January 2002 Table of Contents
Tuning Up Your Patient Schedule
These scheduling tips can help you smooth out the peaks and valleys in your patient flow and increase your bottom line.
M. Kyu Chung, MD
Covered in FPM Quiz
Perhaps one of the most important factors in the success of a family practice is patient flow. An office that can successfully smooth out the peaks and valleys in its schedule can see more patients more efficiently, reduce wear and tear on office staff and physicians and make more money.
Although much recent attention has been given to open-access scheduling, there are other, more moderate changes you can make in your scheduling that can yield significant results. You can begin by identifying where in your schedule peaks and valleys tend to occur. Several causes of peaks and valleys and strategies for dealing with them are described in boxes that appear throughout this article.
KEY POINTS:
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To address peaks and valleys in my practice's schedule, I adopted "modified-wave scheduling," a simple technique where patients are purposely double-booked at the front end of each hour and the end of the hour is left open for catch-up. I've used this system with much success for 19 years. It has increased my bottom line by almost 15 percent without increasing my overhead. Here's how it works.
Doing the wave
I first encountered wave scheduling in the early 1980s when I was doing a rotation in pediatric cardiology. Patients traveled from throughout the region to the clinic where I worked, and they were all told to come at 1 p.m. Once there, they were told they'd be seen on a "first-come, first-served" basis. This was how original "wave" scheduling worked. Loading the patients at the front end of the day optimized the efficiency of the staff by guaranteeing there was never a lull in patient flow. While it was good for productivity, it was unpopular with patients. Some had to wait several hours to be seen, despite having arrived on time for their appointments.
The "modified-wave" method takes advantage of the principal behind the "wave" method, but it is more patient friendly. The key to the modified-wave technique is to load up the front end of each hour and leave open slots in the schedule later on to catch up. Perhaps the best way to understand the modified-wave technique is by comparing it to the standard method of scheduling [see "Standard scheduling vs. modified-wave scheduling"].
| Modified-wave scheduling has increased my bottom line by almost 15 percent without increasing my overhead. |
Using the modified-wave technique helps prevent long patient wait times by giving physicians free time at the end of each hour to catch up if they've begun to run behind. In my experience, patients rarely complain when they have to wait from 15 to 25 minutes to see the doctor. It's when the wait exceeds the 25-minute mark that patients start to get upset and satisfaction begins to suffer. With modified-wave scheduling, if a physician begins to run late, the effect isn't cumulative: There is time built into the schedule at the end of the hour to catch up.
Another plus of modified-wave scheduling is that because the first appointment of the hour is double-booked, the physician ― aware that the next patient is either already waiting or is in the process of being put in an exam room ― tends to use time more wisely. And patients who need more attention do not end up getting rushed through. Why? The modified-wave schedule allows physicians to borrow the unscheduled time from the end of the hour or from patients with less complex problems without having to rush to get back on schedule.
| The key to the modified-wave technique is to load up the front end of each hour and leave open slots in the schedule later on to catch up. |
Finally, by stacking patients at the beginning of an hour or session, you ensure that physician and staff time isn't wasted if one of the two patients booked at the top of the hour is a no-show.
Fine-tuning the schedule
To get even more out of modified-wave scheduling, you can group similar types of office visits in a single session. Some practices have surgical-procedure days, complete-physical days or all-pediatric days. For example, consider setting aside one mid-week morning office session for physicals. If an average physical takes 25 to 30 minutes, two physicals can be scheduled at 9 a.m. and one at 9:30 a.m. The physician sees one of the patients at 9 a.m. while the second patient has testing done by the ancillary staff. Then, 20 minutes later, the patients can switch, and the first patient can have testing done while the second patient sees the physician. This way, both patients with 9 a.m. appointments have the perception that they've been seen immediately. The entire office gets into a groove, and you end up seeing more patients.
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SEASONAL VARIATION In addition to smoothing out your workload, scheduling comprehensive, non-urgent evaluations during low season allows you more time during the visit to discuss health maintenance issues and clean up the patient's medication list, problem list and the overall chart. There's also more time to ensure that your documentation and coding support the high level of care you provided. And, with a clear and organized chart, acute visits during the busy months can be handled much more efficiently. An unanticipated benefit of scheduling complete evaluations well in advance is that patients arrive expecting a longer visit and don't seem to mind paying more for it. Early in my practice years, I recall several patients with whom I had spent twice the normal amount of time bitterly complaining that I had charged more than my usual rate. It didn't take me long to learn that when patients make an appointment for a "regular office visit" they expect a "regular office charge." Scheduling comprehensive visits well in advance seems to increase patients' satisfaction that they're getting what they (or their insurance plan) pay for. Also, in our practice, where the low season is summer, many patients have already met their deductibles by the time they see us for these more expensive office visits. |
There is one valuable strategy that can make a huge difference in smoothing patient flow regardless of the scheduling method you use: Review the schedule several days prior to the appointment day. My medical assistant and I do this together prior to re-confirming appointments. That way, we can fix any odd glitches in the schedule by asking certain patients to come earlier or later in the day or even on another day, if necessary.
Why do I assign this task to my medical assistant and not the receptionist or scheduler? Experience has taught me that the scheduler is often too busy to put a lot of thought into how patients are scheduled. The medical assistant is generally the one who is most accustomed to the work style of the doctor(s) as well as to the idiosyncrasies of the patients, and, consequently, is better equipped to mix and match patients so that each hour is balanced. A final adjustment to the schedule prior to the appointment day can correct the mistakes before they become a reality that both the staff and the patients have to deal with.
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STANDARD SCHEDULING VS.
MODIFIED-WAVE SCHEDULING
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VACATIONS
In a group practice, it is often just as important to block out some slots on the other physicians' schedules during the week(s) a physician is on vacation. Frequently, it is the remaining partner(s) who gets the brunt of the patient overflow. These appointment slots should be blocked out well in advance and should be reserved for same-day appointments. After each vacation, the physician, the office manager and the person scheduling patient appointments can evaluate how well they did in predicting the patient flow. Depending on what they decide, more or fewer appointment slots can be blocked before and after the next vacation. |
Pitfalls to avoid
Over the years, I've helped many practices implement modified-wave scheduling. I would be remiss not to mention having encountered a few problems along the way. Here are some past mistakes I've seen and what your practice can do to avoid them:
Pitfall 1: Filling the catch-up time slots with acute visits. Avoid this at all costs. Physicians who are double-booked at the front end of the hour and then have no unscheduled time at the end of the hour to catch up will fall markedly behind in no time flat.
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INTRAWEEK HIGHS AND
LOWS In this practice, the solution was simple. On Mondays, they allowed only two patients to be scheduled in advance for the first two morning appointment slots. That way, the doctor would be assured of starting on time. The rest of the schedule was filled as the calls came in on Monday. By the time the first two scheduled morning appointments had been completed, patients who had been added to the schedule that morning were already arriving at the office. The difference in patient and staff satisfaction was remarkable. Ill patients were told to come in almost immediately. There were also fewer phone calls to confirm patient appointments and less time spent on the phone on Mondays to triage patients away from an already full schedule. Your practice may not need to block out such a large amount of time on Mondays, but you can use the same principles to help you determine the number of slots you'll need. |
Pitfall 2: Double-booking new patients, difficult patients or patients with complicated problems at the front of the hour. For example, if two new patients are scheduled at 9 a.m., the schedule can quickly turn into a mess. Don't book these patients during peak time periods whenever possible, and try to ensure that their visits are mixed with others that are likely to take less time. If the patient asks, simply explain that 9 a.m. is a high-traffic time in the office and does not give the doctor sufficient time to spend with the patient.
| Experience has taught me that the scheduler is often too busy to put a lot of thought into how patients are scheduled. |
Pitfall 3: Implementing modified-wave scheduling in a large practice (20+ physicians) with centralized scheduling. Practices with centralized scheduling can have terrible scheduling problems and have greater difficulty implementing this method. The only way that I've found to make modified-wave scheduling work in a practice with centralized scheduling is to limit a specific scheduler to a specific set of doctors, conduct frequent feedback sessions and commit to modifying the schedule on the fly. I generally discourage centralized scheduling altogether and encourage decentralized scheduling at the primary care office site. This way other issues such as billing matters can be dealt with at the time patients schedule appointments.
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FPM ARTICLES ON SCHEDULING "Same-Day Appointments: Exploding the Access Paradigm." Murray M, Tantau C. September 2000: 45-50. "Reducing Delays and Waiting Times With Open-Office Scheduling." Herriott S. April 1999:38-43. "Is Your Schedule Out of Control?" Shenkel R. September 1995:66-67. "A Checklist for Scheduling Success." Matthies F. January 1995:68-71. |
The bottom line
Successfully managing patient flow takes thought and careful planning.
It is by far one of the most challenging aspects of practice management. But
when done correctly, smoothing the peaks and valleys in your schedule using the
modified-wave technique will increase the capacity and efficiency of your
practice without increasing your overhead. Add to that staff and physicians who
are less stressed and patients who aren't enduring lengthy waits to be seen and
you've got a better practice all around.
Dr. Chung is chief of the Department of Family Medicine at the Cooper Health System in Camden, N.J., and associate professor at the Robert Wood Johnson Medical School in Camden. Conflicts of interest: none reported
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