Take Control of Your Patient Flow (Part 2)

Lea Chatham April 16th, 2013

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by Rico Lopez, Senior Market Advisor at Kareo

Rico Lopez

In my last post, Take Control of Your Patient Flow (Part 1), I reviewed the impact of poor patient flow and the signs that is a problem in your practice. So, now you are probably wondering what to do next. There are several possible root causes for problems with patient flow that in turn affect your bottom line.  In this, and subsequent, posts, I will look at some of the bigger problems and offer solutions.

To have any hope for resolution of any condition, you have to make a commitment to change. There will be struggles and even the dreaded trial and error, but in the end, you can make it better. In this treatment plan, we will discuss designing your Appointment Scheduling Template based on your projected patient flow.

Was your schedule set up to maximize your provider times or was it established using the traditional business hours that start at 8 AM and end at 5 PM? Don’t feel bad if you said the latter – surprisingly, most practices still build their appointment schedules in the same manner today as it was done 10-15 years ago.

Schedules that are tailored to the traditional business hours do not account for the “true” available time of your provider(s) and your staff. If your provider arrives at the office at 8:00 AM and your first appointment is at 8:00 AM – how quickly will your staff prep the patient to see the provider?

Coincidentally, if your front desk staff also arrives at work at the same time, are they ready to jump in to work and get the patient’s chart ready for the nursing staff? They typically have to log in to their workstations and prepare their work area before they can even call up the first patient.

A lot of practices will also plug in new patients or physicals (appointment types that typically require a longer visit time) in what they think are logical places in the schedule without fully understanding the downstream effect to their staff and to their providers. Worse yet, they will overbook slots to ensure that the provider always has a patient ready to be seen – again without fully understanding the downstream effect.

Some practices, by experience, have adjusted their schedule to account for staff coming in earlier to ensure that patients are ready to be seen when the provider is ready. The question now is whether you accounted for the full patient flow from beginning to the end of the day. Before you can fine tune your Appointment Schedule Template you must first create a projected patient flow.

So how do you create your projected patient flow? 15+ years ago, we used colored notecards, color markers and pushpins on a large bulletin board. Later on we moved to colored post-it notes and then finally to Microsoft Excel, which allows you to easily adjust slots, labels, colors and maintain versions in separate worksheets by copying the previous sheet and then applying adjustments.

Patient Flow Worksheet

What do I need to create this worksheet?

The provider start and end times represent the time when the provider is ready to see the first patient and when the last patient of the day should be complete. This needs to be very specific since everything else will revolve around it. This is why the Provider Time column has a label “Start Here.”

The projected patient “stops” or staff interactions occur at Patient Check-in, Registration, Nursing, Provider Exam, Visit Wrap-up and Patient Check-out. In your practice, you may have more or less.  This may sound very simple but be sure to account for all areas since it will impact the overall timing.

You’ll need to create a list of all Appointment Reason Types (New Patient, Physical Exam, Follow-up, Consult, Nurse Visit, etc.) and the average length of time to perform this type of visit. Also, estimate the number of patients by appointment types for a typical day.

Once you have all of the above, then it is time to assemble. Start with the Provider Time column. Based on the number of exam rooms in your practice, determine the timing between patients to keep your provider going from one room to the next.

Now go backwards to the previous stops and determine the average interaction time required and keep going back until you arrive at the Check-in time.

Note that the “Check-in” time is the time you want the patient to initiate the visit. For the majority of the appointment types, this is the same as the patient’s appointment time, but many practices want their new patients to arrive 30 minutes before their appointment time to complete paperwork or fill out forms. Be sure to factor this in to your scheduling template.

Do not rely on your staff to tell the patient to come in a few minutes early to “fill out forms” before they are seen. Your staff may not always remember to tell the patient or the patient may not remember by the time the appointment comes up.

If the patient does not show up early as instructed, you are now waiting for the patient to complete your forms and the practice will fall behind. These types of delays will cause gaps in your provider slots and push all appointments back. We will talk more about other unanticipated delays later, but for this one, why not just factor this in to the patient’s appointment time and allow you to maintain control of your schedule?

In my example, I scheduled the first new patient to arrive at 7:30 AM, even though my staff will not begin registering the patient in the system until 8 AM allowing the patient 25-30 minutes to complete the forms. You will need to adjust this “padding” based on your experience with your patients and the number of forms you require.

Additional Tips and Tricks

  • Do NOT book multiple patients with the same Appointment Reason Types on the same time slot. We will discuss overbooking in a future post and why this is not always the right solution.
  • Do NOT book extended Appointment Reason Types either on the same time slot or in back to back time slots (i.e. Back to back New Patient slots). Try to stagger these throughout the day and fill in the gaps with nursing appointments or other visit types that do not require face-to-face interaction with your provider.
  • It is ok to have a New Patient come in on your first time slot, but be sure to also schedule follow-up appointments at the same time and shortly thereafter. This will allow the patients to flow back to the provider to be seen while the New Patient is going through registration.
  • If you only have a couple of exam rooms, you may want to stagger your patients by 10 or 15 minute increments. If you have more than two then, you can space out by 5 or 10 minutes. The patient wait time in the exam room should never be more than 5 minutes and definitely less than 10 minutes. When sitting alone in a room, 5 minutes feels like an eternity. Remember, the exam rooms may still require cleaning/ restocking before you bring in the next patient, so be sure to account for this.
  • Make sure you build in time throughout the day for your provider to do charting, coding and returning phone calls.
  • Establish your policy on walk-in or triage patients. If this is a normal occurrence in your practice, then go ahead and designate time slots to accommodate these patients. Balance it out with your average no-shows – so if you have an average of two no-shows a day, then you can fill in with a couple of walk-in or triage patients.
  • For some practices, it may be ideal to factor in lunch breaks to the template to account for the availability of staff. Note: Not everyone goes to lunch from 12 to 1 PM when the typical practice is closed for lunch break. At 12 PM, the provider and nurses may still be finishing up the last few patients of the morning so they may not be able to go to lunch until 12:15 or 12:30. However, the front desk may be able to go to lunch at 11:30 or 11:45 when all the morning patients have been checked in and will be back at the front desk to greet the first afternoon patients.

Fine-tuning your Appointment Schedule Template will take weeks and sometimes longer. Be patient and do not be too quick to make adjustments. I always say, “Don’t second guess your decisions unless outcomes tell you to do so.” If you have spent the time to analyze and map out your patient flow, then the expected changes will eventually come. Remember, you are dealing with a lot of old habits from your patients, your employees and your providers. It will require a total effort and buy in to succeed.

Watch for my next post when I’ll look at fine tuning your staff’s work schedule and how cross training will improve bottlenecks in your patient flow.

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