Not all growth is good growth

[00:00:00] And specialty healthcare growth is not optional, but scaling with operational excellence. That's the hard part. I'm Joseph Zboch. This is Scaling Specialty Growth.

[00:00:08] Joe: Thanks for listening. Today's guest is Michelle Hanrahan, chief clinical access officer and associate vice chancellor, University of Arkansas for Medical Sciences. UAMS is Arkansas' only academic medical center and a level one trauma center. There, Michelle oversees the full breadth of how patients move through it.

Enterprise access, care management, utilization, transfers, clinical command — my goodness — operations, oncology nursing. Michelle, even before we started, you were talking about the 50 things on your plate. You do quite a few things. Welcome to the show. It's good to see you again. We go way back.

[00:00:42] Michelle: Thanks, Joe. Happy to have this opportunity to talk with you in this venue.

[00:00:47] Joe: I feel like there's a lot going on in healthcare, in the world, and everything. And so it brings a question I like to lead off with, which is growth is a mandate, it's the imperative, but operational excellence has to be maintained. And so, people in your position where access almost equals operations from a philosophical standpoint — what's your approach?

What's your operating mindset for balancing growth goals as well as the systems that need to be in place to support it, so that a patient doesn't fall through the cracks or there's not poor experiences across the board? Growth at all costs just does not equate when it means patient experience or patients suffer. So what's your take? How do you find the balance?

[00:01:28] Michelle: Sure. There's a lot of things that have to be considered when you talk about growth, and I think every healthcare institution across the country, to your point, is focusing on growth and how do we get there. And I think some of the things that I focus on as a leader in access in this space is, not all growth is good growth, number one.

Growth has to be in alignment with a lot of things. You have to have capacity. You have to have the workforce. It has to be a financially sound decision — you actually have to have the financial backing to be able to support some of that growth — and then the quality component of it as well.

It's really great to shove 60 people through a clinic, but if notes aren't getting closed, or we aren't able to take care of the patient, or respond to messages in in-baskets and things like that, we're not really providing a great quality of care for patients. So I think from my perspective, when I look at things, it's: do we have the right recipe in order to be successful in the growth? And that to me is important.

[00:02:25] Joe: So I would assume that you start with a solution and then go frantically searching for a problem. Is that usually how a rollout works?

[00:02:32] Michelle: Yeah. It's usually I'm presented with a problem and then how do we find the solution.

[00:02:35] Joe: Oh, yes, of course. I got that completely wrong. That's right.

[00:02:38] Michelle: It happens all the time. There's low-hanging problems that you can fix very quickly, and then there's other problems that are perceived problems, or thought to be problems.

And everybody in their roles in healthcare are in their roles because they're subject matter experts in that area. And sometimes we do things in silos, where administrators look at the financial aspect of it, and they just look at the financial aspect of it, and then the operators are looking at purely the operations, and then you've got the physicians that are just looking purely at the work that they do, and nobody's really talking to each other.

And then the next thing you know, you're in a meeting with 25 people, and you're presented with a pro forma, and you can take a look at it and go, "This is never gonna be successful because we don't have X, Y, and Z."

One of the things that we frequently find from an access perspective is, we wanna acquire a new building or we wanna open a new practice, and then nobody thinks about — we have to have two people at a registration desk to check people in, and it's not on anybody's budget. And then I find out after the fact that we're doing this, and then we're trying to scramble.

So I think in order to work on these either real problems or perceived problems, we have to understand the problem and understand what we're trying to achieve. And that's a key component that I think people get really excited about — they see the growth and they wanna be able to capitalize on that.

A lot of times we think we need to grow, but nobody's really doing a good job of looking at the referral pattern, or: do we have backlog? How much backlog do we have? If we hire one provider, does that solve some of the backlog of the referrals? So referrals is another piece where it is imperative that you put that into your tick sheet, if you will, of what you're looking for from a growth perspective.

[00:04:25] Joe: Yeah, and I wanna come back to the referrals part in a bit, 'cause I think earlier you said not all growth is good growth, and I think referral growth fits nicely on that. We'll come back to that.

So what are some of the specific things that you have done, or that you think about, or try to implement, to prevent these natural silos that can occur — because people take pride in being a subject matter expert and an expert in their domain, but really you're in the position where you have to be the glue, and make sure that the thing is staffed and make sure that this flows and make sure that the patient is considered in all of this. So what does that actually look like? And maybe put it in context of a recent project that you worked on that could have gone off the rails, or went smoothly because of, "Ah, I've seen this play out before."

[00:05:06] Michelle: Yeah. So there's been some work that I've been asked to take on, and it was from another leader, and some of that work was outsourced, some of it was insourced. And everything came as, "This isn't working. This is a terrible problem. We're having all of these issues. Why doesn't this work? The outsourcing is the problem. No, our process is the problem. No, we don't have policies — that's the problem."

So when it comes to me, I typically will sit down and go, "Okay, who are all the players that need to be involved? Who are all the key stakeholders, and how do we get all these people together?" And then you have to sometimes be very strategic on some of the initial conversations, because I don't find it productive when you have 60 people on a phone call trying to tell you, "This is what we do, this is how we do it," those types of things. So I try to take bites of the problem and then go, "Okay, this is what we're being told. How does this map out? Does this make sense?"

So recently it was just a complete overhaul of a process that we were doing here. I can't get into much more detail around that. And in the end, there were some areas of opportunity, but it wasn't nearly as broken as everybody thought. It wasn't as bad as everybody thought. It was just everybody coming to the table to talk about their piece, and then understanding where the dots connected and how do we make all those dots flow together.

So typically it's a people, process, technology setup for me. Do we have the right people? Do we have the right processes? Nine times out of 10 we do or do not. And then technology. And then the other question is, a lot of people wanna solve everything with technology. I think there are areas where technology absolutely 100% solves a lot of problems. And then I think sometimes we try and fit ourselves into the box of, we have to use technology to fix it, and sometimes it's not the right solution.

[00:06:59] Joe: Yeah. People, process, technology. I hear that quite a bit, and I have a deeper understanding of it now than ever before. Because going into this show, and really wanting to more deeply understand operations leaders, I thought, "Oh, very much system thinkers, right?" There's a function, then you get the inputs and then the outputs, and then ta-da, everything.

And what I hear over and over again is like, "Oh, you have to start with the people, the deep understanding of the people." And your background is in nursing, and I think you bring a level of empathy to the job, and understanding that we have to get people in the room together. I think that's really key too.

I've been in digital health for a while now, and there's been many a conversation where you kind of stop and you're like, "I think this might be the first time that these people..." And it's almost like the conversation with the technology vendor or whoever is a backdrop for a much needed strategic conversation. And that seems to happen a little bit too often.

It sounds like you are intentionally bringing these folks together, 'cause people can have just different understandings of what the problem is. So when you talk about taking bites out of the problem, what does that mean? Is it about putting it on a whiteboard — like, what do you think the problem is, what do you guys think the problem is? What does that look like in terms of identifying the first thing to tackle in a chain to lead to the outcome you want?

[00:08:19] Michelle: So typically what I'll do is I'll bring everybody together and say, "Okay, everybody tell me where you think the problem is. What is the problem? Where do we think that lies?" And if you've got 10 people in a room, four people might tell you the same thing, six people might tell you the same thing.

So typically where I start to really — to use a clinical term — triage out the problem is: what is the thing that is most frequently being referenced by everybody? And I'm making it up. If it's an appointment scheduling scenario, and everybody said, "Oh, it's intake" — if there's 10 people and six people tell me it's intake, I'm like, "Maybe we need to look at the intake process. Maybe that's where we start in this gamut."

When everybody is giving me disparate answers, and no two people are saying the same thing, then I think we have a really big problem. It really indicates to me that nobody knows what they're talking about, or is very confused on what we're talking about. So then I often go back to: okay, what are we trying to achieve? What is the outcome that we're trying to get? And then how do we, on paper, back up to the beginning to get to the outcome?

Because sometimes you just have to take the whole process apart that is there today, and rip it apart and re-put it back together. And sometimes you use some of the legacy pieces, and sometimes you throw them away.

I think in healthcare, we've all heard it, you've heard it: "Well, this is the way we've always done it." And sometimes people are afraid to think a different way or do something differently. And I think there's times when you really just have to turn around and go, "Okay, we have to do this differently. We can't do this the same way."

I was moderating a book club yesterday for "Service Fanatics" by James Merlino — we're reading it here. And some of our older faculty that have been here for quite some time had a really great perspective on how much healthcare has changed in the 34 or 37 years that they've been in the institution.

And when you really think about that, and both the positive and negative effects that sometimes can be had due to that, you really have to take a step back. Because when you think about healthcare, very simplified — 100 years ago... not 100 years ago, 20 years ago, 30 years ago, 40 years ago, we documented on paper. We don't document on paper anymore. But if we have an electricity outage, we go to downtime. Half of our teams here don't even know what it's like to document on paper, because they've never had to do it.

So it just goes to show you, when you tackle problems in healthcare, you really have to almost figure out where the legacy work came from, and then: is the legacy work relevant today? And if it is, do we need to optimize it? Or do we just need to say, "Yeah, this isn't really relevant anymore. We need to do something different." So I find that to be a challenge at times.

[00:11:00] Joe: Yeah, that's a good bit to chew on. Going back to where we were speaking a few moments ago — people in the room, can we agree on what the problem is? It's a weird thing to say, but if you see signal on the problem, you're like, "Okay, I've got somewhere to start from." Because I feel like sometimes the de facto starting point would be: what are we trying to do here?

But maybe I'm reading into something, or maybe you wanna correct me — it sounds like if you start from there, it's possible that these different siloed folks won't even be heard, and it's just kind of like, "All right, well, why don't you tell me what the goal is?" But if you start with a problem and then you recognize that there's no agreement there, it's like, "Okay, clearly, class, we need to take a step back and talk about what the outcome or what the goal is." That's pretty interesting. I've not heard that earned insight before.

You talked about referrals earlier. I feel like that is something that really does bring together the conversation that we've had so far. There's legacy workflows. In a sense, there's even a legacy understanding of what a referral is to the business. I've used the language — maybe it's a little bit too bold — that referrals a lot of times feel guaranteed. They're provider-to-provider relationships. But I think that has changed, where the idea of a referral has become much more competitive. It is not a foregone conclusion. A referral in does not mean appointment booked.

And so when we think about problems with traditional referral management, and when we think about maybe taking a step back — wait a second, referrals is not just the cost of doing business, it's a key growth driver now — what does that perspective shift look like? I know you've done some things. And I promise, for anybody listening, I am coming back to "not all growth is good growth" as related to referrals. So I threw a lot at you. Referral management: how has it changed? How are you thinking about it differently? And what bones are you trying to break and almost reset when it comes to thinking about it?

[00:12:59] Michelle: Sure. So prior to my role here at UAMS, and a few roles prior to that, I was a healthcare access consultant. And I went to a lot of institutions that were very academic in nature. Maybe an academic medical center in a state that was rural, or had a scenario where they were the only thing, the only one of. And UAMS is very similar in that way, but our mindset is a little bit different.

But I remember we were contracted to work in an institution. It was an academic medical center, it was a university, and they wanted to fix patient access. And they knew what their problems were. I mean, let's face it, as a consultant, it's the running joke — I think the joke is something like, they just wanna know what time it is, and you look at your watch and tell them. It's really basic. When you're reaching out to consultants, you kind of know what your problem is. You just want somebody to help you fix it.

So anyways, we had done this body of work. We did this whole assessment and kind of pinned down, these are the work streams that we would recommend that you do, these are what the outcomes would be, this is what this would look like. And they took a step back and they said, "Yeah, we've got lines of people around the block. We've got referrals for miles. I don't really think we wanna invest in this. We don't have a problem with volume."

And I was like, okay — but when Jeff Bezos puts the Amazon hospital right next door to you, or another healthcare system puts up something right next door to you, you are gonna have a problem, and you're gonna want your referrals, and you're gonna treat your referred providers differently.

One of the things for us at UAMS that we're really striving to work towards is, obviously every referral we want — we want them all. And I think when you go back to when we talk about not all growth is good growth, there's a lot of institutions across the country where there's sometimes a perception out there that this patient is too complicated, or this isn't the type of patient that we want, so we're gonna refer that patient somewhere else. And then suddenly you have this patient that may not have the greatest payer mix and things like that, and those are some things that you have to work through. I always say you have to take the good with the bad.

But to go back to the referral piece, I think it's really important when you are getting referrals from the ambulatory spaces or anywhere out in the community, that you follow back up with that provider to let them know that you did see their patient, and this was the outcome. And that's, to your point, the relationship building.

Sometimes you hire a lot of new providers out of school, and they may not necessarily understand you have to go out and build those relationships in order to get those referrals into the system. So that's how you build that relationship to make sure that you get referrals.

The second piece to it is, when that referral gets into the institution, we have to make sure that we act on it. And my expectation is that the patient gets reached out to within twenty-four hours of receiving the referral. And some people can say, "Oh God, twenty-four hours, that seems like a long time." The patient has just been in the clinic. They've just been told that they need to see somebody else. I think twenty-four hours seems like a long time, but it's actually really not when you think about how life happens. If you see your provider at five o'clock, you're not expecting someone to call you at ten o'clock at night and go, "Hey, do you wanna schedule an appointment in cardiology?" So the timing on it is important — and then making sure that we're doing everything possible to actually get in touch with that patient, whether it's by text message, phone call, voicemail, MyChart, all the things to make sure that we can get that patient.

And then the other thing that I think is very important in the referral space is, a lot of times you'll be on a phone call with a patient telling them you're trying to schedule them an appointment in cardiology or rheumatology, or your provider would like you to see whoever, and they don't even understand why they're coming. They don't know — "I didn't know I had to see a rheumatologist. Why am I seeing a cardiologist?" And I think some of that is, I can't tell you what the communication was in the room with the patient. So there's a little bit of a disconnect there. And then again, closing that loop back up to say, "Met with your patient, this is the outcome," things like that. I don't know if we do a great job of that all the time.

[00:16:56] Joe: Yeah. I feel like closing the loop is becoming less and less of a nice-to-have and more of a way to actually fortify the relationship and ensure that volume keeps coming. I think especially in a more value-based scenario — I mean, go Google search "as we shift towards value-based care," in quotes, and you'll see the first reference of that phrase like 20 years ago.

However, with self-insured employers, the rise of that, working with specific entities to really steer patients to high quality, low cost care, things of that nature — the payers obviously — closing the loop is really more important, because if you don't deliver that experience, you can actually turn off the tap of that referral volume.

I think things like referral leakage used to be a problem within the four walls of the practice only, and it was a purely operational thing to maybe get around to and fix. But in terms of consolidation, competitors down the street, like you referenced — hey, you might not feel like you have a volume problem now, but when competition really increases, you're like, "Oh, wait a second, I did. It just wasn't in my face yet."

And it's really easy — you didn't quite dig into this, I'm curious your thoughts — it's like, we don't wanna deal with this type of patient, bluntly paraphrasing, so they refer them out. Your EHR might be filled with, like, referral Doritos, right? Where we got a lot of volume, we got a lot going in, but in terms of the nutrition to the system, maybe it's not quite what you expected. Do groups struggle with the insight in terms of how that referral actually flows through the system and the nature of it?

[00:18:43] Michelle: You know what? Referrals is always an enigma. If you don't have a great referral structure — a referral is a wealth of data. And when you think about all the referrals that flow into a physician or into an institution, and when I say outside referrals, I mean referrals that are coming from the outside, not your internal referrals. People that are on EHRs are getting all their internal stuff. They know exactly what patients are being seen for, and you see Dr. Smith in the hallway and say, "Hey, I just referred one of my patients to you."

On the outpatient side, or out of the hospital side, or out of the institution side — if you combine all of that together, and the hundreds of thousands of referrals that come in every day, every year, every whatever, you can learn a lot about what your community thinks about you. You can learn a lot about what the providers in the area think about you. You can sometimes identify patterns where you know, "Hey, Dr. Smith only refers us patients that are self-pay or don't have insurance," and things like that. And there's nothing we're gonna do about that, because our goal is to take care of the patient, and we wanna make sure that we take care of the patient and do the right thing.

But I don't think people put enough stock in the intelligence that comes out of the referral space. The challenges that we have are, a lot of times someone will email me and say, "Hey Michelle, can you tell me how many referrals am I getting from this location, this provider, this whatever, and what is the diagnosis?"

Any of you out there that work in healthcare that do anything with referrals — it could be on a prescription pad, it could be on a piece of paper that actually spells out what is needed. So I think healthcare in general, we need to get a little bit better around how we manage referring patients into locations. Because if you just get "Michelle needs a CGI," and it doesn't have any other information on it, no named provider... And provider-named referrals versus not provider-named referrals, that's a whole other thing. We could have a whole other discussion about that.

Referrals are tough. They're very enlightening, but they're tough, and they're tough to manage at times. And it's tough if you don't have a great system to help you sort through the noise of what's out there and who's coming to you for what, and those types of things.

And the other piece to referrals — referrals aren't just necessarily paper. You would want any referring physician to be able to pick up their phone and call you mid-colonoscopy, mid-whatever, and say, "Hey, I've got a patient that I think has a giant tumor and needs to be seen as quick as possible." It should be able to get to that level of communication.

[00:21:18] Joe: Yeah. So related to referrals, or related to access and general operations, what is next? What are you focused on?

[00:21:25] Michelle: My goal always is to make sure that we underpromise and overdeliver. There's nothing more that you can do when we say, "Send us all of your patients, do all of these things," than to really operationally make sure that we know that we can manage what is coming.

I will never, ever forget — I was in an institution when I was consulting, and one of the hospitals in the surrounding areas, one of their competitors, I think Blue Cross Blue Shield was going out-of-network with them. So the institution I was consulting in, it's the story to this day that they tell us, or told us when we were there. They said, "Oh my God, this is an opportunity for us to garner all this volume. Blue Cross Blue Shield's out-of-network with them, so we're gonna set up a dedicated line, and these people can call this line, and we can get them set up in our system, and we can do all this stuff."

They blasted the phone number everywhere, sent out flyers, "We're gonna help you" — and they put one person to answer the phone. And they were getting, like, 100 calls an hour, and they put one person on the phone to answer it. And as you can imagine, it failed miserably.

So my job, and what I always am looking at and what is next, is just operationally making sure that what we are trying to do from a growth perspective, from a patient experience perspective, that we can actually deliver on that. It's not groundbreaking and it's not anything different than we do every single day, but that always has to be forward for me.

So I think what's next in that space is, how do we maybe leverage a little bit more in the AI space? How do we help our front desk staff, our frontline staff, do things easier, better, quicker? And how do we really make sure that the next iteration after us can carry on the methodology of the way that we do things?

So, my leaders — succession planning is a big thing for me. I meet with my leaders frequently and make sure that my way may not be the only way, but making sure that they have a starting point on where to start when they get these... I mean, there's nothing worse than when someone's standing in your doorway saying, "We have a terrible problem and it has to be fixed." And I'm always like, "Define terrible." Like, where are we on the scale?

And sometimes problems are perceived to be way worse than they actually are, and then there's times when problems are really bad and no one seems to think they're that bad. So it's kind of all around. But I think for me, it's just really keeping my finger on the pulse of what's going on around here, and making sure that we're delivering on what we say we're gonna.

[00:23:43] Joe: Michelle, this has been a great conversation. You kicked it off with — not all growth is good growth. And perhaps the worst kind of growth is the kind you can't operationally support.

[00:23:54] Michelle: Right.

[00:23:55] Joe: Thank you so much for your insights, your knowledge, your wisdom, and very much your time.

[00:24:00] Michelle: Yeah, thanks for having me. It was a pleasure.

[00:24:02] Hey, it's Joe. Thanks for listening. If you like what you hear, share with the peer, and if you're looking to scale referral operations to drive growth and efficiency, visit hatchcare.com.