Now I've heard everything: A practice manager recently told me about a patient who ordered a pizza for delivery to his exam room. The patient was waiting for such a long time for the doctor to see him that he ordered, received, and ate the pizza before the physician walked in the door. We laughed about it, but the patient assuredly was not equally amused.
The story highlighted the need for this physician's office to improve its operations.
Even if they're not ordering pizza, the old adage, "I love my doctor, but I hate his office," may roll off many of your patients' tongues.
Indeed, your office may be one of many in need of help in reducing the lengthy waits and delays that frustrate patients and plague office efficiency. These delays contrast with the "touch time" patients want and need with their care team. It's this time with patients that probably attracted you to medicine in the first place, and it's this time that is compensated by our reimbursement system, creating a merging of goals for all parties involved.
Few would argue that there is plenty of room for improvement. Your office can take steps to ensure that your patients have a positive experience.
Consultant Deborah Walker Keegan, PhD, advises starting with your patients. "The key to success is to design your patient flow process around the patient - not the physician or the nurse," she says. "The patient flow process should be patient-centered and physician-led in order to reduce cycle time and meet or exceed patient expectations."
When applied to a physician office, "cycle time," an engineering term, refers to the time from when the patient enters the office until her exit. Although many office visits can be accomplished in 60 minutes or less, beating this cycle time - or some other specific time benchmark - should not be considered the goal of a cycle time performance improvement initiative. The goal is to make sure that the percentage of time valued by the patient - the touch time - is the highest it can be.
10 Steps to More Touching
To maximize touch time, follow these 10 steps:
- Schedule appropriately. Most often, lengthy patient waits are a result of poor scheduling on the part of the office. Dick Haines, an architect and president of Medical Design International, has seen too many doctors set themselves up for disaster. He urges physicians to identify how many patients they can see in a specific time period. The appointment schedule should be configured to match this rate of production, such as four patients per hour. "Otherwise," he says, "patients can be brought in much earlier than they can possibly be seen ... and they will be forced to wait."
- Don't double-book. If the schedule you established reflects your productivity, double-booking means extending patient waits. Haines notes, "Doctors don't work faster because someone in the business office puts more patients in a time slot than they can see. When that happens, everything jams up and patients who had an appointment are unnecessarily delayed." Instead, determine which slots may be available by holding some for same-day scheduling, and using a daily staff/physician huddle to determine if slots may be open unexpectedly - for example, an obstetrics patient who delivered the evening prior. (More on huddles in step 5.)
- Be prepared. Before the patient even walks through the door, make sure that you're ready for him. This process should begin with a chart preview days before his appointment. Scrutinize the chart to ensure that all of the information the physician needs is in place. This includes results from tests ordered, hospital discharge summaries, and any communication from physicians to whom you referred the patient. Physicians should summarize their orders in writing in a specific place in the chart. With a chart preview process, your staff will have at least a day to track down any missing information. Most importantly, this will prevent you from having to hurriedly search for information while the now-stressed patient sits on the exam room table in a paper gown. Also vital is an administrative preview. Encourage patients to complete insurance and other forms before they arrive by mailing them ahead of time, or use your Web site to allow patients to download or submit information to you directly. Patient cycle time is reduced significantly by improving the initial check-in processing time.
- Get the patient to help. Instead of waiting for the patient to check her calendar for when she started her medication, or ponder about her latest symptoms, prompt your patients to consider the details of their complaint before they walk into the exam room. Walker Keegan advocates creating a symptoms checklist for patients to complete, and encouraging them to write down the questions they wish to address during the encounter. "If a patient is prepared for his visit, cycle time can greatly be reduced," she explains.
- Huddle. Get together with your clinical and scheduling staff five minutes before the start of every clinic. Use that days' schedule as your agenda, reviewing every appointment for special needs, probability of the patient not showing, and any predictable variance of time. A hypothetical example: Betty Smith, a 60-year old, wheelchair-bound patient who is always escorted by her three daughters, is scheduled for a full physical at 11 a.m. You might direct your staff to use your procedure room, which offers extra space, and an exam table that can be lowered and tilted. Perhaps they should also get the urine sample you know you'll need (based on her clinical history) before she is assisted onto the table, and if necessary ask a female staffer to be ready at 11:15 to serve as an escort for you for the pelvic exam. Advise that no patients can be double-booked during that slot as you can predict that Ms. Smith will need the full time allotted. Go patient-by-patient, establishing your expectations for every visit, as well as reviewing any special circumstances.
- "Arrive" the patient on time. Although arriving a patient once they check-in seems like it need not be a stated expectation, it is often overlooked in offices. Patients walk in, and the front office gives them paperwork with few instructions, or asks that they wait while a task is completed. Sometimes patients are simply forgotten. When a patient arrives, check him in immediately and make sure that the clinical team is promptly alerted. Oklahoma Heart Institute, in Tulsa, established a redundant process to make sure that the clinical team knows about every patient arrival in a timely manner. Operations manager Anne Alsabrook says, "We arrive the patient in the computer at the time they arrive so that the clinical staff can always tell when their patient is the in the waiting room. We also use a light system to show that the patient chart is in the slot and ready to room."
- Start work on time. Staff and physicians should be ready for clinic to begin before it does. Too many offices take the attitude that patients won't be roomed until well after the doors open, and clinic start time slips farther and farther behind. At least one clinical staff member per physician should arrive a half hour before the office opens, and the physician should arrive no later than 15 minutes before clinic. The team should address any work that needs to be performed before clinic, and leave time for the huddle.
- Have supplies and equipment ready. Establish responsibility for clinical assistants to perform an inventory round on every exam room before clinic starts, looking for any missing equipment or low supplies. Carry small colored flags during clinic to mark low supplies, and look for the flags during your inventory rounds to determine what needs to be restocked. Include a rundown of unusual supplies and equipment needed for clinic during your huddle. Although equipment costs money, Haines advises that having enough is worth the investment. He explains, "Duplicate equipment where it will save steps. For instance, having one blood pressure cuff saves the practice money, but having one in every exam room can speed up the pace of exam." If you are forced to find needed supplies and equipment in the middle of clinic, the wait time of the affected patient, as well as all of those who follow, will increase.
- Focus on the patient's needs. Family physician Rich Honaker, president of Family Medicine Associates of Texas, marvels at the comments his patients make about his practice style. For example: "Dr. Honaker makes me feel like I'm his only patient of the day." Yet, Honaker, who also trains physicians on improving their productivity, easily sees 20 to 25 patients per half-day clinic. He believes that most physicians can double their patient load - and their patient satisfaction - by adopting some simple techniques to improve flow. In addition to deploying the strategies listed above, Honaker has honed his interactions with patients to ensure that his clinical skills are optimized for his patients' benefit: "Let's take a patient who is experiencing signs of depression. I can spend 20 minutes convincing her that she has the symptoms of depression and selling her on the fact that she should be treated," or he can administer the Beck Depression Inventory test. He leaves the exam room for her to complete the scale, calculate the results, and review related literature. When her returns a few minutes later (after handling another patient in the meantime), she's ready to discuss her depression and options for treatment. Honaker has similar strategies for high blood pressure, osteoporosis, and most other chronic illnesses. Techniques like this are more common among specialists, where a diagnosis is often made before or confirmed at the first patient appointment. Open-heart surgery candidates visiting a cardiac surgeon's office for the first time are often treated to videos describing the surgery and postoperative recovery. Parents whose children are referred for ear tubes review a booklet about the procedure while waiting to see the otolaryngologist.
- Bring closure to the visit. A difficult task for many physicians is concluding the conversation with patients. "There are many things to discuss with my patients with whom I've had a 25-year relationship," Honaker notes, "but I've honed my closure skills out of respect for all of my patients' time." Honaker closes his visits by advising the patient that his nurse will be in soon to bring in the contact information for the orthopedist he's referred the patient to, or an educational handout he wants the patient to have. His nurse can then handle the inevitable patient questions about the number to call for the appointment, and any questions after the patient peruses the educational handouts.
If you find yourself walking around apologizing for the wait all day long - or find some empty pizza boxes in your exam rooms - it's time to focus on improving your cycle time. You and your patients will certainly be better for it.
Elizabeth Woodcock, MBA, FACMPE, CPC, is a professional speaker and consultant specializing in practice management, with more than 13 years' experience. She is a Fellow in the American College of Medical Practice Executives and a Certified Professional Coder. She can be reached at firstname.lastname@example.org or via email@example.com.
This article originally appeared in the January 2006 issue of Physicians Practice.