the organization who are good at operations can teach others, helping them find solutions within or tapping resources outside the organization when necessary.

Active committees, one for Operations, another Finance, provided another key link between front line operations and the Board of Directors. These committees, populated largely by representative Division Chiefs and other active physician members, reinforced unity of purpose, further cementing the group's identity and culture as a practice, while supporting front line decisions and insuring a balance between Practice-level and Division-level issues.

7. Infuse a Supporting Role

While challenged by financial losses, the CCMC FPP resisted the temptation to slash staff support. Physician productivity goals would be met only if physicians were free of administrative burdens and focused solely on meeting patient needs in the exam room. Staffing configurations were developed that ensured performance benchmarks were met and that were affordable to the CCMC FPP.

Staff had a pivotal role in CCMC FPP's success. They understand that their job

In Closing

Faced with financial crisis, the CCMC FPP undertook the painful process of self-evaluation to ensure self-preservation. After thoughtful analysis, and tremendous effort, its pediatricians developed a master plan for success, sorted goals into short-term fixes and long-term solutions, restructured care delivery, and chose a different path than many faculty practice plans in operation today. The hard work paid off with a healthy bottom line and an organization on sound footing, positioned to deliver care to the state's sickest children into the new millennium. The CCMC FPP's success serves as a valuable road map for other faculty practice plans struggling with similar challenges in today's health care marketplace.

Dean Rapoza is Executive Director of the Faculty Practice Plan at Connecticut Children's Medical Center in Hartford, which provides pediatric healthcare services, teaching and research for children from birth to age 18.

Jayne Oliva is a principal with The Croes Oliva Group in Burlington, Mass., a team of medical group management diagnosticians working with health care organizations and affiliated physicians to improve front-line operations.