• Boost Practice Efficiency, Part 15: How to Improve Office Flow

    By Leslie Burling-Phillips, Contributing Writer

    This article is from June 2009 and may contain outdated material.

    Some days run smoothly. Others seem to get worse by the minute, leaving you one hour, maybe two hours, behind schedule. At the end of the day, you wonder what happened. Are you the culprit? Was it a problem with staffing? Here’s how to spot and, even better, prevent bottlenecks.

    Find your bottleneck. Tracking patient flow—whether it is done daily, occasionally or just once—can provide a tremendous amount of information about how efficiently patients progress through each stage of their office visit. Consultant Larry R. Brooks, AIA, principal of Practice Flow Solutions in Norcross, Ga., urges you to continually track the volume of patients seen each day. “Break this information down into new patients and follow-ups. Track any no-shows and add-ins. Then determine the number of hours that the physician actually spent seeing patients. With this information, you can schedule and plan according to that volume and therefore keep the physician’s output in sync with the expectation,” said Mr. Brooks.

    Every minute counts. “It’s often spending an additional minute here or there that adds up to an extra half hour or more,” said Derek P. Kuhl, MD, PhD, OCS, a solo practitioner and retina specialist in Bryan, Texas, who tracks patient flow daily. “I find that tracking reduces patient residence times dramatically. We all pay more attention to the time and are better able to stay on schedule.”

    Reduce No-Shows and Late-Shows

    Practices fine-tune their scheduling in a variety of ways.

    New patients—add an extra appointment for paperwork before the day of the exam. Dr. Kuhl found a way to reduce his no-show rate from 40 percent to 5 percent. “We noticed that people who simply made phone contact with our office often did not arrive for their scheduled appointment. Now, we ask our new patients to come by the office, provide their insurance information and complete the preliminary paperwork after seeing their referring ophthalmologist. By doing so, they not only find out where our office is located, but they have also become invested in the process.”

    Use patient demographics as a guide. Nuances in patient demographics, particularly age and location, should guide how you and your staff communicate—both verbally and nonverbally—about arriving on time for scheduled appointments.

    “We see many Navajo Indian patients who are accustomed to waiting for health care at the Indian Health Service (IHS) for many hours at a time. As a result, they may arrive two hours before or after their scheduled appointment or any time in between,” said Paula Vaughan, OCS, office manager of a solo practice in Farmington, N.M. “For those who show up early or late, we let them know that we will work them in when we can. Patients frequently travel 50 miles or more to get here, so we cannot say, ‘We’re sorry, but we can’t see you today.’”

    Be ready for the early birds. “We schedule the first part of our morning somewhat densely because we always have patients who arrive early,” said Ms. Vaughan. “In the past, our first patients were scheduled for 8:15 a.m. and they routinely arrived at 8 a.m.—the same time as our tech. As a result, we felt like we were rushed to get the day started. We decided to modify our schedule and now a tech arrives at 7:30 a.m. When patients arrive early, they are immediately worked up. By 8 a.m. we have one or two patients ready to see the physician. We do the same at lunch. It has worked well for us.”

    Consider contingencies when scheduling. “Our practice philosophy is that if you call with a problem, we offer to let you come in,” said Dr. Kuhl. “We allocate time slots at the end of the morning and the end of the afternoon for emergencies. If they do not fill up, we finish early.”

    Mr. Brooks offers three pearls to ensure patients arrive on time:

    • Schedule two appointments for each patient on the clinic’s calendar—one with the practice and one with the physician. Rather than asking patients to arrive 15 minutes early to complete preliminary paperwork, a request they often forget about, tell them they have an initial appointment with the practice followed by an appointment with the doctor. This allots ample time for the front desk to obtain all the necessary information.
    • Give patients a call two days prior to their appointment. You will have fewer last-minute cancellations and more time to fill empty slots.
    • The physician needs to see patients on time. Patients notice when a physician consistently runs late, and they begin to arrive late as well.

    Why the Delay?

    TRACK PATIENT FLOW. “We were having trouble sticking to our schedule, so I tracked patient flow,” said Ms. Vaughan. “It gave us valuable insight into the problems we had. We worked out our issues and now stay within 15 to 20 minutes of our schedule on most days.” Here are some key points in time that you should note down.

    • Time of appointment, and when the patient arrived and departed.
    • When the patient goes back to a room with a tech, and when the tech leaves.
    • When the physician comes into the room and leaves.
    • If any tests are done, the amount of time spent testing with a patient.

    The Front Desk—Got Bottlenecks?

    Obstacles at the front desk can quickly snowball through the entire practice, putting everyone behind schedule. So improving patient flow here pays off downstream. “Sometimes this means redelegating duties,” explained Mr. Brooks, “or perhaps handling the phones differently.” You could, for instance, hire a dedicated receptionist—someone not located at the front desk—who answers the phone, makes appointments and distributes calls.

    Fill in the blanks in advance. In an ideal world, patients would complete patient information forms before arriving for an appointment. They can give this to you by fax, by mail, online or in person. At Ms. Vaughan’s practice, when patients phone to make an appointment, the staff member gets as much information as possible during that call. “It only takes a minute or two in most cases, and it helps prevent a backlog at the front desk. Then our patients simply review the information for accuracy when they arrive.”

    Five Ways to Improve Patient Flow

    • When you get behind schedule, let your patients know. Give them the option of waiting, leaving and coming back, or rescheduling.
    • Allocate certain time slots for injections, procedures, follow-ups, new patients/consults.
    • Assign patient data entry to scribes and refracting to techs.
    • Arrange equipment and services in a logical progression.
    • Create sub-waiting areas for patients between testing and examination so you don’t have to walk patients back to the main waiting area.

    The Technician’s Role

    Techs have multiple responsibilities, such as phone triage, diagnostic testing, assisting the physician, refracting patients, loading the examination room and scribing. Staffing each area with enough techs is essential for keeping the practice running smoothly. However, bottlenecks can occur when techs spend too much time reviewing charts or working up patients. “It takes a lot of time to review a chart. In the past we had a tech who reviewed each chart prior to seeing a patient and, as a result, that person was never able to keep up with the schedule. From a work-up standpoint, it isn’t necessary. A quick review of the previous diagnostics and diagnoses is adequate,” Dr. Kuhl said.

    The physician should help techs to plan for the day ahead. “The practice physician should spend about five minutes at the start of each session with the techs to review the appointment schedule and determine what types of patients will be coming in that day. Giving them guidelines about what needs to be done enables techs to efficiently prepare each patient for the physician. The goal is for the physician to make one trip into the exam lane to see a patient,” said Mr. Brooks.

    The Physician’s Role

    “Physicians should be the limiting factor to production. Their personality and ability to see patients at a comfortable rate should determine the overall output of the practice,” said Mr. Brooks. However, when the physician is the cause of a bottleneck, the staff should assist when they can. “If we are running behind schedule and I see that Dr. Allen has a talkative patient, I knock on the door and help him exit,” said Ms. Vaughan. Handing over the patient to a scribe is another way to help the patient transition from exam to departure.

    Nip problems in the bud. “At the end of every day that doesn’t go so well, we all discuss what happened,” said Dr. Kuhl. “Then we fix it. Don’t wait for things to go poorly for a month or two. If the scheduling template is too dense and I cannot handle it, I change it immediately.”