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What are wait times costing you?
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Susan Miller, administrator of a nine-physician family practice in Lexington, Ky., laughs ruefully when asked to talk about keeping a practice running on time. "That's always a touchy subject," she said.

Why so touchy? Perhaps because physicians already are under time pressures, from paperwork to rounds to a full appointment schedule to late patients to countless phone calls to referrals to patients who say, "Oh, just one more thing, doctor."

How can you stay on time when so much gets thrown at you every day, from directions you often don't expect?

Actually, experts say, all those interruptions, hassles and pressures make staying on schedule even more important. From the start of a practice day to its end, there are many ways to ensure that you stay on schedule, that your staff stays on schedule and that even a hectic day doesn't make everyone -- patients included -- frazzled. It also keeps these same patients from seeking a different practice that knows how to manage its time better.

"I think the biggest reason [to stay on time is] for customer service," said Kim Pollock, RN, a consultant and speaker with Chicago-based Karen Zupko & Associates, a practice management consulting firm. "And also just for your own peace of mind and to create a sense of balance -- so we don't feel like going to work is chaos every day."

If that doesn't inspire you to stay on schedule, many experts say doing so will let you see more patients or find the time and energy to boost practice revenue in other ways.

Miller, whose Family Practice Associates has instituted numerous changes to improve its on-time performance, said her practice had to hire one full-time-equivalent position to institute changes that helped it become more efficient. But the time opened up for new business more than made up for the salary.

Even one extra patient per day, compounded over time, can make a big difference.

"I don't think a lot of physicians understand [that] whoever has control over your appointment schedule has control of your income," Pollock said.

Organizing your day

Experts advise practices wanting to improve their on-time performance to do a study about what causes appointments to fall behind. "When people bring food to eat in the waiting area, that's when you know you have a problem," said Cindy Dunn, senior consultant with the MGMA Health Care Consulting Group.

Is the issue that physicians are taking longer than expected with patients? That clinical assistants are slow? That exam rooms aren't turned around quickly? That patients run late?

Before considering those questions, experts recommend answering this one: Is the physician on time for the first appointment?

When you have a physician "who comes in a half hour late every single time, you're backed up from the get-go," said Cheryl Gregg Fahrenholz, president of Preferred Healthcare Solutions, a Bellbrook, Ohio-based practice management consultant.

There are many reasons a physician might be late, and not all of them will be the doctor's fault. But experts said everybody -- physicians included -- need to be in place and ready to go when the day's first appointment begins.

Even if everyone in the practice is on time, other matters can put you behind before the first patient enters. Are the exam rooms ready? Have the sharps containers been emptied? Are charts ready? Is everyone aware of who is doing what today? Has there been a huddle to discuss the varieties of appointments that are scheduled?

Experts say having even a short discussion before the day starts can eliminate later confusion that costs your practice time.

Next comes planning the rest of the day.

A time study might find that the practice isn't budgeting enough time for certain appointments. Staff may be too slow in turning around exam rooms. A slow physician might be paired with a slow nurse or assistant (experts recommend pairing opposite types -- the fast one moves the slow one along).

Or, as in the case of Family Practice Associates, the bottlenecks could start with the check-in process.

Miller said her practice noticed that 20% of patients weren't getting checked in until after their appointment time. That wasn't because patients were late. It was because paperwork and front-desk responsibilities were creating delays. "Sometimes a patient would get up and sit down three or four times" before finally being called back to see a physician, she said.

Now, Miller said, the practice has cut down that late check-in ratio to 2%. How did they do it?

One strategy was getting patients to fill out necessary paperwork before coming in for their appointments. The practice has forms online, but experts say you could mail them to patients as well.

Another was to find ways to speed up the check-in process. The practice created one full-time-equivalent position just for check-in, so it could have three people handling that at once. Those front-desk staff don't handle phone calls; instead, the line goes directly to a clinical person.

Even if check-in lines get long, they move quickly -- and patients get up again only when it's time to see a physician.

The practice didn't say how much it spent to hire new staff, or how much revenue it gained as a result. But as Miller said, "You may require more FTEs, but with the increased capacity, it more than pays for itself."

Family Practice Associates looked beyond the front desk to find ways to be more efficient. For example, rather than keeping patients in the exam room during referral requests, it handles the requests by fax after the patient was left the office. That frees up the exam room and lets another patient move into the open room. The referring physician later contacts the patient directly, then the family practice.

When scheduling same-day acute appointments, the practice also looks at how its physicians are handling their schedules that day. Any physician falling behind will not receive acute appointments.

Handling the schedule

For all the efficiencies gained throughout the practice day, experts say the schedule -- and how it's managed -- can make a big difference in keeping a physician on time.

However your practice schedule is organized, Dunn said, it needs constant re-evaluation. "Do you change [your schedule] all the time, or has it been the same since 2004?"

She said practices have tried many different strategies to make schedules more efficient, such as:

• Scheduling appointments for similar types of patients, whether by age or condition, in the same part of the day.
• Using longer group visits for chronic disease care, which Dunn said can help if you have patients who like to talk a lot.
• Using open-access scheduling for part of the day. For example, block out the first few hours on Monday, when patients call early about problems developed over the weekend, for first-come, first-serve acute care.

One scheduling practice Dunn doesn't recommend is overbooking.

The risk is that everyone does show up, and you have no hope of seeing everyone when promised. Dunn compared the situation with how airlines tell customers that a flight is overbooked. Most travelers think, "You know what, I don't want your voucher. I want to get to where I'm going."

Part of the time study that experts recommend includes getting a realistic view of how long certain visits take.

How long are new patient visits? Follow-ups? Checkups? Acute-care visits?

After you determine all visits' current length, you can look at whether they are taking too long or whether certain visits inevitably will take longer than others.

For new patients, however, all visits aren't the same when it comes to time management, Pollack said. In any time study, a practice should track not only the general types of appointments for any new patients but also what care was delivered during those appointments.

"A practice needs to trend its appointments for a couple of weeks and make note of where some of the issues are," Pollock said.

Making patients & doctors happy

Experts acknowledge that these strategies won't guarantee that your practice is always running as scheduled. Emergencies happen. Staff members call in sick. Patients bring in problems you didn't expect. But patients understand waiting because of an emergency. What they don't like is having to wait because the practice chronically runs late.

If your practice is running on schedule, experts say, it not only improves patient satisfaction but also gives you more leverage when a patient is running late or doesn't show up, especially if you have a system to remind patients of their appointments a few days in advance.

Patients also may be less likely to be late or ignore appointments, because they realize you respect their time as much as you respect your own.

And once you become time efficient, you can predict how scheduling more patients can help your bottom line.

For example, Fahrenholz said, a practice that wants to know how greater efficiency can increase revenue can take its payment for CPT code 99213 (established office visit, mid-level) and multiply that by adding just one patient per day. Or, she said, it can set a longer-term goal of adding three or five patients.

She and other experts don't expect the practice to turn on a dime to get more efficient. But they say the investment is worth it, both for happy patients and happy physicians.

Staff reporter Emily Berry assisted in the reporting of this story.

The print version of this content appeared in the May 24 issue of American Medical News.

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