Flow and Efficiency “Red Flags”
When a patient presents in your office with an eye problem, many physicians look for specific signs and symptoms that quickly lead to a diagnosis and eventually to a solution to the patient’s problem. Similarly, when analyzing a practice for flow and efficiency problems, it is important to look for certain “red flags” that suggest there might be a problem and then search for possible solutions. Listed below are a number of “red flags” common to flow and efficiency problems in an ophthalmic practice. They are followed by recommended ways to resolve the problem.
Recommendation
Determine if there is a physical problem in or around the building that could be causing patients to be late. The culprit could be a lack of parking, an elevator that is out of order, construction on the street or highway that leads to the building, etc. If there is problem you can fix, fix it as soon as possible. If the problem is out of your control, your
appointment scheduler or telephone confirmation person can tell patients in advance about the problem so they can plan additional time for their trip to your office. We also suggest you politely remind patients of the importance of being on time when you call to confirm their appointment.
Recommendation
If this is a frequent occurrence in your office, you might not have enough staff dedicated to the chart preparation process. In larger practices, it is usually necessary to have full-time staff dedicated to chart preparation. In other practices, chart preparation becomes just one of the responsibilities of the front office staff. At times, a part-time person can assist the front office team while some practices ask technicians to assist with chart preparation during the latter part of the day when they likely are not directly working with patients.
Patients Consistently Arrive Late
Patient Charts are Frequently Not
Ready When Patients Arrive
Recommendation
Most practices dedicate two or three exam lanes to each physician working in the practice on a particular day. They also dedicate one exam lane, or preliminary exam room or station, to each work-up technician. Some practices get creative, using “quick check” rooms that might be smaller than the traditional exam room. “Quick check” rooms use portable equipment, i.e., slit lamps, smaller chairs, etc. Approximately 10% to 15% of all patients can be seen in this type of room, if necessary. Of course, sometimes it is necessary to call in a space planner to assist with the reconfiguration of space.
Recommendation
This is a problem that should be easy to fix by focusing on the technician staff. If you do not have written protocols defining the time technicians should be ready to start seeing patients, create one. Most practices require techs be at the practice 15 minutes before the official start time so they can be ready to call patients slightly before, or precisely at, start time.
If you have a physician who consistently arrives late to the practice, it may be helpful to visit with the doctor to determine why he/she is consistently late. Frequently we hear from these doctors that they come late because “patients are not ready to be seen.” If this is the case, adjust your schedule to “front-load” brief exams so technicians can have these patients worked up quickly and ready for the doctor when he/she arrives close to the official start time.
Some doctors say they have responsibilities at home in the morning (i.e., taking the kids to school, exercising, supervising the gardener, etc.) which do not allow them to get to the office on time. If this is the case, you could consider starting the patient schedule later to accommodate the time when the physician normally arrives at the office. The doctor may want to start patients later in the morning and work later into the day.
There Does Not Seem to be
Enough Exam Lanes
Technicians or Doctors Consistently
Start Seeing Patients Late
Recommendation
It is important not to interrupt the doctors while they are seeing patients. Most staff will say they do not interrupt the doctor, saying that “the doctor interrupts himself,” meaning the doctor will leave the clinical area to make a brief phone call (that lasts 15 minutes or more!), etc. Usually, the doctor will not leave the clinical area unless there are no
patients to see, so it is imperative to schedule patients in such a way that the doctor has to keep working. In addition, it is important to remember that even short interruptions by staff while the doctor is seeing patients can add up to a considerable amount of lost time at the end of the day.
Recommendation
It is important that all exam lanes be properly equipped and functioning smoothly. If a doctor or technician has to leave an exam room to retrieve a piece of equipment or eye drops from another area, this is an inefficient use of time. Additionally, because a
projector, slit lamp, or another piece of equipment is not working properly, we have seen technicians and physicians completely ignore an exam room, thus reducing the amount of usable exam space in a practice. It is recommended that you establish inventory supply lists for every exam room and assign a staff person to maintain and monitor the inventory. If a piece of equipment needs to be repaired, have it fixed so the room can be used to its full potential.
Recommendation
In the ideal office, the preliminary exam area is as close as practical to the patient
Physicians are Frequently Interrupted
When Seeing Patients
Exam Lanes Are Not Properly
Equipped
Patients and Clinical Staff Walk a Long
Way to the Preliminary Exam Area
Recommendation
You can tell your charts are not organized if you frequently see doctors and technicians paging endlessly through the chart in an attempt to find information. Charts can be organized by using tabular separators identifying the various components of the chart (i.e., all clinical data should be grouped together in one portion of the chart, all
correspondence in another portion, etc.) to help reduce the amount of time physicians and staff spend looking for information in the chart.
In addition, use patient “work-up” forms that are designed to reduce the amount of time physicians and clinical staff spend manually writing in the chart. These “work-up” forms, which typically use check boxes to indicate normal or abnormal findings, can save considerable time by eliminating the need to write the same data manually.
Recommendation
In today’s busy practice environment, it is important for each staff member to be able to perform multiple duties. From an efficiency standpoint, however, it is better to utilize your most skilled technicians in the roles that require the highest skill level. Skilled techs usually perform tasks more accurately and efficiently. When the patient flow requires accuracy and efficiency, the best technicians should be in the positions where the patients are moved through the practice as quickly as possible. Place less skilled techs in more responsible roles at times when the practice is not so busy.
Recommendation
National benchmarks indicate that well-trained technicians should be able to do an examination work-up, including refractometry, in approximately 16.5 minutes. We suggest the physician or clinic supervisor review examination protocols and make necessary adjustments. Additional technician training may be required.
Patient Charts Are Not Well Organized
The Most Skilled Tech Perform Tasks
That Do Not Require the Most Skill
Techs Often Spend More Than 15 Minutes
With the Patient for Exam Work-Up
Recommendation
Busy eye surgeons should not be utilizing exam room time to perform time-consuming refraction checks. The practice should have at least one “go to” technician or optometrist who can perform refractions at the highest level.
If the existing group of technicians does not refract at the highest level -- or you do not have an optometrist on staff that performs refractions -- then additional
refraction
training might be necessary for one or more of your technicians. This will eliminate the need for the ophthalmologist to spend valuable exam room time performing refraction checks.
Recommendation
Patients, clinical staff, and doctors will appreciate the benefits of having a wheelchair ramp device installed in at least one of your exam lanes. This device permits a regular exam chair to slide back on rollers, allowing a wheelchair to be easily moved into the exam chair position. A wheelchair device is not overly expensive and saves considerable staff time and energy. Wheelchair patients like it because they do not have to leave their chair to be examined; staff likes the wheelchair device because less energy is used to help patients get in and out of their wheelchairs.
Recommendation
Writers and scribes can help make a physician more efficient and move patients through
Eye Surgeons Perform Refractions
None of the Exam Lanes Are
Equipped with a Wheelchair Ramp
Practice Does Not Use a Writer or
Scribe
In addition, a scribe can assist in the exam room by removing coats, glasses, and purses from patients before the doctor enters the exam room. This individual can also instill eye drops, pass instruments, write prescriptions, and simply assist in the room as needed. Once the doctor has completed the exam, the scribe can provide follow-up instructions and escort the patient to the check-out station while the doctor goes to the next exam room to see another patient. This system can save one to three minutes per patient, thus saving a substantial amount of time at the end of the day.
Recommendation
Typically, congestion at check-in and check-out is due to understaffing at each station during peak hours. In addition, the check-in and check-out process can be lengthened by computer software that is slow or by staff that needs more training on how to
accelerate the process. Observe the check-in and check-out process in your practice to identify the specific reasons for delays and implement necessary adjustments to correct the problem(s).
Recommendation
Several factors normally produce this challenge, including time-consuming insurance authorizations and not having enough staff assisting patients at check-in. If either of these are causing delays in your practice, we suggest you look at completing a portion of the pre-authorization process in advance and putting additional staff at check-in during peak hours.
Sometimes, the manner in which patients are scheduled causes patients to wait too long to be called for their appointment. If too many long exams are grouped together, the technician and doctor cannot process patients quickly enough to avoid lengthy delays. Balancing the schedule with the proper amount of brief, intermediate, and long
appointments should help solve this problem.
It is also possible that part of the delay is caused by limitations of space, staff in the back office, or techs/doctor spending too much time with each patient. You should complete a thorough evaluation of this problem to identify specific reasons for any delays. As part of your assessment, examine the number of patients seen during each hourly segment to determine if there are too many patients on the schedule to be seen within the allotted timeframe.
Check-In and Check-Out Stations are
Congested During Peak Patient Hours
Patient Wait Time From Arrival to
Start of the Examination is Too Long
Recommendation
While this is a nice gesture, it is extremely time consuming. The time it takes to walk a patient out and walking back to the clinical area is approximately 30 - 45 seconds per patient (this also exposes the doctor to the possibility of being further delayed in the check-out area by staff or patients). This time could be better spent working in the clinical area. We recommend the doctors begin the process of reducing the number of times they walk patients to the check-out area with the eventual goal of eliminating this practice.
