Some words are said so often in practice management that they start to lose their meaning. “Efficiency“ is one of those words. It gets used interchangeably with words like “successful,” “profitable,” and “productive,” so it’s no wonder offices want it. Efficiency, however, is not a piece of equipment that can be purchased for the office; it requires continuous work to be successful.
What exactly is efficiency? Simply defined, it is “effective operation as measured by a comparison of production with cost (as in energy, time, and money).”1 This comparison is ongoing; viewing efficiency as a project that has a finite end is bound to set an office up for frustration; it is crucial to accept that efficiency is an evolving, moving target.
Efficiency in dry eye treatment
It is estimated that dry eye disease affects 5 to 20% of the population in Western countries and 45 to 70% in Asian countries—this translates to approximately 20 million people in the United States and 344 million people worldwide who have been diagnosed with DED.2,3
Considering these statistics, dry eye treatment should have a place in every modern eyecare practice, but dry eye patients are often complex, as dry eye is a multifactorial condition and often time-consuming to diagnose, treat, and manage.4
The surge in dry eye practices has created new problems in office efficiency, problems that can’t always be solved using old tools. DED patients tend to require longer appointment slots, which means seeing fewer patients and this can translate to less revenue. But if they’re given a standard appointment slot, the schedule runs the risk of falling behind, which leads to patient dissatisfaction.
Luckily, the options of either fewer appointments or more dysfunction are not the only two possibilities. Other industries have created several models of efficiency that can be borrowed from when crafting an office’s own brand of a high-functioning dry eye practice.
7 steps to create a more efficient dry eye practice
The principles of Lean Six Sigma have been utilized for four decades to help decrease waste and increase quality production. Although often associated with the manufacturing industry, these principles can be valuable to medical offices when trying to identify weak points and help come up with solutions.5
The five techniques to improve existing processes are:
- Define
- Measure
- Analyze
- Improve
- Control
Step 1: Define and measure.
To start, eye doctors should mentally walk through their practices to pinpoint areas that could use improvement. In the Harvard Medical Review article Paying for Health Care with Time, Jake Miller investigates the average amount of time spent by patients at any given medical appointment.
His research found that Americans spent an average of 121 minutes traveling to, checking in, waiting, seeing the physician, checking out, and traveling from their doctor's appointments. If wait times are a problem, analyze each area of the appointment to work toward a solution.6
There are several reasons dry eye appointments can run longer than a standard eye exam. For example, if a patient is required to fill out a dry eye questionnaire while they’re in the office, if the doctor is performing intense pulsed light (IPL) therapy or a Schirmer’s test, or if the technician is explaining how to use a new medication or lid scrub, a dry eye appointment may run longer than anticipated.
Each patient’s case is unique, often with several factors requiring additional testing and lengthy discussions about their treatment options. With so many factors, it can be difficult to keep dry eye appointments from running behind; however, with proper planning, it is possible to reduce the amount of uncontrolled variables and stay on schedule.
Step 2: Analyze and improve.
Pausing for paperwork
It is a major disruption in office flow when technicians are forced to wait for patients to finish paperwork before taking them back to the exam room. To decrease intake time, make electronic forms easily available to be either printed and filled out at home or submitted securely through an online portal prior to the appointment.
Strongly encourage dry eye patients to fill out a dry eye questionnaire prior to their appointment. Armed with the information prior to seeing the patient, doctors and technicians can ask pointed questions, prepare treatment options, and reach solutions faster.
Be transparent with patients in regards to why it is important to have this information in advance. A patient may be more likely to fill out a questionnaire if they understand it will expedite their appointment or possibly even their diagnosis.
In addition, make sure paperwork is worded simply, and listen to feedback from patients regarding the forms. If multiple patients ask for clarification on a particular part of the paperwork, that’s an indication that it needs to be reworded or changed. Every time a patient has to stop reading their paperwork to ask a question, they not only slow themselves down, but they also slow down the staff member who is assisting them.
Customizing paperwork for different appointment types
Cut down on check-in time by customizing paperwork for each type of appointment. It may be tempting to give all patients the same paperwork to avoid missing key documents, but giving the same paperwork to every patient regardless of the appointment type is inefficient.
To reduce the amount of unnecessary paperwork for the patient to complete, educate reception and staff on the specific types of paperwork needed for each appointment and, if working with paper, prepare those packets in advance. For example, returning patients may not need to fill out all the paperwork every year; reception can print the patient demographics to be reviewed by the patient and signed upon arrival.
Also, patients who are not using Medicare do not need to sign an Advanced Beneficiary Notice (ABN). For surprises, like a patient who suddenly remembers they want contact lenses, additional forms such as contact lens policies can be stored in the rooms.
First come, first serve
Trying to juggle a patient's arrival time with their appointment time can be a delicate task. Ophthalmologist Husam Ansari, MD, PhD, recommends seeing patients in the order they arrive when possible.7 At first glance, seeing patients in the order they arrive rather than in order of their appointment time may seem unfair, but by doing so you potentially reduce the overall time a patient is in the office.
Make wait times productive. Patients do not need to be idly scrolling on their phones while they wait for the doctor. The optician can use this as an opportunity to build a rapport and speak to a captive audience about what the patient is looking for as far as the style or function of their next pair of glasses.
If the patient is “only getting contacts,” the optician could be showing them sunglasses while informing them of the benefits of purchasing a year's supply of contact lenses from your office. Every short interaction reduces the amount of time the patient is calculating as “wasted time” in an office, and could also translate to increased revenue.
Know when to go
When reception knows that it will be a few minutes before the patient will be taken back, they should let the patient know and suggest that if they need to use the restroom, now would be a good time.
Many patients travel long distances to see their eye doctor, and by the time they get to the office, they need a restroom break, but if they aren’t sure of the amount of time they have, they may not want to risk leaving to use the restroom, lest they miss being called back or holding up the appointment.
One of the aggravating factors of dry eye disease is the use of common diuretic medications, so in a dry eye practice especially, staff needs to be conscious of the amount of time they expect patients to wait between restroom breaks.8
Even if the patient doesn’t necessarily have to go urgently, they may still take the receptionist up on the offer when they learn there is a wait, which could reduce the risk that the patient will need to use the restroom later, during their exam, leaving the doctor to wait for them.
Step 3: Reduce no-shows.
When patients miss their appointments, it disrupts flow. In addition, no-show rates in healthcare account for a tremendous amount of financial loss. One study conducted across multiple hospitals and universities showed no-show rates range between 12 and 80% of all appointments.9
No-shows are due to a number of factors ranging from forgetfulness to cost. A no-show rate of just 12% can cost a practice nearly $90,000 annually. Even if you’re only having one no-show a day at a rate of $100 a visit, that would equal $500 a week, or roughly $23,000 a year, excluding major holidays and weekends.
There are ways to reduce no-shows considerably; for example, a study done by the University of Chicago found that no-show rates drop by 25% when patients receive automated reminder emails, and as much as 40% when a staff member calls to remind the patient directly.10
Where 15 years ago, we may have shied away from email reminders due to an older patient demographic, we now have a patient base that is perfectly capable of communicating with technology. Younger demographics may respond better to text notifications rather than phone calls. Regardless of age, aligning a patient’s notification preference with their appointment reminder type will reduce no-shows and improve patient satisfaction.
Another common reason for missing appointments is financial anxiety. To help ease the fear of a surprise bill, make sure to verify the patient's insurance prior to their appointment. If the appointment is likely to fall outside the realm of vision insurance, communicate this to the patient prior to their appointment. Many patients do not understand the difference between a healthy routine eye exam and a medical eye problem such as dry eye disease.
Make no-shows work for you
Rather than seeing a no-show as purely wasted or lost time, consider it “Found Time.” To make the found time of a missed appointment work for your practice, track your no show rates over the course of a few months. If there is a specific day or time of day when you notice no-shows are at their highest, consider dedicating that time to writing letters and refilling prescriptions.
To systematically reduce no-show rates, calculate the percentage of your appointments that are no-shows and then implement one change, such as increased calls or a reminder email, and then measure the change in no-show rates after a few months. If an additional call or the implementation of a fee does not notably affect no-show rates, it's not worth continuing to waste resources on those methods.
And you can forgo the appointment reminder postcards—a study done by Family Research Journal found that although patients stated they appreciated the cards, they had no actual effect on the rate of missed appointments.11
Step 4: Streamline the checkout process.
Another common bottleneck in practices is check-out. This can be a major point of frustration for patients, especially if they’ve already had a lengthy appointment, so getting them out of the office quickly is critical to maintaining their satisfaction.
One way to help check out is to collect co-pays prior to their workup. If the patient is scheduled for a routine exam or testing, reception should know the minimum amount the patient will owe for services.
Waiting for the doctor at the beginning of the appointment is fairly common, so there may be time to discuss fees with the patient then. Also, make sure optical has their own way of collecting payment, so check-out does not get doubled-up checking out optical orders and exams.
Step 5: Cross-train with purpose.
Just as patients will not always show up when expected, in practice management, we will inevitably be faced with staffing shortages at one time or another. Whether you credit the 5th century Chinese General Sun Tzu, George Washington, or boxer Jack Dempsey, they all agree: “The best offense is a good defense.”
Consider former CEO of the consulting firm IDEO Tim Brown’s T-Shaped method, where an employee has one main area of expertise, but is competent to assist in two other roles if needed. The expertise makes up the larger part of the “T” while the smaller roles are the smaller prongs of the “T.”12
The benefit of thoughtful cross-training and limiting employees' additional roles is that you reduce the risk of resentment over the potential added workload. One of the easiest ways to avoid demotivation is to make sure that your pay scale accounts for the additional skills you’ll be requiring of your staff.
Cross-training also allows for staff to work more collaboratively and understand other’s roles better, which can help foster a team environment. To properly cross-train, start with just one person at a time. Your most senior technician should be the one responsible for training.
Find the area where bottlenecks are at their worst, and train for those areas first. This may be ancillary testing such as visual fields, optical coherence tomography (OCT) imaging, intraocular lens (IOL) calculations, or at the check-in/out reception.
Depending on the size of your practice, it may be beneficial to cross-train someone in reception to do routine patient work-ups. By mindfully training in advance, you show trust in your employees, which encourages autonomy.
A lesson from an efficiency master
Fujio Cho, former president of Toyota Motor Corporation, was named one of Time Magazine's 100 most influential people in 2004 because of his contribution to the Toyota Production System (TPS), which revolutionized the way not just Toyota, but countless other factories operated worldwide.13
One of the keys to the success of TPS is the elimination of waste. As stated in a lecture given during a visit to Kentucky University in 1988, Cho divides the way people spend their time into two categories: Work and Waste. Cho describes “Muda,” a Japanese word roughly meaning “wastefulness” or “uselessness” as "anything other than the minimum amount of equipment, materials, parts, space, and workers time, which are absolutely essential to add value to the product."13
Always consider these key factors when analyzing your practice efficiency. Do you have equipment that is consistently out of order? Are there areas of your practice where machines are bunched together in an inconvenient manner, or out of the way so they’re made obsolete just by nature of how hard it is to get a patient to them?
Consider your favorite exam lane (because almost everyone has one). Why is it your favorite? What are the other lanes lacking, and what do you need to do to make them better? These are problems that every practice encounters, but are often overlooked because day-to-day operations take precedence.
Step 6: Enhance ergonomics
It may sound simple, but put things where they are being used to improve utilization and flow. This means drops and tissues are within reach of the exam chair, extra slit lamp bulbs are kept in the rooms rather than a supply closet on the other side of the office, and samples and educational material are uniformly stocked in each exam lane.
Some practices hesitate to stock samples in the exam lanes for fear of theft, but when drops and wipes are kept in a drawer or cabinet, the risk of theft is relatively low. If theft has been a problem, only keep two or three of each item in the exam cabinet, possibly behind a tissue box, and restock daily.
Having a centralized location for the majority of office supplies and keeping a small amount where they are physically needed helps highlight the most commonly used supplies, as you’ll be refilling them the most often. These supplies should be viewed as high value, and more care should be put into where they’re purchased and how much is spent on them.
If you’re only buying visual field printer paper once every 18 months, but you’re purchasing facial tissue bi-weekly, it stands to reason that getting a good deal on a large order of tissue paper is more valuable than scouring the internet for the best prices on visual field paper.
Improving office workflows to increase practice efficiency
It's not just drops and light bulbs that need to be optimized for ergonomics, but also the doctor. To optimize flow, move the doctor (from room to room), not the patient. This is for several reasons, the biggest reason being that moving patients takes time, but also, especially with our geriatric or low vision patients, any transition from one chair to another increases the risk of a fall.
So rather than moving patients from room to room, when possible, do any ancillary testing on the way to the exam room, and then do the workup and the exam in the same room. When you cannot do testing prior to the doctor seeing the patient, have them review the results with the patient at the machine prior to check out, rather than making the patient go back to the exam room.
This may mean reconfiguring your testing space to have more of an exam room appearance, and adding additional educational material to give to the patient in that space, rather than just in the exam lane.
In addition to being more efficient, patients get to see the results of their testing in a format that is often the highest definition, which is both impressive and can improve education.
Step 7: Simplify office communication
When utilizing a system that moves the doctor rather than the patient, communication is crucial to success. The doctor needs to know where they are going, not just next, but two or three steps ahead. Develop an interoffice communication that works best for your team.
For some offices, this means implementing a flag system on the doors where red could mean “go there next,” black means “needs more time to dilate,” yellow means “go here after red,” etc. If a doctor or technician is consistently getting caught in the room and it disrupts flow, it may help to add a phone in the room, so they can be buzzed out when needed.
Lastly, most medical software has some type of in-software instant messaging system. Using the resources you have to your advantage, you can message the doctor to let them know where they need to go next, or the doctor can message their technicians when they need additional testing.
Final thoughts
Dry eye appointments have a reputation for being complicated and lengthy because dry eye disease is such a complex diagnosis. Just as our patients are one of a kind, to be as efficient as possible, we need to treat the entire dry eye appointment process as one of a kind.
This means paperwork that only relates to the patient in question, reminders designed to best suit their preferences, and questionnaires to target their specific needs. We need to streamline our offices to be as user-friendly as possible, remove or replace old equipment, and train our staff to be resilient against the unexpected.
