The Great Practice Makeover: An End to the Waiting Game

April 1, 2007

In our revamped Makeover column, expert Laurie Hyland Robertson helps a busy pediatric office solve its patient-flow problems.


Five years ago, Primary Pediatrics fell dangerously into the red. Management changes and the efforts of a core group of loyal staff have improved the situation dramatically, but the practice still struggles with inefficient patient visits. Playing a constant game of catch-up makes for frustrated, stressed-out physicians and a front-office staff continually turning over. Even with its fiscal house in order, the Laurel, Md.-based group needs to make some changes to bring about lasting stability.

One friendly dad, schlepping his two daughters and their considerable paraphernalia through the main office’s hallways on a rainy Monday morning, sighs gently when I ask him about his experiences there. He echoes a refrain I hear virtually every time I visit a medical office: “The doctors are great, but you know, it takes soo long! I guess that’s just the way it is …”

But does this have to be the case? I don’t think so.

Backup in front

Pediatrician My-Huong Nguyen says the front desk at Primary Pediatrics too often has “too many fires to put out during the day” to make any headway updating office processes. Insurance verification is a major culprit, and given the number of different payer policies most practices have to keep track of, it’s easy to see why. It’s also easy to see how keeping the morning’s first patient in the waiting room for a few extra minutes while you call his insurer can snowball into chronic missed lunches for the physicians and huge backups by closing time.

Conducting verifications online in advance of patients’ visits whenever possible would be a huge timesaver. But two of the practice’s three offices don’t have high-speed Internet access, and management worries about potential misuse, even though nearly everyone in the practice agrees that insurance verification is the single-biggest contributor to delays. A clear, written policy prohibiting personal use of the Internet would suffice to discourage its employees from abusing it, although it seems to me that these people are far too busy to mess around anyway.

The practice can also try performing only strategic preverifications, say, for new patients or those on plans with the most denials for membership-related issues. It would be great, too, to set expectations for staff regarding how they should communicate insurance problems to patients, perhaps with some role-playing or even following a written script. A script might seem artificial at first, but it could help everyone adjust to new processes and consistently present the customer-service message the practice wants to deliver.

Primary Pediatrics might also consider moving its scheduling - whether for follow-ups with patients in the office or for patients phoning in - away from its front desk. As Nguyen herself notes, “The amount of things they deal with is unreal.” In a busy practice, it’s impractical to expect one person to answer multiple phone lines, greet arriving patients, collect payments, schedule appointments, and verify insurance all at the same time. It’s also just plain bad patient service. A pile of never-ending, conflicting demands can make a job that’s stressful on the best of days simply unbearable. Although the staff primarily responsible for scheduling would certainly have additional duties, physically removing them from the front-office fray eliminates the bottlenecks produced when they are fielding too many simultaneous demands.

Fount of knowledge

Once Primary Pediatrics patients make it past the waiting room, the slowdowns continue. I watched a nurse leave an exam room three times just to gather the thermometers and scales she needed to take vitals on our friendly dad’s daughters. The practice could minimize such waits for patients - and the physician backups that inevitably follow - simply by investing in an identical set of basic diagnostic tools for each room and then placing those items in the same spot.

One physician, Swapna Abhyankar, who other staff members praise as being “the efficient one,” is already illustrating this idea by toting a little supply bag everywhere she goes. Her example is worth putting into practice to benefit all of the group’s providers. Sure, it’ll take some time to select and assemble standardized kits for each room and to develop a restocking plan, but imagine five nurses, each wasting just two minutes per appointment per day, searching for simple equipment. That time adds up quickly to produce significant costs.

You’re usually better off spending a penny now to save dollars down the road, even when budgets are tight - on those thermometers, for instance, or on replacing the ancient spooling dot-matrix printer the practice is still using. Given physicians’ natural desire to devote scarce practice resources directly to patient care, this type of skimping isn’t all that unusual. Several staff members, though, told me that the printer jams frequently and slows them down at every turn. Here too backups can quickly snowball: Not only is the machine’s output much slower than that of low-cost laser printers, but someone’s periodically forced to spend additional time hunting down ink cartridges and replacing parts on a machine that’s become an antique.

A better-stocked office is another staff quality-of-life issue; maintaining a high level of morale is a challenge when you’re forced to repeatedly scrounge around for supplies. By all means, keep a close watch on spending and inventory, but don’t sweat the small stuff, especially when taking a step back - and a cue from the staff - would clearly result in savings over the long term.

Also, the managing physician partners in the group seem reluctant to give individual staff members sufficient authority within their areas of expertise. Nurse manager Linda Sawyer, for instance, has been with the practice for nearly 14 years and has some good ideas to ease problems regarding the practice’s weekend hours. This issue represents another constant source of physician frustration and staff unhappiness, so it would be wise to consider her perspective. And that Internet problem? Office manager Tameka Babb, a no-nonsense techie type, spent weeks researching high-speed connectivity options. She’s found a reliable, relatively low-cost solution, but she hasn’t been given the go-ahead to act on it.

Before embarking on another project and inadvertently throwing your staff into chaos and your patients into waiting limbo, stop and ask yourself who the expert in a particular operational area may be. Sometimes that person is a physician; sometimes it’s not.


Laurie Hyland Robertson is a managing editor for Med-IQ, the parent company of Physicians Practice. She can be reached at LHyland-Robertson@mediq.com.

This article originally appeared in the April 2007 issue of Physicians Practice.