Boosting Medical Practice Productivity: A Case Study

Several readers requested I provide an example of the process I outlined in "Six Steps to Boost Productivity by 30 Percent at Your Medical Practice." So here is an abridged case study from my consulting practice.

Process:
Checking Patients into the Practice Management System
Situation:
• Busy, multiple physician practice
• 150-200 patients per day
• Practice management system in use, no EHR
• Patient check-in takes an average of 38 minutes
• Physicians are often idle because patients are in the office but not yet checked in according to the practice management system

Objectives:
• Get a super bill printed for patients before physicians get frustrated and render services without one
      • Better utilization of physician time
      • Avoid loss of payment and much additional work in insurance and billing
• Minimize patient aggravation at long waits
• Capture all updates and releases required for billing, claims processing and HIPAA

Process Steps
1. Patient signs arrival sheet

2. Receptionist
• Pulls patient's strip from arrival sheet
• Attaches patient's strip to computer monitor to indicate patient is in process

3. Receptionist locates patient on day's schedule
• Looks for special handling notes regarding insurance or billing
      • If any, receptionist alerts back office that patient is on premises
      • Insurance or billing staff comes to escort patient to consultation room
• Updates patient status to "present," but not checked in

4. If patient is new or has not been seen this calendar year, receptionist calls patient to desk and requests
• Patient's driver's license and insurance card
• Patient to complete practice information and release forms
• Receptionist then:
      • Scans driver's license and insurance card
      • Calls patient to desk to return driver's license and insurance card
• Patient returns completed forms.
• Receptionist reviews forms for completeness.

NOTE: Receptionist neither identifies changes from previous documents nor updates the practice management system.

5. Receptionist
• Locates patient chart
• Adds completed forms, if any, to chart
• Prints super bill
• Attaches patient's strip from arrival sheet to super bill
• Attaches super bill to front of chart
• Places chart in provider's bin for pick up by medical assistant
• Updates patient status to checked in

Observations
• Patients tend to arrive in groups of five to 15.
• The receptionists are often idle waiting for a group of patients to sign the arrival sheet.
• The printer is 10 feet to 15 feet from the receptionists.
• The patient charts are on carts about 5 feet from the receptionists.
• Receptionists have significant trouble locating a patient's chart five to eight times per day, searching for 10 minutes to 30 minutes.
• Patients are processed strictly in the order of arrival; that is, an established patient who is in for a recheck can be stuck for an hour behind three new patients who arrived with no paperwork completed.

Questions asked for each step:
• What does this step have to do with the goal?
• Is another step performing the same function?
• Is there a better way?
• Could a step be added that would have a positive impact on a subsequent step?
• Are any additional steps necessary?
• Are the steps in the most logical order?
• Is the process intuitive?
• Are any steps error-prone?

Changes
• Implemented a second arrival sheet.
When the receptionist finishes processing the patients on one arrival sheet, she swaps it with the arrival sheet currently being used by patients. Patients can continue signing in and she can begin to process the most recently signed in patients.
• Began to immediately check in each patient who requires no special handling related to insurance, billing, or documentation.
• Moved the printer to between the two receptionists.
Now, each can take documents from the printer without leaving her chair.
• Removed the charts from the reception area to the physicians' pods.
The best estimate is that the move saves the receptionists 250 minutes to 300 minutes per day. It adds very little work to the pod staff because familiarity with the patients and a much smaller number of charts make the charts easier to locate.
• Stopped asking established patients to complete new documents. At their first visit of the calendar year, established patients are asked to review a printout of their demographic information from the practice management system and their most recent HIPAA release.
      • If there are no changes, the patient signs the current document.
      • If there are changes, the patient updates the document; the receptionist updates the practice management system and/or scans the documents; the receptionist prints the modified documents; and the patient reviews the updated documents.
      • The documents are shredded and not filed in the patient's chart, reducing filing time as well as space requirements. An additional benefit is that the demographic information verified is what is actually in the practice management system.
• Utilized the receptionists' idle time in the late afternoon to review the next day's patients to identify those who needed to review documentation.
Printing those documents the afternoon before the patient's visit makes them immediately ready for patient review at the patient's arrival.

Amended Process
1. Patient signs one of two arrival sheets. When receptionist has worked all patients on one arrival sheet, she swaps it for the arrival sheet on the counter for patient sign-in.

2. Receptionist locates patient on that day's schedule and looks for special handling notes regarding insurance, billing or documentation.
• If patient needs no financial counseling or additional documentation, receptionist goes directly to Step 5
• If special handling for billing or insurance is required, receptionist alerts the back office, and insurance or billing staff comes to escort patient to a consultation room

3. If patient is new, receptionist calls patient to desk:
• Receptionist requests patient's driver's license and patient's insurance card.
• Receptionist immediately scans driver's license and insurance card and returns both to patient. Neither the patient nor the receptionist requires a second interaction to return the cards.
• Receptionist asks patient if she has retrieved forms from the website and completed them. Patients tend to prefer to complete the forms at their leisure and when they have access to all necessary information.
      • If yes, receptionist accepts completed form
      • If no, receptionist asks patient to complete
• Patient delivers completed forms
• Receptionist
• Reviews forms for completeness
• Enters appropriate information into practice management system
• Goes to Step 5

4. If patient has not been seen in the current calendar year:
• Receptionist prints and asks patient to review and correct as necessary.
      • Face sheet (all demographic information)
      • Patient's current HIPAA release
• If patient has indicated a change in demographic information:
      • If patient has indicated a change in name, address, and/or insurance, receptionist requests appropriate card(s), scans, and returns to patient
      •Receptionist makes changes to practice management system as indicated by patient
      •Receptionist prints a new face page for patient review
• If patient has indicated a change in HIPAA authorization, receptionist updates practice management system as necessary and scans new HIPAA authorization.
• Receptionist puts any face sheets and HIPAA authorizations into the shred box.

5. Receptionist
• Prints super bill
NOTE: Printer has been moved to the floor between the two receptionists' work areas. They do not need to move from their seats to retrieve printed documents.
• Attaches patient's strip from arrival sheet to super bill
• Attaches super bill to front of chart
• Places super bill provider's bin for pick up by MA
• Updates patient status to checked in

Results Achieved within 30 days of project inception:
• Physicians no longer have to wait on check-in.
• The average time elapsed between a patient's arrival and being designated as ready:
      • 9 minutes for an established patient, including those needed to confirm or update  documentation; 17 minutes for a new patient arriving with no paperwork completed
• Changes to patient demographic and insurance information reliably make it into the practice management system.
• Receptionist desk requires two receptionists during only a portion of the day.
• Receptionists are relaxed and have time to greet patients.
• Receptionist activities have expanded to keeping the reception area tidy.

The changes required no additional equipment or software. The only requirement was for someone to take the time to observe the situation, identify what currently made no sense, and make the changes suggested by some simple questions.

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