FEATURE ›› CLINICAL EFFICIENCY

HIT THE GROUND Running

Additional tips for boosting efficiency on the clinic side of practice.
Part 2

BY DESIREE IFFT, CONTRIBUTING EDITOR

In the September issue of New Retinal Physician, we brought you advice from several experienced retina specialists on how to run an efficient clinic. They told us that when a clinic is functioning well, patients are happier, doctors and staff are more productive and revenue is maximized. They also said efficiency must be a mission, with a battle plan that’s constantly reassessed and readjusted to meet each new wave of change. Here, we bring you more tips from doctors who continue to find ways to streamline (again, in their own words but minus the quotation marks that would just slow you down).

PAUL HAHN, MD, PHD
DUKE EYE CENTER
DURHAM, N.C.

›› Try a morning “huddle.” Every morning, our entire team — physicians, technicians and front desk staff — get together for a brief meeting. It takes us 5 minutes at most to review the schedule for the day as well as any staff absences or other factors that could have an impact on the day. The huddle is a rare opportunity for everyone to be together and it’s a perfect opportunity for either staff members or physicians to proactively raise any issues or concerns. It helps ensure everyone is on the same page, so we can tackle a busy day efficiently. Even if there are no active issues on a given day, the regular face-to-face time engenders a team environment for patient care.

›› As requirements for clinical care are constantly expanding, physicians and technicians are increasingly taxed for time. Technicians are often asked to perform additional functions. If they’re asked to perform new duties without the benefit of knowing why these tasks need to be done, it’s counterproductive. It invites oversights and sloppy mistakes, which are, at best, a time-wasting annoyance and at worst, a compromise of patient care. When technicians are provided with an explanation of why they’re being asked to perform a task, it empowers them to do it properly. An educated technician performs much more efficiently than one performing tasks just from instruction and memorization. Taking the time to provide this education will pay off with dividends.

›› Educating staff members about the nuances of billing is also a critical component of efficiency. For example, understanding that postoperative visits or injection-only visits are generally not billable allows the technician to perform only a directed workup rather than a full workup that may require documentation of pupils, extraocular motility, visual fields and other assessments (sometimes primarily for billing purposes and not always for contribution to the retinal assessment). Another example is ensuring the staff knows that injections for patients with AMD require a neovascular AMD code, not just an unspecified AMD code, to be reimbursed. When the technicians are aware of these types of distinctions, they enter the appropriate codes, minimizing the need for constant and cumbersome oversight and correction by the physician.

Teaching the staff about retinal diseases, diagnostic modalities and treatment options helps them to make informed decisions throughout the clinic day. It also enables them to serve as your first-line representatives in providing basic patient education, freeing you up to move to the next exam room. In my experience, the staff enjoys learning about the eye conditions and diseases they see every day.

SVETLANA PILYUGINA, MD
ASSIL EYE INSTITUTE
BEVERLY HILLS, CALIF.

›› Analyze patient flow accurately. A very helpful tool for revealing deficiencies and bottlenecks is a clinic time flow study, which is also known as a cycle time study. This type of evaluation is used to document the amount of time patients are spending at each of the key points as they move through the clinic. Our practice benefitted from a recent time flow study, which we carried out in a relatively simple, low-tech way. We printed a sheet that went on top of every patient chart. Starting with check-in, the staff member responsible for the patient during each part of the visit initialed the sheet and noted the beginning and end times for the encounter. We collected data for a month and then used a spreadsheet to analyze it.

Our latest time study was enlightening in several ways and led us to make some adjustments. For example, we now use a “floater” whose sole responsibility is to escort patients from point A to point B in the clinic, such as from photography to the exam room or from the exam room to the front desk. This allows everyone else to continue working instead of walking around. Entry level technicians and student volunteers who are interested in a career in medicine make good floaters. Our time study also showed that we have somewhat of a backup at our imaging device that performs multiple tests, including both fluorescein angiography and OCT. Now that we’re aware of the delay, we can consider when and how to address it.

›› For patients waiting to be seen in the exam room, we play short retina-related videos. The technicians know to choose a video that is specific to a patient’s diagnosis. The videos reduce the number of questions patients ask about their disease process, making for a faster and more focused discussion. On the other hand, I’ve found that playing non-medical programs on the TVs in the waiting room makes time go faster for patients, which helps to reduce complaints about wait times.

CAMERON JAVID, MD
RETINA ASSOCIATES
TUCSON, ARIZ.

›› When you’re hiring support staff, go for quality. A key attribute for practice employees is that they’re capable of and willing to learn the physician’s routine so they can anticipate what he or she needs throughout the clinic day. For example, when I walk into the exam room, my staff members have the patient’s EHR open and all of the diagnostic scans on the screen for me to evaluate in one view. I don’t need to spend time downloading the information I need for the visit.

Speaking of EHR, hiring quality scribes has allowed our practice to take full advantage of being paperless. We train our scribes to extract what is needed for documentation in the chart from my conversation with the patient, making it unnecessary for me to write or type anything during an exam. It has proved to be a very efficient way to work. We’ve had very good luck hiring college grads who are going on to medical school to serve as scribes.

›› Evaluate your office layout. Working intravitreal injections into the clinic flow efficiently has been a huge challenge for retina practices. If you’re building a new practice from the ground up, you have the luxury of planning for that challenge accordingly. However, even in an older practice, if you evaluate the situation and take some time to visualize a more efficient layout, you may be able to rearrange at least some aspects to improve efficiency.

›› Be at the top of your game mentally and physically. When it comes to being physically fit, we may get a free pass of sorts up until around age 40. But eventually we can’t escape the effects of not eating right and not exercising. After all, even though we’re plenty busy on the job, ours is a relatively sedentary profession. We work indoors, breathing recirculated air, and the heaviest thing we lift in a day is a scleral depressor. To greet each day with the necessary energy and focus, and thus efficiency, we need to take care of ourselves. Anything we can do to get out in the fresh air, physically move and reduce stress helps. When I was in pre-med, a family friend who was a neurosurgeon told me how stepping up his workout and exercise routine was essential for staying fit and performing at his top level with a demanding workload. That advice stuck with me, and I’ve experienced for myself just how true it is.

›› Adopt a Kaizen-like approach. The Kaizen philosophy is based on the concept that continuous improvement, even in small increments, greatly benefits individuals and organizations. The mindset involves aiming to improve a bit every month so as not to become complacent or find yourself in a rut. Kaizen is definitely applicable to improving clinic efficiency. Frequent small changes can be just as effective, if not more, than radical changes that are few and far between.

THOMAS W. STONE, MD
RETINA ASSOCIATES OF KENTUCKY

›› Some retina specialists recommend reviewing a patient’s imaging results for the first time with the patient in the exam room. But depending on the other aspects of your current clinic processes, you may find the process I adopted to be more efficient. I preview the chart and all imaging thoroughly before I enter the exam room. Then I can concentrate on the history and exam elements that will allow me to make a treatment decision. This makes the encounter flow more smoothly for me. Also, I find that being able to ask patients directed questions right from the start confirms for them that I really know them and their case.

›› Staff training is a common theme in discussions about clinic efficiency, and can’t be overemphasized. One strategy I’ve found particularly important is to make sure workup staff have specific guidelines for handling the various scenarios they will encounter. For example, they should know what to do with patients who present with a uveitis flare, an unexpected high IOP, and any other situations you want addressed prior to the patient coming into the exam room. In addition, if you use scribes, they should be made aware of how you expect information to be documented and how to keep the exam rooms full so you can focus on patient care.

›› Communicate follow-up so the checkout staff knows how to schedule the patient without coming back to the scribe or physician. In our practice, what’s next for each patient is conveyed via the EHR. Before we implemented EHR, we had a special section on the exam page in the chart that indicated when the patient should return to the office, what testing needed to be done prior to his return visit, and if any special equipment, e.g. laser or B-Scan, would be needed at the return appointment.

SUNIL GUPTA, MD
RETINA SPECIALTY INSTITUTE
PENSACOLA, FLA.

›› Fast track injection-only patients. In our practice, we don’t schedule all injection patients on a separate day. Instead, we designate a special appointment type for them. We flag their file and superbill in a clear colored folder with the code we have designated for this purpose, which is the drug they will receive, e.g., Lucentis, and a “B” for injection only. So, when a patient whose file is designated with “Lucentis B” arrives, he’s taken directly to the injection room, where informed consent and prep take place and the treatment is delivered. This process limits the facility resources needed to support these visits and gets them in and out of the clinic in 20 minutes.

›› We cross-train all clinical staff to perform all aspects of technician work, with the exception of fluorescein angiograms. This allows us to transition resources and rooms accordingly if a bottleneck develops. For example, if a backup occurs in OCT, whichever staff subgroup has the fewest patients waiting, which could be front desk, scribes, and so on, can jump in to help perform OCTs or help the OCT operators call and move patients in and out of the OCT room. We also have a subset of techs who move patients in and out of rooms, open charts, provide educational material and escort patients to checkout. In the event of a backup, they can step in to help in the OCT room or with vision checks. As they gain experience, we typically transition them to become scribes or certified technicians. The bottom line is that we’re all working as a team to keep the clinic flowing smoothly. NRP

SET THE TONE OR YOU MAY BE STRIVING TO BE EFFICIENT ALONE

Pamela Ann Weber, MD, founder of Island Retina in New York, told us in the previous issue of New Retinal Physician that a key component of her overall strategy for running an efficient clinic is that, as the leader, she sets the tone. Several retina specialists who shared their tips in this issue share her beliefs about being on time and focused.

PAUL HAHN, MD, PHD: Start on time. Any delay at the beginning of clinic — whether it’s due to technicians not working up patients promptly or the physician not showing up on time — will only get worse as the day goes on. Make timeliness for yourself and your staff a priority to cultivate a culture of efficiency. Your patients will certainly appreciate it!

CAMERON JAVID, MD: Maximize clinic time by being focused. Do only “doctor things,” i.e., examine, diagnose and treat patients. If you find yourself performing tasks other than direct patient care, evaluate whether you can delegate them. For example, in our practice, staff members are trained to provide patient education on recurring topics, such as using the Amsler grid and taking vitamins. The 2 to 3 minutes per patient this saves me times the number of patients I see in a day adds up to a great deal of time. As I’m about to leave the exam room, I do a simple handoff: “Jenny will talk to you about X, Y and Z.”

Also, save the personal e-mails for lunchtime and if possible return nonclinical phone calls (such as answering questions from a patient’s son or daughter about dad’s AMD) while driving to and from the office.

THOMAS W. STONE, MD: You’ll likely be the person most responsible for whether your clinic hours stay on track. Focus on seeing patients when scheduled to do so. It can be tempting to work on papers, read journals or squeeze in some other task, but this will slow everything down if you have patients waiting. If you need to communicate with another doctor or schedule a test for a patient, have a staff member initiate or schedule those tasks so you can continue to see patients.