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What is Efficiency?

We have to start somewhere:

efficient:

adj. 1. producing or causing effects or results. 2. producing results, etc. with the least amount of money or work.

(The Pocket Webster for School & Office, Pocket Books, 1990)

What is the Desired Result of Being Efficient?

Before you can make your office efficient, you must know what results you want to produce.

Do you want:

• to join a lot of insurance plans?
• to have high turnover and low morale from your staff?
• to keep patients waiting, on hold or in the waiting room?
• to decrease the quality of your patient care?

More likely, you want "to provide high quality medical care to your patients at a reasonable cost." Perhaps you have quality-of- life goals for you and your staff. Perhaps you are simply interested in one or two small facets of your office that you wish to improve.

Whatever your office wants to do, however, you must consciously decide to achieve specific results.

What Efforts and Expenses go into Achieving These Results?

Obviously, every office hires staff to assist in achieving its goals. You must also pay for any number of improvements to your practice, be it new telephone systems, new software, more parking space, or extra exam rooms.

The effects of expenses are typically very easy to track and quantify. Do not forget, however, that the effort that goes into running an efficient practice is also substantial. Here is a brief list of the many efforts that go into running a Primary Care office:

• Logistical Details
  • Answering the phone
  • Scheduling providers' times
  • Scheduling staff
  • Scheduling appointments
• Medical Care
  • Giving phone triage advice
  • Screening patients
  • Seeing patients
  • Processing lab work
  • Following up on lab results/serious problems
  • Maintaining chart notes
  • Auditing charts
• Business Details
  • Negotiating with insurance companies
  • Handling ersonnel issues
  • Sending out bills
  • Monitoring cash flow
  • Monitoring Employees

General Guidelines for Minimizing Effort and Expense

These guidelines are covered in more detail in the previous Office Efficiency article.

1. Ask your employees to help.
2. Think ahead.
3. Implement only one change at a time.
4. Be patient.
5. Examine your office "from the ground up" at least once a year.
6. Develop a personnel policy.
7. Develop a financial policy and stick to it!
8. Use the telephone to your advantage.
9. Conduct peer reviews.
10. Add nurse practitioners to your practice.

Specific Areas to Ponder

• Develop a personnel policy.

  Having a well documented personnel policy will help you find and keep good employees. Too often, we see a constant turnover of low paid employees in medical offices around the country. Your local book store probably has ten different workbooks that will make developing a personnel policy a straightforward project.

• Consider paying your staff more.

  If you pay your entry level staff an extra $2 per hour, it might cost $3-$5,000 more per person, per year. Each employee, however, will be more interested in coming to work each morning, working hard, and doing the job right! If you pay too little, your low paid employees will often last six months if you're lucky. Numerous studies have shown that it could easily cost your practice $10,000 or more in time, effort, or advertising to find and train replacements.

• Develop a financial policy and stick to it.

  Some patients like to play games, and if they realize that they can pit the doctor against the office manager, they will never pay you for your services.

  Once you have written down your financial policy, you should review it once or twice a year and modify it when necessary. Also, you can hand it out to new employees as part of their training (killing several birds with one stone is always efficient).

  Should you run into problems with particular patients, do not undermine the efforts of your staff. In a smart practice, the physicians back up their office managers when dealing with an unruly patient.

• Take advantage of the telephone.

  Develop triage guidelines so that your nursing staff knows when a patient should and should not come into the office. This becomes even more crucial with capitated plans.

• Conduct peer reviews.

  Review your monthly statistical reports. For example, does one provider consistently order more lab work than the others? Is this lab work necessary? If not, you should find a way to change this provider's habit, as capitated plans rarely cover lab work on a fee-for-service basis.

  Review each others' chart notes. Are they complete and easy to read? If they are not, you should work to change that now, rather than waiting until an insurance company or Medicaid inspector finds the same problem and assesses a large fine against your practice.

• Add several nurse practitioners to your practice.

  With the proper organization, nurses can see many of the routine visits (be it for well care or common illnesses) allowing the office to see more patients.

Large versus Small Office Myths

Many people are quick to point out the differences between large and small offices. Conventional wisdom tells us, of course, that it is much easier to make major decisions in a small office than in a large office because fewer people have to approve of and work with the decision. However, our experience has shown that the most common problem in a large office, lack of communication, happens just as frequently in small offices. The politics in a small office can be just as hair-raising as large office politics.

Whether you work in a large office or a small office, you should take time to agree on a set of goals for your practice. These goals should be shared with everyone who works for you. Once you have these goals in place, it will be much easier for everyone to make the correct decisions.

Common Problems that are Easy to Avoid

• Each time the phone rings, how many people jump up to answer it?

  Many offices fail to assign the specific task of answering the phones. Having everyone in your offices ready to pick up the phone leads not only to distractions, but also inconsistent service to your patients.

  Assign one person to answer the phone, and only one person. This person should learn how to handle several calls at once. Some offices may need two people, but only in extreme circumstances.

  Keep in mind, however, that the person answering the phone should have no other greater responsibility. Asking someone to answer the phone as well has check patients out is usually a mistake.

  Select a phone nurse (or, if your office is busy enough, several phone nurses) to handle medical questions and triage. Train them to schedule appointments using sam.

  Investigate one of those slick phone systems that says, "Press 0 if this is an emergency, 1 for an appointment, 2 to speak with someone about your insurance coverage, etc." A number of our offices have reported substantial success with the organization a phone system provides. While some of your patients may complain, the majority of them will prefer the better organization of your office.

• Do you have too few phone lines?

  Have the phone company conduct a "busy study" for your office. This is typically a free service.

  Remember, patients covered by an HMO are being surveyed about how easy it is to get through to your office.

• Do your patients spend more than twenty seconds on hold?

  If they are, this is a sign of a disorganized or understaffed office. Find out why patients are spending so much time on hold. If it is because they have a lot of questions about their bills or insurance, then your computer system may not be configured properly for your office.

• How long does it take a patient to schedule an appointment?

  If one or more of your providers is booked more than two months in advance, then you should consider adding nurse practitioners to your practice.

  If your nurse must transfer a parent back to the receptionist to make an appointment, then you need to use sam, PCC's Advanced Scheduler Software. If you have sam, and this still happens, then you need to set aside some training time for your nurses.

  If it takes your nurse or receptionist more than a minute to schedule an appointment using Partner, then sam may not be configured properly for your office or your staff needs to learn more about how to use sam.

• Who provides medical advice over the phone?

  We know practices where doctors handle all of their own phone advice, and other offices where the billing staff provides medical advice to new patients. This is one of those questions where you have to work to find the correct answer for your office.

  However, once you find the answer, make sure that your staff sticks with it. Having medical advice, phone triage, or any other information from your practice come from whoever happens to be on the phone can lead to trouble!

• Do you have an office manager or an office worker?

  A doctor, trained in medicine, should practice medicine. A person trained in business (whether through a degreed program or the college of hard knocks) should be running the business side of your practice.

  Hiring someone to be your office manager, and then making her work twenty to forty hours a week as your front desk receptionist, is not an effective use of her time. However, having her monitor your receivables, review other people's work, and negotiate insurance contracts is. The lack of a true office manager, in both title and true responsibility, is one of the most detrimental, yet common, flaws we see.

• Doctors as Managers?

  Unless the doctor has specific experience managing employees and a business (and, no, a business degree does not mean one will be a good manager), it is probably not a good idea to have physicians manage your practice. During a staff meeting or partner meeting, it may sound like a good idea. However, caring for patients should always come first.

• Are you really saving money?

  Robert Burton coined the phrase "penny wise and pound foolish" back in the 16^th century and its wisdom has not diminished in the last 400 years. While we each prefer to get a "good deal," it is very important to consider the long term costs associated with any large purchase.

  For example, what good is a new car that costs only $4,000 if you have to spend $1,000 each month on mechanic's fees? After two years, you could have easily purchased a new $20,000 car and saved money and time in the process.

  The Burton adage ties in with all aspects of your practice, from paying employees to choosing your office software to purchasing photo copiers. Too often, practices only consider the short term costs of making an office change rather than considering the long term returns.

• When the doctor falls behind...

  One of the most common complaints about doctors is the amount of time a patient has to wait before being seen. HMO's are reducing their payments to providers who score low on patient satisfaction surveys.

  If a doctor falls behind over the course of the day, then you need to adjust the appointment lengths for that doctor and you have to stop "squeezing in patients."

  If there are more patients to see, then it is time to evaluate your practice's goals and the composition of providers. (This is a diplomatic way of saying "think about adding a nurse practitioner.")

• How long does it take to find a patient's chart?

  Many offices have asked PCC to modify their encounter forms so that it provides an "Out Guide" for each chart that is pulled. The Out Guide is placed in plastic slip cover which is then filed in place of the chart. The Out Guide tells you the date and time of the appointments, as well as which doctor the patients are going to see. Then, when a chart turns up missing, you have a good idea of whose desk to look on.

• Can you read the patient's chart?

  If you can't, consider using a Structured Charting method, like the one developed by Dr. Ken Katz for Partner (or you can design one yourself!). It will not only save you time and money, but your charts will be easier to read monitor, keeping your patients healthier and happier.

• How many letters does your staff type each day?

  If it is more than one, then you should look into setting up some additional form letters through your computer system.

• When calling PCC with a question...
  • Before calling, ask your System Administrator about the problem.
  • Review your PCC's online documentation to see if your questions are answered there.
  • If you are calling to have us reconfigure an insurance company, just fill out the insurance company work sheet for it and fax that to us. If you do not have an Insurance Company Worksheet, simply type "inscows" at your prompt and Partner will generate a new one.
  • Record both your question and your answer in a notebook that you or the members of your office can refer to later.

Summary

• You need to make your office as efficient as possible.
• Efficiency means achieving the desired result with a minimum of effort and cost.
• Do some soul searching at your office:
  • What are your desired results?
  • What efforts go into achieving these results?
  • Set time aside to think about better ways of doing things.
  • Be patient when implementing changes.