Solo and small-group practices are the mainstay of the American health care system. Even in California, the birthplace of health maintenance organizations and home to some of the largest medical groups in the country, most of the state's residents receive their medical care from physician offices with only one or two practicing doctors. Solo and small-group practices also play a crucial role in America's health care safety net. And in California, solo and small-group practitioners make up the lion's share of the safety net—without them, entire California counties would not have access to a physician and many of the state's already overwhelmed emergency rooms and trauma centers would be forced to close. For these and myriad other reasons, it is worth paying close attention to the plight of solo and small-group practitioners. The health of their practices is essential to the good health of Californians.

This toolkit offers a series of proven steps that solo and small-group practices can take to improve many facets of their practice, including the delivery of better-quality medical care. It is based on an important premise: that in order to provide quality medical care, a physician practice must be efficient and well run.

The toolkit is organized into nine chapters that can be read sequentially or on an as-needed basis. We've outlined the contents of each chapter here so users can go straight to the information they need.

The Chapters

Chapter I of this toolkit looks at the very first step a physician must take when starting a practice. Even the most talented physician cannot deliver high-quality medical care without hiring a good staff. Therefore, we offer advice on the art of finding, interviewing, hiring, training, and evaluating employees. Among other helpful pieces of information, we've included questions for both telephone and in-person staff interviews, a section on hiring and the law, hints for marrying work assignments with performance standards and practice goals, and a discussion of how well-trained receptionists can be instrumental in improving patient care.

Chapter II looks at the elements of a successful practice. Every practice is different, but each requires the same basic resources to be financially successful and to deliver high-quality medical care. Identifying the right tools helps medical practices improve the accuracy of their record-keeping, coding, and billing. It also helps practices become more efficient businesses and maintain compliance with protocols that are established by private insurers and government programs such as Medicare and Medicaid. Another tool discussed is the consultant. Outside consultants offer a variety of services and can be helpful with everything from regulatory compliance to choosing and implementing practice management and electronic health record systems. We look at when and how a consultant can be helpful and offer suggestions for finding the right one.

With Medicare reimbursements projected to decrease by as much as 30 percent over the next several years, and with major health plans unwilling to negotiate contract rates that cover the cost of care, the viability of today's medical practice depends increasingly on improved efficiency.

Chapter III looks at areas such as time management and administrative streamlining, with practical advice on how to conduct a needs assessment for your practice and how to identify variances in the ways common tasks are executed. Left unaddressed, variances can cause inefficiencies and compromise the quality of medical care. We also discuss techniques for reducing patient waiting times and for maximizing the value of the time patients spend in a physician's office. Managing call volume, reducing late arrivals and no-shows, using efficiency-related technology, and making maximum use of physician time are also covered. All these changes directly impact the bottom line, improve patient experience, and can result in better care.

Chapter IV looks at improving practices from the perspective of the patient. Because both physicians and patients are such an important referral source for new patients, good customer service is a vital component of a successful practice. Improving the patient's experience starts with soliciting feedback. Here we discuss how to survey your patients and what you can do with various results. Patient surveys can best provide information about three areas: quality issues—whether the patient is satisfied with his or her medical care; access issues—whether he or she is having a hard time being seen; and interpersonal issues—whether practice staff are providing good customer service. Chapter IV also looks at the process of surveying referring physicians, a step that can reveal ways to shorten referral times and improve the patient's overall care. These types of surveys also give you a better picture of how well you are meeting the needs of referring physicians and, more important, how you can do it better.

Chapter V returns to the topic of staying financially healthy, scrutinizing how practices can better understand and improve their revenue stream. Financial crises, even short-term ones, jeopardize both the viability of a practice and quality of care. The key to preventing revenue shortfalls is actively monitoring what is coming in the door. We offer guidance on how to manage accounts receivable through proven best practices in a number of areas: measuring days in accounts receivable, or DAR, by payor, service, and provider; managing self-pay revenue stemming from co-pays, co-insurance, deductibles, and other non-covered services; benchmarking key financial indicators; and minimizing DAR.

Chapters VI and VII look at two areas that present challenges to all physicians, but particularly those in solo or small-group practices. The first is compliance with the federal Health Insurance Portability and Accountability Act, or HIPAA, for short. The second is selecting, implementing, and using electronic health-records systems. Ironically, part of the impetus behind HIPAA was the thought that it would facilitate conversion from paper-based medical records to more easily shared electronic ones. As a practical matter, HIPAA compliance has been one of the main obstacles to achieving that end.

The discussion in Chapter VI looks at a number of gaps that frequently cause medical practices to violate HIPAA and ways to significantly lower that risk. The chapter also looks at medical identity theft and state privacy laws that can be even stricter than HIPAA. It recommends a series of practical steps that physician practices can take to ensure compliance in those areas as well.

The discussion of electronic health records in Chapter VII aims to demystify what is often a very frustrating process. There is no doubt as to the great potential of electronic health records. Properly used, they can reduce medical errors and improve patient care. Using electronic health records can also save a practice a lot of money in the long term. But making EHR work for solo and small-group practices can be tricky. In this chapter we tell you exactly how to do it. We start with advice for conducting an EHR needs assessment, discuss the issues of readiness and timing, and offer advice for selecting the right system for your practice and making sure it will meet your HIPAA compliance needs.

Chapter VIII looks at yet another key to practice viability—developing a defensible fee schedule. The fee schedule is the single most important financial tool within a medical practice. Yet most practices develop their fee schedules with very little, if any, understanding of the methodology for doing so. Understanding this methodology is not easy, but the physician who puts the time into learning it will benefit greatly. The chapter looks at the basic perspectives underlying sound fee scheduling and walks physicians though the task of creating their own.

Chapter IX offers a model that one physician believes can improve both quality of patient care and the quality of life for a physician. Dr. Dan Lensink is a board-certified ophthalmologist in Redding, California, whose practice focuses on plastic surgery of the eyes. As he writes, dissatisfaction with loss of control over his practice prompted a shift to his current practice status—providing his services outside most traditional commercial insurance networks. Lensink contends this change gives him, and other physicians making similar choices, more time with his patients and a higher quality of life. Making the case for practicing out of network, he deems it one of the best ways to improve quality of care. He offers practical advice for surviving out of network, including tips on developing an out-of-network strategic plan.