Here’s a telling statistic: The average time patients wait in an office to see an otolaryngologist is 24 minutes, according to Press Ganey Associates, Inc., a South Bend, Ind., health care performance measurement and improvement firm. If that doesn’t sound bad, or if you think your practice exceeds that benchmark, consider that otolaryngology ranked 19th in overall satisfaction among 25 medical specialties measured in Press Ganey’s 2010 Medical Practice Pulse Report.
Numbers don’t tell the whole story when examining patient wait times, according to health care management consultant Elizabeth W. Woodcock, MBA, FACMPE, CPC, principal of Woodcock & Associates in Atlanta and author of Mastering Patient Flow: Using Lean Thinking to Improve Your Practice Operations, 3rd Edition (Medical Group Management Association, 2009).
“Everybody thinks they’re efficient, but it’s hard to put on their industrial engineering glasses and be self-reflective,” Woodcock said. True operational improvement requires you to conduct a top-to-bottom evaluation of every operational factor that touches your physicians, including the use of staff, communications systems, appointment scheduling and space design.
Otolaryngologists may worry about their ability to throw resources at these systems, but improving efficiency and decreasing patient wait times aren’t necessarily expensive propositions.
You could, for example, contact a colleague at a highly regarded otolaryngology practice outside your market and ask to spend a half day watching how the practice organizes traffic flow around its physicians. Alternatively, hire a team of MBA or industrial engineering students to create a process improvement program for your practice, Woodcock suggested. Most research universities offer programs that are free to businesses, because the process offers hands-on training for students.
When considering which processes to measure, a scheduler’s adherence to consistent phone etiquette is a good starting point, said Woodcock. Schedulers can help to deflect patient demand for a particular physician and improve overall access by advising callers that they can see another partner in the practice at a particular time the next day or even the same afternoon.
Schedulers should also adjust appointments to each physician’s style. Some physicians are strictly business, while others like to chat with patients informally. Only a physician can change his or her natural style, but the practice manager should analyze each physician’s productivity by tracking the average number of patient visits per hour.
“The doctor’s job is to go from CPT code to CPT code as efficiently as possible,” said Richard C. Haines, Jr., president of Medical Design International (MDI) in Atlanta. “That doesn’t mean doctors have to hustle, but you should organize your systems to reflect each doctor’s production, whether four patients an hour, six an hour or more, so the doctors can move easily and succinctly through their patient encounters.”
Rethink Exam Rooms
To determine how to improve coordination of care, Michael Benninger, MD, chair of the Head and Neck Institute at the Cleveland Clinic, modeled the number of staff and exam rooms needed to optimize efficiency in an otolaryngology office. A solo physician in an office setting should have three exam rooms and “one-plus” medical assistants (MA) to manage the rooms, Dr. Benninger said. A practice can select 1.25, 1.5 or 2.0 full-time equivalents, “but you need someone who’s moving patients in and out of each room and another individual who can help clean scopes and handle anything that falls behind.”
The model is designed for otolaryngology practices that perform procedures on a majority of patients, since the additional staff member’s role includes cleaning and preparing scopes and setting out instruments and sprays. “I can go into an exam room, say hello to the patient, take a quick history, spray them and then go to the next room while the first patient is decongesting,” Dr. Benninger explained.
Having three exam rooms and two MAs per physician “is fairly expensive,” he conceded, “so a more cost-efficient model is to have two physicians in the office at the same time, because you can get by with five rooms and two or three support staff.”
You should also make sure to allow sufficient exam room space. Layout is critical to physician productivity, because “there’s a finite amount of work that a given number of exam rooms can produce,” said Haines. “If a doctor has a high production capacity, the exam rooms might be the limiting factor.”
An otolaryngologist who can see eight patients an hour should have a dedicated exam module that contains at least four exam rooms, a physician’s station, and sufficient MA support, according to Haines. The practice should have different sizes of modules depending on the physicians’ subspecialties and practice styles. If your practice is unable to make large renovations, consider small changes that might improve efficiency. In Dr. Benninger’s exam rooms, the computer screens and terminals are located on a rotating scaffold that is attached to the wall and can be moved 180 degrees and pushed out of the way to accommodate patients on stretchers or in wheelchairs.
“While taking the history, I can place the computer between myself and the patient,” Dr. Benninger explained. “But when I need to have a serious conversation, I can push it out of the way, remain seated so the patient is eye to eye, and not have the real or perceived barrier of the computer between us.”
In a practice with high-volume procedures, having redundant equipment in the exam rooms, two scopes that can be cleaned and sterilized in each room, for instance, also improves efficiency, Dr. Benninger said.
Use Technology to Communicate
Scheduling and technology should support, not hinder, a physician’s efficiency. Instead of standing outside an exam room and waiting for the physician, MAs should be prepping the next patient, according to Haines. To facilitate this process, physicians and MAs need to communicate without face-to-face contact. Low-tech tools such as check-off lists and light signals “keep physicians moving from room to room in the proper sequence,” he said.
In contrast, electronic medical record (EMR) systems can drastically reduce physician productivity when they’re first introduced. “Many EMRs are cumbersome, so the documentation takes a lot longer than when you jotted quick notes and filed them,” Dr. Benninger said. He advises otolaryngologists using EMRs to adopt mechanisms like templating, voice-activated dictation and systems that retrieve and incorporate other chart data, such as family and social history.
Ramp Up Staffing
Inadequate staffing is the single biggest problem Haines sees in physician practices. To maximize a physician’s productivity, a practice should actually have excess capacity in its staffing levels. “In order for the doctor to be fully engaged, you want the staff always to be ahead of the doctor,” Haines said.
If an otolaryngologist can see six patients per hour and a medical assistant can prepare six patients per hour, the practice seems in balance, Haines explained. “But that system only works when everything is perfect. To maximize the physician’s effectiveness, the practice should have enough staff to prepare seven patients per hour so the doctor never waits between exams.”
Different types of staff drive patient throughput. Although it’s a good idea to slightly overstaff MAs in the exam area, staffing levels in other areas, such as check-in and checkout, should match the volume of patients coming into and leaving the office.
Tweak Patient Flow
Bottlenecks in staffing, technology and layout can also be addressed with improved communications among patients, staff and physicians. If you arrange the front desk so that reception staff can alert MAs when patients arrive, the MAs can move up an early arrival when a scheduled patient is late, Woodcock said.
Simple, efficient check-in tools such as touch screen systems can also speed patient throughput. Dr. Benninger’s practice is also piloting electronic tablets that patients can use in the waiting room to record their medical histories, which can then be inserted automatically into their medical records.
Well-functioning practices should also give patients a short survey when they arrive at the check-in desk and ask them to record their arrival time, the time they’re called back to the exam room and the time they see their physician, Woodcock suggested. “Many patients feel empowered when they help the practice to improve,” she said.
In any event, don’t wait for patient complaints to address operational shortcomings. Patient “murmurs” at the checkout desk are an obvious sign that action is needed, according to Woodcock. “If you wait to see an issue arise on a formal patient satisfaction survey, you’ve missed the boat,” she said. ENT Today