At A Glance
- The key to efficient patient flow is understanding the controlling factor. The controlling factor should be the doctor’s style and potential rate of seeing patients.
- Think of your practice as a funnel, wide at the top (input) and narrow at the bottom (output).
- There are four links in the process of practice flow: the doctor’s style, staff, systems, and space.
Do you find yourself frustrated with running behind? With not having staff available when you need them? With not having a patient ready to be seen? Does your practice seem more chaotic and hectic than you would like? You’re not alone. Over the past 28 years I have spent countless hours observing and performing time and motion studies on medical practices. These concerns are a common thread I have seen across many practices.
The issue causing these inefficiencies is simple: There is a disconnect between the input, the throughput, and the output of patients flowing through the office. In other words, the rate that doctors are seeing patients (output) is out of sync with the systems and staff processing those patients (throughput) and the rate that the appointment template brings in patients (input).
Solving this issue is not so simple. The key is understanding the controlling factor. In a retina practice, the controlling factor should be the doctor’s style and potential rate of seeing patients. The doctors’ potential—not current—rate of seeing patients should dictate the organization of all aspects of the practice’s throughput and input.
This article explains how to identify a doctor’s potential patient rate and how to set up throughput and input systems to match that rate. But first I want to explain the concept of maximizing output.
The weakest link in a process dictates the output. In a medical practice, there are typically four links in the process of seeing patients (see Links in the Process).
If your practice’s doctor is capable of seeing six patients per hour, but one or more of the other links are not set up to process at least six patients per hour, the doctor will never reach his or her potential. On the flip side, if the appointment template is bringing in patients at nine per hour but the staffing, systems, or doctor can handle only six per hour, after 2 hours you are 1 hour behind.
How do you find the perfect balance? A good visual is to think of your practice as a funnel: wide at the top and narrow at the bottom. To maximize the output of the funnel, the input is wider than the output opening. There is excess capacity upstream from the output (Figure). With that image in mind, let’s consider how to identify the needs for each section—the top of the funnel (input), middle (throughput), and bottom (output). We’ll start at the bottom.
Looking at computer data to see how many patients your doctor sees in a day does not tell you your output capacity; it only provides you with the current output. To determine what the doctor’s capacity or potential is, you must determine how much of his or her present time is spent practicing medicine—doing the tasks that only the doctor can do—versus time consumed performing tasks that could be delegated to staff or technology, or time lost due to not having a patient ready.
To calculate the amount of lost and misused time, you need to do a time study. I know, many of you are saying, “Been there, done that.” But this type of time study is not simply placing a tracking slip on a chart or a patient, as many time studies do. Those studies tell you only how long the patient or chart is at each stop. To actually determine output potential, you must watch the output resource—the doctor. This requires observing and timing every task the doctor completes for a few hours. Then, after gathering this data, place each event and the time that the event consumed into one of three categories:
- Category 1, Doctor: Tasks that only the doctor can do;
- Category 2, Delegate: Tasks that the doctor is doing now but does not necessarily have to do;
- Category 3, Lost: Time lost because no patient is ready or the task being done provided no patient care benefit.
Remember, the criterion is “Does the doctor have to do this certain task or event?” If not, it does not go in Category 1. You must be critical of statements like “That’s how we have always done it” or “There is no one else available to do it.”
Once you’ve gathered this data, take the amount of time the doctor spent doing only “doctor” things and divide that by the number of patients the doctor saw while being observed. This gives you that doctor’s potential average patient-per-hour (PPH) rate.
The same type of time study can be performed on the technicians and check-in and checkout staff to determine their capacity and properly project the need in this area. By focusing on tasks that are not specific to these staff members’ primary jobs, you can identify the things that are pulling them off track and creating delays in processing patients.
As you perform the time study on the staff, keep an eye out for job duties that conflict with or are not aligned with the ultimate goal of always having a patient ready for the doctor to see. Here are a few things to look out for:
- Are staff members walking to deliver information or instructions that could be sent electronically?
- Is the same staff member handling phones (patient calls, reminder calls, pharmacy orders, etc.) and patients in the office?
- Are the technicians assigned to prep or work up patients for the doctor also performing other duties that pull them off track?
- Are the doctor’s lanes grouped to reduce walking or exposure to waiting patients?
- Are technicians or patients
waiting for available rooms or equipment?
Once you know the potential of your doctors and staff, you can begin to design a staffing model for the practice to properly handle that patient volume or throughput.
In addition to determining the proper number of staff, you must also put in place efficient systems to best use the staff’s time. One adage to remember when assessing a staffing model is, “A staff member cannot perform two stat functions and succeed at both.” For example, receptionists cannot answer the phone and check in patients at the same time. They will fail at one of their two tasks—through no fault of their own.
Links in the Process
- Doctor’s Style: How the doctor manages patients and the rate that style produces.
- Staff: Staffing model in place and how it is set up to assist the doctor.
- Systems: Appointment template, processes, and communication systems.
- Space: The amount, types, and layout of space.
The amount and configuration of space is based on the doctor’s style and the PPH rate from the time study. The number of lanes the doctor needs is based on his or her average time in the lane per patient and how long the staff needs to ready another patient in that same lane once the doctor leaves (called lane turn time). The idea is that the doctor needs enough lanes to keep himself or herself effectively seeing patients and to give the staff time to ready a patient in the last lane used.
For example, if the doctor’s PPH average is six, he or she spends an average of 10 minutes in each lane. If the staff needs 12 minutes to turn a lane (finish up follow-up instructions, move the patient out, clean the room, ready the next patient in the lane), then the doctor needs two other lanes to keep effectively busy. The lanes the technician needs to work up the patient (history, complaint, vision, etc.) are in addition to these doctor lanes.
Input is the information gathered before the patient’s arrival and the subsequent appointment template. As much as possible, data-gathering should be completed beforehand (via mail-in forms, web portals, phone, etc.) to lessen the time and effort it takes to check patients in.
Set up the appointment template to bring in patients a bit faster than the doctor’s PPH rate, so that there is a small pool of patients ready to be seen. One to three patients more than the doctor’s rate is a good range. Then, cut back for the last hour of the day.
Scheduling a lot faster than the doctor’s PPH rate will overflow the waiting room and cause frustration. It does no good to have four, five, or six patients sitting around, ready for the doctor. The practice needs to stay only one or two patients ahead of the doctor. Scheduling at a rate slower than the doctor’s potential PPH rate will create gaps in the doctor’s time.
THE KEY TO EFFICIENT FLOW
The key to making your practice flow efficient and productive is not thinking of your business as a medical practice and concerning yourself only with patient flow. You are orchestrating the movement of many parts that all need to be in sync. Think of it as a manufacturing plant that assembles patient visits. Concentrate on identifying output capacity, and then build your systems and resources upstream based on that capacity.