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Thursday, July 29, 2010

How to improve wait times

Wait times at doctors' offices are an often complained about phenomenon. We on the provider side have many reasons for our long wait times, but patients don’t often care about or accept these reasons. One component of the TransforMed national demonstration project (NDP) involved measuring cycle time (the total time a patient spends at the doctor’s office) and then working on shortening it. At the time of the NDP, there were not any “industry standards” on what a good cycle time should be, but two to three hours at the doctor's office is clearly not acceptable. What can be done to reduce wait times?

As usual, we started with a survey. Each patient was given a clipboard and a pen when entering the office and was asked to record the time at each point in their visit. Patients are quite honest about their time. Having our patients complete the survey communicated that being on time is actually important to the practice and that we value their help in making wait times better. This alone can help patients' perception of wait times.

Our survey looked like this:

Time you arrive at office: ___
Time nurse brings you to exam room: ___
Time doctor enters the room: ___
Time doctor leaves the room: ___
Time you leave the office: ___

The practice can then tabulate the total time the patient spends in the office. It will be longer, of course, if the patient is having ancillary testing such as labs or x-rays done on site. The quick survey will also help to identify bottlenecks in patient flow. It is a good idea to do the surveys on a few different days or even weeks. Patient flow patterns can markedly change from day to day for a variety of reasons such as physician absence, community illness prevalence, equipment malfunction or just one particular patient.

The next step is acting upon the survey results. Use team meetings to brainstorm reasons why the bottlenecks may occur, or have staff trail a few patients through their visit. Better yet, consider asking patients directly. Once the reasons for delays are discovered, have staff members involved in that portion of the visit come up with solutions to fix the problem. Set deadlines for implementation of changes to fix the flow issues. Then, repeat the survey to make sure the cycle time has improved.

The best practice in the NDP was able to achieve 30-minute cycle times. That practice did not perform any ancillary services on site. They were able to achieve a 30-minute cycle time by working closely in teams. They even designed their office space to put all team members, from front-office staff to physicians, in close proximity, which encouraged ongoing communication throughout the day. They started on time. They staffed appropriately and scheduled realistically for the work capacity of the day. And they made being on time a priority.

Friday, July 9, 2010

Medical home implementation: "How do we get started?"

Transitioning to the medical home can be a daunting process. What should a practice do first? How do we get started? To answer these questions, practice leaders will need to take a good hard look at the current state of the practice. One practice may discover that wait times are the bane of the practice. It would then make sense to begin with open-access scheduling. Another practice may wonder why its rate of payment on claims is so low. It may want to start with an investigation into billing and coding.

Surveying staff or, better yet, surveying patients are excellent ways to help shape an agenda. There may be aspects of the practice that have not worked well for a long time and just need some time and attention to fix. Asking your customers can help you prioritize what to do first. For example, one practice developed a survey to assess patients’ readiness for online services.

During our experience in the TransforMed national demonstration project (NDP), we held staff project meetings and discussed at length where we should begin. We did not make any decisions until we had learned what it would mean to implement each component of the medical home. We ultimately decided to create a web site and start virtual office visits. We already had an electronic medical record, which we were very comfortable with, so implementing another IT project was not hard. See “Our implementation of virtual office visits” in this series to see exactly how we did this. We used a patient survey to pick topics and set prices for the virtual office visits.

For any project you are considering taking on, be sure to develop time and cost estimates up front. It is also important to take breaks between big implementation projects. TransforMed facilitators like to describe the transformation process as progressing in “fits and starts.” Breaks are needed to recover, regroup and recharge after a lot of practice time and energy have been put into making innovative changes.

Spreading ownership of change is also a good strategy to help in prioritization. If a staff member is particularly passionate about an element of the medical home, let that person take charge. You may even want to survey staff about their interests and time availability to help with the change process. Understanding and communicating the true amount of resources necessary for a particular project is critical. The AAFP has recently posted an excellent step-by-tiny-step guide to implementing medical home components.

In the end, the decision about which components of the medical home model to implement first, second, third, etc. is very individualized. No two practices in the NDP followed the same path. This is one of the important lessons learned from the NDP.

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About the Author

Melissa Gerdes, MD, is a family physician practicing at Methodist Family Health Center – South Arlington in Arlington, Texas, and former president of the Texas Academy of Family Physicians.

Note: This blog is no longer updated; this is archived content.

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Real-Life Practice Transformation is a Family Practice Management (FPM) blog. However, the views expressed here are those of the individual authors. They do not necessarily reflect the opinion of FPM or the AAFP. The FPM blogs are not intended to provide medical, financial or legal advice. For more information see Terms of Use.