Create a more efficient environment, reward employees by delegating

Issue: June 1999

Twenty years ago, the average patient probably saw much more of his or her doctor during the course of an eye examination than today. Of course, that same patient also probably had to wait longer to make an appointment and spent more time in the waiting room after arriving.

Today, more and more practitioners are finding that technicians and other staff members can do more than just schedule appointments and make phone calls. In the era of managed care, doctors are making the most of their precious time by effectively training the staff to handle more tasks than ever before, such as visual field testing, applanation and air-puff tonometry, corneal topography, lensometry, keratometry and even refraction.

“Maybe it's time ODs realize that we don’t have to only be test givers, but instead be true health care practitioners and diagnosticians,” said Wayne W. Wood, OD, in private practice in Jacksonville, Fla. “We can analyze the data much as physicians do when they walk into the exam room and they already have the patient’s blood pressure, temperature and other vital signs. They look over the tests that have been run by ancillary personnel, listen to patients with a stethoscope, make the medical decision and leave the room. Optometry has historically been a very people-oriented profession, and I don’t think we need to lose that. In fact, I think it would give us more quality time to spend with our patients.”

Staff training: Hands-on experience

“New staff members begin their training informally. First, they shadow the doctor, to observe the interaction between the doctor and the patient and to become familiar with various tests and procedures,” said Ronald Snyder, OD, director of professional relations at Millennium Laser Eye Centers in Sunrise, Fla. “The technician should watch the doctor, for example, perform visual acuity on two or three separate occasions. Next the technician performs the test while the doctor observes his or her technique. Time should be set aside at the end of the day to do more formal training.”

Dr. Wood said that monthly meetings in his office serve as continuing training for the staff members even after their formal on-site training has been completed. The meetings, which are conducted behind closed doors usually before office hours, are made up of four parts: A group discussion/brainstorming session; dialogue about the practice’s financial success; technical education and staff presentations; and an award for employee of the month as well as a chance for staff members to acknowledge each other’s talents and any special assistance they may have received. The final part is the most important, he said.

“Not only does it build camaraderie in the staff members showing gratitude toward each other, but it helps them practice being gracious,” he said. “We want them to have that same attitude with our patients — to thank them for coming to see us, to be grateful that they’re here and to compliment them on their appearance, whether it be their glasses or contacts or just what they happen to be wearing that day. That’s the important part of building maturity and patient-pleasing attitudes that make our practice successful.”

Formal education

Dr. Wood said that while there are many well-thought-of optometric assistant schools, they are few and far between to supply an adequate number of trained assistants. Anthony A. Cavallerano, OD, of the New England College of Optometry, said that self-study courses also reinforce what is being learned in the office through hands-on experience. “We train on site by doing inservices, and then we do home-study programs when applicable and appropriate. Also, we send the technicians to the Vision Expo meetings, for example, or to the New England Council of Optometrists meetings, which often offer courses for technicians.”

Ample training before taking on additional tasks is important for the technician to be prepared and confident, Dr. Wood said. “Instead of learning under fire, they’re learning in a systematic and pre-planned fashion,” he said. “Generally, this involves having them spend at least a portion of the day with every other staff member, learning that person’s job. This is important for cross-training and also for making them sympathetic to the needs and demands of other staff members.”

Satisfy patients who want only the doctor

Occasionally, a patient may refuse to accept the technician’s help, insisting on only seeing the practitioner personally. While this problem is uncommon, Dr. Snyder said that this more stubborn patient presents the staff member with two choices. “One is to back off and say that the doctor will be with him or her shortly,” he said. “Or, the staff member can inform the patient that the doctor asked him or her to obtain the necessary information in order to facilitate the visit — to save both the doctor and the patient a lot of time.”

Another way to avert such a predicament in the first place is to have an extern from a college of optometry present to greet the patient in the exam room. By introducing himself or herself as a doctor whom the practitioner has asked to conduct some tests prior to the actual exam, he said, the patient feels more comfortable. “Now those few ‘preliminary’ tests means that you do as much as you can until the doctor can get in the exam room,” Dr. Snyder said. “Sometimes, another technique that works is for the doctor to walk in with the technician, greet the patient and say that the staff member will be running a few tests beforehand. That breaks the ice as well.”

Dr. Cavallerano said that the dentist’s office should serve as a model for optometry to look to in the staff delegation arena. “Dentists did a wonderful job of transferring that responsibility to the dental assistant, and I have very rarely heard patients complain about that,” he noted. “I think it's all in how it's presented. If you’re defensive and apologetic, then patients are going to think you’re cutting corners. But if you present it in a positive way, you can be more comprehensive and do a better job by delegating.”

Should technicians refract?

While optometry may be hesitant to let go of “the big R,” Dr. Cavallerano said, refraction is a time-consuming procedure that can be easily delegated to a technician “I think of it as data gathering, just like any other procedure,” he said. “It can be the longest part of the exam for the optometrist, and he or she can’t afford that time. In the era of managed care, I think we need to be more willing to delegate and less reticent about it.”

Dr. Wood said that while the concept is not widely accepted, it seems to be the way of the future with ophthalmology serving as the model. “My view is that it's probably going to happen, and assistants will be refracting as long as optometrists are involved in the final refinement, whether it be just by coming in and intuitively knowing that the results are correct or by going back and checking the final diopter cylinder and adjusting the axis a bit after the refractionist has done the bulk of the work,” he said.

In fact, that’s how Dr. Snyder said refraction is handled at the laser center. “The practitioner can come in and re-check it in a matter of minutes,” he said. “Some of my technicians can refract just as well as I can, although I hate to admit it.”

Efficiency through staff delegation

Delegating various tasks to staff members frees up the doctor’s time and makes better use of the patient’s time as well, Dr. Cavallerano said. “Patients are seen sooner, you tend to run behind schedule less and, even if the doctor is tied up with emergencies or if unforeseen circumstances arise, at least the technician gets the patient in and begins the work-up schedules,” he said. “That way, the patient is not sitting in the exam room or waiting area doing nothing. People are too busy for that.”

Dr. Snyder said that while the “old” way may generate a more individualized type of practice, many doctors today are under constraints that prevent them from pursuing this method. “If you want to have a very personalized practice, you can work without a technician and do every test yourself and have a very nice rapport with these patients,” he said. “I think that’s a dying breed in this day and age because of managed care, and we're under pressure to see a lot more patients.”

The patient will likely appreciate the comprehensive exam created by the group effort, Dr. Wood said. “Even though they may be used to having doctors do all the tests, they seem to appreciate the battery of tests that we do,” he said. “It's common to hear patients say that they've never had an examination so thorough. I'm spending a miniscule amount of time with them compared to what I might have spent with them 20 years ago when I ran every test.”

Because technicians carry so much more responsibility than in the past, this often serves to propagate a feeling of true job satisfaction, Dr. Cavallerano contended. “In my experience, technicians or employees feel much more appreciated,” he said. “They feel there’s more job enrichment and more job rewards, both real and indirect. I think it also reduces turnover. Without a doubt, it is very rewarding for an employee to assume these tasks.”

He said that implementing these and exploring other avenues in task delegation, such as instructions for installation and dosage of medications and providing the patient with education about a newly diagnosed condition, will soon be the anchor for a successful practice. “I think it's going to become a matter of survival for optometrists to do this,” he said.

For Your Information:

Wayne W. Wood, OD, may be reached at 1500 Riverside Ave., Jacksonville, FL 32204; (904) 356-7102 (7101); fax: (904) 356-7947; e-mail: wwwood@mediaone.net.

Ronald Snyder, OD, may be reached at Millennium Laser Eye Centers, 8201 Peters Road, Ste. 1000, Sunrise, FL 33324; (954) 915-9964; fax: (954) 915-9967.

Anthony A. Cavallerano, OD, may be reached at the New England College of Optometry, 424 Beacon St., Boston, MA 02115; (617) 236-6320; fax: (617) 424-9202; e-mail: tonycav@earthlink.net.