Redesigned work flow can save time, improve your bottom line

OB/GYN News, May 15, 2006 by Christina Chase

PHILADELPHIA -- Office-based physicians who maximize efficiency can see more patients per day without any loss of quality--in fact, smoother work flow can actually boost patient satisfaction, Dr. Mary S. Applegate said at the annual meeting of the American College of Physicians.

Improved efficiency can have "huge financial implications." By saving 2 minutes per patient, physicians can see two more patients daily. At $50 per patient, this amounts to $10,000 more per year. Alternatively, doctors can choose to work a shorter day, going home about 45 minutes earlier instead of seeing those two extra patients, added Dr. Applegate, a family physician in a small group practice in rural Ohio.

One pressing reason to improve efficiency is the anticipated effect of pay for performance and other mandated initiatives. Physicians already have too much to do, and they need to find ways to protect their sanity if their workload actually escalates, she said. "In the end, we all don't want to become psych patients!"

In the past year, Dr. Applegate and her colleagues--two other physicians and two nurse-practitioners--looked critically at work flow and practice design to identify these strategies for enhancing time management:

* Delegate all "nondoctoring" tasks. Physicians should not spend their time on simple activities such as taking blood pressure, administering vaccinations, handling prescription refills, and filling out forms. Midlevel providers--nurse practitioners and physician assistants--can do a lot of these tasks. Designate a "queen of forms," typically a nurse, who can fill in codes and dates; the physician may only need to sign. Save your time for diagnostic dilemmas and treatment failures, she suggested.

* Give staff clear instructions on handling common situations. Flowcharts work well and can empower paraprofessionals to manage various problems and tasks without consulting physicians.

* Cross-train your staff. Avoid situations where only one person knows how to do a certain task; when that person is out, work flow is disrupted. Staff members may be happier with more variety once they are comfortable with the new responsibilities, but "the transition sometimes can be difficult," Dr. Apple-gate noted. To ease the transition, offer incentives to staff members willing to learn new things.

* Avoid routine phone calls. Although you may need to return calls to other physicians personally, a staff member can call patients back on routine matters. If bad news needs to be communicated to a patient, this should be done in person.

* Organize work space logically. Look at how the exam rooms, equipment, and inner offices are arranged and consider whether simple changes could streamline tasks that physicians and staff perform repeatedly. Simply moving a patient scale, or buying an extra one, might save snippets of time that can really add up. All exam rooms should be stocked with the same supplies and should be set up identically if possible.

* Listen to your patients. The patient interview will actually go faster if you do not interrupt. Patients talk for only about 60 seconds if they are not interrupted, she said. The patient feels heard, and clearer communications can lead to greater patient satisfaction. Make eye contact, sit down with the patient, and briefly touch the patient reassuringly or shake hands.

* Avoid batching of unpleasant or difficult tasks. Putting off work until later in the day when you're probably tired--and have forgotten some details about a patient encounter--can become "an unhealthy addiction," Dr. Applegate said. One task that physicians often batch is writing notes in patient charts. The inefficiencies can add up when errors are made and patients are dissatisfied with their care down the line.

* Work in real time and get the job done. This is the opposite of batching: Stay focused and complete the entire patient encounter before that patient leaves. It is fine to look up information and even dictate in the exam room with the patient present. When some tasks unavoidably accumulate, set a rule that you will stop at regular intervals (for example, every two to four patients) to catch up before taking the next patient.

* Be a team player. Huddle with your staff for a few minutes every morning and afternoon to set a game plan and take control of the day before it controls you. This can help prevent glitches that would eat up valuable time. "Empower the staff to help you stay on time," Dr. Applegate said.

* Take care of yourself. Balance work demands against personal time to avoid burnout. Physicians who neglect their needs for downtime and recreation are less productive and efficient. In extreme cases, this can lead to financial losses and even bankruptcy, she said.

* Embrace new technology. Use the available tools for billing, coding, and communications. Electronic medical records are not perfect and the transition can be painful--"It's like 3 months of pure hell"--but they are becoming a necessity. The need to log lab results for pay for performance is "the single best argument for an EMR," she added.