Building Your Business

Style, staff, system, space. These are the foundations upon which Dick Haines crafts strategic plans and builds results-oriented medical facilities for physician practices, academic departments, clinics, and hospitals.

Over the course of his career, clients have included such institutions as The Cleveland Clinic and University of Rochester, and projects have spanned the spectrum, from cancer centers to nursing schools to an eye institute converted from a meat packing plant.

Haines isn't just about drafting sketches and hanging drywall - he knows the business side of practicing medicine, and believes that improving a physician's productivity is both an opportunity and an obligation. Making changes to achieve greater efficiency is "difficult because you have to be sort of introspective," he says, "and it's really hard for people to understand when they're doing something that's kind of silly."

Haines spoke with Physicians Practice about his straightforward approach to helping physicians make such changes, and to "think of their office as an integrated system of events."

Q: Office design and architecture are typically not top-of-mind subjects for most physicians. What do you say to physicians who may not realize the effect that their physical office space has on how they practice?

Haines: A lot of doctors come to us frustrated by their ability to be effective practitioners; they understand that space has an impact on that ability. If I'm trying to illustrate that space can limit productivity, I ask, "If I give you one exam room and put five doctors in the practice and as many patients as you need, what is going to limit the growth of that business?" They understand that it's going to be limited by having just that one exam room.

If we're dealing with a multiphysician practice with a main office and satellite offices, we ask them to compare the two. Often they will relate how pleasant it is to practice in the satellite. They see more patients there, the day is less harried. What they are really saying is that in the main office, there's competition for staff and fewer resources. Production suffers. The point is, if you have that high level of productivity in the satellite office, shouldn't you have it in the main office?

Q: Describe how you help your clients to see "the big picture" in order to integrate various work functions into a cohesive operation.

Haines: We developed our concept of the four S's - style, staff, system, and space-in the early '80s when we noticed that space had a significant impact on productivity. Doctors we were building for told us how much more efficient they were in their new spaces. We realized we needed to anticipate what their productivity might become, not just concentrate on what it was, so we wouldn't design a space that was limiting. Then we started thinking what other elements start to impact productivity, and we came up with the other three S's.

Q: Describe the four S's in more detail. How do they fit in to the day-to-day operations of a practice?

Haines: The first one, which has to do with the physician's own working style, is one we rarely get involved in. But an example would be the doctor who complained to me that he didn't make eye contact with the patient because he had his nose in the chart. So we suggested that he hire a technician to work up the patient, then the technician would present the patient to the doctor, much like he did to the attending in medical school. It was a way to help him get around a counterproductive element of his style.

The second one is staff, and there are two parts to consider. One is to make sure you have staff to delegate to and that you understand what you can and should delegate. The second - and this is a tough one - is that if you can see five patients an hour, the staff has to be able to handle more than five patients an hour. This may mean sometimes the staff is idle - but not the doctor. It's amazing how many times we see the nurses running around like crazy and the doctor has time on his hands. You want it the other way around.

Q: That sounds like a communication issue.

Haines: Actually, the third S, systems, has a lot to do with communication. Between the doctor and nurse, one element that's a constant bit of friction in terms of productivity is transmission of information. Doctors either want to convey information that they want the nurse to follow up on, or they want to ask, "Which room do we go to next?" At the end of the day, that time spent just looking for the nurse is a lost appointment or two. And the nurse has a lot of her own tasks to do - they run at a particular pace, and the doctor's jobs run at a particular pace. Those jobs just don't overlap continually. So we look for other ways to transmit information like a light visual system, checklists, or a white board.

The last element, space, is about making sure the doctor has enough space to manage patients well. You simply need to have enough exam rooms. Often the cost of that additional room is not nearly as great as what will be produced by having it. We start by making sure the doctor has adequate space to go from patient to patient, and the rest of the staff can manage the other issues.

Q: The roles of other health professionals appear to be expanding. How does that affect the office space and productivity?

Haines: One area many offices need to work on is using staff appropriately. A lot of medical practices hire registered nurses and then don't give them RN responsibilities. At the same time, the number of receptionists used to triage phone calls is significant. Why not have your nurses triaging patients' problems, where they can apply their knowledge and expertise?

When you get to nurse practitioners and physician assistants there are two models we see. One is where they actually assist the doctor, managing patient flow. The net result is that physician is going to see more patients in a given unit of time, because he's delegated effectively and more of the exam process is being handled by the nurse than the doctor. So the nurse work area gets bigger.

The second model is where NPs or PAs have their own patient appointment schedules. Typically, the practice has gone to a substantial amount of trouble to define what kinds of patients that professional can manage, like well-baby checks or pre-op history and physical. Those professionals then become as significant to that practice as the physician. Once you do that, you have to be as concerned about their four S's as the doctor's.

In the future, we are going to see more effective delegation to nonphysicians. Ten years ago, I'd go into a practice and say, "What about PAs?" and the response would be, "Oh, our community would never accept that." Now clients are saying, "We've got two, we're planning for a third, how do we incorporate them into the practice?" There has been a significant change in attitude.

Q: A perennial challenge for physician offices is making patients' wait time as painless as possible. What can they do to improve patients' comfort levels?

Haines: There are a number of things that can be done. For example, it's better to have the patient sit in a nice chair rather than a sterile waiting room or exam room. Arrange furniture in groups, rather than like a big bus station with everybody lined up in a row. Use soothing colors, and have fluorescent lights mixed with table lamps so the light level is bright enough for people to read. And we don't recommend patients get moved a lot from place to place.

The procedure room, by definition, may be a rather austere place. You may have to have tile on the floor so it can be cleaned easily. But you can add some nice touches. One practice had a whole wall in the procedure room with a laser light system that was timed to music; they let the patients bring their own CDs. That decreased the sense of anxiety immensely.

Scheduling is important, too. As a patient, I would prefer procedures early in the morning. If it's going to be at 4 in the afternoon, I've got all day to worry about it.

Q: How can a practice prepare for working effectively with an architect or design firm once they've decided to make changes or additions to the office?

Haines: If I'm working with a group that is planning changes or redesign, there are a couple of expectations they need to have. First, the meetings should be after hours, not during patient visit time. The doctor's time should be kept to a minimum, to reflect those areas in which he needs to have input. For example, we have the doctor review the exam room, but when it comes to the business office, we say, "Doctor, this space belongs to your staff, not you."

It's very important that doctors understand the implications of change or growth that they anticipate, because they will change the pattern of patient management and care delivery. Before you start designing you need to understand what the final practice entity is going to be, or at least have some sense of the stages: "We're three doctors, we're going to go to five, we expect to go to seven," and so on.

Finally, you need to have a planner or architect who understands that there's a business and operations side to ambulatory medicine. The things doctors ask questions about - and that you really have to work on in initial stages - are business and operational issues, not architectural issues.

Q: How can physicians begin to think about integrating physical space and productivity as an ongoing process?

Haines: By the time a doctor can practice medicine, he has been imbued with a tremendous amount of knowledge and skill. The question is, how available do you make that? You can be sloppy and see 10 patients a day and a lot of that knowledge goes to waste, or you can be more effectively organized and have that knowledge touch more people's lives.

A management consultant told me he thought healthcare in the future would be managing volume well. That's what we're talking about. A lot of doctors pay lip service to that; but patients are calling in and [practices] put them in the line and hope it works out at the end of the day.

Doctors need to think of their office as an integrated system of events. Managing volume well, respecting the economic needs of the practice, and managing and respecting patients. I think these, in the best of situations, are totally integrated. You solve one problem, you solve them all.

This article originally appeared in the January/February 2002 issue of Physicians Practice.