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Who is the one person in your practice who can do it all — check in patients, verify eligibility, file for insurance, clean the treatment room, and treat patients? It’s the physician, of course. But the fact that a doctor can take on many tasks in a practice doesn’t mean he or she should do so, says Richard C. Haines, Jr., president of Atlanta-based Medical Design International.
If the physicians in your practice don’t concentrate on the job they were trained to do, it’s a huge waste of time and a roadblock to efficiency, he adds. "A classic problem is that doctors typically do all kinds of things they don’t have to do. You don’t have to go to medical school to get patients out of the waiting room," he says. The only way to gain efficiency in an ambulatory care setting is to control access to the physician and the physician’s time, Haines says.
Haines has developed what he calls the "four S’s" that affect doctor potential: style of practice, staffing, systems, and space. One of the first steps in creating efficiency is to keep the doctor on task and on time and to eliminate as much wasted time and effort as possible. That’s where manipulating the four S’s can help. Here’s an explanation of how the four S’s affect physician practices:
• Style of practice. This element is the hardest of the four S’s to change because it depends on the individual personality of each physician, and it’s hard to change someone’s style, Haines says. "A doctor is entitled to practice in the style he prefers, but you can influence the impact of the style," he says. For instance, Haines worked with one physician who had a difficult time leaving the exam room. He’d often stay and chat with the patient while other patients cooled their heels in other exam rooms. Haines’ solution was to design examination rooms with the sink by the door so the doctor could talk to the patient, wash his hands, and exit.
Another physician client insisted on walking patients to the check-out counter. The physician felt it was part of his practice style and that he was communicating with the patient at the time. After watching the doctor in action, Haines pointed out that the doctor typically was three steps ahead of the patient and waited to talk to the patient until he got to the checkout counter where the staff could hear what was going on. Changing his habit increased his efficiency, Haines says.
The optimal practice environment is different for every doctor, and, furthermore, is likely to change through the years, Haines adds. For instance, Haines has observed over time that internists tend to see patients at a slower rate as they get older. "It’s not because they’re slowing down. It’s because their patients are getting older and they end up seeing patients with more problems," he says.
Expect a variation in the time each doctor spends with patients, and work to maximize each individual doctor’s potential. "You don’t want to tell one doctor he has to speed up when it’s unnatural for the doctor to do that," he says. It’s not an issue of pure speed, Haines notes. "We don’t want to rush the doctor through his office visits. What we want to do is eliminate all the waste that impairs efficiency," he says.
• Staffing. Doctors must have adequate staff and be able to delegate efficiently. "We hear a lot of about holding staff down to save money, but what usually happens is that tasks that could be handled by the nurse or the support staff are done by the doctor. You don’t need a $200-an-hour person doing a $10-an-hour job," Haines says. Haines tells of doctors who clean the paper off the examining table and set up the room in the interest of holding down staffing costs. "It’s simply false economy," he says.
One good rule in physician office staffing is that the staff should be able to manage more patients than the doctor. For instance, if you expect a doctor to see six patients an hour, you need a staff that can manage at least seven patients per hour, Haines says. That way, if staff have to deal with extra problems or someone is absent, the physician still sees six patients an hour. "If the staff can manage fewer patients, it means the doctor sees less. If they can manage the same number as the doctors and there is a glitch, the practice’s productivity falls behind," he adds.
• Systems. There must be a good system in place to maximize the doctors’ time, allowing them to go from patient to patient in the least amount of time and with the least dependency on other people. The two most common reasons doctors come out of the examination room and look for a nurse is to give the nurse verbal instructions or to ask which room they go into next, Haines says. "Both can be done in other ways so the doctor can keep working and the staff can do their job without having to worry about being around for the doctor," he says.
To optimize the doctor’s time, you need systems that allow the doctor to transmit the information to the nurse without having to find her and tell her directly, he adds. Some practices have set up order slips and check-off lists that the doctor leaves on the door. Others use inter-office pagers to let the nurse know what needs to be done. "These simple things can take a tremendous burden off the staff," he says.
• Space. If the space isn’t adequate and well-designed, productivity goes out the window. Doctors with a higher volume need more examination rooms. For instance, a doctor who sees two patients an hour doesn’t need as many rooms as one who sees eight patients an hour.
When you plan space, look at how it is arranged as well as how much space you have. For instance, Haines says he worked with one doctor who had three examining rooms and typically saw about 40 patients a day but was exhausted at the end of the day. Haines found that two examining rooms were together, while the third was down the hall. To get to the third room, the doctor had to pass the check-out counter and often stopped to chat with the patients who were paying their bills. Haines redesigned the space to make all the exam rooms adjacent. Subsequently, the doctor’s productivity reached 50 to 70 patients a day and he wasn’t as tired. "When we kept all three exam rooms together, he stayed on task," Haines says.
As a general rule, plan for 15 minutes to elapse in the period of time in which the doctor leaves the room, the patient gets dressed, the staff re-does the room, a new patient is brought in, and vital signs are done. When the patient doesn’t undress, it usually takes eight minutes for the room to turn around. If you have a surgical practice, plan on having an extra room for each surgeon to take care of the stream of patients coming in for postoperative rechecks. "To have one extra room sitting there is going to cost about $20 a day. If you have to err, err on the side of having too many," Haines says.
If you want to maximize the efficiency of the doctors in your practice, Haines recommends you consider implementing the following steps:
• Come up with external strategies to help the doctors stay on task. For instance, Some doctors have difficulty bringing the patient encounter to an end. If this is the case with a doctor in your practice, the medical assistant could pop into the room near the end of the visit to go over the prescription or put on a bandage. "Find a way to turn over the last minutes of the visit to the assistant," Haines suggests.
• Manipulate the schedule to give every doctor the time he or she needs to practice. The number of patients a doctor schedules each day will depend on the severity of the patient and on the doctor’s practice style.
• Make sure not every doctor is scheduled at the same hours every day. "You don’t want to have everybody working on Tuesday but nobody on Monday, " he says.
• Recognize that the doctor and nurse have different jobs that probably require them to work at different paces.
• Maximize the number of hours a clinic is used. If there are a number of physicians in your practice, you need fewer examining rooms if all of them aren’t seeing patients at the same time. "The space is an expensive part of the cost of running a practice and it’s normally used just six or seven hours a day. Any time you can use it longer, you get more results out of the same investment," Haines says.