Operations: Staying on Time

It’s the stress.

When patients are stacked up in your waiting area and peering angrily out of exam rooms, tempers flare. Blood pressures rise. If your practice runs behind every day, it’s a drag to show up in the mornings. And it can seem impossible to tame the teeming swarms of patients, lackadaisical schedulers, and bossy nurses into a well-oiled machine. It’s chaos.

But it doesn’t have to be.

The single, easy secret to getting your practice to run on time - and to making your life less stressful - is to base your schedule on reality. Just be honest with yourself.

“The thing that usually gets in the way is denial of reality,” says Judy Bee, a consultant with the Practice Performance Group in La Jolla, Calif., explaining why some waiting rooms resemble bus stations. Physicians have an idea of how many patients they should see each day. Scheduling means cramming that many patients into a morning and afternoon clinic. If you get behind, it’s because you aren’t working fast enough.

Take a deep breath. Stop. Don’t squeeze yourself into the system; put the system to work for you.

Take a new way

The staff and physicians at Panorama Orthopedics and Spine Center used to feel overwhelmed by their patients. Each doctor had his or her own set of rules about when to schedule new or post-op appointments. As a result, a horde of new patients would show up simultaneously, creating jams at registration and X-ray. The practice staffed frantically when trying to cover peak times, but found itself overstaffed when things slowed down. It handled more than 50 types of appointments, reports Brandi Ramirez, the front-office manager for the three-location practice in suburban Denver.

The result? High staff turnover and long patient waits.

So the staff and physicians started over with the help of an engineer from New York who used the Kaizen method, a Japanese work flow tool. (Google “Kaizen” for oodles of information about it.)

“We took the system apart with no obstacles and tried to build the perfect system from scratch,” Ramirez says. “It was number-based, which was great. We built from facts.”

Every 30 minutes, someone counted how many patients were in the waiting room. Ramirez says staff members “ran reports to see how many patients per day we were seeing and divided that by the number of minutes in a day. That told us what we were capable of doing and what we had to do.”

Ramirez’s employees also ran reports showing how many add-on or urgent patients they’d had each day over the previous six months. They took the average and left that many slots available in the new schedule. “We are no longer overbooking; we already planned for this to happen,” says Ramirez.

The practice aimed to match patients with staff and resources such as the X-ray machines so patient flow remained steady throughout the day. The group slashed its appointment types from 50 to three.

Since rolling out the new, fact-based schedule, wait times at Panorama have decreased 55 percent, even though patient volume is up 10 percent. The practice also cut three full-time positions. Now fewer employees are needed to enter data on new-patient forms because new patients are now spaced more evenly throughout the day. The practice also cut one staff person previously used to room patients during peak times; now fewer patients are waiting at any one time to be herded into exam rooms. The remaining staff members are happier not to be so rushed, says Ramirez.

And perhaps best of all for this referral-driven practice, physicians who visit the practice as patients are telling their managers to call Ramirez and learn her secrets. They can’t believe how smooth their visits are.

Study patients per day

Physicians can emulate Panorama without having to employ the services of a big-city engineer.

Start simple. Determine how many patients your practice sees each day for three weeks.

Also time yourself from when you see your first patient of the day to when your last patient leaves the office. You’ll probably arrive at a time that differs greatly from what your current schedule is designed to accommodate.

Bee likes to clock patient arrival and departure times when she is at a practice. A physician might tell her the practice sees - or “needs to see” - 15 patients per physician in the morning clinic, typically between 9 a.m. and 11:30 a.m.

While 11:30 a.m. may mark the morning’s final patient appointment, the facts are often that most of the time, the last patient in the morning clinic doesn’t actually leave the office until 1 p.m. - right about the time the afternoon clinic begins. In other words, it takes four hours for a physician to see 15 patients - not two-and-a-half. And that’s fine. Just prepare the day that way instead of pretending - day after day - that you’ll be able to see all your appointments in two-and-a-half hours.

Such a practice might as well change its schedule, give each appointment slot a little more time, and plan to run its morning clinic through to 1 p.m. Physicians will see the same number of patients per day. The clinic will even take the same amount of time it currently does; but stress will be reduced since everyone will expect to devote four hours to 15 patients.

Measuring your performance is crucial to making such adjustments easier. Bee says most physicians don’t realize how often they run behind, driving patients mad and employee overtime up.

Here’s another way to put it: If you can’t see a patient every 10 or 15 minutes, stop scheduling appointments that way. Practices have become rightfully obsessed with the bottom line; partners agree that productivity has to go up, so they accept an appointment every 10 minutes or so. Some physicians can do it, but others just can’t.

In fact, consultant Judy Capko says she often visits practices in which some partners stay on schedule while others, often the senior partner, run late - like two hours late - each day. The staff knows it. The patients know it. And the physician in question just shrugs and says something like, “Hey, I just give good patient care, and that’s what it takes. Besides, my patients all love me. They don’t mind waiting.”

Don’t be so sure.

NCR Corp. just completed a survey asking consumers about their waiting times in physician offices. Your patients replied that waiting to check in at a doctor’s office ranks as the third-most-annoying wait among consumers. It’s right up there with waiting at the Department of Motor Vehicles.

If someone in your practice routinely runs two hours behind, stop scheduling that physician a patient every 15 minutes. Take a reality check. Physicians who take more time with patients will most likely continue taking more time with patients. They are working late every night already. Just schedule them - and their staff - to reflect their working schedules. The physician in question will then magically be on time overnight, without working any faster or longer, and the staff won’t be working overtime if the hours are appropriately staggered.

This may mean that a physician sees fewer patients per day. Then that physician has some choices: She may find that the comprehensive nature of the care she offers to her patients is worth the revenue reduction. Or she may find ways to boost revenue by charging for all she does in the extra time. Or she certainly could decide to work a little faster to keep revenue the same. All those choices are great. What’s not so great is attempting to avoid such hard choices by hiding behind the illusion that it’s OK to run two hours behind or that things will change via divine intervention.

Start on time

As you analyze when you begin and stop seeing patients each day, pay close attention to your start time. Starting late is the single-biggest cause of off-kilter offices, says Capko. “Physicians rarely start on time, and, if they do, they fall behind in the first hour. They come into the office at 8:30 for an 8:30 appointment and think they are starting on time, but, of course, they stop and talk to the nurse, talk to the staff, check some notes on their desk. They actually are starting closer to 8:40. They are already behind.”

Or a physician will show up on time but then begin doing something else while waiting for the front desk to finish checking in her first patient. Physicians subsequently get off track and end up starting 20 minutes behind.

Physicians often aren’t aware of these patterns, Capko says: “I was working with one practice; the doctor insisted he came in on time every day. The staff scheduled the first patient at 8:30 a.m., and we measured it. In fact, the physician showed up at 10 a.m. every day. We told him to just face the facts.”

You should plan to arrive with or before your first patient, so that by the time that patient is in the exam room, you are ready to go.

Early-bird physicians should schedule early appointments and then knock off in the late afternoon, suggests operations consultant Owen Dahl. At the very least, schedule your more complex work earlier, Dahl suggests. If you’re a zombie before your fourth cup of coffee but really catch your wind after lunch, consider coming in late and staying late. Unconventional hours could be a big benefit to your patients who have to work 9-to-5 jobs.

“You’ve got to know yourself as a doctor,” says Dahl.

Bee agrees: “Some people are just early birds and are out of steam by about 3 p.m. But other physicians come in monosyllabic until 10 a.m. It doesn’t make sense for these people to start at 8 a.m. They can reach out to working people by working late. Staff won’t love it, but at least they’ll know what the schedule will be.”

Measure cycle time

Here’s another way to get the facts on your office’s “real” schedule. Calculate patient cycle time - that is, the time patients spend in the office measured from when they walk through the door until they leave. You could ask staff to gauge it, but patients will be more honest. You want to know how long each step during a typical office visit in your office takes. This will help you identify bottleneck patterns and determine the total average length of time an office visit takes.

Here’s how: Give each patient a small clock and a form on a clipboard. The form should list each step of a typical visit to your office. Instruct patients to note the time they arrived, the time they were checked in (fully), the time it took to complete any necessary lab work, the time that they entered an exam room, the time they saw their physician, and the time their appointment ended. Then ask them to tally the total time they spent in your office. Ask at least 10 patients per physician to do this over one week. Then type the resulting data into a spreadsheet and look for problems.

Start by assessing patients’ total cycle time. “How long should a patient be in your office?” asks Bee. “Well, what’s the longest kind of appointment you would do for a returning patient? Let’s say 25 minutes. Even if you add 20 minutes to that, no return patient should ever be in your office more than an hour.”

Women’s Health Specialists in Germantown, Tenn., routinely measures the length of each patient visit from check-in to checkout. If an appointment lasts longer than 45 minutes, the practice sends the patient a physician-signed letter of apology, says practice president Thomas Stovall.

Patients who are scheduled for a procedure that will take longer than 45 minutes are told in advance how long they can expect to be at the office.

Sure, the practice sometimes gets behind if several physicians are delivering babies or attending to unexpected emergencies, but generally it doesn’t have to mail many apology letters, says Stovall. “Everybody has emergencies, but we don’t have emergencies every single day. There is absolutely no reason not to meet [the goal]. If you’re not meeting that, there is something wrong with your scheduling.”

To reduce your patient cycle time, determine when during their appointments patients are waiting the longest.

Is it at check-in? Then consider spacing out new patients, as Panorama did. Or consider moving phone duty off the front desk so front-desk staff can focus on processing patients as they arrive. You could send patients forms in advance via mail or post them to your Web site, suggesting that patients print and complete them ahead of time. Patients who do so can be roomed quickly after they arrive. “Patients should start their appointment time 80 percent of the time within 20 minutes of appointment time,” Bee advises.

Perhaps your patients experience delays after they are shown into exam rooms. Again, you can adjust your schedule to suit your mode of practice. Or try being a little more efficient during visits.

Adequate preparation can be a huge help in this area. Take the time to train your staff to fully stock and restock exam rooms; everyone should have access to the same equipment in the same place every time. And tell nurses what you’ll need in exam rooms for common types of visits. You never want to have to leave a patient to look for a nurse or a piece of equipment. “Any time we can keep that doctor in the room, it’s better for everyone involved,” says Capko. “Imagine a physician coming out of an exam room; he can’t immediately find his nurse. He gets distracted and ends up answering a question for someone. If he loses four minutes, that’s 16 minutes after the first four patients of the day. Even if he finds the nurse, he has to distract her from what she is doing. Every time you have an interruption, you lose time and efficiency.”

So if you always need an Ace bandage after removing a bunion, tell your nurses to have them ready. If you always need a Pap kit for annual visits, it should be there. Teach your staff to conduct chart previews so they can ensure lab results or consultation notes from referred specialists are back and in patients’ charts before the patients arrive.

This will take some training on your part, and you’ll need to hold staff accountable. But your staff may very well welcome the challenge. “I don’t think our doctors give our nurses and medical assistants (MAs) credit for what they can do,” opines Capko. “They don’t train them and don’t rely on them.”

“If you’ve got a good MA,” Dahl adds, “they can anticipate what’s going to happen and have the right form for the lab, whatever. Just be patient enough to train that person. … You can fire four MAs in a row when there are no gloves in the exam room. But it’s not the MA’s fault. It’s a process problem. Eighty-five percent of the problems in practices aren’t people problems, but process problems; it’s the process to make sure those gloves get ordered and put in the exam room.”

You can also keep your staff on track by meeting with them briefly each morning and afternoon to plan the day. “There is always Grandma Jones who comes in with a list of 25 questions. Staff knows at 9 [o’clock] that she is coming in at 11. They know she calls every day and always needs a lot of time. They can set a work-around at that meeting,” explains Dahl. “A busy professional might be coming in at 11 as well. The practice can plan for the physician to see the professional first, before Grandma Jones. Otherwise, it becomes a tension all over the practice. You all know he’s in there and has opened the door twice.”

Prepare for the realities of how your staff works and who your patients are. Don’t pretend that every patient requires the same 10-minute visit.

Forget the schedule

So what’s the first rule for effective scheduling? Don’t get all hung up about the schedule. Good schedules don’t come from secret, ideal intervals, but from planning based on facts.

“The ideal scheduling type varies with each doctor and each practice,” says Dahl. “An exam room is like an airplane seat; you need it full to make money.”

Flexibility is crucial.

That’s how Linda Arneson, the nurse manager for Iowa Cancer Care in Cedar Rapids, tackles scheduling for her five-physician practice. For example, each doctor is scheduled slightly differently for new-patient visits. Some get an hour; others get 90 minutes. Because the physicians who take longer tend to see patients with more complex conditions and thus bill at a higher level, their partners don’t mind that they take more time, says Arneson. At the end of the day, everyone brings in about the same amount of money.

Arneson doesn’t just set a schedule and hope for the best. “You have to actively watch your schedule and stay on top of it,” she says. When she noticed that many new patients with high acuity were being scheduled for Fridays, she called some of the patients back, explained that she didn’t want them to have to wait, and asked if she could move their appointments. “People are generally pretty good about it,” she says. “They don’t want to wait. It’s about how you approach it.”

Arneson, like Ramirez at Panorama, also likes to stagger new patients so they don’t arrive all at once. She also schedules quick visits - like a patient who needs an injection - at the start or end of the day so that they don’t end up waiting behind a patient who has arrived for a long chemotherapy session.

In the end, Arneson manages to make the practice feel a little less frantic, which is good for staff, physicians, and patients. She considers good patient flow a safety issue, realizing that her eager-to-help nurses will hurry if they know patients are backed up.

Try getting real. See what happens. At first, staying on time might feel weird. Some physicians are so used to a crowded waiting room that they freak out if it’s empty. Others feel that any physician who runs on time can’t be any good; she must not spend enough time with her patients, or she isn’t very popular. There’s a certain cultural appeal to appearing frenzied. But a calm office will take you much further than your false sense of self-importance.

Pamela L. Moore, PhD, is senior editor, practice management, for Physicians Practice. She can be reached at pmoore@physicianspractice.com.
This article originally appeared in the April 2007 issue of Physicians Practice.