Managing Patient Flow

Tactics run the gamut from beefing up staff members' duties and cross-training to adding personnel and space

Managing Patient Flow

Tactics run the gamut from beefing up staff members' duties and cross-training to adding personnel and space.

The new paradigm in retina dictates that patients with exudative macular degeneration return to the retina specialist for evaluation, including imaging and possibly treatment, once a month. The result, a significant increase in the number of overall visits per patient, is a paradigm shift in the true sense. Some people have referred to this as a treatment burden, but David M. Brown, MD, Retina Consultants of Houston, begs to differ.

"We now have a treatment for macular degeneration that saves vision, and saving vision is why we became retina specialists," he says. "It does mean that we have to adjust our office routines, practice management and staffing to accommodate this breakthrough therapy."

Over the years, often through trial-and-error, most practices have developed tactics to manage the increased volume, which some estimate at 30% or more. We spoke with several physicians and their managers to uncover their best practices.


Patients with exudative age-related macular degeneration, who might have seen a retina specialist once or twice a year 10 years ago, are now in the practice 12 times a year, or even 24 times a year if they have bilateral disease, for anti-VEGF therapy, Dr. Brown says. "At least 30% of my patients need injections almost every month. So this therapy is exponentially increasing the number of patients who come through our office. That is what makes staff efficiency and management issues so pertinent."

Office efficiency depends on streamlined, consistent processes, and to that end, physicians must determine where bottlenecks in patient flow are occurring. "It used to be I was always the rate-limiting factor," Dr. Brown says. "In other words, the time I spent with patients was usually the reason we were stacked up in the clinic."

Nowadays, the rate-limiting factor can vary. Patient flow is often stalled at the OCT machine but can also become an issue in the workup area or where injections are being prepared.

"For practices still using paper charts, finding the bottleneck is easy," Dr. Brown says. "Just look for the biggest stack of charts. That is where you should focus your efforts on improving workflow."

Once you determine the rate-limiting factor — in Dr. Brown's practice, the bottleneck was at the OCT machine — your goal should be to eliminate all activities that are not associated with the primary task, in this case, taking OCT scans. "If the OCT technician is going to the waiting room, picking up the chart, finding Mrs. Jones, helping her with her walker all the way to the OCT room, settling her in the chair, taking the image and then helping her back to the waiting room, about 70% or more of that time is spent doing things the technician should not have to do. If someone else can escort Mrs. Jones to the OCT area, the OCT technician can do 20% to 40% more images per hour."

All of the technicians at Retina Consultants of Houston are now attuned to what is happening in the OCT area. When the technician is ready, he moves patients from the waiting room to what they call the "on-deck circle" and from the on-deck circle to the OCT machine. According to Dr. Brown, that change has greatly decreased the time the OCT technician needs to perform testing on each patient.


If the term "military precision" comes to mind, you are not far off the mark. "Most of this work on how to improve workflow came out of military efficiency studies," Dr. Brown says. "They figured out that generals should do only what generals are supposed to do. The same holds true for retina specialists. Instead of trying to direct every aspect of what happens in my office, I am the person receiving direction. In other words, when I walk out of a room, I ask where I should go next. Someone else makes those decisions for me, because my time should be spent face-to-face, examining and talking to patients, so they get the most from the time they have with me."

At Retina Consultants of Houston, a bottleneck at the OCT machine was alleviated through a change in workflow using current personnel. (For more on the importance of teamwork, see "Systems, Training and Teamwork" of this supplement issue.) Some practices, however, have found it necessary to increase staff to improve efficiency.


At Vitreous-Retina-Macula Consultants of New York, a plan to build a new office came to fruition at just the right time, but adding space was just the beginning of the practice's new approach to managing patient flow.

"About 6-1/2 years ago, we were planning our new office," Dr. Slakter says. "We saw the potential for increased volume with the new AMD therapies, so we planned a dedicated treatment area, which includes multiple rooms for intraocular injections.

"This has allowed us to treat on demand or as the need arises. We were extremely lucky with the timing and managed to avoid what would have been, for us, a practice disaster if we'd had to manage this increased volume in our old office."

Even with a new, larger space designed to optimize patient flow, Dr. Slakter's group found patients still needed help navigating from reception to imaging to examination to treatment and checkout. Their response to this need was to create a new position: patient service liaison, a.k.a. "floater."

"Floaters are individuals whose main purpose is to get patients from here to there and to ensure that things are done properly," Dr. Slakter says. For example, when a patient arrives at the office, he is checked in and a technician escorts him from the front waiting area to a back waiting area, where the vision workup is completed, and he waits for the physician or for imaging studies. At that point, the chart goes into the doctor's bin, and the patient service liaison assigned to that doctor takes over.

The patient service liaison makes sure examination rooms have patients in them and that each patient's needs are met during the visit. They bring in the chart, escort the patient into a room, clean the equipment, and make sure the patient's most recent images are on the computer monitor.

If a patient needs a glass of water or asks for his family member to be brought into the room, the patient service liaison takes care of those needs. After the doctor's examination, the patient service liaison escorts the patient to the imaging suite or the treatment area. "This system has radically increased my efficiency," Dr. Slakter says. "Adding patient service liaisons to our staff was a major step forward. It's the single best thing we have done."

Hiring a Patient Service Liaison
According to Hildy Abel, general manager at Vitreous-Retina-Macula Consultants of New York, key qualities for a patient service liaison include:
Outgoing personality
Eager to learn
Ms. Abel adds that this fast-paced job requires a person to be on his or her feet most of the day, covering the 15,000-square-foot office quickly, so physical stamina is also a must. "The patient service liaison doesn't have to have experience in ophthalmology or even medicine," she says, "But they must possess a willingness to learn and to help the doctors and their patients." Or as Dr. Slakter says, they have to be nice people.
"Our patient service liaisons answer to only two people," Dr. Slakter says, "the doctor with whom they are working and the patient. They make sure our patients are comfortable and their questions are answered every step of the way. Adding this position to our staff has enabled us to be more efficient, and it also reassures our patients that we have not lost the personal touch they have come to expect in our practice."

Systems, Training and Teamwork
Ms. Abel jokes that being a Virgo helps her keep Vitreous-Retina-Macula Consultants of New York running smoothly and efficiently.
"To me, it's all about organization and systems," she says. "If you don't start from the ground up and build a system and follow it, then it won't be a smooth operation. We all work together as a team, and we have standard operating procedures for almost everything we do in our office."
A clinical educator at the practice helps develop the practice's standard operating procedures and then trains all new clinical employees. She also retrains current staff as needed. "Our clinical educator has been a tremendous asset," Ms. Abel says. "We have a checklist of things everyone needs to learn, from how to obtain consent to preparing drops for injection."
Consistency is an important attribute of an efficient practice, Ms. Abel says. "Everybody needs to be on the same page with every procedure in the office. If you have five people doing the same thing five different ways, you lose efficiency. From the minute a patient walks into the practice, from the initial greeting to looking for information in the chart, consistency is key."
To help achieve this consistency, all technicians' stations are set up in exactly the same way. "By doing this, we know, for example, that the same drops are in the same place in each station, so that when the technicians are with patients, they have everything they need and they don't have to leave the room to find something, which appears inefficient to the patient."
Dr. Brown also emphasizes teamwork in his practice. "It's an absolute team," he says. "Typically, the only thinking I do relates to my interaction with my patients. I may help with a decision on where we need to improve workflow, but then it's up to the team to implement the change and work together. When we address these issues as a team, every member of the team feels like an integral part of an organization that is helping patients and curing blindness, which is what we're here to do."
Cross-training is another tactic used to improve efficiency. According to David S. Boyer, MD, photographers at Retinal-Vitreous Associates Medical Group in Los Angeles usually take OCT scans, but they may be called away to do a fluorescein angiogram or auto-fluorescence. To minimize downtime at the OCT, most technicians in the practice have been trained to do OCTs. "The machines are very user-friendly today, and the technicians do a very good job," Dr. Boyer says. "Almost everyone can interchange and do the other person's job as necessary."


At Retina Consultants of Houston, the role of the most senior technician, called the administrative technician, is to educate patients. Typically, she is in the room as Dr. Brown completes his examination and gives instructions to the patient.

"I may tell a patient I want him to take a vitamin with lutein instead of beta-carotene because he is a former smoker, but it is our administrative technician who follows up with the patient and explains the different formulations in more detail, which allows me to move on to the next patient."

Having observed the physicians during their discussions with patients about diseases and treatments, the administrative technician often can repeat this information to the patient exactly as his physician explained it. "Having someone who can explain the Amsler grid, postoperative positions and postoperative drops saves me a lot of time," Dr. Brown says. "And I am confident that patients are receiving the education they need."

The administrative technician also performs some scribe functions, such as entering data into patients' charts, but as Dr. Brown explains, "Her primary function is patient liaison and advocate. She ensures patients and their families receive the quality time they deserve. In many practices, education falls to the physician or is cut short in an effort to improve patient flow."


After examining and updating processes to improve efficiency, and reassigning, cross-training or adding staff, some practice owners may conclude the next best step in their quest to manage the ever-increasing volume of patient visits is to hire additional physicians. Vitreous-Retina-Macula Consultants of New York did just that. "We have hired two new associates over the last few years, and we have added a satellite office," says Jason S. Slakter, partner in the practice. "Ultimately, there are only a certain number of hours in a day, and a certain number of patients you can see, so in the end, you add people."

According to Alison Nowak, practice research director at Ophthalmic Consultants of Boston, practice owners are discovering another paradigm shift has occurred since the introduction of anti-VEGF therapy. "In multi-subspecialty ophthalmology practices, traditional thinking held that it took five anterior segment doctors to keep one retina specialist busy," she says. "Today, that ratio is closer to 3:1, mostly owing to the availability of therapies for conditions that previously could not be treated. Retina doctors are that much busier."

Retina Consultants of Houston also has hired physicians. "You cannot realistically think you can see 80 or 90 patients a day and give great care," Dr. Brown says. "So if your volume increases to such a point that the number of visits is overwhelming, you need to look at hiring a new associate."


As we have learned from our conversations with these physicians, the road to streamlining your practice may not be a direct route. Taking a step back to assess daily routines may reveal redundancies or disconnects that are interfering with efficiency. Read on for insights into systems, training and teamwork that are integral to improving practice efficiencies. RP