April 2010




A delicate balance

by Richard C. Haines, Jr.


The problem: The waiting room for the ophthalmology practice was constantly overflowing. The doctor wanted to expand his waiting room to handle the patients.

There is a delicate balance that runs through your office. The appointment book brings patients in at a predetermined rate, the front desk gets them registered based on staffing and your registration protocol, your work-up staff gets the patient ready, and then many, but not all, of the patients have to wait while they dilate. When everything is coordinated, the office “runs like a top.” But when things do not, “What happened?” “Who’s to blame?”

There are many parallels between an assembly line and the linear relationship of tasks done in an ophthalmologist’s office. A bottleneck at any one of these places can cause the entire system to back-up. How do you figure what is wrong and how can you correct it? The investigation: Time-motion studies on the doctor were conducted to understand the actual rate of patient output from the clinic. These studies showed that the doctor comfortably saw 14.0 patients per hour. Work flow studies were also conducted in the clinic on patient work-up and at the front desk for registration. The appointment book certainly starts the process. But in order to layout an appointment schedule, the practice has to know how fast the doctor will discharge patients from his service. To determine this, look at the doctor’s prior 10-20 sessions. Identify how many patients the doctor actually saw, and the precise time over which the doctor saw them. (In other words, what the doctor did, not what s/he planned or was scheduled to do.) If it turns out that the doctor sees patients at an average of eight patients per hour, then plan the appointment template for 9-10 patients (depending on your no-show rate) per hour.

It often takes upwards of 45 minutes from the time a patient is taken back into the clinic until that patient is ready to be seen by the doctor. If the doctor expects to start seeing patients at 8:30 a.m., then that patient needs to be checked-in and registered by 7:45 a.m. The patient’s appointment with the practice is not the same as the doctor’s appointment with the patient.

Next, look at your check-in staffing and protocols. If your check-in process requires 5 minutes with each patient, then one staff person is needed (5 minutes/patient x 8 patients per hour = 40 minutes per hour).

Patient work-up is a little more complicated. You need to know what percentage of your patients need extensive work-ups versus quick work-ups. If 60% of your patients are refracted (i.e. five of your eight every hour) and it takes 18 minutes to work-up and refract a patient, then 90 minutes per hour of staff time is needed to get those patients processed. Add to that another 20 minutes or so for the other three patients who are not being refracted, and you can easily see that you need about 120 minutes per hour of staff time—or two staff. (By the way, these staff are not scribing for you. If you want them to scribe also, then at least one more staff member is required.) To have fewer staff either bottlenecks the process on patient work-up, or some tasks shift to the doctor (which wastes his/her time).

The solution: There was no problem with patient registration or work-up. The staff was easily able to stay ahead of the doctor. The waiting room problem either was inadequate seating or the patients were arriving faster than the clinic end of the practice could absorb them. A quick calculation showed that the seating was sufficient to handle 14 patients per hour plus their family. So the appointment book was reviewed. The first hour 19 patients were brought in; the second hour 24 patients were brought in. After 2 hours, the clinic was one hour behind (in those 2 hours 43 patients were being brought in, but the doctor was only able to see 28)—and this happened every day. The reason the waiting room was overflowing was because patients were being brought in too quickly. Rather than add onto the building to increase waiting capacity, it was recommended that the appointment template be adjusted to reflect the actual hourly production capacity of the clinic.

It is hard to imagine that an automobile company would order engine blocks without some idea of the rate they would be needed on the assembly line and the rate cars would be discharged into transit lots. Yet, many practices do exactly this all the time. The doctors set up appointment templates based on what their colleagues’ templates are or what they wish to see. Staff is empowered to double and triple book. However, the doctor will work at the rate that s/he can comfortably sustain and reflects his style and training. They don’t see patients twice as fast because they are double booked.

Planning the timing of patients through the office is the delicate balance that runs through your practice. Each step in the process needs to have its capacity understood, so it can be synced with the tasks that occur before and after it.

Ultimately, to keep the office from choking on patient flow, you have to start with the physician and plan backwards. When done properly, the office will run smoothly, the staff will not feel like they are rushed to keep up, and the doctor will not feel under pressure because patients are “waiting too long.” And one of the best results, the patient will feel like they are getting timely care, that you are concerned about their time. It is a win-win situation for everyone.


Dick Haines is president of Atlanta-based Medical Design International (MDI), a recognized leader in the medical design and architectural field. With over 35 years of architectural and design experience, Mr. Haines is widely acknowledged by his colleagues as one of the industry's top medical space planners.

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