8 Barriers That Hinder Change in Small Medical Practices

The healthcare industry is constantly changing for many reasons. Most recently, quality improvement has been the trend and small medical practices are faced with implementing complex strategies to enhance the quality of care for patients. Several improvements that a medical practice may consider include reducing wait times, improving patient follow-up practices, improving patient complaints, improving clinical documentation, and standardizing processes.

In order to implement change in a small medical practice, it is important to identify and understand the barriers and challenges that hinder change. There are both internal and external barriers that hinder change in small medical practices.

The internal barriers include:

  • Staff resistance to change
  • Lack of motivation of practice members
  • Lack of relationship among practice members
  • Lack of adequate space
  • Power struggles

The external barriers include:

  • Competition
  • Payment reform
  • Patient involvement

1
Staff Resistance to Change

Resistance to change is high on the list of barriers to implementing change in any environment. In a medical practice in which teamwork is essential, it is important to predict the sources of resistance and develop strategies to work around them. Some of the most common reasons staff may be resistant to change include:

  1. The fear of the unknown. People tend to automatically associate or perceive change as a negative experience. This is especially true if they don't have adequate warning or without understanding how it will affect their work.
  2. The fear of losing their jobs. People often perceive change as a threat to their jobs. They may view implementing new processes as restructuring and think if the medical practice becomes more efficient, their position will be eliminated.
  3. Lack of trust. If practice members do not trust management, they are less likely to easily follow new policies and procedures. If management has either lost trust or never truly gained the trust of practice members, they may be resistant to change.
  4. Prefers routine. Some people have no reason to be resistant to change other than they prefer their current routine. After working at the same place, in the same position, for many years, its just easier to stick to the familiar. These individuals do not enjoy learning new things and are likely to be the most resistant practice members.
  5. Poor timing. Every step in a transition or an implementation must be introduced at the right time. If not, practice members will definitely resist any changes introduced will be met with resistance.

2
Lack of Motivation of Practice Members

Practice members that lack motivation to implement change are different from those that are resistant to change. Resistance is the refusal to accept or comply with a change. The lack of motivation refers to the unwillingness of someone either due to a lack of desire or interest. 

Another difference between resistance and motivation is that resistance can be overcome by communicating with staff what the changes include, who will be impacted by them, and how the changes will impact them  before any changes are implemented. Motivation, on the other hand, is a bit more complex.

There are two types of motivators: intrinsic and extrinsic.

Intrinsic motivators are driven by internal factors. An individual gains personal satisfaction from undertaking a specific activity. Some examples of intrinsic motivators are achievement, recognition, enjoyment, or a sense of fulfillment.

Extrinsic motivators are driven by external factors. These usually involve some type of control either by giving or withholding of rewards, or some form of punishment. Some examples of extrinsic motivators are money, praise, disciplinary action, job security, or benefits.

3
Lack of Relationship Among Practice Members

When practice members lack relationship, they lack cohesiveness and productivity. In order to be successful, especially during a time of change, practice members need to trust, support, and respect one another. 

Before implementing change in a small practice, it may be necessary to use team-building activities to improve relationships among practice members. ​

Here are ten identifiers that practice members lack relationship:

  1. Patient complaints about quality of service
  2. Decreasing productivity
  3. Confusion about work roles and responsibilities
  4. Tasks not carried out in a proper or timely manner
  5. Lack of motivation
  6. Routine tasks requiring complex decisions
  7. Conflicts among practice members
  8. Negative attitudes towards management
  9. Complaints of favoritism
  10. Lack of cooperation

4
Lack of Adequate Space

Traditional physician practices often lack the adequate space to implement changes. Specifically, changes made to improve patient flow are often difficult due to outdated designs. The costs of remodeling or moving to a larger space may not be an option due to the financial strain it could place on the practice. 

Performing an assessment of patient flow can help to determine whether space is really the issue or if changes to the process should be made. If it is determined that space is truly the issue, it is in the best interest of the practice to invest in construction that will improve patient satisfaction for current and future patients.

5
Power Struggles

There are many power struggles in a medical practice. One that is a barrier to implementing change is the struggle between delivering quality care while reducing costs. Poor quality of care and increasing healthcare costs have been at the center of healthcare reform efforts for many years.

Research indicates that traditional volume-based payment models are responsible for the problems with the quality and costs of care. Volume-based payment models encourage providers to treat more patients to generate higher profits without any regard for improving quality outcomes or reducing costs while value-based payment models encourage providers to achieve certain performance measures to generate higher reimbursements. 

For medical practices that attempt to improve quality outcomes and reduce costs are aware of the constant power struggle between providing patient care and maintaining financially healthy. Until payment models change that support quality of care while allowing the medical practice to achieve financial sustainability, it is likely that implementing change will continue to be hindered.

6
Competition

Healthy competition is good for business, however, a large number of independent medical practices are consolidating their practices in order to become a multi-specialized physician practice. Some experts indicate that merging different physician specialties into one practice is beneficial for patients and the practice. 

Independent medical practices have the sole responsibility of maintaining and updating existing equipment, software (information technology) and infrastructure. These costs can put a strain on the medical office with a limited cash flow. The requirements for ICD-10, HIPAA, meaningful use and the implementation of the electronic health record require health care providers to increase their capabilities in information technology and education.

Larger practices are in a better financial position to implement these changes.

7
Payment Reform

Medicare and Medicaid reimbursement cuts, also identified as payment reform, is a huge barrier to change in a small medical practice. Medicare and Medicaid cuts create a major financial setback for independent or private practices. Low profits make it almost impossible to implement change because small practices are barely able to maintain much less make improvements.

In addition, practices that treat a large number of Medicare and/or Medicaid patients, the reduction in reimbursement may cause them to stop accepting new Medicare and Medicaid patients at the very least. For some, it means shutting down their practice. 

8
Patient Involvement

Without patient involvement, it is difficult to implement change. An easy and effective way to make sure your patients receive information important to their care is to give them handouts. The five most necessary handouts for new patients include:

  1. The first visit handout
    • Patient welcome message
    • An introduction to the medical practice
    • A brief bio of each physician
    • What they should expect from their first examination
    • Contact information
    • Hours of operation
    • Services provided
    • Other locations
  2. The list of what to bring to each visit
    • Insurance Information
    • Photo ID
    • Responsible Party/Information
    • Demographic Information
    • Payments
    • Clinical Information
    • Emergency Contacts
    • Accident Information
    • Advance Directives
    • Pre-authorizations/Referrals
  3. The payment policy
    • Co-pays, deductibles, and co-insurance amounts are due prior to services being rendered for each visit
    • Self-pay patients are responsible for paying the entire amount in full
    • Acceptable forms of payment such as personal checks, credit cards, and debit cards
    • Late fees for billed amounts not paid within a certain time frame
    • Charges for missed appointments not canceled or rescheduled in advance
    • A list of participating insurance companies
    • Patients must provide proof of insurance prior to treatment or be considered self-pay
  4. The notice of privacy practices
    • How the provider will use and disclose their PHI
    • The rights patients have regarding their own PHI
    • A statement informing the patient of laws requiring the provider to maintain the privacy of their PHI
    • Who patients can contact for further information regarding the provider's privacy policies
  5. The patient satisfaction survey
    • Was the patient spoken to with respect when calling in for an appointment?
    • Was the patient greeted by the receptionist with courtesy and respect?
    • How long did the patient wait to see the doctor?
    • Did the nurse and doctor explain the details of the services provided to the patient?
    • Did the nurse and doctor answer all the patient's questions?
    • Did the patient receive excellent customer service?
    • Was the exam room clean, comfortable and prepared?
    • Was the waiting area safe, clean and spacious?

This is not an all inclusive list but just a few basic ways to keep patients engaged and aware of how important their involvement is to their own care.

References

Arar, Nedal H., et al. "Implementing Quality Improvement In Small, Autonomous Primary Care Practices: Implications For The Patient-Centred Medical Home." Quality In Primary Care 19.5 (2011): 289-300. CINAHL with Full Text. 

Forbes. Forbes Magazine, n.d. 

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