When patients arrive at your practice for their appointments, can they get in and out within an hour or so at the most? Or are they forced to spend their valuable time waiting because of traffic jams at the testing stations? Are doctors standing around waiting for patients because of backups in the exam rooms?
If so, it could be time to treat your office itself like a patient; ie, examine your physical space to assess the severity of its symptoms, diagnose the cause and then take steps to treat it — either by reconfiguring the space or even moving into a new and bigger space.
MANY CAUSES OF INEFFICIENCY
Insufficient or poorly used space is just one of many potential factors in inefficiency in ophthalmology, according to Thomas A. Ciulla, MD, MBA, clinical professor of ophthalmology at Indiana University School of Medicine and of Vitreoretinal Medicine and Surgery at Midwest Eye Institute, both in Indianapolis, Ind. Some of these factors, Dr. Ciulla says, include inappropriate testing, improper workup protocols, overscheduling, unbalanced workloads, inadequate staffing, long setup times and even inappropriate referrals.
“When a patient should have been referred to another physician for a different problem, [that] creates waste on numerous levels: for the patient and the family who spend time in the office, for those paying for the visit, for the patient whose appropriate visit was bumped by the inappropriate referral and for the practice, which likely forgoes higher revenue associated with treating a more appropriate referral,” says Dr. Ciulla, who has written about inefficiency in ophthalmology as it relates to Lean Six Sigma principles. “Also, this adds to staffing expenses, equipment expenses, space expenses and waiting times for other patients.”
Larry Brooks, AIA, an Atlanta-based architect whose firm specializes in designing medical practice clinics, looks at what he calls the “Four S’s” of clinic efficiency: physician style of care; the clinic’s staffing model; the clinic’s systems of check-in, scheduling, and patient processing; and, finally, the clinic’s physical space.
“Presenting the doctor with a ready patient is really the goal of an efficient office,” Mr. Brooks says. “That’s your practice’s resource: the doctor. Everybody’s there to get care.”
THE PATIENT HISTORY: GATHERING DATA
The best way to determine whether your office space itself is a major factor in your practice efficiency issues is to start by gathering data, says Mr. Brooks, who notes the process of identifying and correcting space issues parallels that of a patient doctor visit. “We’re going to really take a critical look at the practice and the flow, and what they do well and what they don’t do well, and then we’re going to come up with a treatment plan.”
Mr. Brooks also has his clients complete a questionnaire covering items such as patient volume, staffing size and model, job descriptions, services and equipment as well as their goals for future growth.
“It all starts by knowing your data,” says Cynthia Matossian, MD, founder and medical director of Matossian Eye Associates, a multispecialty practice with offices in Doylestown, Pa., and New Jersey. Dr. Matossian is in the midst of expanding one of her offices into an adjoining space and says you must consider several key questions during your planning session.
“You need to know how many patients you’ll see per day, even how many you’ll see per morning or per afternoon session. Are there going to be two MDs seeing patients side by side? Is there going to be a mix of MDs and ODs? Will there be a subspecialty MD who does a lot of procedures? Oculoplastics and retina specialists perform unscheduled procedures constantly, so when they see patients you have to assume there will be multiple add-on procedures. Are there plans to add new services or additional eye-care providers?”
Be forewarned: there is always a certain degree of uncertainty in this part of the process.
“Over time, the nature of a practice evolves,” Dr. Matossian says. “All of a sudden, the space that may have been adequate for two doctors becomes greatly constrained when you add your third doctor. You’re not only adding one doctor — you’re adding his or her entire book of patients, associated technicians and perhaps testing equipment.”
Mr. Brooks adds he tries to plan enough space for anywhere from two to four new pieces of equipment in a new office. “We don’t know what it’s going to be, but that new technology is coming, so trying to plan for that ‘unplanned growth’ can be challenging. We don’t have a crystal ball.”
ASSESSING SPACE-RELATED SYMPTOMS
Imperfect as it may be, however, the information gleaned from the planning process enables practices to calculate as accurately as possible virtually everything from the number of exam and testing rooms to the number of staff that should be needed to function optimally — even how many parking spaces should be available. It also helps enable a practice to assess whatever issues, or symptoms, of space-related inefficiency it may be experiencing and how best to address, or treat, them.
“Some of the symptoms would be, do the doctors have times when they have nobody to see? They come out of an exam lane and they’re standing around because no patient is ready for them. On the flip side, you’ve got a whole slew of patients ready to see, so now you’re running behind,” Mr. Brooks says.
Situations like these can arise especially in practices where any given doctor might get five lanes one day but only two lanes the next because more doctors are in. “That’s a symptom that there’s an issue between your space need and what is actually available,” Mr. Brooks says, noting that such issues are sometimes misdiagnosed solely as patient-volume or staffing-level problems.
Another common symptom: patient complaints about waiting times or being bounced around from one room to another. “What we hear most of the time is that patients love their doctor, but they have other issues with the practice — ‘They made me walk all over the place,’ or ‘I waited forever,’” Mr. Brooks says. If you see those complaints in your satisfaction surveys, he adds, you have some underlying issues that could be related to space.
DEVISING THE TREATMENT PLAN
Armed with this information — essential data related to the practice itself and its goals, along with the issues keeping it from providing quick and efficient care — a practice can now effectively treat its space conditions. That, Mr. Brooks says, takes the form of the “treatment plan,” otherwise known as a space-needs spreadsheet, which is based on how the clinic should function optimally.
“Too many times, architects want to think about how the building is going to look and the view to the mountains or whatever, but it is counterproductive to how the building should flow,” he says. “Every design decision needs to be based on, ‘Is this going to help my doctor see patients?’ The patient flow and the efficiency of the practice should trump the view.”
Oftentimes, practices simply don’t provide enough workup or testing rooms. The key, he says, is to provide just enough excess capacity upstream from the doctor. “So, if the doctor can see six patients in an hour, we want our work-up rooms and techs upstream to be able to process seven or eight patients an hour,” he says. Similarly, with testing rooms, it is wise to limit equipment to just two or three pieces per room and to provide each specialty with its own rooms, he says.
RENOVATE, EXPAND OR MOVE?
This process of identifying space-related issues is likely to lead to a question: how do I best solve these challenges? Is renovation or expansion into an adjacent space the answer, or will the entire practice need to be moved to a larger space? Dr. Matossian recently faced that question with her practice, which ran out of room to house its growing stable of eye-testing technology.
“We are actually able to take over the only empty space in our whole building, which happens to be contiguous to us,” she says, noting that her clinic expansion will require relocating whole departments, including billing and the call center, along with the reception, testing and exam rooms. “But, just by getting contiguous space, the entire office flow is going to change,” Dr. Matossian says.
Not every practice is as fortunate, however, and the need to relocate into a larger space or even to build from the ground up may be more appropriate solutions. This can be especially true when patient volume is growing and there’s just not enough space left to grow into or to reconfigure to improve efficiency.
In those cases, Mr. Brooks says ophthalmology practices should avoid L-shaped and long, narrow spaces.
“The more square the space, the better, he says. “The longer or odder-shaped the space, the more you lose the ability to get a good plan.”
Indeed, Mr. Brooks recommends the “pod system,” or grouping rooms by specialty or similar purposes, for maximum efficiency and patient convenience.
“If a doctor needs two lanes to see patients and three lanes for techs to do the workup based on volume and staffing, you might put those five rooms in a pod,” he says. “Patients are now going to come and get everything in that pod. They’re not being walked all over the building to go get worked up over on this side, and then walked down here to see the doctor.
“Pods allow you to shorten the distance that the patient walks as well as make it more comfortable for the patient and staff,” he says, noting that the pod principles of grouping work equally well for large and small practices. “You don’t want to come out of your exam lane and have everybody’s patients up and down the hallway. You’d much rather live and practice on a nice little cul-de-sac, not on that interstate of a hallway.”
GOOD DESIGN SHOWS RESPECT FOR PATIENTS
Ultimately, achieving a more efficient office results from much more than simply expanding to a larger, more attractive space.
Referring to his “Four S” system for assessing practice efficiency, Mr. Brooks says, “Those four things, choreographed to mesh well like a nice Broadway play, is what generates an efficient office. You should never lose sight of the goal of having that next patient ready for the doctor to see and treat.”
Patients place a high value on their time, Dr. Matossian says, and designing an ophthalmology practice’s office for quick and efficient care shows respect for their time. “Back in the day, patients expected to be at the doctor’s office the whole morning or the whole afternoon. That’s gone now; everybody has a schedule that needs to be respected, and you can’t assume they have all the time in the world. Our goal should be to take care of patients as efficiently as possible while making their experience as personal as possible.” OM