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Clinical Reviews

The 10 principles of practice efficiency

Time-saving routines to manage the “psychology of waiting” and set a game plan for each day

December 2005 · Vol. 17, No. 12
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As reimbursement plummets and expenses rise, the options to improve your practice’s profits may seem more limited than ever—either you see more patients or spend less time with the ones you have. There is another option, which is often overlooked: Reduce the constraints on your time by improving your efficiency.

This article outlines 10 practical steps you can take to streamline your practice.

1. Manage the psychology of waiting

The link between patient wait times and practice efficiency may not be immediately apparent, but it does exist. When a patient feels you have kept her waiting unnecessarily, she may conclude that you have no respect for her or her time.

This perception can lead to situations in which you must spend time fielding complaints and making apologies and explanations in the exam room. Although such “service recovery” may consume only a minute of your time, it takes precious minutes away from your efficiency.

Keep patients informed about extended waits

Instruct your staff to inform patients of longer-than-usual waiting times when they first arrive at the office for their appointment. Maister and colleagues found that patients perceive waiting to be longer than it actually is when they are uninformed, uncomfortable, and unoccupied.

Update patients about delays every 15 minutes. Consider asking a member of your clinical team to address the issue if the wait exceeds 30 minutes. Explain lengthy delays, and give patients the choice of waiting or rescheduling. This attention to communication makes patients feel you value their time, too.

Waiting room comforts, personal touches, entertainment

Pay attention to comfort issues such as chairs, room temperature, and back-ground music. Review pre- and post-exam dressing protocols, and make sure to stock extra-large gowns for patients who may need them.

Make your waiting room a delight

Some creative but tasteful ideas to brighten the reception area include hanging artwork from your personal collection or from local artists, many of whom are happy to display their work in exchange for the exposure (place their business cards discreetly next to the work). Other ideas:

  • Baby pictures of you and your staff
  • Pictures of you at your hobby or with your family
  • Interesting memorabilia
  • Jigsaw or crossword puzzles, word searches, and other lap games (you can create your own using Web sites such as
  • Personal computers with Internet access
  • Free long-distance on available phones (restricted to domestic calls only)
  • A diverse magazine collection for patients and their partners
  • Pagers to allow patients to walk to nearby shops if delays are lengthy
  • Notepads and envelopes for patients to write a letter or 2 (consider offering to stamp and mail completed letters)
  • Brochures about services you offer

In short, comfort and entertain your patients, and you can turn the potentially negative situation of waiting into a delight.

2. Review charts in advance

A failure to review charts prior to seeing patients can limit your efficiency, add to your frustration, and give patients the impression that your practice is disorganized.

Tell your staff that chart preparation is a high priority. Require that all charts be previewed 1 or 2 days before patients are seen. Let staff know you expect them to include in the chart the results of tests you ordered at the last exam, communications from physicians to whom you referred the patient, and relevant operative reports.

Don’t overlook billing issues

In addition to the clinical review, an administrative review of a chart in advance of the visit can ensure that your efficiency and good care will be remunerated.

Assign a biller to review your charts for insurance verification and benefits eligibility. He or she also can note any accounts with outstanding balances, and evaluate and resolve any outstanding referral or authorization problems.

Check samples and supplies

As a corollary to chart preparation, assign a staff member to ensure that the pharmaceutical sample closet has adequate supplies for the following day, and review equipment and supplies to see what needs to be ordered.

Red-sticker the low inventory items. To make it easier for staff to spot low inventory, provide small red adhesive flags for them to stick on shelves (or remaining stock) when supplies run low. Appoint a staff member to make the rounds of exam rooms and closets to identify the flags, restock, and order any necessary supplies. Items should not be allowed to run out.

3. Ready the room

A well-prepared exam room means you can care for patients without unnecessary delays. Rooms should be cleaned between—not in front of—patients, and staff should ensure that supplies and equipment are readily available.

A quick and easy tip for equipment preparation is to draw an outline of the equipment in the base of the drawer, or hang a hook on the wall for each piece. That makes it easy to see at a glance whether something is missing—and you’ll always know where to look for the equipment.

If physicians change rooms (eg, at lunch), make sure that the staff knows to restock personalized items such as notepads and prescription pads.

4. Create a start-of-the-day checklist

Provide a written description of what you expect your staff to have accomplished by the start of the clinic. The list may instruct them to:

  • Ensure cleanliness of the clinic
  • Turn on computers, including those in exam rooms
  • Contact the hospital for overnight admissions and cross-match with your schedule
  • Review all schedules to anticipate problems
  • Evaluate inventory of supplies and equipment in the clinic and each exam room
  • Gather and organize incoming results from email and fax machines
  • Ready equipment

5. Huddle with your staff

Commit 5 minutes every morning to huddle with your staff, using your schedule as the agenda. At a minimum, ask your clinical assistant and scheduler to be present.

This huddle is not a meeting. It’s about setting the game plan for the day. Consider the analogy of a football team: The quarterback huddles with his teammates before every play. The team members have practiced the play and are prepared to execute it, but the opposing team creates some dynamics they need to plan for. Your day is similar: You and your team are prepared, but every patient poses a challenge to the routine plan. Predict and prepare for that challenge and you’re more apt to be efficient at managing it. Start huddles a few minutes before the clinic begins.

The huddle is your opportunity to anticipate problems—and solve them before they happen. Don’t let the day control you; predict problems and manage them proactively.

Let’s consider a couple of examples that are a daily occurrence in ObGyn offices, yet wreak havoc in practice efficiency:

The situation: Too few slots for acute needs

Several patients call at 8:15 AM with acute needs that must be handled today in the office. The scheduler has to guess where to direct them. You delivered Mrs. Smith’s baby at 2 AM this morning, yet she is still on your partner’s schedule for 9:30 AM today.

The game plan: The huddle reveals that Mrs. Smith won’t be presenting for her 40-week antepartum visit; 2 patients with acute needs can be scheduled during her now-open slot.

The situation: 3 patients with depression are scheduled for the same slot

Three patients, all in their 50s and all with a history of depression, were scheduled for annual well-woman visits at 10 AM. At 10:05, you’re looking for someone to blame for the scheduling mistake that will cost you—and the rest of your patients—dearly that day.

The game plan: Holding the huddle in advance of the clinic reveals that 3 patients were mistakenly scheduled at the same hour. Decisions are made about where and how to accommodate the patients elsewhere in the schedule. A decision is made to contact 1 or 2 of the patients immediately and ask them to reschedule.

6. Establish intake protocols

An efficient ObGyn knows that, when he or she walks into an exam room, the patient is ready to be seen. Intake protocols tend to vary with the style of practice, but it is wise to set minimum expectations for the following intake activities based on the patient’s chief complaint:

  • Documentation of chief complaint and symptoms
  • Position of patient; for example, seated or on the exam table
  • Dress of patient
  • Vital signs
  • Date of last menstrual period
  • Urine sample
  • Standing orders for laboratory or other tests
  • Current medications and refills needed
  • History

Train staff to anticipate needs

Teach your clinical assistant to anticipate needs for each patient. For example, if a 50-year-old is presenting for her well-woman exam, your assistant should anticipate completing the administrative portions of the mammogram requisition form in advance of the exam.

The power of a simple introduction

Although it might seem the intuitive thing to do, make sure your clinical assistant introduces herself to the patient, provides an overview of her role, and briefly describes the course of the encounter. Thus informed, the patient will be less anxious about the few minutes she may spend waiting for you after your clinical assistant leaves the room.

7. Ask the patient about other concerns—first

Your first step with a patient should be introducing yourself (if she is new) or greeting her warmly (if she is an established patient). A handshake often is appropriate, or a gentle touch of the shoulder.

You might also consider including a place in your charts to record personal notes about the patient, such as a hobby or pet. Exhibit care and concern for your patients, and they will be relaxed and ready to begin the encounter.

To start the exam efficiently, and avoid having the patient withhold important questions until the end of the visit, direct the conversation as follows: “Ms. Jones, I see that you’re here because of painful cramps. Is there anything else that you would like for us to address today?”

If the patient raises an issue that can’t be managed in the time allotted for the visit, tell her the issue is so important you’ll need to schedule another visit in order to address it adequately.

Using the patient’s chief complaint and any other issues that have been raised as a starting point, commence the exam. Make eye contact with the patient whenever possible and keep her informed about your actions during the physical exam.

8. Do the documentation immediately

When the exam is completed, document the encounter. Consider dictating in front of your patient. This strategy can be advantageous because the patient will hear your advice repeated and will be able to provide any clarification needed. You can also document that the note was “dictated in the presence of the patient” this notation is a good way to reduce medicolegal risk. Finally, completing the record before you move on to the next patient means you won’t end up spending extra time at the end of the day recalling that encounter along with all the others.

9. Multitask between patients

Ask your clinical assistant to bring you any outstanding messages and test results so you can review them between patients. Processing work on a real-time basis means less work will be waiting for you at the end of the day. It will save staff time from constantly sorting and re-prioritizing an ever-higher number of messages and tasks accumulating as the day wears on.

The problem with batching

If you batch work until the end of the day, your staff is forced to constantly reorganize the workflow throughout the day, as well as manage all incoming communication from patients. If patients could be counted on to call only once and patiently wait for your response, batching would be more palatable. But when their messages remain unaddressed until the end of the day, chances are that some number of anxious patients will call back.

Batching these communications also increases the odds that your staff’s return calls will be missed. If it seems that your staff is in the phone room most of the day instead of helping you in the clinic, batched communications may be the culprit.

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