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what I want to do is really just share with you the genesis of our practice the startup art operating we started 15 years ago - - physical medicine physician therapy and I'm sort of community for several years but really need to succeed and truly survive really adapt and really alter our mindset so we wanted more diversified a practice with their company and IFC innovation excellence involving health care company we excited with from our slight amount of frankness just fine about it correct we'll talk about that and then us with what competing urgent clinic announced with the leading centers overall in this sort of current daunting challenge of ACA with acquisitions consolidations alliances rapidly accelerating it was important for us to really diversify and offer our services in a broader fashion to really really get value generated opportunities for our practice overall we're more uh more of an issue for us to deal with both economically and just from a fundamental access point of view and really preparing for that in the practices there's something that everything guided us in the past and certainly enough the focus on a silo here obviously model this is fragmented care it's disrupting the patients too expensive way of practicing communication I think that's why we feel we can do a better job learning we're going to talk about five tenets keep it simple of what we believe Maxim's if you like for our practice I'm a believer in mind I show so the critical tenants I'm a visual guy so explain this they're very reasonable but it's old lady on freedom together and trying to get anybody explain that there's a methodology so why we gonna do this I'm trying to get people to understand as Hawaii but whitey will work with you if they can explain why you work with you seven thought that I Monday morning then you've got them the why is very important see if you can get your staff and your providers 32 providers and the rest against OFI staff to understand your mission huge I came up with this visual and you all remember this 55 ran for about 40 years and the game is all about controlling against everyone knows yes it's my other connections or has made other nations on the square the others in the corners are very important as well as you know all the other boxes kind of history connections waste ago but if you control the X you control the game so we look at the 5 pennants with this we take them out so number one clearly oddly important things access you have another practice on an access point for patients whether that's multiple offices the patient's you get to see you a very efficient manner all the weights tolerated anymore as we know the competition regardless of how they think how I even receive yourself and you know self-realization of that and your self accusation is that they issued on board emotional intelligence in particular what your satisfaction scores are and what your reputation is having a good access to patients really critical until then we're certainly on the right side of the value equation how becomes very important to measure when we do this to do this for the last 15 years because you really have no business talking about body superior excellence in all that unless you can measure it everyone thinks they're doing a better job the next but until you prove it it's really just you know conversation and obviously control the game you have to have patient satisfaction that's what's going to determine whether we're doing a good job so obviously you primary care your chiropractic referrals the muscle skeletal the environments are critical they're they're really initial access points as how you grow your practice you've certainly a large part of your your base as you grow gravitational lives would be self-referrals so these are the three really key components primary care the chiropractic group emotional skeletal who have higher patient satisfaction scores and primary care physicians physical therapists and certainly higher than any physician and physicians and specialists they're really a point to work work with you and then we include them in your network and I think you know from experience a really good understanding of what chiropractic care is now when I started off at a residency in my first thing years of practice or they didn't have a good concept of what they did and bring ease probably at my own side to it so what marginalized from my practice we don't have chiropractor groups in our practice we work very close to it goes around there's a huge party network and to work them together I really haven't been full circle care patients love the chiropractor's it's fascinating how so many physicians new ones imitate that are coming to our practice and they dismiss at times they're less than appreciative at times and chiropractors do not say that to you when your patients patients have ladies hair dressers don't miss their hairdresser they used to have a butcher's now we can use to be back in and nowadays they have a chiropractor Cartwright haven't seen one twenty years don't respect a chiropractor so we have an access point you know the hybrid model really incision to take the volume patients we see over 5,000 patients of service and practice and there's a lot of learning to to see patients to really offer an experience to really excel but we have that opportunity now with a lot of opportunity comes the chance of failure and certainly that's always there with appointments and how you make this whole symphony kind of work is really a critical component but we can clearly spend a lot of time addressing this access to services like this which is emerging and then we're spine about it correct and I'm kind of model out of along if you like Apple Genius Bar you know you can call in the morning if you have a slot open you can convince an appointment or you can make an appointment to be seen the next day so we give a 24 hour guarantee access point for spy Nevada correct which is proven to be very successful preferred referrals come that way and we certainly grade all our referrals when patients come in one of the providers referrals and then we grade them accordingly and if they don't really if they haven't classifications three days of maintain their referral to us and sometimes as well you know dr. L took care of my son right here doing a good job I want to go see dr. L well that's kind of an educational component you know the GP is just done yes patient they're not going to take some physical therapy injections well they've got 30 patients out in the waiting room mrs. min wants to go see dr. pail I want to send over a helicopter he'll gets it now got really getting frustrated she said well that's not a certain flow referral oh you know what you gotta go back to the practice primary care doctors family because that's really what could happen end of the day referral group so what we came up with is having this access look at that base you can easily be seen in our spy Nevada director seen by the physician assistants in there that work alongside in this with center so they can be seen in an efficient manner I can seem to get an x-ray as needed they get settled down with must and confine the trees Tortola shot if necessary and then oftentimes were brought over immediately to sway the physical therapy and so we work with the insurance companies on that so that pointed care for a patient can be seen first of all within 24 hours sometimes same day with the musculoskeletal condition they they get evaluated learn about 45 minutes and hitting the door registration getting getting x-ray getting seen getting processed and walk back to physical therapy if indicated on that point in care that the patient can be finished and out of there within an hour and half that those many things number one the captions of patients and we bring them in and they're scared to us we've seen this day in day out but they're scared because they don't know that this neck pain is a big issue or not and you sort of try to deal with it themselves so when we bring this is what they're called sometimes they're better after a few sessions they certainly don't get on the paint behavior pathway and escalate that they don't have to wait two three four five six weeks to get in to see a provider whatever the physical medicine or surgery and most times they're actually treated and on the way before that process that that referral process may take place so the teams exit point for us and we've sort of expanded upon that and as we see here it's very important for our access you have no surprise for patients practice obviously it's low cost compared to emergency rooms to see here at two-thirds of the patients going to emergency rooms or not for the emergencies fragmented they're not by specialists it's fully the kinds of very very expensive triage system and they get seen and then created properly or not off to the bank provider or order back into that hospital network which the patient involves to lead some time so again for hours of care at the emergency room and I you know the cost operators bills there's a differentiation for us between what can be seen in this with purging clinic versus the hospital yes life-threatening go to the emergency room cetera so we really distinguish the two and threat and the we measure outcomes pretty importantly we've been doing this for the last 15 years for the patient satisfaction scores at least 10 years longer and CMS has been speaking about patient satisfaction very important to have data to publish it we work with Daleks and really is a network and we really compare ourselves and we are compared to other centers nationwide as to save data points I really just it's a mark to see how you're doing and how compared to you your colleagues nationwide equality knows about questions it's important we only have a to focus on the physician quality and the patient experience whether it's whatever we build where these offices waiting top-of-the-line imaging hazardous here we've got several - in motion week barring open MRIs and really to really deliver a differentiation in our market they're the only memorized have this room be a region in northern Nevada and they proven to be very popular great when we see quite a patient that most of it in closed tomb of terror and I MRI it also that the u.s. at least 30 percent more pick up compared to the standard MRI no justice taken line down as we all know you don't hurt from you lying down someone hurt you stand up you know your spine or your leg or knee so that this is really been a practice differentiator for us and that we follow kind of protocols a lot of this is by attention not to be looked at but just we follow a protocol such as a you know classical thing in our practice compression fractures to see a lot of them and they're needed to take care of as long as you have a treatment pathway for them the patient gets seen and can see them in this one about right you know they need racing and racing and there decided a cute non-acute and then give them a conservative period of treatment a certain pathway that all the providers know they hold all those patients whether they eventually most let me get better without high-capacity very few the meter kind of lasting cement on there but what they all need is is to make sure that when they have is that they're tithing and their GP say all the patient follow energy P we develop all the patient's get deferred for their early physical medicine and she really has a great interest in that and so she manages those patients for us you know and Emily aids with crafting care doctors for sure beliefs we know that patients take care she sees that patient and so it doesn't fall back on the surgery side know worked out to partly to make patients we see I'm not doing kind of lasting pictures of need one yeah but my no fractures to easily seen given our side Oh piano themselves they're not doing the injections on it they're a busy for two weeks trying to do injections and see patients their volume so this just worked out pretty good for us that we've really increased our mental patient satisfaction and delivery of care by having simple protocol that everybody understands we have the top of line until scoliosis x-rays and x-ray machines across the board you're going to do it I believe we do it right we have a stay at the same time and I thought I used to do my job and then well we expanded and gonna part of our muscle cells above development third MRI scan which is a focused extremity MRI for upper extremity and lower extremity and this is my wife here on the right and as you know I need to get an MRI on my ankle so I've said no problem go down there go base not a problem so doing down there the Carolinas at home do me a favor grab him that day on the lake and please get a photograph so she's having a lot say and on her iPhone and she's and a clam Ryan this is real this is Maggie doesn't work outside of the box it's all closed it's dragging on them and actually hasn't pretty cool things acini MRI as well so you can get ahold most member I have a joint it's fascinating so there's a new firm aged understand neurosurgeon spine guy so learning like other joints oh great what would you see patients having experiences like this and then the three MRI Tech's who've been in average five to 20 years before hands come back oh my goodness how many patients come out of there raving about it well that's making change that's the differentiation for our practice and seeing that you sort of illuminate the fear you eliminate that sort of the obstacles that people have to access the healthcare I will have the attention injection Suites the top-of-the-line and all the Centers for good purpose that's part of the holy Springs from the waiting room to the checkout it's really just a it's a it's a high quality operation and it's a high delivery of care with with patients who were you know just come to your Center and they enjoy that experience they also enjoy the benefits that reach when they don't have a facility fee so instead of a $500 thousand dollar facility fees for an epidural they just have an office copay is this work assistance that you know this is waiting to go or physical medicine doctors like this they can do you know make it up in volume they do it the office don't have to drive into the surgery center he knows the surgery center meeting and I'm owners of a surgery center this is really a new care we've been doing this for several years that survey Center in Reno which I found in 2006 over 13 years is here which we can certainly help and I'm very successful but for surgery for certain high-end procedures but for the regular day-to-day stuff in office procedures really where things that move and all of this comes to increasing patient satisfaction controlling the box controlling the board is really important to this one what really matters is the end today how we do this and so we looked at patient satisfaction outcomes and we looked at it so we're doing okay you know sometimes we could do better for sure we have a free show is a take thing and it gives us a score and we really looked at those data points on here we saw there was a little lagging here and on the surface it will when you see your colleagues in it they put on one marker on the website 99 98 percent patient satisfaction yeah if they're doing spine even our practice and you're not just a certain Club you have more difficult patients that now you get pain related to be here except for exceptional etc and your scores coming down home this was a pretty good one but don't okay how do we do better and one of the issues with appointment access and now it doesn't look bad at 89% that means one out of ten of your patients isn't happy with them now when they tell you they're not happy with it you know very well what was that one person and you know you nearly expect that one you put out there somewhere so but that one person for the ninth we're very happy and giving you hands up in the community that one will do more detrimental damage and the ninth could ever hope because they've got about their business the other 10% that you messed up on and you drop the point and you look at it you look at your dad you look in you pull out the records oh my god issed calls didn't follow up that didn't get ordered and it's like you just double down instead of you know upsetting five people you just decided to pile it all that one person for that one person I've got a lot of ammunition now they're really annoyed you left them down and they came with great expectations drove 300 miles and earlier all the way up to get the best even delivered you just you got a lot of ways to make up for that and so that's really important so if that's really where we kind of focused a few years ago and say hmm you know being busy is good but if you're too busy and you're too far out that's a problem I try to explain that all the providers every Friday they get all the referral data totally transparent world where everything's not what we got everything every referral where it comes from who's going to how the breakdown is I just get it I put it editorial on it send it out to all the staff all the providers they get it if they feel that their numbers are down a little bit and somebody else or colleague is up a little bit well maybe they should make a look at how much vacation they took that month etc so everything's kinds of parenting pretty important for that keeps everybody kind of happy and it really gives you a bit of ammunition when they're in your office they're upset about something you say well just think let's take a look at it importantly what we also do is we send out on a Friday where everybody is for the next available acquaintance what it's physical therapy every one therapist where everybody looked out where everybody is on imaging MRI next available next available x-rays they should be one or two days if you have you know one or two days waiting for MRI may be considered by another MRI at the moment now I'll share a story that concert pianist she was that using the white referral sources in Reno and so our marketing team round discussing things with them and you know showing our wares and marketing and educating at the same time for grooving the things that I can this beam and she fell and she hurt her wrist she saw orthopedic hand surgeon because of her insurance which is our best insurance counts the hospital affiliated insurance just wait three weeks for a rich art program and so my marketing guys you know what I think we could probably get her in this afternoon so they called to make sure the orthopedic surgeon was happy with it and they said sure great get it so you called our team one of the doctors shops and dines there is stuff in the new fantasy a MRI and that lady got an MRI dat afternoon I called the insurance company so they don't know they were thrilled baby but that was an access point and a happy customer of the Bears but the hospital could have matched because they're too busy and they don't have enough MRIs and by the way it's a big laborious system and it got lost in the weeds so that's not as so much important well every referral to us is important the hospital every proposal at the end of the day you're talking millions of dollars versus we're talking thousands that physician-patient us and you just can't buy the boys you can put as much money and TV advertising radios you want that one patient loyalty forever change their life by doing something like that and their dependent is just a cavity that's a whole lot of them would go on so anyways that changed our focus and that's why we did this with their patient experience exception we talked about the environment high performers so minor tenants you heard nothing maybe not I didn't order what I thought these were important as we look at it works things are going forward so we look at the minor tenants you know really you got to communicate consumers are really the most word if you look at 2018 value-based care seemed to be everywhere in the buzzword and 2019 whatever it is and that seems to be just everywhere so what we communicate very important I agree with the community patients and internally with your staff very important you've got a large staff sort of you gotta let them know what's going on but the biggest planning getting staff survey but any loop is gonna have any any foundation has any organization or company has it's been enough I mean you look at every leadership book and it doesn't matter how good you're doing the job communications between they're not telling us everything well that's on purpose most of times but in this new generation they want to know everything now and they want to know what you're thinking they want to know what you're going to do before you told anybody what you want to do it they're not happy with sort of this it's coming in time we've got a plan of strategy you can't overemphasize that it's fascinating how they feel disconnected you sort of feel like you're sharing everything so with that we've done a newsletter Molly our director of communications and digital media together by the way everybody starts off with a newsletter well the first one is easy that's the idea you build up the last four years you're head of the thing is going to talk about and we're all excited with the first and the second one okay who's going to the next one and then by the third one who just falls off and the majority of them I don't know what the number majority practices you see that volume one you know 303 and that's it because you need to have a focus on you you have somebody dedicated that but you haven't been engaged the staff good so we use it as a really a method of communicating with the staff and whether it's you know a ward site here I understand but Rachel are tired head of HR she's homegrown if you like you started with us as a scheduler she went into marketing then say you know what I'm gonna do a chart and a clue about HR she's smart College gotta be a got all their degrees and levels I suppose all in a chart there's no don't bring him some an HR person I wouldn't do this and she really did underneath the director came in and just this week she won top a chart and health care in Nevada I'm out of 300 people so they didn't work for her and see really did you see that and then you can share that with her and we knew who's coming up there we sent her flowers and how dare you but to communicate that with a staff that was massive to the public relations and your staff and sharing you know you we got eight offices and staff all over the place and all that you know they don't hear it because admin centralized so admins in one forty five staff office but they're not necessarily communicating except telemedicine to the other office you might a little bit suppose down and Farkle they don't see each other unless you bring him for a social event so this is very important to communicate internally as much as externally and we have a lot to be thankful for with with Molly our director and that important consumerism as we talk about the buzzword the reality is that staff are going to get it from from patients patients are gonna dictate really what what their experience is if I put it online whether it's a yelp review of other health rating of you they're going to go and really they're gonna great you hope they spray the word because that's what they're gonna do they look at their drinking patient portal is despite than a communication through their online reviews you could have live and die by your hand you make given each 24 hours to access now this continues computer whatever is happening in other industries whether it's Amazon you know Google or whatever company you know over who worries that's a new society we live in I'm talking about everything immediacy affect patients they know the data is there they know the computers there the technology there they're gonna expect that to be delivered in healthcare if anybody thinks they can practice the way they did the last ten years kind of lost the leads and they left behind you really sort of have to try to keep up as you see pollution process so I hope the immediacy of that care before they want fast rapid follow along they want a minimal variation of air and flexibility [Music] you know this is going to cost increase and experience for the patient [Applause]

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