his own injection. I asked him about it,
and he said, 'Usually the nurse does it,
but she's busy.' So he was the element
taking up slack in the system, rather
than somebody else taking up slack in
the system. You're taking your most
valuable resource (the physician) and
reducing it to a very common level.
That's not optimizing production."
Improving Communication
Systems
Frequently, increasing productivity
means refining the communication
systems doctors use to interact with
patients and staff.
A common problem occurs when
physicians don't know which exam
room to go to next. They will either
waste time looking for a nurse to point
them in the right direction, Haines said,
or they will wander down the hall,
lifting out charts to look at progress
notes or check-in times.
Haines suggested that a light-signal
system can solve this problem by
indicating which patient is next. Many
such systems are on the market. While
they have been in use for years, Haines
reported that recently they've become
more sophisticated and doctors have
learned to rely on them a lot more.
"Another reason that a doctor
comes out and looks for the nurse
between patients is he wants to give
an oral instruction. So again he goes
hunting for the nurse," Haines continued.
Alternatively, he suggested, a
physician using a communication
system can signal for a nurse, leaving
instructions as to what needs to be
done, and go on the the next patient.
For instance, if a physician wants
to give a patient a hepatitis injection,
"he can check off the injection he
wants, hit the nurse's button, leave the
room, and go to the next patient."
Then the nurse arrives, sees what the
doctor wants done, and prepares the
injection. "The doctor comes out of
the next room, sees the patient is
ready for the shot, goes back in, and
gives the shot. Meanwhile he's picked
up half a patient or so in that process
just by allowing someone else to do
that preparation work."
The light-signal system is a simple
way for the doctor to save time by
minimizing his need to interact with the
nurse between each patient, according
to Haines. The system can also be used
to alert a physician to an important
incoming telephone call, and is much
less disruptive than an intercom.
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Other simple timesaving communication
systems focus omthe doctor's
method for writing progkss notes.
While some physicians handwrite their
progress notes, Haines said there are
better ways to document patient
encounters. "I've seen one general
surgeon who had a checkoff list that
was extremely fast. He had reduced his
progress note down to a series of boxet
that he could check," he said.
Doctors can also save time by
dictating their notes to a "scribe."
According to Haines, "a scribe is
someone who will take your progress
note for you, so that when you go into
the exam room, you don't manage the
chart. All you do is interact with the
patient." Later, the physician can look
over the note produced by the scribe
and sign it, he explained. "That not
only will be a time-saver, but that will
also improve the sense of communication
with a patient. Because you've
started using a scribe, the reason to
break eye contact with a patient is
significantly reduced."
Productivity is also increased by
getting a physician to handle the
patient encounter with just one visit to
the exam room. To make this work,
the doctor must set up certain protocols.
When a patient comes in with a
set of symptoms, the staff should
know which diagnostics need to be
done first. "When the doctor walks in
the room, he's got the patient, the
EKG strip and the x-ray, and he can
manage the whole interaction with
that one visit," Haines said.
Sometimes small changes can
yield big results. Haines recalled one
physician who had a habit of reading
the patient's chart for several minutes
after he stepped into the exam room.
Not only were those minutes nonprcductive,
but the doctor was essentially
ignoring the patient. Haines and his
colleagues suggested an alternative
procedure. "We said, 'have your
technician work the patient up, and
then have that technician wait for you,
and when you're ready to go in that
room, have the technician present the
patient to you much like you presented
the patient to the attending
when you were in medical school.'" In
this instance, the technique of allowing
the technician to brief the physician on
critical issues increased productivity by
at least 66 percent.
Planning for Productivity
Whether you are optimizing
communications systems or designing
or remodeling clinic space, Haines
said, a general rule of thumb is "to
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make the doctor as efficient as pos-
sible." The physician's time is "either
the income generation or the major
significant overhead item in the
practice." Once the doctor's efficiency
is established, the next priority is to
increase staff efficiency, as staff time
can also contribute si@cantly to
overhead.
Haines cited an orthopedic
practice where the doctors' and
residents' discussion area was down
the hall near the x-ray processing area.
"My point was, why are we paying the
doctors and residents to walk down
there to see the x-ray?" he said. "Why
don't we put them centrally where they
don't walk anywhere, and pay the xray
tech to bring the x-rays up?" It all
goes back to setting priorities, he said.
"You're trying to make sure the x-ray
tech is efficient, but at the expense of
the doctors and residents. Our point
was you need to invert that equation."
When designing clinic space,
Haines advocated clustering a
physician's exam rooms close together
so the doctor spends as little time as
possible going back and forth. Haines
also suggested keeping a physician's
office away from the exam rooms, so
the d'bctor can avoid the temptation of
sitting down at a desk. Instead, he
prefers a stand-up dictation station for
physicians, located in an alcove.
Typically, the location of the exam
room cluster should be at the end of
the clinic flow process. If most patients
are going to have an EKG and then go
to an exam room, Haines suggested
placing the EKG area before the exam
room. The goal is to keep a doctor's
hall space from becoming congested
with patients, creating a distraction.
Managing patient traffic is especially
important for high-volume physicians,
whose halls are already filled with their
own patients and patient's families.
Likewise, Haines suggested, keep
the checkout counter away from exam
rooms to minimize physician distrac-
tions. A well-planned clinic should be
laid out so that patients can find the
exit easily without having to ask staff
for directions.
For more information, contact:
Richard Haines, Jr.
Senior Medical Planning Consultant
Productivity By Design
2100 East Exchange Place, Suite 400
Tucker, GA 30084
404-939-1231
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