Special Coverage: Practice Management

34 ways to make your clinic more productive

by Candace Simerson, COE, and Allen Giannakopoulos, MBA

If you learn from all the books, journals, speakers,

and conferences about productivity improvement, you'd eventually come to the conclusion that improving the throughput of your clinic comes down to some good old-fashioned common sense, mixed with some current technology for fine-tuning. We agree. Much of the information for the clinic administrator to review does have the flavor of productivity improvement; but what we will do here is present a quick "executive review" article rather than an in-depth discussion. 1. Cross-train your clinic's front-end staff to perform all identified basic functions. Many clinics simply haven't had the time to create a list of processes and responsibilities that front-end staff must adequately perform. These could (and should) include answering telephones, collecting cash and copayments from patients, and directing patients to other functions within the clinic. The staff must be able to answer patients' typical questions about common eye problems. We don't mean medical triage; but staff must know the difference, for example, between laser in-situ keratomileusis and photorefractive keratectomy. Collectively, the processes that the administrator assembles as the mandatory processes for performing basic office functions will serve as a springboard for training protocols, flow charts, and for measuring revenue analysis, patient throughput, coding, and productivity improvement. 2. Cross-train staff when possible. For example, cross-train the receptionist and scheduler, the accounts payable (AP) and insurance clerks, the optical staff, and the scheduler. Practice size, styles, and culture will determine which positions offer the best cross-training potential. Cross-training enhances productivity, communication, and efficiency. The practice benefits by increased employee capabilities and many staff members will enjoy the opportunity to learn a new skill. 3. Train all staff to answer the telephones. A clinic in California wanted to know why its callwaiting times were so long and why patient complaints about the number of telephone rings before pick-up were so severe. This practice had an advanced telephone system that could measure

every variable imaginable; however, the one thing not measured was good sense. New telephone systems measure waiting time, not patient satisfaction! The problem? Not one supervisor or manager answered the telephones during the heavy call periods; this caused the senior management to have a meeting about increasing operator and receptionist staffing, an entirely wrong approach. Every staff member, regardless of position, can and should answer the telephone, especially during peak times. Administrators set the example. 4. Show staff monthly reports and charts on accounts receivables (A/R). Explain and show examples of the accounts receivable (AR) "days out." Give samples of AR problems (for example, wrong insurance data) and how they can be prevented. Stimulate a discussion and a problem-solving culture for developing ideas on continuous improvement projects. Motivate the staff to create and implement changes that improve processes. 5. Do a "people flow" of patients through the clinic. If you are wondering how to improve your practice, start by asking what happens when a patient calls for an appointment. Then, work your way through the process from a patient's perspective, asking questions at a high level. You can always get to the details later. You'd be amazed at how many people can't define the process from start to finish. As administrator, your job is to know this process at a high level, because it's your staff's responsibility to know the details. Don't start with anything fancy, just begin with a drawing of the office or clinic. Identify how patients flow through the clinic and put numbers on the drawing that correspond to the major process steps. Identify bottlenecks that can be solved by changing patient flow, scheduling protocols, office layout, or job responsibilities. Then use the drawing to help you. 6. Institute voice mail with an operator to direct staff calls Start with a person, but add voice mail. Plan a mailbox for each staff member: It's faster and more accurate than taking messages. Remember to have all incoming calls answered by a person, but use the voice-mail system for non-urgent messages. Begin having staff members check their voice mail three times a day. Encourage appropriate and effective use of voice-mail capabilities. 7. Jan. 1: Request an insurance card from every patient. Every year, more than 30% of the population changes insurance. In 2 years, the majority of your established patients have changed insurance carriers. This is an easy issue to resolve to prevent payment delays. It's also a good catalyst for

implementing a document imaging system if you have multiple clinic sites. 8. Copy the insurance card and attach it to the charge ticket. Get a legible copy of the front of the card, and don't forget to copy the back. Explore scanning the cards into a new database. This makes a great reference if you need to follow up on a claim. 9. Tag medical records for past-due amounts. First, have the staff use stickers on the front of the chart. Then have the physicians remind patients with past-due amounts (which they recognize by the sticker on the chart) to stop at that desk on their way out. The next step is to create protocols for not scheduling those patients unless payment is received at the time of service. 10. Conduct in-service training on various surgical procedures. Your teachers (the physicians) are already in place and paid for. The stronger your staff's knowledge of ophthalmology, the more confident they will become. An educated staff promotes patient confidence in the practice. Patients respond to intelligent answers, not "I don't know" or "I'll have to locate someone who can answer your question." 11. Conduct in-service training on changes in reimbursement or bil- ling protocols. Reimbursement requirements change continuously. Have several in-house experts on reimbursement for the major payers. Include the physicians! Create a system for communicating billing changes to all staff. 12. Perform in-service training on patient scheduling triage. Many clinics have tried such training but say they did not see the value in it. Ask yourself what should be discussed at in-service sessions. Then ask yourself who would benefit from the discussion. For example, updating staff on new technology or procedures may be appropriate for certain staff members. Conduct in-service training once or twice a year for new employees to explain all services you provide. Hold a different in-service session for all staff to review emergency medical procedures and disaster control. Explain the signs and symptoms of true emergencies. Determine emergency protocols for staff to follow, if you have not already done so, and have your physicians develop the procedures after you outline them. With luck, you'll never need to use these protocols; however, history indicates that every office gets a patient emergency at some point. 13. Create a triage reference sheet for all staff. List common patient concerns, complaints, and symptoms that occur in your clinic. Then refine the list into specific ophthalmic categories. Have your physicians review the list and add comments, assisting with appointment priority issues. Laminate and keep a copy of the triage sheet at all

appointment scheduling areas, as it is a great reference and training tool. 14. Institute a suggestion award process. Your staff members have ideas for improvements, so think of creative ways to unearth these hidden gems. Develop a simple system for "quick fixes" and "good catches" that the staff can use to reward one another without instituting a complicated system of purchasing and stocking gifts. Written thank-you cards are incredibly effective, but most offices don't use them. We continue to forget that the best motivator is a sincere compliment. As for a suggestion award process, keep suggestions anonymous until you and two physicians approve them. This way, you will probably know who made the suggestion, but the probability increases that a person will just make the suggestion in the first place. Poll the clinic to see the types of rewards desired and don't forget that next to cash, time off is the No. 1 motivator. Accumulating points that can be cashed in for a half-day off is a powerful way to reward suggestions. 15. Use one core package for all functions (e.g., scheduling, A/R). Increased communication and operational ability is dependent on system integration. All basic functions must work with one another. If not, productivity and efficiency are adversely affected and money lost. Make certain your software packages can "talk" to one another without conversion of data. If your clinic has multiple locations, this is a must in being able to share information. 16. Use one operating system version on every computer. Many clinics buy new hardware with newer operating systems. This is great, but for simplicity and consistent operations, upgrade all your personal computers to the same system and version, as well as all operating software. As improvements occur, you'll know which computer should get what, because they'll all need the improvements. If you have a network, you already copy software from the server to the PC, so upgrades will simply go from the server to the users' stations. Don't forget to standardize the packages you use. There is no sense in having some use Word, some WordPerfect, some Excel, and others Lotus 1-2-3. This merely increases the costs of upgrades, necessitates user experts in more packages, and increases the amount of time repairing system conflicts and computer bugs. 17. In the optical shop, use certificates for patients who need eye wear. For example, the certificate could offer a percentage off the price, if the eyewear is purchased within 2 days. Create a simple certificate in-house. Change the percentage and the time span to see what works best. Add an incentive for purchasing a second pair.

Have your optical staff monitor the trends and determine what works best for your region and city. 18. In the optical shop, bring the edging process in-house. If the demand warrants, you can perform lens edging in-house. You should recoup your investment in less than a year. Small savings per patient add up. 19. In the optical shop, bar code the inventory system. Institute automatic reordering to your major vendors with electronic data interchange (EDI). Chart your inventory orders to monitor stock turnover and sales. Replace your PCs as needed to allow bar coding. Bring your vendors in and talk to them; you might find that they already use bar coding for their inventory, and that they have a good plan for coding your inventory. 20. In optical, increase the patient-retention rate. Have the physician suggest stopping at your optical shop. If the patient has a problem, guarantee satisfaction; don't make the patient struggle to get the problem fixed. Patients appreciate convenience and quality assurances. Train all staff to encourage optical sales. Retention rates vary from 30% to 80% of patients who purchase their eyewear at your office. 21. Implement a gain-sharing program. A gain-sharing program can be especially effective in the optical and contact lens operations. The plan can work using base revenue achieved or a percentage commission on sales. Expand the program so all staff members have a way to achieve a bonus if they desire. 22. Enhance communication through networking capability. Physicians and administration should have remote access capability for all major clinical functions. In addition, all major departments and administration staff should have an e-mail address. Patients are online and there is no going back. 23. Put human resources information on-line. This program should be tied to the payroll system and group benefits broker. It also enhances compliance with regulatory requirements and is an easy management tool for monitoring the costs of benefits or compiling an employee census. Develop the protocols for system access and use. Allow the staff to perform benefits administration online. 24. Re-engineer processes that have become overly complex. Re-engineering is an overused buzzword that has garnered much bad will, but you can still use the basic premise behind it to improve your operations. Use team members to develop ideas for changing processes that give people headaches. Insurance processing, revenue cycle, patient scheduling, and

collections are processes that continue to grow without restriction. Don't bother trying to standardize these processes until you have a small group evaluate ways to complete the process. People draw on their knowledge base from other offices and use it to apply different ideas. Let your staff have a brainstorming session or two on each major area. You might garner good relations with your staff or strike a gold mine of ideas. 25. Track and trend the mix of production data. Note the trends by physician or division. Also follow procedure code trends and use the data to create run charts. These data sets are useful in creating and evaluating marketing strategies, as well as in measuring goal achievements and determining appropriate staffing needs. 26. Track reimbursement on your top Current Procedural Termin- ology volume codes. Do this for the top 15 to 20 codes, by payer. Determine average reimbursement by code to facilitate forecasting and planning. 27. Use available call-accounting capabilities. Newer telephone systems have call-accounting features. These will help you manage staffing levels with proper back-up and facilitate management decision-making. 28. Provide data to staff. Provide charting days in A/R to the business office staff monthly. For the optical shop, use the percentage of cost of goods sold to the industry standard and your historical data. For scheduling and patient care staff, measure patient volumes and revenues. Compare your results with industry standards in your market region. 29. Establish a formal training program. Formal training programs for teams, such as receptionists and business office personnel, are effective. Determine and prioritize steps for effective training. Identify a key training person, and use the buddy or mentoring system to give a new member a person to go to with questions. 30. Create a collaborative hiring process. Involve other team members to create support and help identify strong candidates. There is so much that your staff can do in the hiring process, including writing advertisement templates, reviewing resumes (paper and e-mail), first stage interviewing, and new employee orientation. This will provide insight into personality dynamics by seeing which of your staff members accept new people and new roles. 31. Establish expectations for conflict resolution. Every day in every office, some kind of conflict arises. It is not possible to avoid it, but it is possible to plan some steps in dealing with the conflict. You

can try these three steps with staff conflicts. The first is to resolve the conflict between the individuals involved. The second step is to have a third party mediate. The third step is disciplinary action, because unresolved conflict destroys the teamwork environment. In clinics, the most common breakdown in disciplinary action occurs when an individual circumvents the administrator's authority and has a physician intervene. This is a true test of an administrator's stamina and leadership ability. Define each step and have the staff members discuss how they would like to be approached and treated if they were in such a situation. 32. Flowchart and standardize common processes. A good ophthalmic office has many attributes; standardized processes are but one. The goals are easy: Reduce bottlenecks, variation, and lost productivity. Flowchart the major processes starting at the front desk for standardization and training, because if your office is like others, that's your highest turnover area. As staff come and go, you will need a tool to help bridge the knowledge gap that's created when a person leaves. Include scheduling, accounts receivable collection, and revenue-cycle analysis as key areas to flowchart, and then set goals to reduce variation or ongoing problem areas by talking with your staff about day-to-day operations. Ask them how they would standardize processes. 33. Minimize insurance claim rejections by auditing claim rejec- tions. Start with major payers, such as Medicare. Track and identify causes for rejection of claims. Once you start tracking the causes, chart the data using a Pareto chart, which is the 80-20 rule, and then determine which are the most common areas to fix. 34. Develop an insurance cheat sheet for the registration area. List required information for processing each type of insurance, such as billing and insurance codes. Note which plans require referral authorizations. Post this sheet with the same intent as the patient triage sheet. This is another great training tool. Most physicians and administrators realize that clinics will continue to face increasing economic pressures. Controlling costs is critical to increasing profit. The key to success is to decrease cost and increase volume without lowering quality. Volume, cost, and quality are all tied to efficiency. Improving efficiency allows a practice to reduce its average cost per patient. h This article was originally published in the Winter 2000 edition of Administrative EyeCare and presented at the 11th annual American Society of Ophthalmic Administrators' Congress on Ophthalmic Practice Management, Seattle, April 1999.