DISCUSSIONS 101

This study explored the options for improving the profits produced by optometric clinical services. This study focused on opportunities centred around improving the efficiency of clinical service provision rather than relying on reducing costs or increasing professional fees.

The efficiency of clinical chair time use was analysed. The clinical chair time should be fully used towards the delivery of clinical services to ensure the maximum use of professional skills and equipment. Maximising clinical chair time utilisation ensures the maximum volume of clinical service sales and enhances revenues and profits. However, clinical chair time may be used for other non-clinical service activities, for instance attending meetings, conferences and training sessions. Although these

activities do not contribute directly to sales, they are still valuable business activities. However, other non-clinical services activities such as no-shows and empty appointments are counterproductive. The majority of non-clinical service chair time at BBR Optometry Ltd is occupied by empty appointments (figure 4.1). This may be a result of late appointment cancellations or insufficient demand for clinical services. Demand for clinical services could be improved by reducing operating hours or reducing staff levels (Gikalov et al, 1997). Another option is having a portion of self-employed “locum” staff who can increase or decrease time according to demand. The downside is that their overall full-time equivalent rate is higher than contacted staff. Empty appointments were generally the greatest across the winter months and the lowest across the summer months (table 4.1). Therefore late cancellations and reduced demand for optometric clinical services may also be associated with seasons and weather conditions. Gikalov (1997) also found that poor weather conditions impacted the number of booked appointments kept in high street optometric practice.

A considerable number of clinical chair time hours were occupied by no-shows and reserved chair time. On average, the other non-clinical services activities occupied less chair time compared to empty, no-show and reserved appointments. Late cancellations and no-shows are common barriers encountered when maximising healthcare delivery and appointment schedules (Gupta and Denton, 2008; Ratcliffe et al, 2012; Tang et al, 2014). Late cancellations and no-shows impact productivity and reduce revenues (Ratcliffe et al, 2012; Tang et al, 2014). In addition, they may also result in increased waiting times and longer delays for other patients (Ratcliffe et al, 2012). However, some studies imply that no-shows and cancellations are actually initiated by appointment delays (Bean and Talago. 1995; Grunebaum et al, 1996; Festinger et al, 2002; Gallucci et al, 2005; Dreiter et al, 2008; Liu et al, 2010), although, other studies found no such relationship (Wang and Gupta, 2011). Nonetheless patients are likely to prefer sooner appointments rather than delayed appointments. Therefore there is a need to reduce appointment delays in high street optometric practice and subsequently reduce the volume of no-shows and cancellations. This may also improve the timeliness of clinical care. Implementing an appointment scheduling technique may improve the appointment delays. BBR Optometry Ltd currently operates using a traditional appointment scheduling system whereby bookings are accepted assuming the requested day and time is available. In some respects this represents a ‘first-come first-serve’ approach as popular slots may book sooner than others. An open access appointment

scheduling system aims to accommodate all bookings on the same day in order to reduce the waiting time for appointments (Ratcliffe et al, 2012; Feldman et al, 2015). However, same day appointments may not be the preference for all patients as some may wish to make advanced arrangements, such as transportation (Parente et al, 2005; Salisbury et al 2007; Gerard et al, 2008; Ratcliffe et al, 2012). Furthermore Sampson et al (2008) reported a reduction in patient satisfaction with same day appointments. Other options for reducing the impact of no-shows and cancellations are to issue no-show penalties, appointment reminders and consider overbooking clinics (Ratcliffe et al, 2012; Schultz and Kolish, 2013). However, it may be difficult to collect financial penalties for no-shows. Furthermore over booking clinics may result in further delays if poorly managed.

Reducing the appointment durations for clinical services may also increase profits generated. A reduction in appointment duration increases the capacity to perform a greater volume of services per clinic and hence increases the volume of clinical service sales. Additionally reducing the appointment duration improves the profit per service as shown in figure 4.3. BBR Optometry Ltd reduced the appointment duration for the adult GOS sight test (30 minutes to 20 minutes) and the Glaucoma Referral Refinement service (40 minutes to 20 minutes). This increased capacity by releasing clinical chair time and also produced cost savings of around £19.40 and £38.80 respectively for each adult GOS sight test and Glaucoma Referral Refinement appointment subsequently booked. In addition this change rendered the Glaucoma Referral Refinement service profitable rather than producing a new loss (figure 3.10). However, significant reductions in appointment durations are required to render all services profitable. This may compromise the level of clinical care provided (Europe Economics, 2013). In their study, Gikalov et al (1997) timed how long each clinician spent with the patient during the appointment in order to determine an appropriate reduction in appointment duration. Therefore this study could be extended to measure the chair time actually used for each clinical service, to ensure reductions in appointment duration does not impair the clinical care delivered. Although, this may result in a variety of wide ranging appointment durations. BBR Optometry Ltd only assigns appointment durations that are multiples of 20-minutes e.g. 20, 40 and 60 minute appointment durations. This allows different clinical services to be booked one after the other without creating any empty and unusable spaces. A wide range of different appointment durations may prevent appointments from neatly following on from each other. This may result in small gaps (e.g. 5 or 10 minutes) of idle chair time, which are too small to

be used towards delivering clinical services. Therefore considerations must be made to ensure appointment durations complement each other and prevents idle chair time. Table 4.1 illustrates the use of ‘reserved’ chair time for clinicians in order to complete administrative tasks and effectively ‘catch up’ if necessary. This may be due to insufficient appointment durations causing clinicians to run late. A survey by Dutton (2010) indicated that optometrists are prepared to overrun to deliver the appropriate clinical care. Further reducing appointment durations may cause an increase in reserved appointment slots, which would be counterproductive. Additionally, it is important to note that increasing the capacity for delivering clinical services by reducing appointment duration may not necessarily increase revenues and profit. This was demonstrated by Gikalov et al (1997) and was the result of insufficient demand for clinical services. However, it is uncertain whether practices should increase demand for services before increasing the capacity, or vice versa (Gikalov et al, 1997).

Clinician preferences can be set for particular appointments to ensure increased revenues and profitability as shown in table 4.5. This also ensures efficient use of staff clinical expertise. Setting preferences restricts the patients’ choice of a preferred clinician. Some patients may prefer to see a familiar clinician and in some cases may even be willing to endure a longer appointment delay to see a preferred clinician (Gupta and Denton, 2008; Wang and Gupta, 2011). Although for popular clinicians this may cause a backlog of appointments (Savin, 2006). The ease of appointment booking with a preferred clinician is associated with increased patient satisfaction (Cheraghi-Sohi et al, 2008; Gerard et al, 2008; Wang and Gupta, 2008). Therefore, although dictating clinician preferences for clinical services will likely increase profits it may be associated with reduced patient satisfaction. Furthermore, allowing patients to choose a preferred clinician offers other benefits such as ensuring continuity of care (Doescher et al, 2004) and may also decrease the likelihood of no-shows (Carlson, 2002; Smith and Yawn, 1994).