I PRACTICE MANAGEMENT ^20 ^110 ^140

Issues to consider in the management of a successful health care practice include staffing requirements; billing systems; patient care coordination; appointments, scheduling, and patient flow; practice coverage for absent physicians; and systems for proper storage and disposal of drugs and other sensitive materials.

Staffing

Staffing Levels

Staffing requirements for an office or institution will vary. Factors in set­ting staffing levels and types include the anticipated need for chaperoning, population served, and scope of services to be provided. State regulations may be relevant, depending on the health care providers needed and their scope of practice. In some cases, contractual arrangements may be required to assist patients with their health care needs (eg, with providers of nutri­tion, ultrasonography, and social services).

The efficient operation of an ambulatory surgical facility requires that the assignment of administrative and professional personnel be based on the number of patients, patient characteristics (eg, intensity of care required and types of procedures performed), the level of preparation and experi­ence of those who provide care, and the facility design. A sufficient number of staff members with the skills needed to provide optimal care for specific procedures should be available to prevent undue delays in the provision of care. Departments in large institutions generally derive their staffing levels from institutional guidelines. Some professional organizations, such as the Association of Women’s Health, Obstetric and Neonatal Nurses, have established staffing guidelines for patients in the labor and delivery suite and mother-to-newborn nursing ratios. Institutions may use these guide­lines to establish their own staffing levels. There are no established national staffing guidelines regarding gynecologic care for patients.

Types of Practitioners

A health care team may include many professionals. These professionals should be licensed and possess the credentials required by their respective professional organizations.

Obstetrician-Gynecologists

Obstetrician-gynecologists are physicians with additional education and experience in reproductive medicine and women’s health care. They have completed a 4-year residency and many go on to be certified by the American Board of Obstetrics and Gynecology, Inc. Those who received their initial board certification in or after November 1986 have time-limited certificates that must be renewed every 6 years through a process of main­tenance of certification (see also the “Evaluating Credentials and Granting Privileges” section in Part 1). Obstetrician-gynecologists who are board cer­tified or active candidates may become members of the American Congress of Obstetricians and Gynecologists. Some obstetrician-gynecologists seek additional training in a subspecialty. At present, the American Board of Obstetrics and Gynecology offers subspecialty certification in four areas: 1) reproductive endocrinology and infertility, 2) maternal-fetal medicine, 3) gynecologic oncology, and 4) female pelvic medicine and reconstructive surgery.

Osteopathic obstetrician-gynecologists receive roughly 200 hours of osteopathic manipulation medicine training during the traditional 4 years of medical school. There is an optional 1-year fellowship in osteopathic manipulation medicine for physicians who desire additional training. After completion of a residency training program, osteopathic obstetrician­gynecologists can apply for board certification from the American Osteopathic Board of Obstetrics and Gynecology.

Registered Nurses

Nursing personnel who care for gynecology patients should be familiar with the special aspects of gynecologic conditions and the equipment needed to care for these patients. Delivery of safe and effective nursing care requires appropriately qualified registered nurses in adequate numbers to meet the needs of each patient in accordance with the care setting. The number of staff members and level of skill required are influenced by the scope of nursing practice and the degree of nursing responsibilities within an institution. Nursing responsibilities in individual hospitals vary accord­ing to the level of care provided by the facility, practice procedures, number of professional registered nurses and ancillary staff, and professional nurs­ing activities in continuing education and research.

Changing trends in medical management and technological advances influence, and may increase, the nursing workload. Each hospital should determine the scope of nursing practice for each nursing unit and specialty department. The scope of practice should be based on national nursing standards and guidelines for the specialty area of practice and should be in accordance with state law or regulations. A multidisciplinary committee comprising representatives from hospital, medical, and nursing admin­istration should follow published professional standards and guidelines, consult state nurse practice acts and any accompanying regulations, iden­tify the types and number of procedures performed in each unit, delineate direct and indirect nursing care activities performed, and identify activities to be performed by nonnursing personnel.

Hospitalists

The term hospitalist refers to a physician whose primary professional focus is the general medical care of hospitalized patients.

Within the specialty of obstetrics and gynecology, the concept of the hospitalist or laborist is an evolving model of care and an alternative type of practice for some physicians. The term laborist commonly refers to an obstetrician-gynecologist who is employed by a hospital or physician group and whose primary focus is to care for laboring patients and to man­age obstetric emergencies. There is no single accepted definition; however, there is general agreement that the specialist hospitalist and the laborist treat patients only in a hospital setting.

For the obstetric-gynecologic hospitalist, practicing solely in the hospi­tal setting relieves the pressures of a private practice, such as overhead and collections, and may help with liability premiums. Among the possible benefits may be more predictable schedules, competitive compensation, paid benefits, and guaranteed time off. The benefits to the hospital include enhancement of patient safety and an increased level of nursing satisfaction because a health care provider is always present and available. In addi­tion, improved outcomes may result from hospitalists being well rested when coming onto their shifts. For obstetrician-gynecologists in general practice in the community, having an obstetric-gynecologic hospitalist in practice at their admitting hospital affords several advantages. For example, obstetric-gynecologic hospitalists can assume the responsibilities of on- call obligations, provide coverage for patients who come to the hospital uninsured or unassigned for prenatal care, and afford office-based physi­cians greater autonomy over their personal and family lives.

However, critics point out that the transfer of care from the office physician to the hospitalist may increase medical errors and that patients dislike the concept of health care delivery by a physician they have never met. A key element for instituting an effective obstetric-gynecologic hos- pitalist program within a facility is the establishment of clear communica­tion methods between obstetric-gynecologic hospitalists and outpatient obstetrician-gynecologists or primary women’s health care providers. In addition, physicians should inform patients that hospitalists and laborists are part of the health care team that may provide their care.

The obstetric-gynecologic hospitalist model may be met with some resistance from some physicians and patients. However, this model may be appealing, particularly for younger obstetrician-gynecologists who are con­cerned about maintaining liability coverage, establishing an independent practice, and maintaining a balanced life style. The model of the obstetric- gynecologic hospitalist is still evolving, yet it is one potential solution to achieving increased professional and patient satisfaction while maintaining safe and effective care across delivery settings.

Certified Nurse-Midwives and Certified Midwives

Certified nurse-midwives (CNMs) and certified midwives (CMs) are pri­mary care providers who focus on pregnancy, childbirth, the postpartum period, care of the newborn, and the family planning and gynecologic needs of women. A CNM is a registered nurse who has been educated in the two disciplines of nursing and midwifery; a CM is not a nurse but has met the same standards for midwifery education and certification as the CNM. To obtain certification, applicants must successfully complete a graduate program in midwifery from a school of midwifery accredited by the Accreditation Commission for Midwifery Education. The certification of a CNM or CM is conferred through a national examination and verified by the American Midwifery Certification Board, Inc.

Clinical Nurse Specialists

Clinical nurse specialists are registered nurses who have completed a for­mal educational program at the master’s degree level. Clinical nurse spe­cialists can handle a wide range of physical and mental health problems. They generally work in inpatient settings and are certified by the credential­ing unit of the American Nurses Association.

Nurse Practitioners

Nurse practitioners (NPs) are licensed registered nurses with advanced- practice education, including supervised clinical instruction in health maintenance and diagnosis and treatment of illness. Completion of an NP program may lead to a certificate or a master’s or doctoral degree.

Certification as an NP is required in some jurisdictions and is voluntary in others. Certification is based on completing an approved educational program, passing a national certification examination, or both. Nurse practitioners who specialize in women’s health are certified by the National Certification Corporation. Requirements for certification vary according to the specialty area and are determined by the certifying organization.

Nurse practitioners are qualified to provide a wide range of primary and preventive health care services, including obtaining medical, surgical, and psychosocial histories; performing physical examinations; and diagnosing and treating common illnesses and injuries. They generally work in pri­mary care outpatient clinics, health maintenance organizations, specialty clinics, and schools. An increasing number of NPs are employed in inpa­tient settings.

Women's Health Nurse Practitioners

The women’s health nurse practitioner (WHNP) is an advanced-practice registered nurse who is prepared through academic and clinical study to provide health care, with an emphasis on reproductive-gynecologic and well-woman health, to women throughout the life span. Women’s health nurse practitioners are licensed and regulated by boards of nursing. In many states they also are subject to regulation by state medical boards, par­ticularly in areas of prescribing and collaboration agreements. The WHNP functions in a variety of settings and provides care that includes wellness promotion and management of gynecologic and common nongynecologic problems. The National Certification Corporation is the recognized certi­fying body for WHNPs. Educational programs for WHNPs are based in a college or university graduate nursing program and should include at least 200 didactic hours of content and at least 600 hours of supervised clinical practice.

Physician Assistants

Physician assistants (PAs) enter the profession from a variety of back­grounds and are educated to provide care as part of a health care team under the supervision of a physician. The Accreditation Review Commission on Education for the Physician Assistant accredits PA programs. Most of these programs have been established in, or have strong affiliations with, medi­cal schools. Applicants generally have at least 4 years of college education, and many programs require applicants to have acquired health care experi­ence or community experience before admission. The educational program traditionally consists of 24-32 months of didactic instruction and clinical rotations. Curriculum design for most PA programs involves basic sciences, clinical sciences, and supervised clinical instruction. Physician assistant students complete, on average, more than 2,000 hours of supervised clinical practice before graduation. Although all programs recognize the professional component of PA education with a document of completion for the professional credential (PA), 80% of the programs award a master’s degree, 15% award bachelor’s degrees, and 5% award associate degrees or certificates.

Physician assistants practice in virtually all specialty areas, in outpatient and inpatient settings, as first or second assistants in surgery, and in pro­viding preoperative and postoperative care. All jurisdictions require PAs to pass a national certification examination before they can practice. The examination is given only to graduates of accredited PA programs and is developed by the independent National Commission on Certification of Physician Assistants. To maintain national certification and use the creden­tial Physician Assistant-Certified, an individual must complete 100 hours of continuing medical education every 2 years and take a recertification examination every 6 years.

Surgical Assistants

Competent surgical assistants should be available for all major obstetric and gynecologic operations. In many cases, the complexity of the surgery or the patient’s condition will require the assistance of one or more physicians or other personnel with special surgical training to provide safe, quality patient care. Often, the complexity of a given surgical procedure cannot be determined prospectively. The judgment and prerogative of the primary surgeon to determine the number and qualifications of appropriately com­pensated assistants should not be overruled by public or private third-party payers. Registered nurses and other personnel assisting in the provision of surgical services should be appropriately trained, be granted privileges to assist in specific procedures, and remain under the direct supervision of the surgeon.

Registered nurse first assistants are employed in hospital-based settings, ambulatory care settings, collaborative practice with physicians, and inde­pendent practice. The role of the registered nurse first assistant falls within the scope of nursing in all 50 state boards of nursing. Registered nurse first assistants must demonstrate the following:

• Competency in performing individualized surgical nursing care management before, during, and after surgery

• Competency in recognizing surgical anatomy, physiology, and operative technique

• Competency in carrying out intraoperative nursing behaviors of handling tissue, providing exposure, using surgical instruments, suturing, and controlling blood loss

• Competency in recognizing surgical hazards and initiating appropri­ate corrective and preventive action, including but not limited to recognizing abnormal laboratory values and diagnostic test results

• Achievement of Basic Cardiac Life Support Certification, Advanced Cardiac Life Support Certification, or both

• Achievement of national Certification in Operating Room Nursing

Other Health Care Providers

Certified professional midwives are certified through the North American Registry of Midwives. There is no single standard for education through the North American Registry of Midwives; a midwife can learn through a structured program, apprenticeship, or self-study, although certified profes­sional midwives usually pass a written and practical examination for certifi­cation. Some states recognize the certified professional midwife credential as the basis for licensure or use the North American Registry of Midwives written examination. However, some midwives act outside of state recog­nition and oversight and, in fact, are not licensed by the state. Although the American College of Obstetricians and Gynecologists supports women having a choice in determining their providers of care, it does not support the provision of care by midwives who are not certified by the American College of Nurse-Midwives or the American Midwifery Certification Board. Most unlicensed midwives do not have hospital privileges, and practice and licensing requirements vary from state to state.

A naturopathic physician (ND) is the highest level of trained practitio­ner in the field of naturopathic medicine. At schools of naturopathic medi­cine, NDs are trained in medical sciences and conventional diagnostics, therapeutic nutrition, botanical medicine, homeopathy, natural childbirth, classical Chinese medicine, hydrotherapy, manipulative therapy, pharma­cology, and minor surgery. Some states have licensing laws for NDs that allow them to practice as primary care general practice physicians, but most states do not license these individuals.

Billing

When scheduling an appointment, the office staff should discuss with the patient customary fees, methods of payment, billing, third-party insurance procedures, requirements for co-payments, practitioner participation, facil­ity affiliation, and preauthorization or referrals that may be required at the visit. Verification of third-party coverage and compliance with continuing authorization requirements should occur at each visit.

The clinician should encourage the patient to review medical plan participation and identification of contractual requirements, including laboratory and imaging facility designations. A system should be in place to ensure proper participating laboratory and imaging service referrals. Appropriate referrals and approvals should be verified. A system should be established to ensure that all preprocedure requirements (laboratory tests, consents, examination records, and third-party authorizations) are met in advance of a procedure.

Staff should be aware of third-party contractual requirements for service and billing and participate in ensuring compliance with payer contracts.

The clinician is responsible for ensuring accuracy in the coding of bills. The clinician must ensure that appropriate documentation exists in the record to justify the level of service billed. Information regarding the Medicare documentation guidelines for evaluation and management ser­vices appears in the “Well-Woman Annual Health Assessment” section in Part 3. Many resources are available for reference and help with coding issues (see Box 2-5 and Resources).

Box 2-5. The American Congress of Obstetricians and Gynecologists’ Coding Resources

• Workshops and webcasts—These workshops are held several times a year in different parts of the country and are designed to teach physicians the essential elements of correct coding and documentation. The American Congress of Obstetricians and Gynecologists’ (ACOG) monthly webcasts cover coding, practice management, and professional liability topics from 1:00-2:30 pm Eastern Time on the second Tuesday of each month. For more information or to register, please visit ACOG’s Education and Events web page at www.acog.org/Education_and_Events.

• List serv—“The Practice Management and Coding Update” is a free monthly e-mail news service that includes effective coding tips, practice management advice, information about regulatory issues, and the latest news on what ACOG is doing to help address reimbursement concerns and improve the practice environment. To subscribe to the list serv, send an e-mail message to coding-request@suse.acog.org.

• Specific questions—Physicians and their staff can submit specific coding questions to ACOG staff by fax at (202) 484-7480 or e-mail at coding@ acog.org. (Per the Health Insurance Portability and Accountability Act regulations, please do not include any patient identifiable information in your fax or e-mail message.)

• Publications—A variety of coding publications may be ordered from ACOG’s catalog, web site (http://sales.acog.org/), or distribution center (1-800-762-2264).

If a patient questions the customary fees, the clinician should be informed and should advise staff as to the appropriate method of address­ing the patient’s concerns. Ideally, a specific staff member should be assigned responsibility for handling the financial concerns or complaints of patients.

Despite the recent passage of landmark health care legislation, every practice will continue to deal with the uninsured patient. According to the Kaiser Family Foundation, in 2011, 21.68% of women of childbearing age (15-44 years of age) were uninsured, and more than 19 million women aged 18-64 years were without health insurance. It is advisable to desig­nate someone in the office who is knowledgeable regarding Medicaid or other state-sponsored programs for the uninsured, as well as community resources such as subsidized clinics or voucher programs.

Care Coordination

The concept of the patient-centered medical home is being advanced by health professionals, administrators, and patient advocates as a cost­effective alternative to the current episodic, sometimes fragmented sys­tem of health care delivery. The principles of the medical home model are based generally on a physician who leads a team of clinicians and staff who in turn provide continuous, comprehensive, coordinated care based on a “whole person” orientation. Care is coordinated across all elements of a complex health care system and the patient’s community using means such as new health systems technologies. In this care model, information exchange between medical providers and between patients and the medical home is especially important. The American Congress of Obstetricians and Gynecologists (ACOG) supports the women’s medical home, which will provide targeted, continuous, coordinated, confidential, and comprehensive care to eligible individuals. The women’s medical home focuses especially on women who are at risk of premature birth, the prevention of cervical cancer, care for women with breast or gynecologic cancer, and care for chronic conditions. For more information, see ACOG’s Medical Home Toolkit web page, available at www.acog.org/About_ ACOG/ACOG_Departments/Practice_Management_and_Managed_Care/ ACOG_Medical_Home_Toolkit.

Appointments, Scheduling, and Patient Flow

Ambulatory Care

The most efficient method of managing patient access and flow in an office setting or clinic begins with appointment scheduling. Appointments should be booked realistically to maintain the clinician’s schedules and allow sufficient time for emergency appointments. The personnel in each facility should establish a realistic goal for minimizing waiting time. The average time a practitioner spends with a patient for various procedures (eg, new patient visit, yearly checkup, and gynecologic procedure) can be analyzed easily to form a basis by which scheduling can be optimized. Such scheduling should be analyzed periodically to ensure minimal patient waiting. Procedures for the following circumstances should be established:

• Rescheduling missed or canceled appointments

• Informing patients when their appointments will be delayed sub­stantially or when an emergency situation may prevent the clinician from keeping an appointment

• Processing patients in a timely manner

• Guiding patients to specific areas of the facility (eg, the laboratory or insurance office)

Operating Room Data and Data Tracking

Operating room data tracking is necessary for scheduling procedures and personnel and for billing. Data tracking provides a means to evaluate the operating room’s utilization, efficiency, and productivity. Specific data points to be tracked depend on the needs of the institution. Data com­monly collected include the following:

• Type of procedure

• Surgeon

• Length of procedure by surgeon

• Time of the

— patient arrival in unit

— patient in procedure room

— anesthesia induction

— incision

— patient out of room

— room cleanup start and finish

— case time (time from room setup to cleanup)

• Turnover time (time from preceding patient out of room to next patient in room)

Practice Coverage

All obstetrician-gynecologists should have appropriate coverage agree­ments with practitioners within their own group practice or other prac­titioners to care for their patients in their absence. When possible, these clinicians should be obstetrician-gynecologists. Careful consideration should be given to managed care contractual agreements and participating physician coverage. Billing policies and procedures should be established in advance and consideration given to reimbursement agreements. The clinicians should be familiar with each other’s practice style and capabili­ties, and practitioners should have privileges at the same hospital or other facilities. An established protocol should exist to introduce the covering practitioner to hospitalized patients and patients with special problems. The institution and answering service should be advised of the dates of a clinician’s absence or unavailability, as well as the names, telephone numbers, and office addresses of the covering practitioner. The covering practitioner, when feasible, should have access to patients’ medical records (see also the “Risk Management” section in Part 1).

Control and Disposal of Drugs and Other Sensitive Materials

A system must be in place for maintaining the security of all controlled drugs. Ideally, a secure system also should be in place for the control of syringes, needles, and prescription pads. An established procedure should exist for monitoring the expiration date of drugs, including sample drugs and laboratory reagents, and proper disposal techniques. Also, procedures should exist for the shredding or other means of destruction of medical records and other sensitive data (see the “Information Management” sec­tion earlier in Part 2).

Bibliography

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American College of Obstetricians and Gynecologists, American College of Nurse­Midwives. Joint statement of practice relations between obstetricians-gynecologists and certified nurse-midwives/certified midwives. College Statement of Policy 87. Washington, DC: American College of Obstetricians and Gynecologists; 2011.

American College of Obstetricians and Gynecologists. Midwifery education and certification. College Statement of Policy 82. Washington, DC: American College of Obstetricians and Gynecologists; 2011.

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Resources

American College of Obstetricians and Gynecologists. Guidelines for implementing collaborative practice. Washington, DC: ACOG; 1995.

American College ofSurgeons. Physicians as assistants at surgery: 2011 study. Chicago (IL): ACS; 2011. Available at: http://www.facs.org/ahp/pubs/2011physasstsurg.pdf. Retrieved July 22, 2013.

American Congress of Obstetricians and Gynecologists. 2014 Ob/Gyn coding man­ual: components of correct procedural coding. Washington, DC: American Congress of Obstetricians and Gynecologists; 2014.

American Congress of Obstetricians and Gynecologists. ACOG Medical home toolkit. Washington, DC: American Congress of Obstetricians and Gynecologists. Available at: http://www.acog.org/About_ACOG/ACOG_Departments/Practice_ Management_and_Managed_Care/ACOG_Medical_Home_Toolkit. Retrieved July 17, 2013.

American Congress of Obstetricians and Gynecologists. Frequently asked questions in obstetric and gynecologic coding. 5th ed. Washington, DC: American Congress of Obstetricians and Gynecologists; 2011.

American Congress of Obstetricians and Gynecologists. ICD-9-CM to ICD-10-CM gynecologic and general medicine diagnoses crosswalk. Washington, DC: American Congress of Obstetricians and Gynecologists; 2013.

American Congress of Obstetricians and Gynecologists. Practice Management and Managed Care. Washington, DC: American Congress of Obstetricians and Gynecologists; 2013. Available at: http://www.acog.org/About_ACOG/ACOG_ Departments/Practice_Management_and_Managed_Care. Retrieved July 16, 2013.

Association of periOperative Registered Nurses. Perioperative standards and recom­mended practices. 2013 ed. Denver, CO: AORN; 2013.

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