The Great Practice Makeover: Radically Simple

July 15, 2007

A Virginia urology practice is struggling with a monster schedule and high staff turnover. Our expert Laurie Hyland Robertson comes to the rescue.


“I’m great at defining the problem,” notes urologist Joseph Carbone. “As a surgeon, I just want to go in there and cut and fix and go on my way. I realize now that it’s a process of evolution,” he says of improving the nonclinical side of things. For the sophisticated nephrology/urology group in southern Virginia of which Carbone is president, the struggles that seem an inevitable part of modern medicine begin with the appointment book.

As in most practices, though, that one problem is the tip of a much larger iceberg. Below the water line for Danville Urologic Clinic lurks high front-office turnover, a problem that persists despite the practice’s competitive compensation and the area’s high unemployment rate, which recent government figures peg as the worst among the state’s metropolitan areas. Again, as in most businesses, turnover usually isn’t solely - or even primarily - a result of financial dissatisfaction.

So what’s causing the staff defections? Carbone thinks the hectic pace at the front desk could be part of the problem. “The front-office staff doesn’t have time to do what they need to do, which is schedule,” he says. Hmm, perhaps. Renee Pickrel, the practice’s director of clinical operations, agrees that the demands of a fairly complicated appointment-booking system and the resulting confusion could be fueling the staffing problem.

“We have a lot of employees who have been here for over 20 years, but we have a high turnover rate in the front offices,” adds Jacque Nelson, who handles physician scheduling for the group. She’s trained three new front-desk people in the past year. “That’s a big chunk of time that could be used to make the schedules for the physicians perfect.”

Simplifying the schedule itself - by, say, limiting the number of appointment types - is the first solution that leaps to mind. However, the staff has already done that to the extent possible. Further streamlining is impractical because the practice has two specialties, a variety of providers (nephrologists, urologists, nurse practitioners, nurses), multiple care settings (office, hospital, surgery center), and three clinic locations. The group should be sure, though, that the structure in place is being used to full advantage. Remember that urban legend about using only 10 percent of your brain? Most practices use only a fraction of the technical resources to which they have ready access, and that includes scheduling programs and time-slot types. Minimize the number of appointment lengths, by all means, but make sure those select few suit the (current!) physicians.

Right process, right person

Danville Urologic has two distinct lists of appointment types because of dissimilar nephrology and urology work flows. The former specialty, for instance, involves frequent out-of-office care, and the latter lends itself to strategic use of nurse practitioners. Although the group probably won’t be able to avoid that complication, it can still take practice-wide steps to sort out scheduling snafus. In the urology department, says Carbone, “I think there’s a disconnect between the front-office staff and [the clinical staff about] how much time would be involved in a discussion, preoperative clearance, and so on,” noting that he often finds himself facing a patient with whom he needs to have a lengthy discussion and only a 15-minute slot in which to do it. “I’d love to be able to say, ‘This patient needs a 20-minute follow-up,’ or a five-minute follow-up, and order that.”

Well, that’s a great idea. Even if your vendor can’t build the process into your software, this would be easy enough to accomplish with a note in the chart or a written “prescription.” It’s another example of applying what’s already in place. Carbone routinely sends “actionable items” to staff through his EMR in an electronic order process for managing tasks such as follow-ups and test results, and he already knows roughly how long he needs for a given patient or procedure. If you don’t know exactly how long you really spend on a given appointment type, track it for two weeks. How long, say, does a postsurgical follow-up take? Then, schedule all postsurgical follow-ups at that length.

Danville Urologic would be well served by reallocating resources in personnel, too. Looking for ways to help front-office staff fit scheduling duties around other tasks doesn’t make much sense if those employees don’t know how to tailor appointments to the providers’ needs. The practice should give serious thought to making scheduling a clinical responsibility. In the event that the physicians themselves aren’t specifying the appointment type for the next visit during the current one, as when a patient calls or is referred, the task would fall to the appropriate nurse or NP. The practice uses a centralized switchboard to handle all incoming calls, so it would be a simple matter to get those folks to route calls to the correct department - nephrology or urology - based on responses to one or two key questions.

Nursing staff members may not be thrilled to take on this task, and it will indeed demand some of their time, but in reality poor scheduling is gobbling up their time already - not to mention probably giving them plenty of gray hairs when they come up against unhappy physicians and patients. Facing constant dissatisfaction from the clinical staff is another potential cause of turnover. And as I’ve hinted, the real job of the front desk isn’t scheduling at all. It’s impossible to greet patients in the office and schedule appointments on the phone at the same time. Patient relations and on-the-spot collections have become too important to consign to second-class status.

The effect of other fixes may seem small but eventually pay off big, especially when current staff and prospective staff see that the practice is committed to finding ways to make their lives easier. To lessen the burden, for instance, Danville Urologic has tried sending new patients registration packages to fill out in advance. “But,” says Carbone, “patients aren’t filling them out right. So we have to have a nurse sit down with the patients and make sure the forms are correct - it may add 10 minutes to a 20-minute office visit.” When determining how long to allow for each appointment type, include time for not only the physician, but also for other clinical staff members who interact with patients. Time for the registration process needs to be allotted as well.

Another point to keep in mind: Someone’s doing that double-checking on every form anyway, and staff must help patients make corrections whether they’ve botched the form at home or in the office. If you can get even a modest percentage to complete the forms in advance (correctly) - whether it’s online or on paper - you’ll be reducing the load on reception. First, reexamine those forms with an eye toward making them easier for patients to understand. Then, take note of the errors that recur most often, and create a link to “frequently asked questions” where the forms appear on your Web site. Finally, compose a brief, easy-to-read explanation of key instructions to use as a cover sheet when you mail registration packets.

Whereas Carbone and the other physicians worry about not having enough time to spend with each patient, Pickrel and Nelson, coming from an operational point of view, dwell on provider shortages and on training staff to use the scheduling templates. All valid concerns, to be sure, but they don’t preclude taking creative advantage of the resources already in place. Effective scheduling really isn’t about the model you use. As Carbone puts it, “Sometimes people are so busy doing things the old way that they don’t have time to look at ways to do things differently.”

Laurie Hyland Robertson, the senior editor of projects for Physicians Practice, has been in the medical publishing field for nearly 10 years, covering clinical and management topics. She can be reached at LCHRobertson@physicianspractice.com.
This article originally appeared in the July/August 2007 issue of
Physicians Practice.