Why manual referral tracking scales a practice backward

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

[00:00:08] Joe: Thanks for listening. Today's guest is Misty Sullivan, care center administrator at Proliance Rainier Orthopedic Institute and the Surgery Center at Rainier, a seven-physician orthopedic private practice in the Pacific Northwest. Rainier is a part of the larger Proliance surgical umbrella, one of the Northwest's biggest independent surgical groups, where each practice runs lean and largely on its own.

Misty oversees everything: 70 employees across a clinic, MRI, X-ray, and a four-room surgery center, plus a satellite location down the road. She's also spent years improving the referral process within the broader Proliance organization, and she'll be the first to tell you that referrals are the heartbeat of the private practice.

Misty, welcome. Thanks for being on the show.

[00:00:51] Misty: Thanks for having me. I appreciate it.

[00:00:54] Joe: I think referral processes, referral management, is the perfect summation of this idea of balancing growth goals and initiatives with operational excellence. Because so often that patient is the intermediary between groups, making sure things happen — and so people like you work really hard to make that process as smooth and simple as possible.

So what is your overarching philosophy when it comes to making sure you're balancing the operational excellence piece with aggressive growth goals from a practice standpoint?

[00:01:31] Misty: Yeah, a really great question. I think especially being in an independent practice, you really have to focus a little bit on both of those things. Customer service has to be at the forefront of everything that we do. I explain that to plenty of people daily — when we're speaking with patients directly, to physicians, PAs, no matter who we're bringing on as a new hire.

Ultimately, if you have poor customer service within your independent practice, you really could tank what you're doing. Referrals are always an important aspect of what any independent practice, and even a larger organization, would do. If you don't have feeder clinics, I think it becomes a little bit more difficult for you to get referrals — and by feeder clinics, I mean primary care clinics attached to what you're doing, if you're a specialty group.

[00:02:18] Joe: And is that the case for your group?

[00:02:21] Misty: That's the case for my group. Yeah. So Proliance Surgeons, as you mentioned, is this massive group — for us, an umbrella group. They handle all of the core stuff, billing, different things of that nature, but they ultimately don't control us getting referrals fed to us.

And so what you have to do is really market yourself and have a great name, I feel like, or be a part of a larger thing. We're a part of the Chamber of Commerce for a local area of Puyallup and Sumner in Washington. So you're marketing yourself in those aspects just by becoming a part of different small things within your community.

It also allows the community to see that you're involved — that you want to partner with other businesses. We partner with private practice primary care physician groups, so that way they can send their patients to us and vice versa. Because believe it or not, right now you see a high level of patients that do not require a referral to go to a specialty. And many of those people are opting out of primary care. They don't wanna see primary care, so they come to specialty directly, and sometimes they don't need specialty. So you could always market yourself in a reverse referral type situation.

Growth, I think, comes hand in hand with that. You have to have access to care. And so while you're kind of stressed about bringing patients in, you have to make sure that you have enough physician assistants, ARNPs, or whatever you might hire in your practice — we're physician assistant, physician-based — to have that access. Because what you don't wanna do is say, "Send me all of your referrals," but I can't see your patients for three months. That's not okay, because that's poor customer service and that's a lack of access to care.

[00:04:02] Joe: Do you have some sort of tracking set up to where you're trying to make sure there's a balance between referrals flowing in and the capacity on the other side, to make sure that you're not over-promising a particular experience and then under-delivering on the access or capacity side of things? How does that look for you?

[00:04:20] Misty: Yeah, really great question. So we do have some systems that we use. We use Qlik that allows us to really look at some data firsthand — first and third next available. Where our gap is, is referrals, which is why I'm talking to you all wonderful people. I was very impressed by the demo that I received.

I think it's very hard, especially with a clinic our size, because we're not considered large at Proliance Rainier Orthopedic Institute. We're not considered small, right? Seven physicians, seven physician assistants, so that's 14 providers in-house. And back in the day, as I like to say, 10 years ago, it was so much easier to manage those things on an Excel spreadsheet, or we could flip through paper and see how many patients are coming in daily.

As you continue to grow and get larger, you don't have that ability to do it. It becomes more difficult. You're relying on people to track their numbers, or you're relying on an Excel spreadsheet to track how many referrals, because someone's manually typing it in. So that takes time, that takes manpower, that takes money because you're paying those people, and then you have to rely on them to manually enter — and we know that there's error there.

So I think when you start to talk about where is our gap in growth, I do feel like if you do not leverage systems like Hatch — the referral database system that Hatch provides — then you really are inadvertently scaling yourself back. You're reducing the manpower that you would have to work your referrals, because you're too busy doing all of those things that a system could do for you.

[00:05:52] Joe: Yeah, that's well said. So tell me about some of the things that you have put in place in terms of the people and process within the broader referral process that has been really helpful for having a more repeatable system. 'Cause I know there's a lot of turnover in a lot of these positions, these coordinator-type roles, and so there's the training aspect to it. But as a broader system of managing referrals, you can't be dependent on any one individual. So what does that look like? What are some of the things that you have put in place to keep the referral process at Rainier humming as you have grown?

[00:06:28] Misty: Yeah, great question. I think the first thing you have to have is a process map. Because if you cannot retain people, you need to be able to train those that are coming in. So it's very important that you understand as a leader — and your operations managers, and the supervisors if you have them, or leads, if you're lucky enough to have that level because you don't run super lean — it's important that everybody knows where they can go to find the process map and see what that process is, or your new staff can go and review that prior to asking questions. I think that's the first thing.

I have been very lucky. I have a 20-year employee that's here. She's pretty much grown up in the space and she just got promoted to referral coordinator lead. She was very reluctant to go back into a lead position, but she's the best of the best, so it was very nice that she's here. We lucked out in that manner.

And we've promoted some other people, and one of the things that I've put into place is that there's a timeframe that you have to be in our group before we promote you. And I'm all for bringing people in from the outside if they have the qualities. However, I love to promote from within. I think that keeps people engaged. I think the employees wanna make sure that they're doing their best work, they're driven, and it allows people that are not stagnant, that actually wanna grow, to do that without looking outside of your group. They have something to work towards.

I think that's important, and that can be hard in a lean environment. So if you cross-train people, that's really beneficial to you, because you're ultimately getting an on-the-job interview. One, if somebody calls out, you have somebody to backfill. And two, when you post a new position — while they should still have to interview for it — they're gonna end up being the best person for the job, or you're gonna know that they're already working.

So I think ensuring that our staff are prepared to work our referrals and can help in many different aspects, as well as making sure we have the documentation, really has helped us. And it used to not be that way many, many moons ago when I came, and we had no documents for training. So people were just training and expecting people to remember those things, and that's nearly impossible to do, especially when you have hands-on learners and people that are visual.

[00:08:35] Joe: Yeah. Clarity is kindness. So it sounds like with this process map, and really paying attention to what is our process, what is the documentation in place, what does training actually look like — that has been a tool that has helped you onboard team members as well as make it easier for more tenured folks to promote from within. That's really cool, and that makes a lot of sense.

I'm just curious, what are some of the gaps that you've identified that you have now filled, or maybe that remain unfilled, that keep someone up at night in your position — that maybe the super high up executives or the C-suite might not be aware of when it comes to referral management? Because I think one of the more interesting things is the primary to specialty care referral has existed since the beginning of time in US healthcare, but in a lot of ways that process remains fragmented across workflows, across data, and asking the patient to fill in those gaps.

And so prior to having a system in place, referral management — maybe feel free to disagree with me — could have been seen as the cost of doing business, or a cost center, or this is a problem that we solve with people alone. But with the uptick in competitiveness, you mentioned earlier that referrals is not the same as it was 10 years ago, where maybe you could just track in a sheet. So what are some of those gaps that you've noticed that maybe folks higher up in their particular organization might not have recognized?

[00:10:03] Misty: Yeah. What keeps me up at night is schedules and visibility. I think that's really important. I actually had a conversation probably about 30 minutes ago with my operations manager, and I said, "I need for you to go and talk to the referral coordinators, ask how many referrals came in over the weekend. How many are they seeing or being held up due to a recent insurance change? We're not filling two weeks out, so let's identify where our areas of opportunity are."

And I feel like that would be solved with a dashboard. And I'm all about the dashboards. I want to be able to log in and see, okay, these are the amount of referrals that came in. This is where they've come in from. Not being able to identify reporting on where the referrals came from without manually going through them is a pain point for me. Because what happens then is if I feel like my volume is down, I have to reach out to the connections that I have and say, "Hey, so-and-so family medicine, we're not seeing as many referrals. Can you pull that report on your side to see how many you've sent to us?" When in all reality, I should just be able to see it myself. And I feel like systems like Hatch's referral database allow you to do that.

It allows you also to ensure that your employees are working. Because when you have a group of referral coordinators, you should not be micromanaging them — that's a higher level position. What you should be able to do is utilize a system that allows you to pull reports on how many referrals were worked by a certain employee. You should be able to see those things, because sometimes referral coordinators unfortunately are not just scheduling the people. There's more work. They're needing more imaging. They're needing reports. They're needing more things from the insurance. So just because they didn't schedule someone didn't mean that they weren't working — but how nice would it be to be able to physically see in front of you that they touched that referral?

Right now we're utilizing some things like SharePoint and Teams, and while those are great sources to work through, it's not ideal for processing referrals. Not only that, those systems also don't take the referrals and pull out the important things that you're looking for. You can't customize by keywords. You can't flag those things by urgency. You ultimately are waiting for someone to identify, by looking through those referrals, "Oh, this is urgent. We have to pay attention to that." So that also leaves gaps. And it could ultimately, if the patient doesn't know to contact you, result in poor customer service — because they think that you're not working fast enough, not understanding you're working them in the order that you receive them, because there's nothing to flag you on urgency.

So in my role as an administrator, since I'm the highest level leadership in my group here, those are the things that stress me out. I want these doctors, I want this group, to be successful. It's almost like having the weight of the world on your shoulders. There's so many moving parts. You need to focus on customer service, you need to focus on referrals, you need to focus on front office. But you also have to be smart enough to hire people that are amazing, which I have — a great group of people underneath me, my operations manager, my nurse director. From the entry-level position to the highest level position, it's important that we do the best that we can and we're motivated and driven.

But at the same time, I wanna make sure that I am not creating a larger stress on my staff by not providing them with the tools to make their job as easy as possible. Because that is where you get satisfaction in employment. That is where you retain people. That is where you get loyal employees — because you're committed. I feel like that commitment to ensuring you're reducing their stress allows them to provide better service to your patients.

[00:13:52] Joe: And I wanna come back to that in a second. But to summarize what I think I heard in terms of what keeps you and your executive counterparts up at night — the gaps: without some way to centralize the referral process and have that single pane of glass, you lack visibility basically across the board. You have to, by anecdote or by feel, determine if there's some volume issue from what felt like established referral relationships. And you kind of have to have longstanding know-how to be like, "Hey, such and such family practice, maybe that's going down."

And then there's the operational insights that you're also lacking, in a system that is spread across multiple workflows, spreadsheets, and point systems, to where you don't really know what the pulse is of that day-to-day. So to summarize, the visibility gap is something that keeps you up at night, because in absence of that infrastructure end to end, you're having to fill in those blanks one-off — and on top of that, when you have time for it. That's obviously very difficult to manage.

[00:15:09] Misty: Yeah. For lack of better terms, time is money, and that relates to everything in every aspect of business. My referral coordinator's working, talking to patients on the phone — time is money. We ultimately are wasting money by not having a system that provides us with a reporting structure, because it would allow us to identify our gaps faster. So we can identify them, it just takes us so much more time to do so, and so much more manpower to do so, and a lot more conversation to do so. And all of that takes time, and every second of that day gets charged to someone. Someone's paying that salary.

And so, while we're not just here for money — because we're ultimately here to provide exceptional customer service and patient care — we still wanna make sure that the physicians get paid and our staff gets paid, and the patients also need the best value for their money. They don't wanna come to an appointment that they don't actually need to come to. So it's important that we're doing those things correctly. And they also don't wanna wait three months when they're in severe pain because their back hurts. That's poor customer service.

So I do believe that historically, especially for independent private practices, you try to identify what's super important and you pay attention to those things first, inadvertently creating an issue. It's like a hamster wheel. Because you wanna grow, you wanna become larger, but to do so you have to ensure that you take a moment to really identify and look at your business plan and your business model and say, "Okay, if we're really gonna grow, how can we do that efficiently and effectively?"

[00:17:03] Joe: So if time is money, what are some of the metrics that you're really paying attention to, especially when it comes to growing overall referral volume? Because I think historically, referral management has really been focused on efficiency alone — how fast we can do a thing. But any efficiency gains that you produce should translate into staff being more productive, having more capacity, to provide not only excellent customer service but also to work more referrals in the same amount of time, which ultimately leads to growth.

So from a conversion rate standpoint, from a throughput standpoint, what metrics are you tracking now versus what metrics do you want to be able to track, to really take your process, your operation, to the next level?

[00:17:47] Misty: Yeah, really great question. Obviously how many referrals we receive is a really important metric for us, and like I said, it's very hard to track right now. It's more of a manual thing, but it's important for us to do.

Another KPI would be receipt of referral to first attempt to contact. Again, very hard to track right now, because we're using SharePoint, we're putting notes on those referrals, so it's manual — we have to open up and see how long that takes.

And then also receipt to schedule. That's really important — how long it took from the time that we received that to actually getting the patient in the door.

And then another metric which doesn't seem as important, but is important to me, is if we could not schedule the patient, why? Is it because the referral was not appropriate for our location? Is it because the physician decided no, they didn't wanna see that patient, and why was that reason? Is it because we're not contracted with that insurance?

So I think those are really four big attributes, and all of those will let you know whether or not you have enough staff in your department. Because if you're having more referrals than you have staff to work them, that can hinder you more than it can help you.

With us being as lean as we are, I would love to say my referral coordinators process referrals all day. That's not the only thing that they're doing. That's the primary focus of what they're doing, but they're doing other aspects amongst that, that all intertwine with referrals. We partner with some groups for first responders, so those are referrals in, but those are not gonna be referrals through us getting a paper referral. Those are an email type system, 'cause those people are very motivated to get back to work — those are injured workers that wanna get back on the job. And so we try to help them in a different manner and we streamline those things, so we track those in a different way, a more manual way.

But I think your normal referral that you're getting from a primary care physician coming in should be able to come into a system, and that system take and automate that referral for you and call out the key primary things that you wanna see. When I think of using a database that allows referral management to become easier for me, it's something that can be primarily customizable to what works for me, that will allow me to identify key things that are important. Tear, laceration, fracture — those are key words. I want that referral to scream at me like, "Work me first. Work me first. Work me first." It doesn't necessarily mean that patient's more important than the next patient. It just means that their problem is more urgent than the next problem.

[00:20:20] Joe: For a group that is looking to get serious about referral management, to take it to the next level, to make it really a growth driver within the practice rather than something that maintains a current level of volume — where do they start? Where do you recommend they start? Do they look at the people first? Do they look at the process first? Do they look at technology to identify gaps? What do you recommend?

[00:20:40] Misty: Yeah, I definitely think you need to look at your staffing first. How many people do you have to answer your phones should be first, and how many people do you have to check in your patients? I think that's very important. Because people that are answering phones, those people are going to also get cold calls, which in a sense are still a referral — somebody may have provided word of mouth referring to your clinic. People that are doing check-in and check-out at the front desk are gonna get people walking in with a paper referral.

And then referral coordinators. I think that position historically gets really overlooked, in a sense where people don't really think that they need it. When I joined this practice in 2021, we had zero call center representatives and zero referral coordinators. There were five people at the front desk. They did all of the phone calls, they did all of the check-in and check-out, and they did all of the referrals. So that was five people doing the job of how many I have now.

I have five at my front desk, four in my call center, and three people that work referrals. So you're looking at about 12 people now that make that access to care better. And so you're gonna grow more if you take the time to really evaluate how you can separate those positions. Because if that thing is really important for you — which is referrals, and referrals are very important for sustainability of an independent practice — then you have to be committed to making sure that you have the manpower to work what you need.

So I wish I could say you could just look at one thing at a time. It's pretty much you kind of have to almost do a SWOT analysis, or Post-it. I love Post-it paper. I'm surprised there's none on my back wall right here now — if I look to the left, there's four of them. And so it's just identifying... I always look at it as areas of opportunity. They're not problems, they're areas of opportunity, because you can do what you need to do to fix them. A lot of times problems cannot be fixed. Areas of opportunity, in my mind, can. And so just taking that time to do the analysis to identify where your areas of opportunity are is probably gonna be your very first step.

[00:22:54] Joe: Amazing. Misty, what's the best way for an operations leader to reach out to you, to get in touch with you, to have a conversation about taking their process, their team, to the next level?

[00:23:04] Misty: Yeah, I'm always available. Email is usually the best way. My email gets bogged down, but I love connecting with people. I just did a conference this last weekend and provided it. My email is m.sullivan@proliancesurgeons.com, which is fairly long. They could obviously reach out to you and you could connect them with me as well. My office number, which lucky me rings to my cell phone as well, is shared in the episode audio. You'll probably have to leave a voicemail because I'm in and out of meetings, but I'd be happy to connect with anyone and just have a conversation.

Very passionate about operations. I'm very passionate about healthcare in general. Orthopedics is my jam, but I have some experience with helping primary care clinics learn to process referrals as well. So I am happy to chat with anyone. I'm a little long-winded at times once you get me going 'cause I'm passionate, but I'm happy to have those conversations.

[00:24:00] Joe: Oh man. Thank you Misty, so much for your time. You're obviously a wealth of knowledge, of inspiration. Thank you so much for your time.

[00:24:10] Misty: Thank you.

[00:24:11] 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.