What We Found
Integrated Clinical Services has implemented three recommendations from our 2019 audit of primary care services, and five are in process.
What The Statuses Mean
- Implemented – Auditee has fully implemented, or auditee has resolved the issue to meet the recommendation’s intent.
- In Process – Auditee has started implementation.
- Not Implemented – Auditee has not implemented, or does not intend to implement
Why We Did This Evaluation
The Auditor’s Office follows up on audit recommendations to support county government’s accountability. This evaluation focused on recommendations with the following deadlines:
- April 1, 2020
- December 31, 2020
- December 31, 2021
Status of Recommendations
Recommendation 1: Change Call Center greeting so that announcements about what to press for different languages occurs in the most commonly used languages of their patient population.
Auditor’s note: Prior to our audit, the Call Center greeting had been in English and Spanish. In early 2020, Integrated Clinical Services added options for Cantonese, Russian, Vietnamese, and Somali so that the greeting was translated into the top languages of the patient population.
Recommendation 2: Develop procedures to ensure that all patients are notified timely of any abnormal lab results.
Auditor’s note: The Medical Director’s Office said that they are strengthening procedures to monitor in-baskets, which will address timely monitoring of lab results. In-baskets are a system that allows users to send and receive messages related to patient care and can be linked to patient charts, lab results, and orders.
The Medical Director’s Office recently updated the in-basket policy which outlines expectations for managing providers’ in-basket as well as responsibilities for oversight. Medical Directors monitor the in-baskets of providers at their locations and provide follow-up and coaching as needed. In-basket management is also part of the provider performance review process. They are also promoting the use of MyChart as a way for clients to easily view test results.
Recommendation 3: Develop a provider retention plan and begin implementation.
Auditor’s note: In early 2020 Integrated Clinical Services’ HR and the Medical Director’s office implemented a provider retention and resiliency project. They worked with an external consultant to survey providers and conduct focus groups to explore issues that contributed to dissatisfaction and what could be done to increase retention. They also convened a taskforce to review key challenges and address top workforce concerns to identify recommendations to keep staff. In the past couple of years, they have worked to strengthen recruitment efforts as recruiting has become more difficult during the pandemic. This work is ongoing.
Recommendation 4: Partner with Human Resources staff to analyze the impact of turnover, including costs.
Auditor’s note: Plans to analyze the impacts of workforce turnover were delayed due to the pandemic when attention was shifted to the COVID-19 pandemic response and increased recruitment efforts. The Integrated Clinical Services’ Financial Director said they are currently in the process of analyzing the impact and costs of turnover.
Recommendation 5: Address the differences in provider (physicians, nurse practitioners and physician assistants) workload across the system by implementing strategies, such as: a) Assign patient panels based on patient complexity; b) Create different productivity targets for the different provider types; c) Negotiate with funding entities on interpreted visits as a performance goal with the intent of getting additional funding for longer times required by interpreted visits; and/or d) Add an additional provider to high volume clinics.
Auditor’s note: In recent interviews, managers described efforts and initiatives they are working on to address the provider workload, including differences across the system. One initiative underway is advanced access scheduling, with the goal of more efficient scheduling that benefit patients and providers. With advanced access scheduling, providers will have some open slots in their schedules to allow patients to schedule appointments with their primary care provider at the day and time of their choosing, rather than seeing another provider or having to wait several days to get an appointment with their provider.
Advanced access scheduling is expected to help to reduce no-show appointments, increase patient satisfaction, provide an opportunity for some longer appointment times, and help improve patient access to their primary care provider. Scheduling changes may also result in reducing the burden on providers by allowing for longer appointment times for some visits, and seeing more of their own patients rather than seeing patients of other providers.
They are also working to identify improvements to their practice management system to allow for more innovation and are negotiating with payers and funders to look for ways to charge for longer visits.
Recommendation 6: Have the Health Department Director, the Director of Business Operations, and the Director of Integrated Clinical Services (ICS) work together to hire a financial director with health care industry experience to be part of the ICS leadership team. This position should be responsible for ICS financial decisions and given the authority to direct Business Services staff.
Auditor’s note: In December 2020 ICS hired a financial director with healthcare industry experience to be part of the ICS leadership team. The new Financial Director reports to the Director of ICS. The financial director currently relies on Health Department Business Services to produce financial reports, monthly snapshots and the monthly financial package for the Community Health Center Board. The director has plans to hire senior financial analysts within ICS to assume responsibility for the financial reporting for ICS, including Primary Care, Dental Services and Pharmacy.
Recommendation 7: Evaluate provider productivity goals to ensure they are aligned with financial goals.
Auditor’s note: Within Integrated Clinical Services, the Financial Director is working with the Operations Director, and the Medical Director’s Office to ensure that productivity goals are aligned with financial goals. This work has been challenging during the pandemic while they have been adjusting to clinic closures, reduced hours, and other impacts from the pandemic. This work is in process.
Recommendation 8: Work with Central Finance to create a special revenue fund.
Auditor’s note: On September 30, 2021, the Multnomah County Chief Financial Officer presented a request to the Board of County Commissioners to approve the establishment of a new Health Department Federally Qualified Health Center (FQHC) fund to segregate the Community Health Center program budget and accounting activity. The action will provide greater financial reporting efficiency and transparency. In addition, the federal oversight agency, Health Resources & Services Administration (HRSA), requires creating this new fund to allow the Community Health Center program to more easily control, track, and report revenue and expenditures. Multnomah County Central Finance is working to complete full implementation of the Enterprise fund that will segregate all health center revenues from the County’s general fund. Expected completion for full enterprise fund functionality will be by June 2022.
Objectives, Scope, & Methodology
The objectives of this evaluation were to determine the status of recommendations from the 2019 audit of Integrated Clinical Services that had the following due dates:
- April 1, 2020
- December 31, 2020
- December 31, 2021
Auditors evaluated the status of recommendations based on interviews, documentation, and other available evidence.
Updating the Status of a Recommendation
During each audit our office conducts, we develop recommendations intended to improve government operations, particularly with regard to effectiveness, transparency, accountability, and equity. Our goal for evaluating the status of recommendations is to help ensure management implements these recommendations for improvement.
We recognize that after we publish an evaluation on the status of recommendations, management may fully implement a recommendation that we reported was in process or not implemented. Management can then provide evidence to the Auditor demonstrating why the recommendation’s status should be changed in the Auditor’s future reporting. The final decision on whether to change any recommendation’s status rests with the Auditor.
Fran Davison, Principal Management Auditor