Inefficiencies in a medical practice do not merely waste time and effort; they can also contribute to errors, reduce productivity, hurt the bottom line, and frustrate patients, staff and physicians. It's no wonder, then, that efficiency was named one of the “aims for improvement” in the Institute of Medicine's landmark report, Crossing the Quality Chasm: A New Health System for the 21st Century.
Despite the potential for serious consequences, many practices fail to address the bottlenecks, redundancies, delays and waste in their workflows. Perhaps they can't see past “the way we've always done it,” or perhaps the complexities of modern medical practice make inefficiency seem inevitable. Or perhaps they just don't know where to begin.
This article identifies common inefficiencies in the patient care process – starting with the front office and ending with the physician – and practical ways to address them.
The front office
The first area to evaluate is the front office. This is a hub of activity: phone lines ringing, faxes coming in and going out, patients checking in, patients scheduling tests or appointments, patients checking out, new patients turning in paperwork, and so on.
The phone system. Your phone system is often your patients' entry point into your practice. Being inefficient in this area can lead to patient irritation and distress, which in turn can lead to a loss of productivity as staff members try to deal with the repercussions.
Your incoming telephone lines are the first area to scrutinize for inefficiencies. Start with these questions:
How many incoming phone lines does your office have? (This number should exclude any back-office lines that staff other than your front desk staff are responsible for answering.)
How many staff members are responsible for answering those phone lines?
Now do the math: How many phone lines is each person potentially responsible to answer at any given time?
If your answer to the last question is more than two phone lines per person, you have a potential problem. Five or more phone lines per person is a serious problem. At worst, no staff member should have more than one person on hold at any given time. Any more than that, and you will lose callers and, eventually, patients.
Although multiple phone lines are desirable in order to keep patients from getting a busy signal, be sure that they are properly staffed. Think of the last time you called a business and were placed on hold. Did you grow increasingly irritated by the minute? Imagine doing that when you are sick.
Automated phone triage systems can help, but remember how it feels to navigate a confusing voice mail menu. Keep menu choices short and limit the number of choices. Always give callers an option that will put them in touch with a real person, and don't make it unreasonably difficult for them to access it. Periodically call your office yourself to see what your phone system sounds like to patients. Also, be sure staff members change their voice mail greeting when they are out of the office for an extended absence, and have a system for changing greetings or checking messages when someone is out sick. I once left a voice mail message for a medical staff member after being directed to her mailbox through a practice's automated triage system. I waited two days for a response and then called back and spoke to the office manager, who told me that the staff member was on vacation for two weeks. Imagine what would have happened if I had been seriously ill while waiting for a call back.
The bottom line is that your phone system can cause inefficiencies, inaccuracies, long wait times and a lack of personal service, so be on the lookout for these problems – and ask your patients for feedback. One tool for doing this is the FPM Phone System Survey.
Messages. One of the most critical activities at the front desk is passing along complete and accurate messages. An incomplete message or one with misinformation is not only aggravating but can be disastrous. If your practice uses paper message slips, try using customized, color-coded slips, with the different colors representing different types of callers. Color coding allows staff members to identify at a glance the types of messages waiting for them (e.g., blue signifies a sick patient who warrants immediate attention and yellow signifies a pharmacy calling about a refill request, which may not be as urgent). By customizing the message slips, you can specify what information needs to be collected from the caller. For example, the information you need from a sick patient seeking care is different than the information you need from a patient seeking a refill. If you involve front-office staff, nurses and physicians in creating these instructions, not only will you have an expert form for your particular situation, but you will have buy-in from your staff because they created it. In addition, in the designing of the form, each will understand the others' needs and perhaps help avoid the problem of areas being left blank.
Examine how often these messages are delivered to staff. Do you have a Janie Jump Up? This would be the staff member who leaves her desk every time she has a message of any kind to deliver, leaving the phones short-staffed or unattended. Or do you have a Let It Wait Linda? She delivers messages at the end of the day – all of them, all at once. Staff who thought they were done suddenly are staring at work they had not budgeted for, possibly resulting in overtime expenses for the office. Find a happy medium for the timely delivery of messages, taking into account efficiency for both the taker and the receiver of the message.
Computerization can also make message sharing more efficient, but you must carefully think through the process and responsibilities. For example, when one staff member takes a message and sends it electronically to another staff member, who is responsible for follow through? In many cases (e.g., a message about a refill request), the recipient is the person responsible for following through, but in other cases, the person who originated the message may be responsible for closing the loop with the caller. The text of the message should make these responsibilities clear. Also, if an employee is absent, how will you access his or her messages to ensure that patients receive the services and information they need without delay? Does a supervisor need the ability to monitor the messaging system to deter employees from using it to have personal “conversations” while appearing to work? If you don't address these issues, efficiency can suffer in new ways.
Paperwork. Another source of inefficiency at the front desk is processing new patients. Sending out information packets to new patients may seem costly (unless you have the patient's permission to e-mail the forms), but it is money well spent. If your information packet includes directions to your office, it will cut down on new patients arriving late or not arriving at all because they got lost trying to find your office or didn't know where to park. Sending new patient registration forms in advance of the visit can reduce delays in the office caused by patients taking too long to complete the forms. Instead, patients can complete the forms in the comfort of their own homes. And whether you have an electronic health record (EHR) system or not, sending out detailed history forms to patients gives your staff a jump on chart documentation. When a staff member calls to confirm the appointment, he or she can remind the patient to bring all forms back into the office.
Appointment confirmation. Calling patients to confirm their appointments is a proven strategy for reducing no-shows and their associated costs, but your system may not be as efficient as it could be. For example, if your front office staff are making reminder calls the day before the appointment, your system is doomed to fail. Patients who work outside the home will probably not receive your message until after work – say 6 p.m., when your office is closed. Their first chance to call you back will be the next morning, the day of their appointment. If for some reason they need to cancel their appointment, you will have very little time to fill that appointment slot and will likely lose revenue.
A simple solution is to call patients two to three days before the scheduled appointment. This gives your patient an entire day to contact you if needed. It also gives your office a day to fill that open time slot.
The back office
Two back-office processes that are commonly rife with inefficiency are preparing the chart and ordering tests and referrals.
Chart preparation. Do you have a standard procedure for preparing the patient's chart for each encounter? Your clinical staff may not actually do the work of chart prep, but they should at least communicate what is needed. Even in an office with an EHR, a staff member needs to check that appropriate test results and referral reports have come in and are recorded in the chart. If results or reports are not in, the staff member needs to have an efficient method for obtaining the results. For example, a staff member could compile a list of all reports needed per lab so that a single call could elicit multiple reports rather than having to call the lab each time a chart is prepped.
A staff member should also check the chart for refills, screenings or preventive services that might be needed and then flag the chart so the nurse or physician can provide those services during the visit. Additionally, clinical staff can be empowered to collect much of the patient history (PFSH and ROS) in the chart before the physician enters the exam room.
Tests and referrals. Your practice also needs a clear process for handling tests and referrals. When a test is ordered, who is responsible for completing the paperwork? Is it the clinical staff or the physician? If your office orders certain tests regularly, consider pre-printing order sheets. You can include information the testing department needs, such as patient name, date of birth, signs and symptoms, and complicating conditions, as well as items that are helpful to your staff and explanations for patients.
One key piece of information that staff members need is a time line. When does this test or consult need to be completed? If you do not want a test conducted for several weeks, but your staff doesn't know this and schedules it for the end of the week, the test may have to be repeated, leading to patient dissatisfaction and increased costs. On the other hand, if a consultation is urgent but your staff is unaware, a potentially bad outcome could occur while the patient is waiting for the appointment. Give your staff clear information on the urgency or timing of the test or referral, and then let the staff negotiate with the offices and testing centers.
In many practices, the physician sets the tone for the practice. Here are two key ways a physician can demonstrate that efficiency is valued.
Start time. In an office setting, one of the most important things that can be done to create an efficient office is for the physician to be on time. In fact, I suggest that the physician arrive at the office at least 15 minutes prior to the first scheduled visit to get a jump on paperwork and patient care. If you see the first patient of the day on time, you are off to a good start. But if you see the first patient of the day after reviewing lab work and test results, signing payroll checks with the office manager and then getting your coffee, you could be as much as 30 minutes behind even if you arrived at work “on time.”
Standardized processes. Another common problem in medical offices occurs when physicians insist on doing things their own way, rather than following a standardized process for the entire group. The best example of this is a physician who refuses to use the practice's EHR system. Excuses range from “I'm going to retire soon, so why should I learn a new system?” to “I work more efficiently with the old system.” The problem is that, because the EHR requires new work-flows throughout the practice, the old system is no longer viable. Requiring your staff to maintain dual systems is a recipe for disaster.
How is your office doing?
To get a sense of how your practice is doing in terms of efficiency, try these simple tests:
Call your office around 9 a.m. on a Monday and try to make an appointment.
Dial into your automated phone system and then try to speak to a human.
Ask your clinical staff how much time they spend tracking down test results after the patient has been roomed.
Check your watch when you enter your office each morning and again when you enter your first patient room.
Chances are good that will find opportunities for improvement.
FPM ARTICLES ON PRACTICE EFFICIENCY
“The Ideal Medical Practice Model: Improving Efficiency, Quality, and the Doctor-Patient Relationship.” Moore LG, Wasson JH. September 2007:20–24.
“Seven Strategies for Creating a More Efficient Practice.” Ho L. September 2007:27–30.
“Huddles: Improve Office Efficiency in Mere Minutes.” Stewart EE, Johnson BC. June 2007:27–29.
“Six Tips for Improving Practice Efficiency and Patient Satisfaction.” Hodges BG. February 2007:28–30.
“Improving Office Practice: Working Smarter, Not Harder.” Sinsky CA. November/December 2006:28–34.
“Escaping the Tyranny of the Urgent by Delivering Planned Care.” Moore LG. May 2006:37–40.
“Making Every Minute Count: Tools to Improve Office Efficiency.” Willis DR. April 2005:61–66.
“Five Strategies for a More Vital Practice.” Nicolette B. January 2004:31–36.
“Strategies for Better Patient Flow and Cycle Time.” Backer LA. June 2002:45–50.