The Physician Advisor as a Quarterback in Managing Silos

The reality is that silos are everywhere, and they are not necessarily bad, but need to be managed.

There are silos in all aspects of life, but most of the time we associate them with farming, as with the classic images of grain silos. The term is often used in the business world, but “silo” is not really an exclusively business or project management term. Yet it is often used. For example, when you say that the teams on a project “work in silos,” it means that each and every individual team works independently of the other team, and the teams don’t know anything about each other’s work.” The use of the term even extends into the healthcare industry, in many aspects, such as departments and even physicians. Department silos will be discussed further on, but I suspect that some may have never thought of physician practices as silos. Yet if you look again at the quote above, it may apply. There are many specialties in the practice of medicine, such as cardiology, GI, GU, infectious disease, and many more. Why do hospitalists, internists, and other general practice physicians get consults, sometimes many of them, during a single admission? Because they need the expertise of that specialty, as they really don’t know in detail about each other’s areas of practice or specialty. As a matter of fact, it has pretty much become the standard of care to get these consults, but does it contribute to efficiency of care delivery? Most of the time, it may not.

Where do silos originate?
The reality is that silos are everywhere, and they are not necessarily bad, but where does the silo mentality come from? Surprisingly, it gets implanted in our minds very early on in life, which may come as a surprise to hear. It was to me. Remembering back to our childhood days, grammar school tended to involve one teacher and multiple subjects, all in the same classroom. The silo process starts in the upper grades, with each subject having its own teacher, with different styles, different rooms, homework assignments, and allotted times. In addition, most of the time, each student had their own desk, their own locker, books, and equipment. This was the beginning of compartmentalization – or, more simply stated, silos. Each subject was independent of all the others. This concept is subliminally implanted in our minds, so why would we not carry it through to our work environment, including healthcare?

What exactly is “subliminal?” It has been defined as “existing or operating below the threshold of consciousness; being or employing stimuli insufficiently intense to produce a discrete sensation but often being or designed to be intense enough to influence the mental processes or the behavior of the individual.”

The physician advisor (PA) may not actually be a silo, but more of a “quarterback,” as they tend to work with the other components (UR, CM, CDI), but not that often with coding. With this unintentional silo concept, each of these components generally works independently, and each really doesn’t know much about the other’s work or role. Working in silos can obstruct communication, hinder productivity, lead to resentment and animosity, and generally just make work a lot more painful than it needs to be.

What are some types of business silos?
According to Corey Moseley, an author whose topics include company culture, employee engagement, and internal communications, there are three types of silos:

1. Organizational – this is division within the department, according to different types of people and skill sets, often making them operationally autonomous entities focusing on specific goals, leading to little interaction and information sharing.
2. Information – this can be secondary to the first one, wherein information remains trapped within the department.
3. Silos of the Mind – these are ingrained thought patterns that influence everyday decision-making within teams. They’re the result of departmental biases and information hoarding.

These are all found in clinical revenue cycle.

What is a physician advisor (PA)?
There really are no exact definitions of a PA. They can be on-site, or there are remote services, and they are typically associated with second-level medical necessity reviews in the utilization review (UR) arena. As this specialty has progressed and grown, its functions have increased to many different areas, including but not exclusive of appeals of denials (with peer-to-peer discussion), length of stay management, participation in the UR committee, physician education (including physician documentation improvement), collaboration with UR and clinical documentation improvement (CDI), case management, and maybe even coding. Many times, PAs are considered the liaison between physicians and leadership – and, in essence, they must primarily integrate with the utilization staff, physicians, and executive level. They become regulatory and subject matter experts. There are probably many other roles that have not been included here, but they will appropriately vary from facility to facility.

Since physician advisors are a key component of clinical revenue cycle, and using the holistic approach, where no one part is more important than the whole, the effect to be achieved in managing the aforementioned silos is collaboration and knowledge sharing. The PA is perfectly positioned to play a major role in helping this to occur, as “boots on the ground,” along with executive levels. In order to accomplish this, it is important to understand how these silos originate in the business world. There are overall common etiologies, and there will be some specific to the healthcare industry.

How do silos originate in business?
As noted, silos are subliminally implanted in our behavior from childhood. It becomes part of adult behavior, as it is already quite prevalent in nature as well. Take, for example, the male lion that has his own “pride,” a group of females, when another male comes along challenging that position. It can lead to a battle to the death. Luckily, that shouldn’t happen in the human environment. Silos are not necessarily bad, intentional, nor the work of any one person, but they must be managed appropriately. You may have seen some examples of such behavior when it gets carried to an extreme, on an individual basis, in the form of territorialism. It’s like “marking my territory:”

• “That’s my chair”
• Hiding material so no one else can use it
• “That’s my staff, they only work for me”

That type of individual thinking and behavior, taken to the departmental level, can be so destructive, especially when making decisions on what’s best for individuals, not the overall goal, vision, or team. In the business and healthcare world, there is a tendency to cluster expertise into specific departments by functions, and employees tend to mimic what they see in management. One can recognize that a silo has or is developing when information or other business resources that would be beneficial to the organization are being kept by an individual or specific group.

Learn what are common goals and visions, and educate all involved
The PA should have the advantage of understanding what the common goals and visions are for their institution. Increasing revenue is certainly number one, but it needs to be sustainable revenue. The PA should meet with management to learn and validate what these goals and visions are. Once that is established, and since the PA would have working knowledge of each component, there needs to be inter-compartmental education at a high level. Team empowerment will play a significant role, as they are the ones in the trenches, not management. Management needs to reduce bottlenecks and constraints to make the teams successful. The PA can be the liaison between the teams and management.

With team empowerment, the IKEA effect comes into play; named after the Swedish manufacturer and furniture retailer, this is defined as a cognitive bias in which consumers place a disproportionately high value on products they partially created.

As you may know, many IKEA products require some degree of assembly. The basic theory is that people place more value, or ownership, in something that they have participated in building and/or creating. It goes back to the old question, heard as a child: what bike did you treat better, the one someone bought for you, or the one you paid for? One must be careful that this enhanced value or ownership does not turn into hoarding and non-sharing. Product development is a perfect example, as they create a new product or service, but they must eventually “let go” of the ownership and relinquish it out to sales and implementation.

Help to build the puzzle
Look at where your components are, and know where you want them to be. This is different than vision and goals, but has to deal with knowing the proper process and functions of each component. One might consider this a gap analysis analogy, and this is where the puzzle concept comes into play. One knows what the completed puzzle should look like, based on the picture on the box or an enlarged provided picture, but it all starts with a bunch of pieces.

There are a couple of ways to build a puzzle:

1. Build the edges first and then fill in the inside – edges are identified easily, but the filling in can be a daunting task;
2. Lay out all the pieces and start looking for those that match; and
3. Build smaller sections of the puzzle, get them into their right places, and then fill in the connecting sections.

Even though management should know what the proper function of a department/team should be, they are not in the trenches. The PA knows what the functions, roles, and team members are for each of the components. Without being intimately involved in the details of daily functions, they can provide the needed education of regulations, standards, and compliant practices to all components and physicians. Following the building technique outlined above, the PA can help them fit into the overall picture, while leadership and management connects the sections. There may be meetings or conferences, such as multi-disciplinary rounds, wherein the PA can serve as a facilitator for all components.

Facilitate communication

All five components of Utilization Management 360â deal in some manner with the patient story, and the care necessary in order to facilitate proper level-of-care placement, treatment and care transition, documentation, and billing. Think about it this way: say there is a football team whose players never block, defenders who won’t tackle unless it is the man they are covering, receivers who run out for a reception only when the ball will be going to them, and individuals who focus only on actions that will run up their statistics. This is another form of silos, and the chances of this team winning are next to nil. This can and does occur in individual healthcare teams, and overall, resentment and disgruntlement will start to build throughout the revenue cycle. In reality, there is a huddle before each down that is run by the quarterback, who lays out the play and options. This is a great form of communication. Everyone on the team knows what the intended play is, and the options for change. And the PA can serve as a “quarterback.”

Just as a few examples: do the team members know:

• The financial consequences to the beneficiary for being in the wrong level of care;
• The challenges of getting a patient transferred to a skilled nursing facility (SNF);
• The extent of documentation that doesn’t support the acuity of the patient;
• How to get a physician to change the level-of-care order;
• The processes and consequences of condition code 44, and trying to notify the patient, the physician, and the facility;
• The consequences of upcoding;
• Why are there so many denials, and how to appeal them;
• And so much more?

One may say, why does each member and component need to know this? Well, they don’t need to know the intimate details, but an overall knowledge base can provide some insight to getting the right results and outcomes for each patient – and the facility achieving sustainable revenue (and thus continued existence). Therefore, that’s where communication and education play a role, a role that the PA can be part of, in managing silos. The physician advisor can provide this communication on a one-on-one basis or overall education.

Summary
The role that the physician advisor provides as communicator, facilitator, subject matter expert, and “quarterback” is invaluable. In just performing intended duties, working with teams and management, managing the silos within clinical revenue cycle can occur.