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An hour's-worth of work
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Creating an efficient practice stems from a properly sized waiting room.
A recent blog at the New York Times raised the question of whether a patient could punish a physician for running late. A physician newsletter I just received addressed ways to help a physician better control his/her schedule and stay on time. In my view, neither of these opinion pieces addressed the “root” problem.
So, let me start addressing this issue from another perspective. How many seats should be in your waiting room? In our practice, we size a waiting room as follows:
- Take the doctor’s hourly rate of seeing patients and add 1.5 family members (two in pediatric practices) for each patient.
- From this number, deduct the number of exam rooms that the doctor uses — after all, they should be full with at least the patient. So, four doctors each seeing six patients per hour means 24 patients will hit the front door every hour, accompanied by 36 family members.
- If each doctor has four refraction lanes, then 24 + 36 – 16 = 44 seats needed in the waiting room.
You can also make a partial deduction for dilating patients. (There is another calculation for this, but it doesn’t impact this argument.) This formula has proven itself over the years.
For this formula to work, however, several things have to happen:
- The doctor has to see patients at a pretty consistent rate. In spite of doctor opinion and the hectic unpredictable aspects of seeing patients, the pace of medical practice is more predictable than many professions.
- The doctor has to show up on time – to start unloading the waiting room and making room for the next patient who has yet to show up.
- The appointment book has to be in sync with the doctor’s production.
The doctor’s rate of production (ie, his/her patient-per-hour rate) defines the pace at which patients will be discharged from his/her service while he/she is seeing patients. The appointment book defines the rate at which patients are brought into the practice. Since the appointment book is often filled in weeks in advance, for the doctor to have a sane practice day, his/her production needs to be as predictable as possible so the appointment book can be more right than wrong most often.
For the doctor to have a predictable practice, there are several things the doctor needs to have:
- The mix of patients needs to be as consistent as possible. This may mean two new patients and four return/follow-up patients every hour, or some other variation.
- The doctor’s patient management team needs to be consistent. If the doctor needs two refractionists and one scribe to handle his/her normal flow, then he/she needs to have that complement each time he/she shows up to see patients. (Preferably the doctor is supported by the same team each time.) Fewer staff can mean that the patient flow bottleneck shifts to the work-up staff. The patient-flow bottleneck should stay with the doctor.
- The doctor needs the same complement of rooms every day to see patients. It does no good to have four refraction lanes 2 days a week and three on another day because an extra doctor is in clinic that day. Your output will vary and become unpredictable.
Once you have a predictable rate of seeing patients (and Medical Design International has studied this for years and realizes that doctors are quite consistent within themselves, but often different from their colleagues), then you can start to gain control over your schedule. Even if your office has Open Access scheduling, you can still see patients only at the rate at which you are comfortable. It is absolutely imperative that you know this rate. We refer to it as the “pulse of your practice.” This is why double-booking does not work. Doctors do not work twice as fast just because a staff member wrote another patient’s name down. This is indicative of an appointment book that is out of control.
Given that, you now have the basic tool to start configuring your appointment schedule and your practice day. If you see six patients per hour, maybe your appointment book should be set up to bring in seven patients per hour (influenced by your no-show/cancellation rate). But you should not bring in 12 patients per hour. We once had an ophthalmologist client whose waiting room was constantly overflowing, and he wanted to expand it. After researching his situation, it was apparent that he was seeing patients at a 14-patient-per-hour rate (he was a cataract-only surgeon) and his appointment book was bringing patients in at the rate of 21.5 patients per hour. After 2 hours he was 1 hour “behind.” So rather than add on to his building, we recommended he change his appointment schedule. Problem solved!
There are other hiccups that can put you behind, as well. For instance, you can understaff the check-in desk and patients can bottleneck there. But fundamental to the flow through your practice is your personal “patient-per-hour” rate. You have to know it so you can have the proper number of seats in your waiting room and the right number of patient parking spaces, and you can keep the appointment book from running ahead of your ability to see patients. Then you won’t be running late, your waiting room won’t be too large and your practice will be in balance. You won’t have to be punished for running late. Your work day will be much more pleasurable and no less productive.
Richard C. Haines Jr., can be reached at Medical Design International, 2526 Mount Vernon Road, Suite B-405, Atlanta, GA 30338; 770-409-8123; fax: 770-409-8662; e-mail: haines@mdiatlanta.com.