AAFP Reprint No.

268

Recommended Curriculum Guidelines for Family Medicine Residents

Management of Health Systems (Practice Management)

Introduction
This Curriculum Guideline defines a recommended training strategy for family medicine residents. Attitudes, knowledge and skills that are critical to family medicine should be attained through longitudinal experience that promotes educational competencies defined by the Accreditation Council for Graduate Medical Education (ACGME) http://www.acgme.org. The curriculum must include structured experience in several specified areas. Most of the residents knowledge will be gained by caring for ambulatory patients who visit the family medicine center. Structured didactic lectures, conferences, journal clubs and workshops must be included in the curriculum with an emphasis on outcomes-oriented, evidence-based studies that delineate common and chronic diseases affecting patients of all ages. Targeted techniques of health promotion and disease prevention are hallmarks of family medicine. Appropriate referral patterns and provision of cost-effective care should also be part of the curriculum. Program requirements specific to family medicine residencies may be found on the ACGME Web site. Current AAFP Curriculum Guidelines may be found online at http://www.aafp.org/cg. These guidelines are periodically updated and endorsed by the AAFP and, in many instances, other specialty societies as indicated on each guideline. Each residency program is responsible for its own curriculum. This guideline provides a useful strategy to help residency programs form their curricula for educating family physicians.

Preamble
Management of health systems (practice management) training is a vital part of the residency curriculum, regardless of the mode of medicine or setting the resident chooses after graduation. Residency graduates are faced with an increasingly complex spectrum of opportunities for medical practice, and their understanding of the choices involved is crucial for their future careers as family physicians. Furthermore, most new physicians will experience practice changes as the health care environment evolves, and a broad knowledge of practice management issues in a variety of settings will be needed for the duration of their medical careers. Practice management is defined as the body of knowledge, attitudes and skills necessary to efficiently lead and continuously improve the multiple elements of care delivery within a medical practice, including compliance with external regulatory agencies and accreditation requirements. Management of health systems integrates these practice elements into the context of health system organization, administration, communication, marketing and, more importantly, the establishment of a patientcentered medical home for patients. Although the future family physician may delegate many aspects of practice management to other staff and consultants or may, in fact, be a salaried employee of a large organization, an understanding of management of health systems (practice management) is still critical. This knowledge will assist future family physicians when making appropriate personal choices and when fulfilling the ethical responsibility to advocate for the highest standards in delivery of patient care. Furthermore, legal liability for many aspects of patient outcomes continues to remain with physicians even if they are part of a larger organization.

Competencies
At the completion of residency training, a family medicine resident should: Advocate for the patients welfare while balancing the business realities of practice management and financial success. (Patient Care and Professionalism) Actively conduct a practice search, interviews, contract negotiations and successfully enter practice. (Interpersonal and Communication Skills) Demonstrate knowledge of the legalities and ethics of hiring, promoting and firing of employees in a practice setting. (Professionalism) Identify the structure and operations of health organizations and systems, and the role of the family physician in this structure. (Systems-based Practice) Identify the measures of health, including determinants of health, health indicators and health disparities. (Practice Based Learning and Improvement) Identify and foster partnerships that maximize achievement of public health goals. (Systems-based Practice)

Attitudes
The resident should develop attitudes that encompass: A professional approach to job interviewing and contract negotiation. Flexibility in responding to interviewing and contract negotiation. An understanding of external quality review that mandates effective participation in outcomes research. Respectful participation in multidisciplinary teams with other health professionals.

Knowledge
In the appropriate setting, the resident should demonstrate the ability to apply knowledge of: 1. Practice opportunities a. Location i. Part of the country ii. Size and type of community b. Mode of practice i. Traditional solo or group practice ii. Urgent care or emergency department iii. Staff and group model health maintenance organization (HMO) iv. Managed care contracting v. Administrative 1). Private industry 2). Government 3). Education vi. National Health Service Corps and Indian Health Service c. Configuration i. Solo ii. Partnership iii. Group iv. Salaried employee v. Corporate management vi. Educator d. Employment agreements/contracts i. Compensation and benefits ii. Workload and performance expectations iii. Professional liability coverage iv. Legal provisions v. Ethical issues 2. Practice facilities a. Location and market analysis

b. Design and regulations c. Financing d. Equipment and services e. Inventories and supplies f. Rent, lease or own g. Laboratories and government regulations h. Radiology and ultrasonography i. Special office-based procedures

3. Office organization a. Chain of command b. Schedules c. Number and type of support staff d. Computer systems and other technologies e. Supply and inventory management 4. Practice operations a. Patient flow and scheduling b. Vendors c. Electronic medical records (EMRs) and chart documentation d. Written office policies and procedures e. Front desk duties f. Insurance and other third-party billing g. Management of pharmaceutical representatives and samples h. Management of phone calls i. j. l. Telephone and paging systems Advanced planning and timetable for entering practice Consultation referrals

k. Chart and filing options, retention of records m. Management of patient education n. Clinical tracking systems and preventative services o. 360 degree evaluations of self and staff 5. Office and business management a. Systems-based learning and analysis b. Taxes and insurance i. Estate planning and investment

ii. iii. iv. v.

Pension plan and/or profit sharing Tax considerations and social security payments Payroll systems Insurance needs

c. Personal (e.g., life, disability, health) d. Practice (e.g., employee benefits, premises liability, overhead, fire) e. Monitoring the business i. Reading financial reports ii. Cash flow and lines of credit iii. Accounting systems iv. Billing and collection principles and policies v. Accounts receivable management vi. Financing and capital vii. Overhead management f. Personal financial planning i. Budgeting, debt consolidation ii. Retirement g. Billing i. Coding and documentation (e.g., how to, and importance of inpatient and ambulatory coding) ii. Fee for service iii. Third-party payers h. Contracting i. Medicare ii. Medicaid iii. Capitated contracts 6. Medical records a. Storage and filing systems b. Indexing and coding c. Release of information d. Confidentiality e. Audits and tracking f. Types of records (including EMRs) g. Structure of records h. Legal issues, including HIPPA 7. Staff and personnel policies a. Employee relations i. Mutual respect ii. Salaries and benefits iii. Motivation iv. Recruitment and retention

v. Terminations vi. Evaluation vii. Accountability viii. Job descriptions b. Labor laws c. Personnel records 8. Legal issues Refer to Curriculum Guideline on Risk Management and Medical Liability. (AAFP Reprint No. 281) 9. Computer utilization Refer to Curriculum Guideline on Medical Informatics and Computer Applications. (AAFP Reprint No. 288) 10. Hospital issues a. Selection of hospital b. Staff appointments and privileges c. Medical staff and departmental responsibilities 11. Marketing a. Marketing strategy, ethical marketing goals b. Patient-retention techniques (such as patient satisfaction surveys) 12. Resources a. Practice management consultants b. Accountants c. Lawyers d. Financial planning consultants e. Bankers f. Marketing consultants 13. Professional relations a. Medical and specialty society involvement b. Community and government c. Interdisciplinary, multidisciplinary and transdisciplinary 14. Health care risk contracting 15. Quality indicators and reimbursement relationships with payers and reimbursement.

Skills
In the appropriate setting, the resident should demonstrate the ability to independently perform or appropriately refer: 1. Balance personal and professional goals a. Effective leadership skills b. Professionalism c. Determining personal and professional goals. 2. Selection of type of practice (involves decisions about lifestyle, residence location and professional interrelationships) a. Position Application i. Career goal setting ii. Curriculum vitae development iii. Letter of interest (cover letter) iv. Identification of available position, recruiters v. Interviewing skills vi. Culture and politics of the practice b. Practice configuration i. Single vs. multispecialty ii. Associations 3. Contract negotiation a. Employment agreements i. Sexual harassment ii. Confidentiality iii. Requirements as an employee iv. Productivity/bonuses v. Teaching opportunities 4. Prudent selection and utilization of advisors and vendors 5. Personnel management and delegation of responsibilities 6. Computer competency, including information technologies 7. Time management 8. Personal and public (oral and written) communication, including advocacy 9. Resources management 10. Leadership of health care teams 11. Adapting to changes in the health care environment (team building and teamwork) 12. Networking and collaboration

Implementation
These Curriculum Guidelines should be implemented longitudinally throughout the residency program, with increasing emphasis in the latter half of the residency. These guidelines should be integrated into the schedule of conferences and other teaching modalities, such as monographs, group discussions and case examples. The resident should gain hands-on experience by being involved in on-site practice management in a family medicine center or similar environment. Residencies whose clinical activities are limited to only one model of practice should make special efforts to expose residents to other practice types. Evaluation of the effectiveness of the program is desirable. Physicians and others who have demonstrated expertise in the skills of practice management should be available to the residents. Appropriate clinical and business systems, coordinated by a family physician, are a useful structure for providing experience in this area. Each family medicine resident should be able to demonstrate the ability to work with various individuals involved in practice management. This ability includes an understanding of their relationships to practice needs, office personnel, practice management systems, consultants and various other resources available in the community.

Resources
Baldor, RA. Managed care made simple. 2nd ed. Malden, Ma: Blackwell Science, 1998. Beach RA. Interviewing 101. Fam Pract Manag 2001;8:38-40. Burke MR. A primer on employment contracts. Fam Pract Manag 2002;9:73-4. Bush J. Life balance: 17 tips from doctors, for doctors. Fam Pract Manag 2001;8:60. Bush J. Looking for a good electronic medical records system? Fam Pract Manag 2002;9:50-1. Giovino JM., 14 alternative practice styles. Fam Pract Manag 2001;8:33-8. Giovino JM. How to recruit new residency graduates. Fam Pract Manag 2002;9:33-6. Henley DE. Coding for better reimbursement. Fam Pract Manag,2003;10:29-35. Hofford RA. Seven tips for effecting legislative change. Fam Pract Manag 2001;8:35-8. Maresh OK. Choosing a practice facility. Fam Pract Manag 2002;9:37-41.

Moore KJ. A productivity primer. Fam Pract Manag 2002;9:72-3. Morrison KM. Coding and billing software for palm-top computers, Fam Pract Manag 2002;9:33-7. On your own: starting a medical practice from the ground up. Leawood, Ks; American Academy of Family Physicians, 2001. Rust G, Ferris ME. From residency to reality: practice management teaching tools. Leawood, ks: American Academy of Family Physicians, 1997. Tallon R. Critical concepts in medical practice management: working in a managed care environment. New York: McGraw-Hill, 1996. Teichman PG, Caffee AE. Prescription writing to maximize patient safety. Fam Pract Manag 2002;9:27-30. Zuber TJ, James EH. Managing your boss. Fam Pract Manag 2001;8:33-6. Curtis VA, Scott B, Garbrah-Aidoo N. Masters of marketing: bringing private sector skills to public health partnerships. Am J Public Health 2007;97(4):634-41. Smith J, Wohlstetter P. Understanding the different faces of partnering: a typology of public-private partnerships. School Leadership & Management 2006;26(3):249-68.

Web Sites
Agency for Healthcare Research and Quality, Health Care Report Card Compendium: http://www.talkingquality.gov/compendium/ American Academy of Family Physicians (AAFP): http://www.aafp.org AAFP, Office Laboratory Medicine (Reprint No. 283): http://www.aafp.org/cg Baldrige National Quality Program: http://www.quality.nist.gov/index.html Centers for Disease Control and Prevention, Public Health Information Network (phin): http://www.cdc.gov/phin/index.html Centers for Medicare and Medicaid Services, SCHIP Approved State Plan Information:.http://www.cms.hhs.gov/LowCostHealthInsFamChild/SCHIPASPI/list.asp Connecticut Health Policy Project, 2002 Connecticut Policymaker Survey: http://www.cthealthpolicy.org/policy/2002survey.htm Connecticut Health Policy Project, Profiles in Advocacy: http://www.cthealthpolicy.org/toolbox/profiles/index.htm

HealthGrades: http://www.healthgrades.com/ National Committee for Quality Assurance: http://web.ncqa.org/ Partners in Information Access for the Public Health Workforce, Healthy People 2010 Information Access Project: http://phpartners.org/hp/ Trust for Americas Health, Your States Health: http://healthyamericans.org/state/ Also see other AAFP Curriculum Guidelines related to management of health systems (practice management) issues: Reprint No. 281 - Risk Management and Medical Liability: http://www.aafp.org/cg Reprint No. 283 Office Laboratory Medicine: http://www.aafp.org/cg Reprint No. 288 - Medical Informatics and Computer Applications: http://www.aafp.org/cg

Published 09/1985 Revised 10/1991 Revised 07/1997 Revised 01/2003 Revised 02/2008