Patient Flow Primer ― Get On Track and On Time

August 3, 2011

For all the metrics that medical offices use to benchmark performance, it is patient flow that may be the most accurate measure of productivity. Managing patient flow is a delicate balance, but it can be done with a little forethought.

When it comes to managing patient flow, most practices could take a few cues from the House of Mouse. Despite the tens of thousands of visitors who flock to Disney World on a daily basis, the world's most popular theme park is uniquely adept at funneling patrons into the gate, through the elaborate maze of rides, and past the parade route with nary a bottleneck in sight. "You have to think about your practice as if it were a ride at Disney World," suggests Murray Cote, associate professor and director at Texas A&M's Health Science Center. "They're very deliberate about where you go in and where you go out. You have a clear point of entry, they move you through the line where they provide entertainment while you wait, and they dump you out at the end. The people coming in never see the people going out." A similar efficiency should be the goal of every private practice, he says.

Indeed, for all the metrics that medical offices use to benchmark performance, it's patient flow that may be the most accurate measure of productivity, says L. Gordon Moore, a former family medicine physician and current director of clinical transformation for healthcare consulting firm Treo Solutions in Albany, N.Y. The ability to move patients from door to doctor with minimal delay, he says, enables practices to increase volume without sacrificing quality of care. But it also helps practices deliver a more positive patient experience by decreasing wait times and giving doctors more time to complete exams. And that, says Moore, makes patients more likely to adhere to treatment regimens and keep their follow-up appointments. "The importance of this goes well beyond any financial indicator, to how well we help our patients achieve good outcomes," he says.

The goal of patient flow, of course, is to strike a balance that keeps your exam rooms full and your wait times to a reasonable limit - a task easier said than done. Though the formula is different for every practice, the Institute for Healthcare Improvement says you know you've got it right when the providers in your practice are consistently in a position to move through the schedule from one room to the next without waiting for a patient to be roomed. Another good sign? Wait times of 15 minutes or less. "People, in general, don't get too cranky with waits up to 15 minutes, but it is possible to get below five minutes if your flow is exceptionally good," Moore says.

Perform a diagnostic

Before you can effect change, however, you must first review your internal systems to determine where any problem areas might lie. If you're willing to spend the bucks, you can hire a consulting firm to do it for you. A patient flow study essentially tracks who did what to whom and for how long. They also identify "down time" for clients and staff, the number of interruptions that create delays and opportunities to improve efficiencies in the patient visit. But you can take the pulse of your own practice easily enough on your own. "You generally don't need to go out and get a consultant," says Moore. "Some of the ideas [for flow improvement] are pretty obvious."

For example, Moore suggests asking the patients you serve for their take on the office experience. That can be accomplished either verbally in the exam room or by a short, written survey. In either case, ask them the degree to which they believe the office is well organized, how long they had to wait, what they like about your practice, and what they would like to see change, he says.

It's also important to get input from your staff on how patient flow in their work space can be improved, says Moore - and to follow up with a test run that quantifies how long it takes to move patients through the practice. "Walk through the practice as if you were a patient, jotting down what you observe," he says. "Where do we see confusion or bottlenecks?"

The results may surprise you. According to Cote, one "busy primary-care practice" he worked with complained that they fell behind each day because most of their patients showed up late for their appointments. "We studied it for over three weeks and we found that on average their patients were actually seven minutes early," he says. "It was a case of the practice not being as on time as they should be. The patients were there, but the staff wasn't ready to process them."

Ultimately, practices identify inefficiencies using the same skill set that a physician would use for making a clinical diagnosis - by asking questions, says Steven Chinn, a consultant with Joint Commission Resources, an affiliate of the non-profit Joint Commission, which is focused on patient safety and quality care. How often do inefficiencies happen and what's the magnitude of the effect they have on the practice? If your last patient leaves at 5 p.m., why are your doctors still there at 8 p.m? Is it due to poor scheduling? Are you trying to do too much, or are you not leaving enough time for the unexpected? "Those are all different fixes," says Chinn, noting the practice where he previously worked blocked out half an hour every day for unexpected walk-ins. "If your practice is prone to same-day emergency calls, build a buffer into your schedule so you can better plan."

Common delays

As you embark on your campaign to get patients in and out in a timely manner, it's useful to familiarize yourself with the most common roadblocks to patient flow. The registration process is among them. The best practice approach is to get patients to complete their paperwork prior to their appointment, says Chinn. "The more efficient systems do all registration and paperwork online, so before the patient even shows up you've verified their eligibility and confirmed their demographic information," says Chinn, noting that initiative alone can reduce wait times significantly.

Redundancies in the registration process can also put efficiency on hold. "Evaluate your intake forms," says Moore. "Practices need to look at how their clinicians do their documentation and how they gather information pre-visit." Some practices, for example, duplicate efforts at check-in because they think an external accrediting agency requires it. "You should always question how you've interpreted that," says Moore. "Go back to the source and find out what the actual requirement is. There may be opportunities to streamline the process in the information-gathering session."

Another leading driver of delay? Ineffective scheduling. Rather than blocking out a fixed amount of time for all patient visits, try tailoring your appointment slots based on the reason for the visit. You might, for example, decide that new patients require 20 minutes, while existing patients who are in for routine care need half that amount, and more chronic patients need 30 minutes or more. "If you have the right appointment times for the right patients you should be able to move them through quickly and the better you can prepare your resources around that," says Cote.

That's where chart preparation comes in. Moore suggests doctors and nurses review their patient schedule at the start of each day. "Have a daily huddle so you can look at the schedule and say, 'This person is coming in for a follow-up from a lab result. Do we have the lab results in their chart?'" he says. "Anytime a doctor or nurse has to step out of the room it creates a big bottleneck so making sure your charts are ready is time well spent."

At the same time, your front desk clerks should be instructed to keep the lines of communication open. "When the front office is collecting information at check-in, they should be working with the back office staff as well," says Chinn. "If they find out that Mrs. Jones is also now asking about her other foot, or having problems with her back, they should share that with the clinicians. Queuing things up gives you a heads up so you can better allocate your time in the exam room."

Standardize

Yet another way to improve patient flow is to develop standardized order sheets for common conditions or procedures, like X-rays and labs, making it faster for clinicians to communicate orders and allowing them to spend more time with the patient, the Agency for Healthcare Research and Quality says in its guidelines for improving the patient care experience. Standardized forms for recording patient information also make it possible for clinical staff to assume more of the clinician's responsibilities, freeing doctors to work at the highest level of their training. Midlevel providers should be responsible for routine care, such as physical exams, performing histories, basic prescribing, and ordering X-rays, the AHRQ states.

Cote agrees. "Is the right person doing the right job in your practice?" he says. "Physicians shouldn't be doing transcriptions. That's what medical assistants are for. This is a big issue in terms of improving flow. Do we have the most qualified and least expensive person doing the right job?"

But the advantages of uniformity don't just pertain to information. On its website, the nonprofit Institute for Healthcare Improvement notes that reducing variation in exam room layout, equipment, and supplies is equally effective in optimizing patient flow. Doing so ensures that "providers and staff don't have to waste time looking for needed items either before or during a patient visit," it notes. Perhaps more importantly, though, standardized exam rooms enable practices to employ the concept of open rooming, which allows any provider to use any exam room at any time - instead of assigning specific rooms to individual providers. Standardizing exam rooms allows all rooms to be used each day, the IHI states, "maximizing the clinic's flexibility to rotate patients into available rooms, and thereby improving flow and decreasing waiting time."

To implement open rooming, the IHI says the set-up and inventory of supplies and equipment must be identical in every room, which should be stocked with everything the providers need. According to the Institute, some practices establish an initial standardization and then set up a room to test the new system before implementation. In specialty clinics where doctors may need specific equipment, your staff can prep the rooms as needed with mobile equipment or special supply trays, the IHI suggests, adding you may get better buy-in from your physicians if they get a single drawer or shelf of their preference in the exam rooms.

To some degree, delays in private practice are inevitable. Lab results get lost, doctors get sick and patients call in with last-minute requests. But you can minimize their impact by making patient flow a priority. Eliminating bottlenecks that cause delay can help deliver increased patient volume, better quality of care, but higher marks in patient satisfaction. "Patients these days are much more involved in their care than in the past and they're not afraid to change providers so there's a business case for keeping the practice running as smoothly as possible," says Cote.

In Summary

• Do a test run that quantifies how long it takes to move patients through your practice.
• Review your check-in process for opportunities to reduce redundancies.
• Use the right appointment slots for the right patient visits.
• Standardized forms allow clinical staff to assume more of the physician's responsibilities.
• The open rooming concept ensures that all exam rooms get used at all times.

Shelly K. Schwartz, a freelance writer in Maplewood, N.J., has covered personal finance, technology, and healthcare for more than 17 years. Her work has appeared on CNBC.com, CNNMoney.com, and Bankrate.com. She can be reached via editor@physicianspractice.com.

This article originally appeared in the September 2011 issue of Physicians Practice.