A design that takes into account efficiencies of access for patients and physicians, shared services, and standardized exam rooms will not only result in better organization but also maximum productivity and increased patient satisfaction.
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AAOS Now

Published 5/1/2012
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Dale A. Reigle

Take Steps to Improve Practice Efficiency

Minimize your down time to help maximize your productivity

How efficient is your orthopaedic practice? Practice efficiency is a way to improve personal satisfaction, patient care, and financial success. An efficient, well-organized practice helps reduce your down time and allocates resources to help maximize your productivity.

Orthopaedic surgeons generally see more patients per clinic hour than other specialty providers. To maintain this volume without sacrificing patient satisfaction, aspects of the practice that are within its control must be managed efficiently. Approaches for improving efficiency generally fall into one or more of the following categories:

  • Facilities
  • Equipment
  • Information technology (IT) systems
  • Staff
  • Processes
  • Self

This article will deal with ways to improve practice efficiency in the first three areas. A subsequent article will cover staff, process, and personal efficiencies.

The practice facility
Because many orthopaedic patients have limited mobility, an efficient orthopaedic facility will minimize distances and avoid encumbrances to patient movement. When designing the space, for example, consider the distances between the reception area and the exam rooms, between the exam rooms and radiology, and between the exam rooms and the cast rooms. The longer it takes a patient to navigate from one area of the clinic to the other, the more likely it is that schedules for physicians and support staff will be disrupted.

Bathrooms for patient use should be located close to each exam pod. This becomes progressively more important as the distance from the reception area to the exam pod increases. Centralized, shared services like radiology should be close to each exam area. Hallways should be wide enough to easily accommodate the passing of two wheelchairs.

Each exam pod should be accessible directly from the reception area, so that patients and staff do not have to go through another pod. Salespeople, attorneys, delivery drivers, and other nonpatients should not have to routinely enter the clinical area. Similarly, access to ancillary services such as magnetic resonance imaging or physical therapy should be from the reception area or through a separate entrance. Congestion slows movement of patients and staff, and the accompanying noise or interruptions can be a distraction.

Exam pods (exam rooms, medical assistant station, physician station, and possibly cast room) should be designed to minimize walking distance for the physician and to allow visual control of the area by the medical assistant. Supplies stored outside the exam room should be readily accessible, not more than a few steps away.

Many practices use flags or lights to quickly inform the physician of pod flow (patients in radiology, where to go next, or location of the clinical team) to enable physicians to plan their next move. These can serve as communication tools because the medical assistant may be in a room with a patient or escorting a patient from the waiting area.

Except for special use rooms, exam rooms should be laid out in a standard manner. Supplies and furniture should be in the same spot in each room. Rooms should be sized so that exam tables can be placed to allow examination of the patient with minimal repositioning. Adequate counter space for items needed by the physician (or other provider)must be within easy reach.

From a financial standpoint, it may be tempting to “save” by moving items such as lamps from exam room to exam room as needed or to centralize items such as view-boxes or computer view-monitors for common use. But if doing so slows down the physician, inefficiency costs can quickly negate the savings.

The physician work station/dictation area and the medical assistant station should provide adequate work space and storage to neatly arrange everything that may be needed in the normal course of the day. Secure storage for certain items may be necessary.

Equipment
An efficient medical practice will have enough of the right equipment items (such as cast saws, computers, and lead aprons) to meet all of its routine needs. For high-cost items, a cost-benefit analysis may be needed and should take physician productivity into account.

One of the most cited bottlenecks in orthopaedic offices is radiology. Many factors contribute to this common problem, including not having the right type or number of machines. Digital radiography (DR) has significantly reduced processing time. Advanced picture archiving and communication systems (PACS) can further increase efficiency by pushing images back to the exam rooms; in many instances, the radiographs arrive before the patient.

Although a DR machine may significantly increase throughput (the number of images that can be taken in a given length of time), processing time is not the limiting factor in radiology efficiency. Positioning patients with restricted mobility due to injury, infirmity, or size will often take more time than processing the images. It may actually be more efficient to have two slightly slower machines than one very fast one. Having multiple machines also ensures the availability of a back-up in the event of a maintenance issue or mechanical failure.

Using tables that can be adjusted quickly and safely makes it easier to move patients. Overhead gantry tubes can generally be positioned more quickly and therefore improve efficiency. If the images require use of steps, positioning boards, or pads, these items should be available in each radiology room to improve efficiency.

Some patients who appear mobile may only be able to move at very slow speeds. Staff should be trained to politely suggest use of wheelchairs to transport such patients, and enough wheelchairs of appropriate sizes should be readily available for use.

Centralizing fax machines, copiers, and printers is usually a poor idea. It can result in delays, as staff members wait for a job to advance in the queue, and confusion when someone picks up the wrong items. Both efficiency and patient perception of service are diminished when employees have to leave their positions to make copies or retrieve print jobs. Congregating at the common use copier is the contemporary version of gossiping around the water cooler.

IT systems
The modern physician office has multiple IT systems, including a practice management system (PMS), electronic health record (EHR), PACS, telephone/messaging systems, and web server. When evaluating IT systems, give consideration to the “fit” among the physicians, the practice flow, and the practice needs. Relevant information is available from a variety of sources, including the AAOS Practice Management webpage (
www.aaos.org/pracman).

The Health Insurance and Portability Act (HIPAA) requires safeguards to secure sensitive personal health information stored in an electronic format. Physicians should insist on periodic reviews of IT security policies to ensure that reasonable measures are in place to protect information without hampering necessary access to that information.

The potential fines, as well as respect for patient privacy, require common sense precautions such as “locking” computers in exam rooms or shared workstations when they are not being used. Many IT policies require use of strong-encryption passwords (8 or more characters including both upper and lower case letters, at least one number and one letter, and a special character) that must be changed at frequent intervals. To avoid forgotten passwords or a lengthy log-on process, consider alternative security identification methods such as biometric scanners or proximity readers (ID cards).

A good PMS will facilitate timely submission of charges that are accurate and complete. Clearinghouse providers will communicate with your PMS to provide patient eligibility data prior to the appointment as well as transmitting billing between your PMS and payers. Automation of the eligibility verification process can save a considerable amount of staff time while providing much needed information.

Patient tracking systems may be integrated into PMS or EHR systems or obtained as stand-alone programs. Patient tracking allows you and your staff to monitor the location of patients (reception room, exam room, radiology) and can provide a database of information that can be used to identify bottlenecks in your patient flow.

For example, if radiology backs up every day at 1:15 p.m., you can begin analyzing possible causes. Are employees returning late from lunch? Are too many new patients scheduled for 1:00 p.m. appointments? Do you have insufficient equipment or staff? Tracking systems are often helpful for scrutinizing problems in physician scheduling templates by providing objective data that can be used to fine tune the schedules.

EHR systems vary widely in form and format. Some allow physicians to dictate with little change from traditional methods while others require significant keyboard interaction. When selecting an EHR, be sure to take into account practice members’ comfort level with automation as well as the patient experience. If you are using a template-driven system, you may want to consider the costs and benefits of having a scribe in the room to do the data-entry functions. (For a more complete discussion of EHRs, download the free AAOS EMR Primer: The next generation at www.aaos.org/pracman)

Dale A. Reigle is chief executive officer of Rocky Mountain Orthopaedic Associates, PC, in Grand Junction, Colo. He can be reached at dreigle@rmodocs.com