"The issue for spine surgeons in the clinic is that we want to see as many patients with true spinal pathology as possible so that we can offer surgical intervention only to those who have the best chance of having a good or excellent outcome," says A. Jay Khanna, MD an Associate Professor of Orthopaedic Surgery and Biomedical Engineering who specializes in spine surgery at Johns Hopkins Medicine and is based in the Washington D.C. region. "My goal is to have an efficient flow of patients in the office so that I have the time to evaluate them, review their imaging studies and discuss their treatment options without falling behind. On some days, I may have 30 patients scheduled and very few of them need surgery or have complex problems, so I'm on or ahead of schedule and the patients are very happy. On other days, I may see several patients who need surgery, have a complex history or have a post-operative complication and thus require 20 to 30 minute discussions. On such days, I can fall an hour behind and the patients can become frustrated and upset."
Here are Dr. Khanna's tips for staying on schedule and running an efficient spine practice.
1. Monitor the schedule and clinic template. When you book patients from 8 a.m. to 5 p.m., keep a close eye on the type of patients scheduled. Depending on whether they are new, follow-up or post-operative patients, the sequence in which you see the patients will make a difference.
"Constantly update and optimize the clinic template," says Dr. Khanna. "Look at it both formally and informally with your office manager, your medical office administrator, medical assistants and your physician assistant or other midlevel providers. Always take input and advice from others who are involved in patient care or flow on improving your template. This will not only improve patient flow and satisfaction but will likely also improve the engagement and satisfaction of those who work with you."
2. Block interruptions during clinic sessions. It's tempting to check email or make quick phone calls in between patients during office hours, but these distractions can quickly put your schedule behind. "Try to avoid meetings in the middle of the day, conference calls and anything else that would slow the day down and break it up," says Dr. Khanna. "Along those same lines, avoid multitasking during clinic. This is likely the mistake I am most guilty of."
3. Confirm patients have necessary studies and reports. Patients should arrive at their appointment with the necessary imaging studies, consultant reports and laboratory studies to move forward with their treatment. Although it is labor intensive, staff members can call patients ahead of time to make sure those studies are available. When patients are missing these items, it's difficult to obtain them during clinic time and can cost clinic staff 10 to 20 minutes per patient to obtain various approvals and have the information sent.
"Additionally, if the patient doesn't have an imaging study, you might have to send the patient out to another facility and then see the patient back in follow-up," says Dr. Khanna. "This costs the patient, physician and healthcare system resources and leads to an extra office visit. These situations also create patient and physician dissatisfaction."
For clinics with the ability to obtain in-office radiographs, the problem may not be as significant but can still lead to duplicate studies and lost time. "Unless your office is equipped with a highly-efficient in-office radiology suite, they should come back for a separate visit," says Dr. Khanna. "The additional time required to flow a patient through an inefficient radiology suite may cost you the ability to see a few additional patients or lead to delays and dissatisfaction of your other patients."
4. Automate as much as possible. Incorporate automation technology into your practice wherever possible to streamline administrative tasks such as outflow of consultation notes and operating room postings. "Develop a system so that letters to referring physicians, notes and other operational tasks are automated as best as possible," says Dr. Khanna. "This will leave the clinic staff with more time to interact with patients which will likely improve their job satisfaction and help with clinic flow and patient satisfaction."
5. Obtain EMR for your practice. Electronic medical records are a hefty investment, but they create efficiencies in your practice once fully implemented. EMR allows you to construct clinic templates, decrease dictation time and eliminate the need to take paper charts home to finish after hours.
"The EMR can improve workflow of information to referring physicians and other providers involved in the care of the patient," says Dr. Khanna. "Although the resultant office note can end up being less personalized and focused than a traditional dictated office note, there are many benefits of an EMR system such as improved communication with other providers, more rigid and reliable compliance with billing and meaningful use criteria and the ability to engage other members of the healthcare team such as medical assistants, physician assistants, residents and fellows in the overall care of the patient."
6. Delegate non-clinical tasks. Seek help with administrative and other non-clinical tasks from staff members whenever possible. "Getting help from your staff with non-clinical tasks will allow you to focus more on patient care including a more thorough discussion clinical and imaging findings and the ensuing clinical decision making and discussion of treatment options," says Dr. Khanna. "Physicians also end up having more time to interact with referring physicians and other professional responsibilities."
7. Avoid a formal lunch break. Office sessions have a ramp-up and ramp-down period as patients arrive for their appointments, fill out paperwork and get into a room so that they can be seen by a physician. Taking a formal lunch break adds another ramp-up and ramp-down period every day. A 30 minute formal lunch break can cost a physician an extra hour-and-a-half of clinic time.
"Avoidance of the formal lunch break allows the provider to eliminate two additional ramp-up and ramp-down sessions," says Dr. Khanna. "Instead, order lunch for yourself, your PA, residents and/or fellows and occasionally your office staff to thank them for helping you see patients and keep things moving. Of course, have your office staff take their formal lunch breaks since they can cross-cover each other during these breaks and keep the office running smoothly."
8. Staff the clinic appropriately. Make sure your clinic has enough full-time equivalent staff to manage everything efficiently. There are guidelines available to benchmark the typical number of FTEs for different types of practices.
"Keep in mind, however, that those ratios are highly dependent on the efficiency of a given office and if that office is inefficient because of a technical or operational reasons, the benchmark ratios may have to be exceeded to allow for appropriate workflow," says Dr. Khanna.
9. Train staff appropriately. Provide staff members with the right training and keep their training updated regularly. A new employee should shadow experienced employees to understand workflow at the clinic before accepting full responsibility for their new position.
"Continue to invest in your staff by providing informal and on-the-job training as well as more formal training," says Dr. Khanna. "This training can be provided by your practice management group, hospital, larger healthcare institution or other professional organizations."
10. Communicate patient complaints. Talk with staff members about feedback from patients and work together on initiatives to make the clinic more efficient and patient-centered. Provide specific and constructive tips to improve office efficiency.
"Be willing to take staff suggestions and recognize the fact that they likely have greater knowledge of the office workflow than you do since they spend time with patients at more points in their flow through the office," says Dr. Khanna. "This communication can occur at staff meetings, by email or in casual conversation. It often helps to provide specific examples as they occur while being careful not to offend other staff members or take offense personally if the fault is yours."
11. Diagram office workflow. Formalize the typical patient flow through the office and provide a visual diagram for staff members. "Document and diagram office workflows so everyone who is involved in patient care can visualize how the various pieces of the puzzle will fit together," says Dr. Khanna. Inefficiencies and redundancies can also be identified more easily with such a tool in some cases.
12. Update patients in the waiting area. It's best if patients have only a short wait before seeing the surgeon, but if a longer wait becomes necessary, keep patients informed about your progress. "Be in constant communication with patients when you are running late," says Dr. Khanna. "Let them know that you are running behind and why this is the case. Additional options include calling afternoon patients to inform them and give them the option to reschedule."
13. Monitor your progress. "To run an efficient office in a specialty such as spine surgery where there is a broad range of patient-types from a simple post-operative follow-up to a lengthy pre-operative discussion about a major spine surgery is no easy task," says Dr. Khanna. Although it helps to follow the above suggestions, each office, surgeon and staff is different and each will require a different formula for success or at least avoidance of failure.
"I believe it is very important to survey patients using objective measures in real time and both formally and informally," says Dr. Khanna. " This information should be used to constantly tweak the 'formula' and see what can be done to improve patient satisfaction, your reputation and, thus, the flow of patients to your practice so that you can continue to do what you enjoy."
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