Maximize physician productivity with better workflow. (Practice Management).

Almost everyone these days has trimmed excess fat from operating budgets, but you can only cut so much of your overhead expense before crippling your practice.

Continue pinching pennies, of course, but turn your attention to eliminating another "profit thief" in your practice as well: wasted time and motion.

Space, staff, systems and style

Ridding yourself of wasted time and motion starts with understanding how physician output happens. Analyze office workflow from back to front. The first question: How many patients does the doctor presently see in the office? From there, work your way back to the front desk and the moment the patient steps in the door.

Patients flow through your office much like water through a pipeline: The pipe's diameter determines the output capacity.

If you need fire-hydrant output, don't install quarter-inch copper tubing. In the same way, take a close look at your production characteristics--both present and future--to effectively assess your medical office space requirements.

Physician productivity, your greatest practice revenue source, depends greatly on four factors:

1. Space--the size and layout of your office can enhance or hamper productivity

2. Staff--the right number of people performing the right tasks produces an efficient workflow

3. Systems--communications, computers and other business systems must work in harmony to support physicians working at capacity

4. Style--your practice style includes characteristics like how quickly you work, when and where you dictate and how you delegate work

Keep these four "S's" in mind as you search for factors that enhance or limit your productivity and try to estimate how high your output potential can grow in the right environment.

Arriving at such an understanding requires analyzing current, potential and projected physician output. You may choose to hire a specialist to guide you through this somewhat complex process, or do it on your own. Either way, it can provide you with a clearer picture of both your present and potential production.

Measuring physician output

Begin the study by looking back through appointment schedules for the last 10 - 20 sessions (office half-days). For each session, count how many patients the physicians saw and divide the total by the total number of hours they worked.

Be careful to account for overtime--that is, starting early or finishing late. Your calculation determines each session's patient-per-hour (PPH) rate, the basic yardstick showing physician output.

Arrange the data like those in Table 1 in the Total the Time Elapsed and Patients Seen columns, then divide the total hours by the total patients to arrive at the average patient output.

Finally, find the highest PPH rate of all the sessions and add a line noting it as the peak output.

Optimize your time

To find and eventually minimize wasted physician time, conduct a time-motion study on each doctor's practice style.

Begin with noting the start time of each identifiable doctor task. That includes chart review in the hall, entering the exam room, greeting and chatting with the patient, history review, conducting a physical exam and more.

Time each task and chart the elapsed time as shown on Table 2. Allocate each task's elapsed time to one of three time categories:

* Doctor time-Tasks requiring your unique knowledge and expertise, or your presence to establish effective rapport with your patient

* Delegable time-Tasks you could delegate to support staff

* Wasted time--Needless tasks caused by inadequate communication systems, unavailable staff and/or poorly designed space

After sorting the tasks by time category, calculate the actual PPH rate by dividing the number of patients seen by the total elapsed time (in hours), and compare that to the potential PPH by dividing the number of patients seen by the total doctor time only.

This is called the potential PPH rate, the physician's "natural" PPH rate, for it represents physician-required time only.

Keeping up the pressure

Once you have a sense of the physician output potential, consider how staffing affects patient flow.

You, as a physician, can reach your optimum output if you recognize your clinical staffs number one job during each session as keeping you supplied with ready patients.

By clinical staff, we mean any employee whose tasks directly support patient flow.

If you want to hit your production maximum, your support staff must actually have excess capacity. If your projected optimum output is 6 PPH, then staff who supply you with patients must be able to prepare 7 or 8 PPH.

Again, like water pipes, maintaining pressure at the output requires the underlying supply lines to be larger in diameter than the outlet itself.

Doesn't this mean that nurses or receptionists will have some idle time through the day? Of course, but it makes more sense (and more profit) for physicians to be 100 percent productive while (lower-salary) staff remains at 80 percent.

What hinders staff production?

Examine support staffers, especially clinical support staff, to see what factors might impede their ability to get patients ready for you to see:

1. Volume--If you simply don't have enough staff, sheer volume bogs down even the most efficient worker. Studies like Medical Group Management Association's Performance and Practices of Successful Medical Groups show time and again that top-performing practices almost always employ more support staff per FTE physician than those with mediocre profit margins.

2. Mistakes and corrections--When staffers make too many errors or spend too much time compensating for other workers' errors, figure out if workers need better training, more effective motivation or improved accountability.

3. Interruptions--Don't mistake regular tasks for interruptions. Patient phone calls during office hours may be interruptions for a physician--but not for a receptionist.

4. Wasted motion--Poorly designed space may require staffers to leave their primary workstations or add miles to their daily walking.

5. Inadequate systems--Slow, unreliable computers and phone systems, redundant paper forms and a host of inadequate business systems frustrate workers and slow the process.

Back to the beginning

Keeping the patient-supply moving to support the physician's output starts, naturally, at the front door.

Appointment scheduling, patient registration and check-in make up patient input. Again, be sure your input staffers can prepare more patients per hour than you can actually see. How many receptionists or registration clerks you need depends on how many patients you expect to see each hour.

Breaking down patient input, throughput and output in this way really allows you to define the production characteristics and space demands for your optimized practice. A one-physician practice where the doctor has the ability to see six patients per hour requires:

* Reception and registration able to check in at least seven patients per hour

* Nursing and ancillary staff capable of putting at least seven patients in exam rooms per hour

* Cashier/reappointment clerks who can check out patients at the same PPH rate as the physician--six

Larger groups with more providers, multiple locations and complex ancillary services can apply these same principles to get a handle on their production characteristics, too.

Advisory Publications, based in Conshohocken, Pa., is a monthly newsletter service that publishes The Physician's Advisory, a newsletter that includes advice on business, tax, management and financial matters involving health care.

TABLE 1

Patient Per Hour (PPH) Rates


                       TIME                    PATIENTS
DOCTOR    Start     Stop      Elapsed      Seen        Per Hour
SESSION                       (in hrs &
                              hundredths)

1         9:15      12.30     3.25         12          3.69
2         9:18      12:18     3.00         15          5.00
3         8:55      11:55     3.00         16          5.33
4         9:05      12:45     3.67         10          2.72
5         8:30      12:20     3.83         11          2.87
6         12:45     3:15      2.50         13          5.20
7         12:55     3:50      2.92         14          4.79
8         1:10      5:10      4.00         10          2.50
9         1:05      4:50      3.75         18          4.80
10        1:00      4:20      3.33         15          4.50

          AVERAGE             33.25        134         4.03

          PEAK                                         5.33

Set up a table like this for each physician and each provider who sees
patients in the office (physician assistants, for example). Measuring
present output provides a baseline, while the next step helps you figure
out how to increase capacity.
TABLE 2.

Time-Motion Analysis

                              TIME (in minutes)
                         Elapsed              Doctor
TASK                                          Time

Patient Work-up          5.25
Look for Nurse           0.75
Doctor Phone Call        2.50                 2.50
Patient Examination      7.50                 7.50
Dictate Chart            1.50                 1.50
Walk to Lab              1.50
Look for Chart           1.00
Talk to Patient in Hall  2.50
Patient Examination      5.25                 5.25
Walk to X-Ray            1.10
Wait for X-Ray           2.50
Dictate Chart            1.75                 1.75

TOTAL MINUTES            33.10                18.50

TOTAL HOURS              0.55                 0.31

Patients Seen            2
Actual PPH Rate          3.63                 (Patients seen)
                                              Elapsed time in hrs.)
Potential PPH Rate       6.49                 (Patients seen)
                                              Doctor time in hrs.)

                           TIME (in minutes)
                         Delegable  Wasted
TASK

Patient Work-up          5.25
Look for Nurse                      0.75
Doctor Phone Call
Patient Examination
Dictate Chart
Walk to Lab                         1.50
Look for Chart                      1.00
Talk to Patient in Hall             2.50
Patient Examination
Walk to X-Ray            1.10
Wait for X-Ray                      2.50
Dictate Chart

TOTAL MINUTES            6.35       8.25

TOTAL HOURS              0.11       0.14

Patients Seen
Actual PPH Rate

Potential PPH Rate