American College of Physicians: Internal Medicine — Doctors for Adults ®

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Running behind? Try re-engineering

Redesigning your practice's patient flow can save time– money

From the July/August 2000 ACP-ASIM Observer, copyright 2000 by the American College of Physicians-American Society of Internal Medicine.

By Edward Martin

Locating the next patient was once a nerve-racking experience for Steven A. Geller, FACP. After searching for the patient's chart, the Ellicott City, Md., internist would hunt down a nurse who might know where the patient was waiting. Occasionally, he would have to start knocking on exam room doors.

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If he guessed incorrectly, he'd politely excuse himself. Often, he'd find a patient in the middle of an ECG, or an empty exam room whose scheduled patient was still in the waiting room.

Several years ago, Dr. Geller's practice of seven internists and family physicians and three nurse practitioners hired a consulting firm to identify tasks that were wasting valuable staff time and eating away at billable hours. Architects redesigned the office layout and added exam rooms so physicians and patients no longer have to wait to see each other. The firm's consultants also put physician offices much closer to exam rooms, so Dr. Geller no longer has to walk 50 feet from his office to an exam room. Now, coded lights allow him to signal his nurse when he finishes an exam and the patient is ready for lab tests, without waiting to tell her in person.

The results have been impressive. "I was seeing 14 patients a day and considered myself busy," he said. "Now I see 22 patients and consider it an average day. I also get home at a more reasonable hour." That's important to this father of three school-aged children.

For internists overwhelmed by the time pressures of modern medicine, Dr. Geller's experience raises interesting questions. Can the type of time and motion analysis traditionally used in industry help physicians practice more efficiently? Can re-engineering a medical practice improve quality of care and get doctors home in time for dinner?

Physicians and consultants who have been through the process give it a thumbs up. They say that with a little guidance, physicians can take currently wasted time and translate it into longer patient visits, improved earnings and increased personal time.

Finding the gaps

Experts explain that the re-engineering process does not necessarily mean ripping out walls. Instead, they say, re-engineering is all about determining where the least change can produce the greatest results.

"When you perform a time and motion study on doctors, you see many little gaps in work flow," said Richard Haines Jr., an architect and president of Medical Design International (MDI), the Tucker, Ga., firm that worked with Dr. Geller's practice. "Physicians see a patient then chase down a nurse to get an injection tray set up, or they pop into their office to check the stock market. Eliminate the gaps, and you create a block of time the physician can put to better use."

Re-engineering typically focuses on two phases. First, consultants look at flow, tracing patients as they move through the office during a visit. Analysts also conduct time and motion studies to examine exactly how doctors and staff members interact with each other and patients, and how those processes can be improved.

When it comes to work flow, consultants start by pinpointing bottlenecks. They find that interruptions often begin with inflexible or poor scheduling. Late patient arrivals can lead to delays that back up internal services like lab tests, stranding patients in exam rooms while doctors wait around in hallways. (For average times that patients spend in physician waiting rooms, see the chart on page 1.)

"The schedule starts perfectly, then bottlenecks develop," said Carolyn Albert, Management Associate in the ACP-ASIM Center for a Competitive Advantage (CCA) in Washington. "Patients go from waiting four minutes in the waiting room to waiting eight minutes in the nursing area because they can't get in the exam room to see the doctor. By noon, the entire schedule disintegrates."

Charles S. Hertz Jr., MD, a gastroenterologist at Medical Specialty Clinic in Jackson, Tenn., said that before his practice went through re-engineering, patients often got lost while negotiating a maze of hallways. They would stop staff members and physicians to ask for directions to the lab or another part of the practice.

Five years ago, the practice began working with MDI, the firm that helped Dr. Geller's practice. Consultants designed a new, more open setting and installed light signals on exam rooms similar to what Dr. Geller's practice uses. "Now I never have to wait for patients," Dr. Hertz said, "and things have sped up tremendously."

To streamline patient flow, the practice began using modified wave scheduling to project the ebb and flow of walk-ins and other variables. Sandy Jackson, the practice's administrator, said the group now schedules more time for appointments like initial rheumatology visits, which require an hour. Other specialties like gastroenterology, however, tend to be more predictable, so the group schedules those appointments in 15-minute increments.

Wasted time and effort

According to Julie Jones, a consultant with the Atlanta firm of Gates, Moore and Co., internists should ideally spend 80% of their time working directly with patients. She said that in many practices, however, patient contact accounts for less than half of physicians' time.

To encourage providers to spend more time on patient care, consultants say, everything physicians and staff members need should be close to the exam room, including the supporting nursing station, sample drug cabinets and booths to dictate progress notes. "If you lay out the practice in nodules of activity, you prevent physicians and staff from running up and down the hallway 200 times a day," explained Ms. Albert from the CCA.

"The moment the doctor steps out of the exam room to look for something, we're paying him $200 an hour for an $8 an hour job," said Mr. Haines, the architect from MDI. "Things come to the doctor, the doctor does not go to things."

Other solutions involve arranging exam rooms specifically for left- or right-handed doctors and standardizing all rooms to minimize wasted motion. At Connecticut Multispecialty Group PC in Wethersfield, for example, all exam rooms are set up exactly the same way.

"What's left is always on the left and what's right is always on the right," explained Michael Z. Lazor, MD, an internist, nephrologist and president of the group. He said that applying time and motion concepts has helped his practice boost its efficiency by nearly 20%. "If you look at our 43 physicians," he said, " even a 1% difference in collections represents $250,000 a year."

Physicians need to remember that flow problems can also bog down nonphysician staff. "Create work stations that are self-sufficient," suggested Elizabeth Woodcock, an Atlanta-based consultant who works with the Medical Group Management Association. Are your receptionists walking 20 feet to copy patient insurance cards dozens of times a day? "Buy a $200 desktop photocopier and put it right beside them," she said.

Other more subtle problems can be more difficult to detect. Ms. Woodcock recently analyzed a practice in which staff members, unbeknownst to each other, were calling patients three separate times in the 72 hours before a scheduled visit. One was a reminder from the appointment office, another was from the billing department to verify insurance coverage, and the third was from a nurse to begin a history.

Space problems

Consultants say that physicians typically face two types of space problems: not enough, or space that is poorly organized.

Dr. Lazor from Connecticut Multispecialty Group said that problems frequently emanate from failing to grow with patient volume. "I began practicing in 1963, when the staff ratio was about 1.5 per physician," he said. Today, the ratio is four or more. While many older practices have increased their staffing levels, others have failed to add the proportional number of exam rooms.

Group practices may think they're saving money on overhead by keeping exam rooms to a minimum, but experts say such reasoning wastes physician time--and money. "You can spend your time trying to reduce the rent by 30 cents a square foot," said MDI's Mr. Haines, "or you can find ways to increase the doctors' production capacity."

Consultants generally recommend about 2.5 exam rooms per internist, although they quickly add that other factors come into play. Do patients, for example, need to undress? If so, room turnover will be slower, requiring more rooms.

The Atlanta consultant Ms. Woodcock cited several studies that show optimum practice size is 5.6 physicians. Once groups exceed that, she said, the group actually gets too large to manage. So how does a 40-physician practice cope?

Some, including Tennessee's Medical Specialty Clinic, employ pods or care-teams composed of clusters of no more than four physicians with supporting aides and nurses. Add more physicians to the cluster, Ms. Woodcock said, and the distance between exam rooms reduces physician efficiency.

Final advice

When it comes to redesigning a practice, consultants offer the following tips:

  • Spend more to make more. Understaffed and inadequate facilities that force physicians to wait for patients to arrive or do their own workups end up costing more than they save. When office staff bears the administrative load, physicians have more time to use their expertise: seeing and treating patients.

    The notion of spending money to make money applies to the re-engineering process itself. Expect to pay a consultant about $140 an hour, depending on geographic region, for help in analyzing your practice. Expect a study of an internal medicine practice, which typically involves three days of on-site data collection and recommendations, to cost between $4,000 and $10,000.

  • Find tools to streamline paperwork. Paperwork created by managed care can swallow countless hours of physician time. Many consultants believe electronic records can relieve much of that paperwork burden.
  • Remember that talk isn't cheap. Eliminate unnecessary face-to-face communication with staff and rely more on tools like checklists.
  • Find better ways to bond with your patients. Walking a patient to the lab or checkout may generate goodwill, but consultants say that the gesture wastes too much of your time. Besides, they point out, a narrow, public hallway isn't the best place for private conversation.
  • Give up your private office. If you use your office more for personal matters than for patient consults, it's probably hurting your productivity.

Consultants acknowledge that re-engineering a practice is obviously not without risk. Ms. Woodcock said she suggests re-evaluating new processes after three to six months. "You have to ask, did it make the physician more productive?" she said. "If not, we should just go on to something else."

Ultimately, though, physicians in re-engineered practices say intangibles shouldn't be overlooked. "I can't even put my finger on exactly what changed," said Dr. Hertz. "But I used to dread the office because everything took forever. Now I come in, do my work and go home earlier."

Edward Martin is a freelance writer in Charlotte, N.C.

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