I have spent a fair amount of time working with practices that needed to get leaner and more efficient in their delivery of patient services. Some also needed to improve the flow of patients, especially in light of the rapid projected increase in the number of baby boomer patients over the next few years.

When evaluating a practice, I look for certain indicators of efficiency and whether the flow of patients is adequate to meet the practice's needs. Prior to an on-site visit, I request a copy of all physicians' schedules and ask the office manager or administrator to pinpoint specific days when the volume of patients may be high. My goal is to preview the schedules of patient visits of the physicians who are especially busy or who have an extreme problem with inadequate volume.

When evaluating a schedule, I look at the classification of the first patients of the morning and afternoon sessions. I want to know if too many short or long examinations are clumped at the beginning of the schedule. Although it may be convenient for you to conduct a high number of short examinations at the beginning of a work session, at some point, longer examinations must be injected into the schedule. If all of the brief visits occur early in the session, the lengthier ones must eventually be addressed, because most physicians have a higher number of long than short examinations. If, however, too many lengthy examinations are grouped together, you likely have to wait for patients later in the session.

This article provides advice on how to analyze and improve your practice's scheduling and efficiency.

ORDER AND BALANCE
Case Example
I was evaluating the schedule of a physician who preferred to conduct all of his postoperative visits at the beginning of the morning and afternoon sessions. The receptionist would also usually schedule several other relatively brief recheck examinations early in the sessions. At 9:30 am, his schedule was filled with examinations requiring dilation as well as with shorter ones or rechecks of IOP. Unfortunately, many of these patients needed visual field testing before they could see the doctor. It did not come as a surprise to me that, by 10:15 am, the physician had finished the brief visits and was waiting for the technicians to work up the more lengthy examinations and follow-up visits. The afternoon session took a similar course.

Type
Regardless of how many patients you want or have to see in a day, I feel it is important to spread the different types of visits over a specific period of time. Keep in mind that you and your staff can only comfortably see a certain number of patients within a given period of time. You and your support staff should therefore determine how many patients you can see without difficulty during a 60-minute period. A 1-hour time slot might comprise two brief and two long examinations in addition to two of intermediate length. After a few short examinations, the schedule should begin to reflect the main type of visit for the day. That pattern should be followed for 2 or 3 hours, until the end of the morning or afternoon session. At that point, a small block of time can be set aside for emergency and walk-in patients.

Number
I also recommend balancing your schedule with an equal number of patients every hour. It is common for practices to schedule different numbers in almost every hourly segment (seven during 1 hour vs five or six in another). In my experience, scheduling the same number of patients for every hour results in fewer peaks and valleys in the flow of patients.

TIPS FOR INCREASED EFFICIENCY AND PATIENT FLOW
Doctor's Rate of Patients per Hour
Your staff should not schedule more patients per hour than you are capable of seeing. If the schedule is designed for you to see one patient every 10 minutes, and you average 14 minutes per patient, either the rate of patients per hour has to be adjusted, or you should reduce the amount of time you spend on each examination.

Benchmarks
There are universally accepted benchmarks for the various ophthalmic subspecialties. Those for efficiency and the flow of patients differ for a glaucoma specialist versus a general ophthalmologist. Table 1 provides the benchmarks for a glaucoma practice. Please keep in mind that every practice is different, because each doctor has a unique style of practice, and the quality and number of clinical technical staff members have a great deal to do with a practice's efficiency.

Writer/Scribe
Properly using a writer/scribe can save you up to 3 minutes during the examination of a patient.

Chart Flow Sheets
Figures 1 and 2 show two good examples of glaucoma flow sheets that allow technicians to record pertinent information about patients in one place within their charts.

Exam Lanes/Rooms/Stations
Most practices dedicate two or three exam lanes to the physician on a typical day. They also dedicate one exam lane, or preliminary exam room or station, to each workup technician. It is important that all exam lanes be properly equipped and function smoothly. Leaving an exam room to retrieve a piece of equipment or eye drops from another area is a waste of your or your technician's time. Additionally, I have seen technicians and physicians completely ignore an exam room, because a projector, slit lamp, or another piece of equipment was not working properly. This problem effectively reduced the amount of usable examination space in the practice. I recommend that practices establish inventory supply lists for every exam room and assign a staff person to maintain and monitor the inventory.

Refractions
Busy glaucoma specialists should not utilize exam-room time to refract patients. Your practice should have at least one go-to technician or optometrist who can perform refractions at the highest level. If your technicians are not skilled refractionists or your practice does not have an optometrist on staff who performs refractions, one or more technicians should receive additional training in refraction.

Interruptions
You should not be interrupted when you are seeing patients. These distractions can occur frequently throughout the day, and each occurrence takes valuable time away from your patients.

Dictation
If you dictate notes to referring physicians during patient hours, consider using a glaucoma comanagement form (Figure 3) to report your findings to shorten the process. This form can be largely completed by the technician or writer, quickly reviewed by you, and sent via fax or email to the comanaging physician.

CRITICAL ELEMENTS
Your and your office's efficiency is critical to the successful practice of medicine in today's challenging healthcare environment. Taking the time to uncover whether your practice faces any or all of the described challenges to scheduling and efficiency—and then implementing the necessary changes—will help keep you on track for financial success.

Vince Giacolone was a partner in and Vice President of Clinical Operations at BSM Consulting in St. James, Missouri. He is now retired. Mr. Giacolone may be reached at (573) 265-3655; giacolon@fidnet.com.