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Eliminating bottlenecks to the bottom line

Physicians PracticePhysicians Practice July 2023
Volume 01
Issue 01

For most of us, doing better will mean doing differently.

dollars shaped into a heart | © Getty Images

© Getty Images

The COVID-19 pandemic and its spinoff — the “great resignation” — have revealed just how hard it is for patients and referrers to reach us.We need to do better.

Why? Because over time, poor service on the front end will erode everything else, including the bottom line. I am going to share some options for improving patient and referrer access, but first I want to share a true story for those clinicians who may think it’s not that big a deal.

One of my employees called a local neurology practice this week to ask a question about a patient they had referred. My employee pressed 2 to get to the clinician priority line. And there she waited for 90 minutes. It gets better —or worse.The person who answered the phone could not help. Rather, she said the best she could do was take a message to give to the neurologist’s nurse.

We don’t bite the hands that feed us, but I called the neurologist on his cellphone directly so his patient’s care would not be delayed. He thanked me. And then he said that he spends time during almost every patient visit apologizing for their lousy phone processes. He shared that new and longtime patients have left, and some reliable referrers have stopped referring.He’s taken to giving them his cellphone number to bypass the process hell.

For most of us, doing better will mean doing differently. We can no longer rely on a revolving support staff. Ask your manager or human resources person: Recruitment/hiring/training/retention is a vicious and frustrating cycle. And if you ask the employees who are leaving or have left, you’ll hear a common theme: I am leaving because there aren’t enough of us to get the work done, I am tired of being yelled at by patients and referrers and I am tired of no one working above me listening or caring.

The sooner we accept the demise of the traditional model of a stable support staff who stay with the practice forever, the faster we can eliminate the bottlenecks that give our practice many black eyes every day.

I have come to believe a hybrid model is the best option, as I am unwilling to completely outsource the “front door” of my practice. I want some of my own employees, supplemented by a combination of technology and on-demand staffing.

Physician, heal thyself

You cannot make a diagnosis without understanding the underlying symptoms. For front-end bottlenecks, gather as much of the following information as feasible:

  1. Average time to answer: measure this statistic by clinic/department/office.
  2. Average time to answer “back” line: same measurements.
  3. Dropped calls/day average: same measurements.
  4. Dropped calls/day/“back” line average: same measurements.
  5. Number of calls/day average: same measurements.
  6. Number of calls/day by hour: same measurements. There are peak days and times when the phones go crazy. Understanding these busy times is critical.
  7. Types of calls: The major types of calls vary by practice; below are several common types. Have calls tracked for a week by type:
    1. Appointment scheduling.
    2. Prescription refills.
    3. Results queries.
    4. Prior authorization requests.
    5. Callbacks (when you didn’t get someone what they needed soon enough, so they call back a second or third time).
    6. Billing questions.

Finally, let me hit on a pet peeve. There is a process for rolling the phones from the answering service/answering machine at the start of the day and rolling them back at the end of the day. Is this process automated? If not, check to see that the phones are being rolled when you think they are being rolled. It’s frustrating to call a clinic at 9:05 a.m. or 4:50 p.m. when the clinic is supposed to be open and get a “We’re closed” message. It happens all the time.

I will stop there. With answers to these queries and a basic understanding of your staffing (and staffing stability; frequent turnover breeds both inefficiency and frequent turnover), you can begin to develop solutions.


Digital forms: Make sure your forms are digitized and available on your website in fillable PDF format. Make sure those PDF forms are integrated into your practice management/electronic health record (EHR) platform. These timesavers are seriously undervalued and underused.Companies such as Phase Zero make this automation easy and fast.

Digital front doors: Most of us are familiar with companies such as Phreesia that automate form completion, check-in and co-pay payment. Their products are designed to automate processes normally assigned to your check-in staff. If you do not have one of these products in place, you should take a look. Make sure to customize the fix to fit your needs.

Now, for those of you who do have one of these products in place, I offer two suggestions.First, make sure they are decompressing your bottlenecks. Second, make sure your staff is making productive use of the saved time. I went into an office in December where things were so automated that the check-in staff had almost nothing to do. They were supposed to handle the overflow of phone calls from the main switchboard, but instead they were reading tarot cards; I am not making this up. The practice was paying the salaries of three employees to play while also paying for the automation to do their work. Pay attention.

Part-time/PRN peak staffing: Staff up for peak periods. This is simple but effective. Your labor pool is wider than you realize: parents with school-age children, retired people, high school vocational education programs, college students and potential pre-med or pre-nursing candidates who need health care experience on their résumé.

Hybrid staffing companies: There are companies such as Hubkom Solutions that provide remote wraparound staffing. In this model, you hire the company to provide hybrid employees to meet ongoing demand, either full time or at peak times. These companies either use their own software or work within your systems. I have tried both options and was surprised I preferred the latter, as it permitted our hybrid employees to function as seamless parts of our existing workflows. In my former practice, we initially used a hybrid staffing company to answer any phone not answered by my staff within three rings. The hybrid employees answered phones, took messages and — because they were logged into our EHR — routed messages. They performed flawlessly and the practice has since expanded their responsibilities to include appointment/procedure scheduling and back-end procedure recalls.

There is a reality to face in considering companies such as these: Their employees are often based overseas. I took no issue with this fact as hourly rates in most practices have gone up significantly in the past five years. We were paying an average hourly wage of about two-thirds of what we were paying in local wages/benefits. And because that average living wage overseas was substantial for where the hybrid employees worked, there was very little turnover.I had concerns about the accents of the hybrid employees, but those concerns were unfounded.

Online ratings: Paper surveys are a thing of the past. They have one benefit — feedback on how the practice is doing — but miss out on another benefit: online reviews for potential patients to see. Companies such as rater8 do an amazing job of automating this process and making it very easy for patients to leave reviews. I espouse rater8 because it makes it very easy for a practice to adjust the percentage of reviews going to different sites (e.g., Google, Healthgrades) even at the clinician level.

Here's another thing I love about collecting online reviews: I share them with my team regularly.The positive reviews I share reinforce our core culture and how my team makes a difference in the lives of our patients. In other words, these reviews are a most effective retention tool.

Make rounds: One of the most important things a leader can do is to make rounds in their departments and clinics regularly. Making rounds means making yourself available. It means meeting your employees in their clinics or workstations to observe how they are faring, to ask how they are doing and to learn what bottlenecks are impacting patient access and patient care. Making rounds is not a digital hack but it is the precursor to any effective digital hack.

I mentioned an office earlier where three check-in employees were reading tarot cards. There was a 2-foot-by-4-foot fluorescent light right above the check-in window. I counted no fewer than eight dead flies all lit up for patients to see. One important task of your check-in staff — and you as a leader — is to pay attention to those first impressions. You can use the above recommendations and get rid of bottlenecks, only to be sabotaged by eight flies in a ceiling light.Pay attention to those details as well.

We are here to serve patients. When we make it hard for patients or for those who refer us patients, we hurt our core mission. Eliminating bottlenecks that stymie access is one way to better serve patients.Another is to incorporate digital hacks that take rote work off our staff and enable them to better serve patients. I hope that you incorporate some of the aforementioned suggestions so that you and your team can focus on your core mission.

Lucien W. Roberts, III, MHA, FACMPE, retired from full-time practice management in February 2022. In semiretirement, he spends time waiting on patients and his staff at an infusion center he co-founded. Lucien has no financial arrangement with any of the companies mentioned in this article.

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