Evaluate daily operations on the clinic floor

Issue: November/December 2011

ByJohn B. Pinto

John Pinto

From time to time, managers and practice owners should observe what kind of service the team members are delivering and how efficient they are.

You have a service business. To effectively manage that service, you have to, in turn, manage the process. And managing the process cannot just be done in the boardroom, even if the biggest decisions do finally end up there. Managing the process starts by looking at all of the moving parts — in action — right on the clinic floor.

In eye care, the “product” we assemble and sell is the preservation, optimization and restoration of eyesight. To be a great manager or practice owner, you have to get out onto the production floor from time to time and observe the “assembly line.”

But after thousands upon thousands of days spent visiting client offices around the country, I can report that only a minority of managers and practice owners take the time to observe, up close, the process by which their service is constructed and delivered.

If you are a managing partner or administrator — no matter the size of your practice — you should be spending 1 or 2 hours each month as an observer on the clinic floor. This does not have to be all in one session. It usually takes observing only two or three patient visits in a row with any given provider to see what kind of service the team is delivering and how efficiently it is doing so.

What you will learn will help you improve patient flow and satisfaction, save costs and boost revenue. And to help, here is a clinical observation checklist you can use as a reminder of some of the most commonly overlooked elements of process and service delivery in eye care. Use this as a gentle nudge to get out on the clinic floor a little more often, even if you are more comfortable with a keyboard and a spreadsheet.

Tidiness and ambiance

Housekeeping should be diligent and pass the white glove test. Scuff marks should be cleaned up, windows washed and carpet stains removed.
Chairs, desks and other furnishings should be in good repair.
Make sure mirrors are cleaned and projectors cleaned and focused to generate a crisp image.
Loose wires should be coiled and bound for appearance and safety.
Have “a place for everything, and everything in its place” (eye drop stands, hooks for equipment, a fixed location for samples, etc.).
Exam room doors should be left open while patients are waiting to be seen. This helps patients know that you have not forgotten them, makes the waiting time seem shorter and lets you notice if they are having a medical crisis of any kind.
All staff and doctors should wear name tags and be appropriately, uniformly and neatly attired.
Use music, soft lighting, refreshments, great reading material and staff charm to camouflage the inevitable waiting time, which is every patient’s chief beef about doctor’s visits.

Patient flow and throughput

Does the doctor delegate avidly: instilling drops, refracting, dilating, scribing, taking pressures, etc.?
Does a scribe enter the room at the same time as (or only shortly after) the provider? Or does the doctor have to inefficiently go back and forth between the examination and charting?
Does the doctor stay on the floor throughout the clinic session (or at least return briskly when the next patient is ready)?
Is there always a clear visual signal of the next room for the doctor to go to, or does the doctor have to find a tech and be directed to the next patient?
Are technicians adequately selected and trained to optimally support the provider? Are they cross-trained so they can step onto any clinic floor in the practice and help any doctor?
Is the clinic floor actively managed by a lead tech, who, like a stage manager, helps to control traffic flow and assures that everyone is making a full contribution?

Orientation, communication and patient relations

Does the doctor review the chart before entering the room and dive right into the exam, or do several awkward moments pass while the doctor orients to the next patient?
Is there ample washing or sanitizing of hands and equipment in front of patients?
Is doctor-patient communication clear with appropriate word choice, age-appropriateness, minimal “medicalese” and no talking down to infirm or elderly patients, etc.?
Is the team letting the patient know what is happening next in the exam flow?
Do doctors maintain good eye contact with patients when speaking to them and when listening?
Does the doctor use warm, affirming language? For example, “You have done an excellent job with your eye drops these past 3 months. I am very pleased that your pressure is now under control. You are doing great!”
Are written, audio or video education materials provided?
Does the doctor address — and ideally, resolve — the patient’s chief complaint before the patient leaves the office?
Is the patient clear about his or her instructions and return appointment?

Ergonomics and posture

Be conscious of your posture. Videotape or bring in a physical therapist to observe you. A significant number of eye surgeons are disabled by cervical and back disorders. Get help early, especially if you are a higher-volume provider or have an adverse family history.
Use sandbags or cushions to prop up your elbows instead of supporting your leaning torso with your lower back alone.
Female doctors and staff: Straddle patients rather than sitting “side saddle” during the slit lamp exam. This is no time to be ladylike if you want to avoid back problems in future years.
Affix foot pedals to the floor so you do not have to hunt for them in the dark.

Miscellaneous efficiency and patient relations pearls

Do not repeat tests or questions that have already been performed or posed by support staff.
Avoid excess socializing. One minute out of a 6- to 8-minute exam is fine. Five minutes out of a 12-minute exam is no longer economically feasible in today’s private practice environment.
Start the clinic session with short exams. This sets a faster early tempo and makes patients who only need brief doctor time wait the shortest amount of time.
Make sure every room has every needed resource (eg, do not hunt around for forceps).
The doctor should arrive at least 5 minutes before the first patient appointment, have a brisk stand-up meeting with his or her techs, and help the crew room the first patients of the day.
Techs should work up, refract and dilate, allowing the doctor to “single-pass” most patients (ie, see them only once).

John B. Pinto is president of J. Pinto & Associates Inc., an ophthalmic practice management consulting firm established in 1979. He can be reached at 619-223-2233 or pintoinc@aol.com.