YMG Practice Standards

I. Telephone Access
II. Appointment Availability and Scheduling
III. Information for Patients: Directions, Signage and Clinical Information
IV. Patient Registration
V. Reception/Waiting Areas
VI. The Patient Experience
VII. Physical Appearance of Facilities
VIII. Human Relations
IX. Medical Records
X. Referring Physician Communication and Reporting
XI. Physician/Clinical Productivity
XII. Answering Services
XIII. Billing and Collection Systems
XIV. Patient Billing Services
XV. Managed Care Referral Process

I. Telephone Access

Telephone Response Time

All clinical area phones will be answered in four rings (or 22 seconds) or less. This applies to all areas and all employees with patient or referring physician contact.

Phone Greetings

Greeting must include at least the three following components:

1. Identification of staff member's name
2. Identification of clinical area
3. Offer of "how may I help you" or "how may I direct your call?"
   Example: "This is Medical Oncology, Jane speaking. How may I help you?"

Voice Mail Utilization

• Use of voice mail or answering machine is prohibited in clinical areas between 8:30 a.m. and 5:00 p.m., Monday through Friday, except when all lines are busy.
• Voice mail and answering machine can be used for internal or business communication, but not for clinically related communication.
• For appropriate numbers answered by voice mail or answering machine, the system must include the ability to automatically transfer the caller to the answering service in case of emergency. The caller should not have to hang up and dial another number.

Phone Tree Utilization

• The use of phone trees is discouraged between 8:30 a.m. and 5:00 p.m. If used, the caller must be given the option to speak to an attendant within the first 30 seconds of the recorded message.
• Phone trees referring the caller to another phone number must use a system that automatically transfers the caller. Callers should not have to hang up and dial another number.

Appointment Scheduling

• Numbers publicized for appointment scheduling must be covered/answered by a staff member from 8:30 a.m. to 5:00 p.m., or until clinical area closes (which-ever is later), Monday - Friday.
• Appointment scheduling numbers should be answered by voice mail, answering service or answering machine only during off-hours, before 8:30 a.m. and after 5:00 p.m. A message providing a number to call in an emergency must be included.
• A central appointment scheduling number will be identified as a back-up service should a caller receive a busy signal in a specific scheduling area. This is not to be used as a replacement for section scheduling staff.
• A central Faculty Practice number, such as the Yale Referral Assistance Line, will be available to help callers locate other specialties or services.
• All clinical areas will utilize the centralized Yale Medical Group (YMG) and Office of Professional Services (OPS) patient appointment reminder/confirmation system.

II. Appointment Availability and Scheduling

Appointment Availability: Specialty Services

• Emergency/urgent care - same day if indicated, but within 24 hours of request for new and return patients. If requested attending is not available, a member of the Service's physician team should offer to see the patient within this time frame.
• Non-urgent or routine care - within one week of request, but not to exceed three weeks with appropriate referral authorization completed.
• Follow-up visit - within three weeks of requested time.
• Each department will define criteria for determining emergent/urgent and routine visits to assist staff in proper triage.
• An attending consultant in each section/specialty will be available for urgent outpatient care during regular office hours, Monday - Friday.
• Compliance/Monitoring - One clinician in each section and/or specialty will be accountable for compliance with access standards. Clinic Chiefs will work with staff in their areas to develop a system to triage level of care as described above.

Appointment Availability: Primary Care Services

• Emergency/Urgent care - same day if indicated, but within 24 hours of request. The accommodation of "walk-in's" is encouraged for urgent visits.
• Non-urgent or routine care - within one week of request.
• Follow-up visit - within one week of requested time.
• Routine physical exam - within three weeks of request.
• Each department will define criteria for determining emergent/urgent and routine visits to assist staff in proper triage.

Appointment Availability: Diagnostic Services

(Including: Diagnostic Radiology, EEG/EMG, Pulmonary Function Lab, GI Procedures, Cardiac Testing, Speech/Hearing Center, EKG, Sleep Study Center, Echocardiography)

• Emergency/Urgent care - same day, not to exceed 24 hours of request.
• Level of urgency will be determined by the referring physician.
• Non-urgent care - preferably same day, but not to exceed 72 hours of request.
• Routine care - at patient's convenience, but within two weeks of request.
• Each department will define criteria for determining emergent/urgent and routine visits to assist staff in proper triage.
• Saturday hours should be offered for routine services such as Mammography.

Referral Process Verification: For New and Return Patients

To ensure that insurer's referral process is followed correctly, staff will verify insurance plan and referral requirements at the time of appointment scheduling. The YMG will provide staff with training and updated materials to verify that the correct referral process is being followed for the patients' health plans.

Access to Yale Services

• No medically necessary professional services will be denied to a patient based solely on their insurance status.
• All clinical areas will make every reasonable effort to pursue out-of-plan referrals when medically indicated. It is understood that there will be times when insurance contracts will prevent out-of-plan referrals.

III. Information for Patients: Directions, Signage and Clinical Information

Getting to the Medical Center

• Yale Medical Group (YMG) standardized patient and visitor guide/map will be utilized by all YMG clinical areas.
• Supplies of map/guide will be distributed to key referring physicians' offices by the YMG.
• All new patients will be mailed or faxed the YMG map/guide at time of appointment scheduling, time permitting.
• The YMG will develop large print and Spanish versions of the YMG Map/Guide.
• Directional signs from the Medical Center to major highways will be placed near exits of parking areas and on adjacent city streets, as permitted by municipal regulations.

Internal Signage

• All signage in the YPB and other clinical areas will follow established color and style guidelines.
• The YMG will ensure that all major hallway intersections and ambiguous internal routes receive expanded signage. This will be coordinated with YNHH.

Clinical Care and Educational Materials

• Materials developed by Yale practices will meet style, content, and quality standards to improve effectiveness and to enhance the Faculty Practice identity. The YMG will develop guidelines and standards for templates and models to be used for patient educational materials.
• The YMG will supply standard brochure racks in patient reception areas.
• The YMG will develop/produce health care magazines/newsletters for patient education and for promotion of new programs. Coordination with YNHH will be pursued where indicated.

IV. Patient Registration

Pre-registration

• The YMG will pursue centralized pre-registration in all YMG clinical areas. Pre-registration materials will include:
  • Clear, easy to read pre-registration form and instructions
  • Postage-paid return mailer
  • YMG patient and visitor map/guide
• The pre-registration form patient return rate goal is 90%.
• The percent of new patients required to visit centralized registration desk on day of visit will not exceed 20%.

Day of Visit Registration

(in all registration locations including: YPB Central Registration, Dana Building, Children's Hospital, Emergency Department, Primary Care Center and Admissions)

• Wait time at all registration locations will not exceed 10 minutes after arrival.
• The registration process will be completed within 10 minutes.

V. Reception/Waiting Areas

Staff Greeting of Patients and Visitors in all Clinical Areas

• All patients/visitors will be acknowledged at time of arrival at the reception desk.
• Staff will greet the patient with "Hello, may I help you?" and address the patient as Mr., Mrs. or Ms., as indicated.
• If staff is busy when patient arrives, the staff member will acknowledge arrival with "Hello, I will be right with you."
• Additional reception courtesy standards include:
  • Greetings will be directed to the patient in a patient-friendly, non-distracted fashion
  • Sensitivity in asking questions in open areas will be maintained to respect patient privacy
• Reception desk appearance guidelines include:
  • No loud talking at desk
  • No personal calls made/taken at desk
  • No crafts, personal business or playing of computer games at desk
  • No food allowed in reception or patient care areas
  • No radios or other electronic distractions permitted
• Name tags will be worn by all employees in Yale Medical Group (YMG) clinical areas which clearly note name, clinical area and job function.
• A policy will be developed to standardize dress codes across the University and Hospital staff working in YMG clinical areas.

Yale Physicians Building and Clinical Area Lobbies

• The YPB lobby desk will be maintained primarily as a reception/information desk rather than a security desk.
• Security guards, while present, will not serve as the initial greeting point for patients and visitors. Guards will wear a more "patient-friendly" jacket rather than security uniform.
• All patients will be greeted in a professional and courteous manner.
• YPB transport staff will wear a neat, easily recognizable uniform and conduct themselves in a friendly, professional manner.

VI. The Patient Experience

Wait Times: Specialty or Primary Care Office Visits

• Wait time in reception area - Staff to follow a 0/10/20 benchmark:
  • Target is zero wait time
  • In most cases, patients will be seen within 10 minutes of appointment time
  • No patient should wait more than 20 minutes
• Wait time in exam room - not to exceed 15 minutes:
  • between exam room arrival and nurse/PCA intake
  • between intake and physician arrival (includes attending, residents and fellows)
• Physicians must be present prior to the start of their clinical session so that nursing issues can be addressed in advance, as needed.
• The physician must be available to see the first patient promptly or no later than five minutes after specified start-time.

Wait Times: Diagnostic Services

Including these service areas:

• Diagnostic Radiology
• EEG/EMG
• Pulmonary Function Lab
• Speech/Hearing Center
• Cardiac Testing
• Sleep Study Center
• EKG
• Echocardiography

Time in waiting room: Staff to follow a 0/10/20 benchmark:

• Target is zero wait time
• In most cases, patients must be seen within 10 minutes of appointment time
• No patient should wait more than 20 minutes

Time in testing/procedure area: not to exceed 15 minutes:
Wait times will not exceed 15 minutes between exam or testing room arrival and time nurse or technician commences testing or intake.Physicians must be present prior to the start of their clinical session so that nursing issues can be addressed in advance, as needed.The physician must be available to see the first patient promptly or no later than five minutes after specified start-time.

Wait Times: Phlebotomy and Other Services without Pre-set Appointments

• Patients will be served on a first come, first serve basis, but the wait may be no longer than 15 minutes.
• If a request is stat/urgent, the patient will automatically move to the front of the queue.
• The staffing structure must accommodate transient increases in patient volume.

Explanation of Delays in All Clinical Areas

• A staff member must inform patients if the physician is delayed more than 10 minutes. A personal apology by the physician and/or primary provider should be made to the patient for the inconvenience.
• A staff member must inform late arriving patients of their "soon as possible" status.
• Inconvenienced patients should be given an estimate of wait time and provided the opportunity to wait or reschedule.
• The attending physician or nurse manager is responsible for ensuring that the delay information is relayed to the patient.
• Patients who arrive much earlier than their appointment time should be told that they will be seen at the next available time slot or at their original appointment time, whichever is sooner.
• Reception area staff will monitor wait times in the reception area and will notify clinical staff of wait times exceeding these standards.

VII. Physical Appearance of Facilities

Lobby Appearance

The Yale Physicians Building (YPB) lobby and main entrances for clinical activity areas will be:

• Smoke-free
• Furnished with ample chairs for waiting
• Clean and uncluttered

Clinical Area/Reception Room Appearance

Aesthetic improvements will be made to reach these minimum standards:

• Coat racks
• Supply of brochures about clinical services
• Racks with current magazines
• Easy access to public phones
• Tasteful art and/or plants
• Furniture clean and in good condition
• Cheerful decor and lighting

Availability of Parking

• Valet parking will be maintained as a special service.
• A standardized policy regarding parking validation will be adopted across clinical areas.
• The School of Medicine will make its best effort to reduce the cost of patient parking.

Wheelchairs and Patient Transport

• Wheelchairs and escort assistance must be readily available to meet patients at key entry points into the medical center, but transport employees will not necessarily be stationed in all lobbies.

Elevators

• The YMG will evaluate the Yale Physicians Building and other clinical area elevators to optimize speed and efficiency.

Facility Cleanliness

• The cleanliness and appearance of the Yale Physicians Building and related YMG clinical areas will be maintained according to current established standards.
• A warm, friendly, and cheerful environment will be maintained.
• Lobby, reception room, rest room, and exam room cleanliness will be maintained to meet patient and visitor expectations.

Facility Access

• All building entrances, rest rooms, reception and exam rooms will be wheelchair and handicap accessible.

VIII. Human Relations

Communications: Among Staff

• Communication among all health professionals will be conducted in a mutually respectful manner. This principle applies to all verbal, non-verbal, and written communication.

Physician-Patient Interactions

• Physicians will communicate with their staff regarding patient issues and incorporate the staff as valued and trusted members of the health care team.
• Physicians will make every reasonable effort to answer all patient phone calls the day they are received. Physicians who do not see patients daily must ensure they receive patient messages on an ongoing basis and respond promptly.
• A physician or covering provider will be available to his/her patients at all times. The covering physician must have the ability to become fully informed of the pertinent patient and medical record information. It is recognized that the primary responsibility of some physicians is research. Therefore, an effort to minimize interruption of their work should be made by judicious use of committed covering providers.
• Clinic Chiefs will structure mechanisms of communication that make it simple and efficient for patients to reach their physicians by telephone.
• Clinic Chiefs will be responsible for monitoring problems regarding physician-patient communication.

Staff-Patient Interactions

• All staff, attending physicians, fellows, residents and medical students will introduce themselves to patients and identify their specific role in the examination and/or visit.
• Physicians and professional staff (including residents and fellows) will provide patients with a professional card that identifies their name, title, YMG affiliation, and a number to call for follow-up communication.
• All physicians and staff will provide full explanations of the steps in clinical care, as indicated. Ample time should be allowed for questions and answers. This should include, but will not be limited to explanations of:
  • History/physical
  • Care plan
  • Diagnostic test results
  • Follow-up
  • Therapeutic options

Communication: Ambulatory Services Agreement

• A structure must be established in which issues of employee performance can be addressed and resolved promptly in a minimally confrontational way.
• The Hospital and University must establish a structure that is acceptable to both organizations so that employees working side-by-side, but with different employers, are treated equitably. This should include a mechanism for appeal of decisions.
• A conflict resolution program will be established that can be customized to meet the needs of each department. The program or mechanism will reflect common elements across departments.

Patient Privacy

• All staff members will at all times respect the privacy of patients while in clinical and public areas.
• Signs will be placed in discrete locations throughout clinical areas noting this standard to educate all providers and staff.
• There will be an organized effort to educate the whole provider and staff community about patient confidentiality and the need to respect it at all times and in all circumstances.
• Medical record confidentiality will be maintained at all times.

IX. Medical Records

Electronic Medical Record

• The Yale Medical Group (YMG) will develop an electronic medical record (EMR) that incorporates the patient's in-hospital and outpatient record.
• The development of the EMR will be a joint undertaking between the School of Medicine and YNHH.
• The EMR must improve record timeliness, availability and completeness.
• The implementation of an EMR will be completed in an efficient and timely manner.

Record Availability

• Current and complete hospital records for ambulatory visits must be available upon physician request.
• Records will be requested by the physician's staff at least one day prior to the patient visit.
• In order to meet the highest level of patient care, all physicians must maintain readily accessible medical records.
• Ambulatory records will be maintained in a readily available fashion.
• In the event of an urgent add-on visit, staff must make a substantial effort to obtain appropriate medical records.

Production/Format

Dictations

• Dictations of ambulatory visits will be completed within 24 hours of visit.
• Review and signature of dictation transcription will be completed within 48 hours of completed transcription.
• Transcriptions will be filed in the medical record within seven days of visit.

Record Format

• All communications to the referring physician will be typed, word-processed, or legibly handwritten.
• All clinical areas will make every effort to have all records typed.
• A standardized telephone message form will be developed by the YMG for use in all ambulatory clinical areas.
• The YMG will explore the use of other standardized forms across all clinical areas.
• All standardized visit templates will reflect HCFA Evaluation and Management (E&M) Coding requirements.

NCQA Medical Record Standards

The healthcare industry is moving toward NCQA standards. As such, ambula-tory records will be maintained in a manner that reflects primary and specialty care NCQA standards. Detailed NCQA guidelines for medical records are presented in Appendix 1.

Service Documentation

• All written records of patient encounters will follow guidelines established in HCFA IL-372 and related regulations.
• The attending physician must document his/her involvement in the service.
• The documentation must be complete.
• The CPT code must reflect the attending level of service documented in the patient record.

Laboratory and Diagnostic Imaging Reports

• The standard for filing reports of diagnostic imaging results in the ambulatory medical record must parallel that of provider visit dictations.
• The results of any diagnostic testing performed more than seven days prior to the ambulatory visit should be filed within the patient's record.
• Electronic access to laboratory and diagnostic imaging results must be available in every ambulatory setting.
• Each clinical department is responsible for developing guidelines for reviewing and acting on abnormal laboratory results.
• All laboratory, procedure/test and diagnostic imaging requisition forms must provide at least the following spaces for completion: a) ordering physician name, b) referring physician name(s) and c) fax number for reporting results.
• Copies of reports will be generated for the Hospital and YMG medical records.
• Each Clinic Chief will develop a process for their clinical area to receive, review, and act upon unexpected laboratory results.

X. Referring Physician Communication and Reporting

Reports of Primary Care and Specialty Outpatient Visits

• Letter to referring physician (RP) will be:
  • Dictated at the end of each clinical day, at most within 24 hours of service
  • Transcribed within two working days of dictation
  • Signed/mailed within two working days of completed transcription
  • Copy of reports must be sent to appropriate RPs, specialists and PCPs.
• The RP will be called on the same day of the visit by the attending, resident or fellow, as indicated, if the patient is admitted or urgent clinical issue arises.

Reports of Invasive Diagnostic and Therapeutic Services

• A telephone call by the attending physician performing the procedure will be made to the referring physician (RP) on day of procedure.
• Procedure/operative note will be:
  • Dictated at the end of each business day, at most within 24 hours of service
  • Transcribed within two working days of dictation
  • Signed/mailed within two working days of completed transcription
  • Copy of reports to appropriate RPs, specialists and PCPs.

Reports of Non-invasive Diagnostic and Therapeutic Services

(Including: EEG, Diagnostic Imaging, Cardiac Testing, Pulmonary Function, EKG, Chemotherapy)

• Test reports will be:
  • Dictated at the end of each business day, at most within 24 hours of service
  • Transcribed within two working days of dictation
  • Report signed/mailed to the RP within two working days of completed transcription.
• A "wet reading" will be available to the RP on the day of study, if requested.
• Unusual, unexpected or clinically significant findings will be called or faxed to the RP by the interpreting physician on the day of the study. When feasible, abnormal results will be faxed as soon as possible.

Inpatient Care Communication

• Attending Physician (AP) or Nurse Clinician will call the Referring Physician (RP) at least once per admission, or at least once per week during an extended stay.
• Unusual, unexpected or urgent clinical issues will be communicated to the RP within 24 hours, preferably on the same day.
• Discharge Summary will be:
  • Dictated within 24 hours of discharge
  • Transcribed within two working days of dictation
  • Signed/mailed to RP within two working days of completed transcription
  • YMG and YNHH will ensure that a system is in place to easily and accurately identify RP
  • A copy of the discharge summary will be sent to the primary care physician if other than the RP.
• Operative Note will be:
  • Dictated within 24 hours of procedure
  • Transcribed within two working days of dictation
  • Signed/Mailed to RP within two working days of completed transcription.

Autopsy Service

Department of Pathology will develop standards of timeliness for post-mortem examinations, consistent with those of other services (as described above).

XI. Physician/Clinical Productivity

Clinical Space Utilization: Individual Standards

• All clinical faculty will conduct their practice in a manner that maximizes the use of clinical resources.
• Each faculty member will see a volume of patients consistent with national standards. The YMG will make guidelines available to departments in order to help define the standard by specialty.

Clinical Space Utilization: Clinical Area Standards

• Each clinical area will reach at least 80% of weekly exam room capacity (capacity to be determined by each department).
• In meeting this standard, no single day (Monday through Friday) will fall below 80% utilization.
• Practices not meeting utilization standards will explore session sharing and internal leasing of space to other departments to improve utilization.
• Departments will utilize the new centralized appointment reminder system and/or take specific steps to reduce no-show rates to 10% or less.

Clinical Productivity

• Each faculty member will reach a minimum level of clinical and financial productivity (to be developed by each department).

Ambulatory Services Agreement

• Ambulatory Services Agreement will be reviewed and revised to optimize service and staffing efficiency in YMG clinical areas.

XII. Answering Services

Operator-Phone Response Time

• Calls to answering service will be answered in 20 seconds, or four rings, at least 80% of the time.
• Calls will be answered in a courteous and professional manner.
• Operator greeting will include the three following components:
  • Identification of clinical area represented
  • Identification of staff member name
  • Offer of "how may I help you?"
    Example: "Good morning. Medical Oncology answering service, Jane Smith speaking. How may I help you?"

Clinical Area Information

• Clinical areas utilizing an answering service are responsible for notifying the answering service of changes in the on-call schedule within 24 hours of change to be in effect. Notification of changes will follow the standard format established by the service.
• Departments will provide their answering service with a contingency phone list in case an attending cannot be reached.
• Clinical areas will provide the answering service with on-call information according to the standard format established by the service.

Holiday, Weekend, and Off-Hour Coverage

• Attending physicians are responsible for notifying the answering service of set schedules and of any changes in that schedule.

XIII. Billing and Collection Systems

Encounter Forms

The attending physician must complete the encounter form for the visit/treatment at the time of service. All other providers, such as nurses, will complete encounter forms within 24 hours after service delivery.

Charge Data Entry

• Data entry of charges must be completed within 48 hours of date of service or the completion of encounter forms for outpatient services and within five working days for inpatient services.
• All patient care documentation must be consistent with HCFA IL-372 and related guidelines.

Claims Processing

• HCFA claim forms (paper and electronic) must be generated daily.
• 96% of claims must be clean in initial claims generation.
• Claims rejections or "kick-outs" will occur in no more than 15% of claims.

Cash Posting

• Cash posting to accounts will be completed within 48 hours of receipt of carrier payment.

Billing Statement

• Statements must be clear, concise, accurate, and easy to read as measured by an overall score of at least 90% on the relevant questions on the YMG Patient Satisfaction Survey.
• Continuous quality improvements will be made to the billing statement as part of IDX implementation and workflow redesign.

Days in Accounts Receivable

• YMG-wide Days in Accounts Receivable will not exceed 90 days once IDX is implemented.

Physician Reporting

• Each faculty member will receive on a regular basis individualized financial reports detailing their billing, collections and accounts receivable.

XIV. Patient Billing Services

Phone Services

• Patient Representatives must answer calls within 20 seconds (or four rings) 90% of the time.
• Call abandonment rate must be 6% or less.
• Busy signal rate must be 1% or less.
• Representatives must follow phone reception and courtesy standards described in Standard I.
• Walk-in inquiries will be handled immediately with no wait.

Collections Office

• This service is an important interface with patients, staff and the community. Thus, the use of voice mail is discouraged.
• If required, calls will be returned within two hours. The voice mail message will be courteous and include a message such as, "we apologize for the inconvenience of waiting."

General Services

• The YMG will evaluate and implement appropriate cost saving and/or service improving processes as recommended by workflow redesign team.
• OPS will conduct regular service quality control audits and develop monthly management reports for patient services functions.

Correspondence Activity

• Written inquiries must be investigated and resolved within 10 working days. A postcard will be mailed to the patient acknowledging that the complaint has been received and outlining the steps that will follow.

Clinical Reporting System

• The Clinical Reporting System (CRS) and Clinical Information System (CIS), will expedite the development of a management reporting system and meet information support requests on a timely basis.
• Yale-New Haven Hospital will develop the ambulatory statistics tracking system to ensure that YMG data is reported accurately and on a timely basis.

XV. Managed Care Referral Process

Staff Training and Support

• The YMG will provide thorough, timely training for clinical area staff for new contracts and/or major changes in current contracts. This will include the development of a "managed care basics" and referral awareness courses for all staff and faculty.
• Departments will be informed of new contract agreements and their contents and will receive provider manuals prior to contract effective dates.
• The YMG will provide referral information updates for all clinical areas on a timely and regular basis and develop additional methods to reduce steps required for scheduling staff in the referral process.

Referral Tracking

• The IDX system will include an automated referral tracking system and managed care module.
• The YMG will provide clinical area staff with ongoing referral awareness training and updated referral tools and materials.
• When scheduling patients, staff will verify that the referral requirements are met for each patient's insurer and ask key questions such as:
  • Are you a member of an HMO/PPO?
  • Does your HMO require a referral form from your primary care doctor?
  • Who is your primary care doctor?; Who referred you to us?
• Before scheduling any return patients, staff will check the referral form in the patient chart or contact the HMO to ensure that the referral remains valid.

YMG (c) 1998-2004