Elizabeth W. Woodcock, MBA, CPC

4 reasons claims are denied

1 The payer includes it in a global package

2 Lack of preauthorization

3 Payer assumes the claim is a duplicate

4 Registration process involved an error

It’s the end of another long day, and your billing manager is in tears. For the third time this month, she is frustrated about the overwhelming amount of work in the billing office. “The staff simply can’t keep up!” she exclaims.

She wants to hire another biller. But you have spent considerable time the past few months brushing up on your coding expertise and renegotiating contracts with your key payers. So why has the billing workload increased so much? Why is your staff overwhelmed?

The problem isn’t limited to your practice. All types of medical practices face increased workloads in their billing offices. Quite often, the added work is from a single source—claim denials. If your billing office always seems overwhelmed, check the volume and types of denied claims. Many of the problems are preventable.

The solution to denials is not always to hire more staff. Too often, the billing staff focuses on managing denials after they happen, but that’s a losing game. Your first line of defense is to fix the problems that cause denials. Then identify strategies to prevent the denials and manage them when they do occur.

1Don’t accept bundling of stand-alone services

Many codes encompass a predetermined period before, during, and after the service you provide. ObGyns are most familiar with the coding for deliveries. For example, a claim for a service coded 59510 includes all routine obstetric care, be it antepartum, postpartum, or the cesarean delivery itself.

If this seems cut and dried, think again. What if the patient returns a week after discharge with a minor infection in the wound site? You’d document your service and bill for an appropriate-level office visit. Despite its merit, that claim might be denied and returned, marked with words such as “inclusive,” “global period,” or “bundled.” Regardless of the exact language, the payer is saying that payment for the service was included in another payment it made.

Train staff to question denials

In many practices, staffers simply accept denials. They write off the charge as a contractual adjustment for that payer, and the money is gone—even though you deserved it! Although many services you provide during a pregnancy can be legitimately included with other procedure codes, this one—and perhaps others you bill—is not one of those bundled services.

Two terms are important: global period and bundling of multiple services.

Global period is the time (0, 10, or 90 days, for example) during which any services you provide are included in the payment for the service. For obstetric services, that period includes antepartum, delivery, and postpartum care. For gynecologic surgeries, the period varies by the surgery. These periods of time—often called “globals”—are established by the Centers for Medicare and Medicaid Services (CMS) and are published annually in the Resource-based Relative Value Scale.

Bundling means that 1 service is identified as the primary service, and any additional services during the same session are included in the payment. That is, you get paid for the primary service only. CMS publishes a list of primary procedures and the procedures secondary to them in its Correct Coding Initiative, which is updated quarterly. However, many payers establish their own bundling rules.

Note when the global period begins. Let’s return to the example of the global obstetric package. Services rendered during this period are often bundled. Often, even if it is coded appropriately (ie, separately), the first encounter is included in the package payment. ACOG attempted to clarify this situation last October, when it observed, “If a patient presents with signs or symptoms of pregnancy and the patient is there to confirm pregnancy, this visit may be reported with the appropriate level of E/M services code. However, if the OB record is initiated at this visit, then the visit becomes part of the global OB package and is not billed separately.” In fact, the visit becomes part of the global OB package whenever the OB record is started at this time, even if the physician is confirming a pregnancy diagnosed by another source.

Services that are often billed separately but considered inclusive by many payers:

• annual preventive exams, which may include a related problem-focused visit and/or related lab tests; and
• global obstetric packages, which may include ultrasounds, nonstress tests, and routine Pap smears.

ACTION PLAN

To manage denials for inclusion, require each payer to outline its rules about bundling for the services you commonly bill. For example, ask the payer to list the services included in the global obstetric package, and get it in writing. Then train yourself and your staff on what’s included—and what’s not.

Have your staff flag denials that can be appealed, and offer to dictate a letter, if necessary, explaining when services you performed were coded and billed appropriately as 2 (or more) distinct services.

2Make preauthorization top priority

Some payers require preauthorization for specific services. A common example is amniocentesis. Ask your billing staff to alert you to any claim denied for lack of preauthorization, precertification, or referral approval. Although appeals of these denials after the fact are often unsuccessful, you should usually make the attempt anyway. For example, if your patient did not provide accurate information about her coverage, you may have unknowingly failed to obtain the necessary authorization or billed the wrong insurance company. Even though it is too late to obtain the authorization after the service is rendered, write an appeal letter for this type of denial. Explain to the payer that the patient failed to disclose the correct insurance coverage; thus, you were not able to follow its rules.

ACTION PLAN

For services you commonly render, make a list of the payers that require authorizations. When the service is ordered, check that list to determine whether preauthorization is necessary. Better yet, summarize those common services and the patient’s benefit coverage in the patient’s paper or electronic chart. If services are denied, consider appealing the decision.

3Stop “duplicate billing” denials

Some claims are denied because the payer concludes it is a duplicate. This may happen if you mistakenly send a claim more than once; at other times, the patient actually had similar services performed, but the payer mistakes them for a single service.

For example, a patient presents with a urinary tract infection (UTI) twice in the same week. You appropriately code your level of service for the encounters, which may be code 99213 in both cases, and attach a diagnosis of UTI. The payer may not spot the different date for the second service, and mistakenly assumes the second is a duplicate.

ACTION PLAN

Put your staff on alert for inappropriate denials based on duplication. Appeal these denials for payment and point out in the appeal that the services were rendered and accurately coded and billed.

Your staff could be a cause of high denial rates. Perhaps they simply resubmit claims without considering the situation, or fail to attach new information to the resubmitted denial to help the payer understand that it is not a duplicate claim. Unfortunately, it is common for unproductive or unknowledgeable staff to simply rebill claims as they work open or denied claims.

Before you rebill a claim, it is important to evaluate the account carefully. Determine the status of an open claim before resubmitting it.

For a denied claim, fix the problem or attach an explanation—instead of making the same mistake twice. If that’s the case, you’ll just get a denial for a duplicate claim, no payment, and more work to do.

4Get the registration right

Many ObGyn practices are plagued by registration-related errors that translate into claim denials. If the registration process is inaccurate, even by a single keystroke, the claim will be denied. Common registration-related denials include: “subscriber not eligible on the date of service” and “subscriber not identified.”

ACTION PLAN

Be a stickler. Track down staffers who make mistakes and show them what they are doing wrong; otherwise, they’ll just keep making errors. At each patient encounter, or at least every 3 months, verify insurance and eligibility—with both patient and the payer. Use payers’ Web sites to confirm coverage.

4 reasons claims are denied

1 The payer includes it in a global package

2 Lack of preauthorization

3 Payer assumes the claim is a duplicate

4 Registration process involved an error

It’s the end of another long day, and your billing manager is in tears. For the third time this month, she is frustrated about the overwhelming amount of work in the billing office. “The staff simply can’t keep up!” she exclaims.

She wants to hire another biller. But you have spent considerable time the past few months brushing up on your coding expertise and renegotiating contracts with your key payers. So why has the billing workload increased so much? Why is your staff overwhelmed?

The problem isn’t limited to your practice. All types of medical practices face increased workloads in their billing offices. Quite often, the added work is from a single source—claim denials. If your billing office always seems overwhelmed, check the volume and types of denied claims. Many of the problems are preventable.

The solution to denials is not always to hire more staff. Too often, the billing staff focuses on managing denials after they happen, but that’s a losing game. Your first line of defense is to fix the problems that cause denials. Then identify strategies to prevent the denials and manage them when they do occur.

1Don’t accept bundling of stand-alone services

Many codes encompass a predetermined period before, during, and after the service you provide. ObGyns are most familiar with the coding for deliveries. For example, a claim for a service coded 59510 includes all routine obstetric care, be it antepartum, postpartum, or the cesarean delivery itself.

If this seems cut and dried, think again. What if the patient returns a week after discharge with a minor infection in the wound site? You’d document your service and bill for an appropriate-level office visit. Despite its merit, that claim might be denied and returned, marked with words such as “inclusive,” “global period,” or “bundled.” Regardless of the exact language, the payer is saying that payment for the service was included in another payment it made.

Train staff to question denials

In many practices, staffers simply accept denials. They write off the charge as a contractual adjustment for that payer, and the money is gone—even though you deserved it! Although many services you provide during a pregnancy can be legitimately included with other procedure codes, this one—and perhaps others you bill—is not one of those bundled services.

Two terms are important: global period and bundling of multiple services.

Global period is the time (0, 10, or 90 days, for example) during which any services you provide are included in the payment for the service. For obstetric services, that period includes antepartum, delivery, and postpartum care. For gynecologic surgeries, the period varies by the surgery. These periods of time—often called “globals”—are established by the Centers for Medicare and Medicaid Services (CMS) and are published annually in the Resource-based Relative Value Scale.

Bundling means that 1 service is identified as the primary service, and any additional services during the same session are included in the payment. That is, you get paid for the primary service only. CMS publishes a list of primary procedures and the procedures secondary to them in its Correct Coding Initiative, which is updated quarterly. However, many payers establish their own bundling rules.

Note when the global period begins. Let’s return to the example of the global obstetric package. Services rendered during this period are often bundled. Often, even if it is coded appropriately (ie, separately), the first encounter is included in the package payment. ACOG attempted to clarify this situation last October, when it observed, “If a patient presents with signs or symptoms of pregnancy and the patient is there to confirm pregnancy, this visit may be reported with the appropriate level of E/M services code. However, if the OB record is initiated at this visit, then the visit becomes part of the global OB package and is not billed separately.” In fact, the visit becomes part of the global OB package whenever the OB record is started at this time, even if the physician is confirming a pregnancy diagnosed by another source.

Services that are often billed separately but considered inclusive by many payers:

• annual preventive exams, which may include a related problem-focused visit and/or related lab tests; and
• global obstetric packages, which may include ultrasounds, nonstress tests, and routine Pap smears.

ACTION PLAN

To manage denials for inclusion, require each payer to outline its rules about bundling for the services you commonly bill. For example, ask the payer to list the services included in the global obstetric package, and get it in writing. Then train yourself and your staff on what’s included—and what’s not.

Have your staff flag denials that can be appealed, and offer to dictate a letter, if necessary, explaining when services you performed were coded and billed appropriately as 2 (or more) distinct services.

2Make preauthorization top priority

Some payers require preauthorization for specific services. A common example is amniocentesis. Ask your billing staff to alert you to any claim denied for lack of preauthorization, precertification, or referral approval. Although appeals of these denials after the fact are often unsuccessful, you should usually make the attempt anyway. For example, if your patient did not provide accurate information about her coverage, you may have unknowingly failed to obtain the necessary authorization or billed the wrong insurance company. Even though it is too late to obtain the authorization after the service is rendered, write an appeal letter for this type of denial. Explain to the payer that the patient failed to disclose the correct insurance coverage; thus, you were not able to follow its rules.

ACTION PLAN

For services you commonly render, make a list of the payers that require authorizations. When the service is ordered, check that list to determine whether preauthorization is necessary. Better yet, summarize those common services and the patient’s benefit coverage in the patient’s paper or electronic chart. If services are denied, consider appealing the decision.

3Stop “duplicate billing” denials

Some claims are denied because the payer concludes it is a duplicate. This may happen if you mistakenly send a claim more than once; at other times, the patient actually had similar services performed, but the payer mistakes them for a single service.

For example, a patient presents with a urinary tract infection (UTI) twice in the same week. You appropriately code your level of service for the encounters, which may be code 99213 in both cases, and attach a diagnosis of UTI. The payer may not spot the different date for the second service, and mistakenly assumes the second is a duplicate.

ACTION PLAN

Put your staff on alert for inappropriate denials based on duplication. Appeal these denials for payment and point out in the appeal that the services were rendered and accurately coded and billed.

Your staff could be a cause of high denial rates. Perhaps they simply resubmit claims without considering the situation, or fail to attach new information to the resubmitted denial to help the payer understand that it is not a duplicate claim. Unfortunately, it is common for unproductive or unknowledgeable staff to simply rebill claims as they work open or denied claims.

Before you rebill a claim, it is important to evaluate the account carefully. Determine the status of an open claim before resubmitting it.

For a denied claim, fix the problem or attach an explanation—instead of making the same mistake twice. If that’s the case, you’ll just get a denial for a duplicate claim, no payment, and more work to do.

4Get the registration right

Many ObGyn practices are plagued by registration-related errors that translate into claim denials. If the registration process is inaccurate, even by a single keystroke, the claim will be denied. Common registration-related denials include: “subscriber not eligible on the date of service” and “subscriber not identified.”

ACTION PLAN

Be a stickler. Track down staffers who make mistakes and show them what they are doing wrong; otherwise, they’ll just keep making errors. At each patient encounter, or at least every 3 months, verify insurance and eligibility—with both patient and the payer. Use payers’ Web sites to confirm coverage.

4 reasons claims are denied

1 The payer includes it in a global package

2 Lack of preauthorization

3 Payer assumes the claim is a duplicate

4 Registration process involved an error

It’s the end of another long day, and your billing manager is in tears. For the third time this month, she is frustrated about the overwhelming amount of work in the billing office. “The staff simply can’t keep up!” she exclaims.

She wants to hire another biller. But you have spent considerable time the past few months brushing up on your coding expertise and renegotiating contracts with your key payers. So why has the billing workload increased so much? Why is your staff overwhelmed?

The problem isn’t limited to your practice. All types of medical practices face increased workloads in their billing offices. Quite often, the added work is from a single source—claim denials. If your billing office always seems overwhelmed, check the volume and types of denied claims. Many of the problems are preventable.

The solution to denials is not always to hire more staff. Too often, the billing staff focuses on managing denials after they happen, but that’s a losing game. Your first line of defense is to fix the problems that cause denials. Then identify strategies to prevent the denials and manage them when they do occur.

1Don’t accept bundling of stand-alone services

Many codes encompass a predetermined period before, during, and after the service you provide. ObGyns are most familiar with the coding for deliveries. For example, a claim for a service coded 59510 includes all routine obstetric care, be it antepartum, postpartum, or the cesarean delivery itself.

If this seems cut and dried, think again. What if the patient returns a week after discharge with a minor infection in the wound site? You’d document your service and bill for an appropriate-level office visit. Despite its merit, that claim might be denied and returned, marked with words such as “inclusive,” “global period,” or “bundled.” Regardless of the exact language, the payer is saying that payment for the service was included in another payment it made.

Train staff to question denials

In many practices, staffers simply accept denials. They write off the charge as a contractual adjustment for that payer, and the money is gone—even though you deserved it! Although many services you provide during a pregnancy can be legitimately included with other procedure codes, this one—and perhaps others you bill—is not one of those bundled services.

Two terms are important: global period and bundling of multiple services.

Global period is the time (0, 10, or 90 days, for example) during which any services you provide are included in the payment for the service. For obstetric services, that period includes antepartum, delivery, and postpartum care. For gynecologic surgeries, the period varies by the surgery. These periods of time—often called “globals”—are established by the Centers for Medicare and Medicaid Services (CMS) and are published annually in the Resource-based Relative Value Scale.

Bundling means that 1 service is identified as the primary service, and any additional services during the same session are included in the payment. That is, you get paid for the primary service only. CMS publishes a list of primary procedures and the procedures secondary to them in its Correct Coding Initiative, which is updated quarterly. However, many payers establish their own bundling rules.

Note when the global period begins. Let’s return to the example of the global obstetric package. Services rendered during this period are often bundled. Often, even if it is coded appropriately (ie, separately), the first encounter is included in the package payment. ACOG attempted to clarify this situation last October, when it observed, “If a patient presents with signs or symptoms of pregnancy and the patient is there to confirm pregnancy, this visit may be reported with the appropriate level of E/M services code. However, if the OB record is initiated at this visit, then the visit becomes part of the global OB package and is not billed separately.” In fact, the visit becomes part of the global OB package whenever the OB record is started at this time, even if the physician is confirming a pregnancy diagnosed by another source.

Services that are often billed separately but considered inclusive by many payers:

• annual preventive exams, which may include a related problem-focused visit and/or related lab tests; and
• global obstetric packages, which may include ultrasounds, nonstress tests, and routine Pap smears.

ACTION PLAN

To manage denials for inclusion, require each payer to outline its rules about bundling for the services you commonly bill. For example, ask the payer to list the services included in the global obstetric package, and get it in writing. Then train yourself and your staff on what’s included—and what’s not.

Have your staff flag denials that can be appealed, and offer to dictate a letter, if necessary, explaining when services you performed were coded and billed appropriately as 2 (or more) distinct services.

2Make preauthorization top priority

Some payers require preauthorization for specific services. A common example is amniocentesis. Ask your billing staff to alert you to any claim denied for lack of preauthorization, precertification, or referral approval. Although appeals of these denials after the fact are often unsuccessful, you should usually make the attempt anyway. For example, if your patient did not provide accurate information about her coverage, you may have unknowingly failed to obtain the necessary authorization or billed the wrong insurance company. Even though it is too late to obtain the authorization after the service is rendered, write an appeal letter for this type of denial. Explain to the payer that the patient failed to disclose the correct insurance coverage; thus, you were not able to follow its rules.

ACTION PLAN

For services you commonly render, make a list of the payers that require authorizations. When the service is ordered, check that list to determine whether preauthorization is necessary. Better yet, summarize those common services and the patient’s benefit coverage in the patient’s paper or electronic chart. If services are denied, consider appealing the decision.

3Stop “duplicate billing” denials

Some claims are denied because the payer concludes it is a duplicate. This may happen if you mistakenly send a claim more than once; at other times, the patient actually had similar services performed, but the payer mistakes them for a single service.

For example, a patient presents with a urinary tract infection (UTI) twice in the same week. You appropriately code your level of service for the encounters, which may be code 99213 in both cases, and attach a diagnosis of UTI. The payer may not spot the different date for the second service, and mistakenly assumes the second is a duplicate.

ACTION PLAN

Put your staff on alert for inappropriate denials based on duplication. Appeal these denials for payment and point out in the appeal that the services were rendered and accurately coded and billed.

Your staff could be a cause of high denial rates. Perhaps they simply resubmit claims without considering the situation, or fail to attach new information to the resubmitted denial to help the payer understand that it is not a duplicate claim. Unfortunately, it is common for unproductive or unknowledgeable staff to simply rebill claims as they work open or denied claims.

Before you rebill a claim, it is important to evaluate the account carefully. Determine the status of an open claim before resubmitting it.

For a denied claim, fix the problem or attach an explanation—instead of making the same mistake twice. If that’s the case, you’ll just get a denial for a duplicate claim, no payment, and more work to do.

4Get the registration right

Many ObGyn practices are plagued by registration-related errors that translate into claim denials. If the registration process is inaccurate, even by a single keystroke, the claim will be denied. Common registration-related denials include: “subscriber not eligible on the date of service” and “subscriber not identified.”

ACTION PLAN

Be a stickler. Track down staffers who make mistakes and show them what they are doing wrong; otherwise, they’ll just keep making errors. At each patient encounter, or at least every 3 months, verify insurance and eligibility—with both patient and the payer. Use payers’ Web sites to confirm coverage.

As reimbursement plummets and expenses rise, the options to improve your practice’s profits may seem more limited than ever—either you see more patients or spend less time with the ones you have. There is another option, which is often overlooked: Reduce the constraints on your time by improving your efficiency.

This article outlines 10 practical steps you can take to streamline your practice.

1. Manage the psychology of waiting

The link between patient wait times and practice efficiency may not be immediately apparent, but it does exist. When a patient feels you have kept her waiting unnecessarily, she may conclude that you have no respect for her or her time.

This perception can lead to situations in which you must spend time fielding complaints and making apologies and explanations in the exam room. Although such “service recovery” may consume only a minute of your time, it takes precious minutes away from your efficiency.

Keep patients informed about extended waits

Instruct your staff to inform patients of longer-than-usual waiting times when they first arrive at the office for their appointment. Maister and colleagues found that patients perceive waiting to be longer than it actually is when they are uninformed, uncomfortable, and unoccupied.

Update patients about delays every 15 minutes. Consider asking a member of your clinical team to address the issue if the wait exceeds 30 minutes. Explain lengthy delays, and give patients the choice of waiting or rescheduling. This attention to communication makes patients feel you value their time, too.

Waiting room comforts, personal touches, entertainment

Pay attention to comfort issues such as chairs, room temperature, and back-ground music. Review pre- and post-exam dressing protocols, and make sure to stock extra-large gowns for patients who may need them.

Make your waiting room a delight

Some creative but tasteful ideas to brighten the reception area include hanging artwork from your personal collection or from local artists, many of whom are happy to display their work in exchange for the exposure (place their business cards discreetly next to the work). Other ideas:

• Baby pictures of you and your staff
• Pictures of you at your hobby or with your family
• Interesting memorabilia
• Jigsaw or crossword puzzles, word searches, and other lap games (you can create your own using Web sites such as www.teach-nology.com)
• Personal computers with Internet access
• Free long-distance on available phones (restricted to domestic calls only)
• A diverse magazine collection for patients and their partners
• Pagers to allow patients to walk to nearby shops if delays are lengthy
• Notepads and envelopes for patients to write a letter or 2 (consider offering to stamp and mail completed letters)
• Brochures about services you offer

In short, comfort and entertain your patients, and you can turn the potentially negative situation of waiting into a delight.

2. Review charts in advance

A failure to review charts prior to seeing patients can limit your efficiency, add to your frustration, and give patients the impression that your practice is disorganized.

Tell your staff that chart preparation is a high priority. Require that all charts be previewed 1 or 2 days before patients are seen. Let staff know you expect them to include in the chart the results of tests you ordered at the last exam, communications from physicians to whom you referred the patient, and relevant operative reports.

Don’t overlook billing issues

In addition to the clinical review, an administrative review of a chart in advance of the visit can ensure that your efficiency and good care will be remunerated.

Assign a biller to review your charts for insurance verification and benefits eligibility. He or she also can note any accounts with outstanding balances, and evaluate and resolve any outstanding referral or authorization problems.

Check samples and supplies

As a corollary to chart preparation, assign a staff member to ensure that the pharmaceutical sample closet has adequate supplies for the following day, and review equipment and supplies to see what needs to be ordered.

Red-sticker the low inventory items. To make it easier for staff to spot low inventory, provide small red adhesive flags for them to stick on shelves (or remaining stock) when supplies run low. Appoint a staff member to make the rounds of exam rooms and closets to identify the flags, restock, and order any necessary supplies. Items should not be allowed to run out.

3. Ready the room

A well-prepared exam room means you can care for patients without unnecessary delays. Rooms should be cleaned between—not in front of—patients, and staff should ensure that supplies and equipment are readily available.

A quick and easy tip for equipment preparation is to draw an outline of the equipment in the base of the drawer, or hang a hook on the wall for each piece. That makes it easy to see at a glance whether something is missing—and you’ll always know where to look for the equipment.

If physicians change rooms (eg, at lunch), make sure that the staff knows to restock personalized items such as notepads and prescription pads.

4. Create a start-of-the-day checklist

Provide a written description of what you expect your staff to have accomplished by the start of the clinic. The list may instruct them to:

• Ensure cleanliness of the clinic
• Turn on computers, including those in exam rooms
• Contact the hospital for overnight admissions and cross-match with your schedule
• Review all schedules to anticipate problems
• Evaluate inventory of supplies and equipment in the clinic and each exam room
• Gather and organize incoming results from email and fax machines
• Ready equipment

5. Huddle with your staff

Commit 5 minutes every morning to huddle with your staff, using your schedule as the agenda. At a minimum, ask your clinical assistant and scheduler to be present.

This huddle is not a meeting. It’s about setting the game plan for the day. Consider the analogy of a football team: The quarterback huddles with his teammates before every play. The team members have practiced the play and are prepared to execute it, but the opposing team creates some dynamics they need to plan for. Your day is similar: You and your team are prepared, but every patient poses a challenge to the routine plan. Predict and prepare for that challenge and you’re more apt to be efficient at managing it. Start huddles a few minutes before the clinic begins.

The huddle is your opportunity to anticipate problems—and solve them before they happen. Don’t let the day control you; predict problems and manage them proactively.

Let’s consider a couple of examples that are a daily occurrence in ObGyn offices, yet wreak havoc in practice efficiency:

The situation: Too few slots for acute needs

Several patients call at 8:15 AM with acute needs that must be handled today in the office. The scheduler has to guess where to direct them. You delivered Mrs. Smith’s baby at 2 AM this morning, yet she is still on your partner’s schedule for 9:30 AM today.

The game plan: The huddle reveals that Mrs. Smith won’t be presenting for her 40-week antepartum visit; 2 patients with acute needs can be scheduled during her now-open slot.

The situation: 3 patients with depression are scheduled for the same slot

Three patients, all in their 50s and all with a history of depression, were scheduled for annual well-woman visits at 10 AM. At 10:05, you’re looking for someone to blame for the scheduling mistake that will cost you—and the rest of your patients—dearly that day.

The game plan: Holding the huddle in advance of the clinic reveals that 3 patients were mistakenly scheduled at the same hour. Decisions are made about where and how to accommodate the patients elsewhere in the schedule. A decision is made to contact 1 or 2 of the patients immediately and ask them to reschedule.

6. Establish intake protocols

An efficient ObGyn knows that, when he or she walks into an exam room, the patient is ready to be seen. Intake protocols tend to vary with the style of practice, but it is wise to set minimum expectations for the following intake activities based on the patient’s chief complaint:

• Documentation of chief complaint and symptoms
• Position of patient; for example, seated or on the exam table
• Dress of patient
• Vital signs
• Date of last menstrual period
• Urine sample
• Standing orders for laboratory or other tests
• Current medications and refills needed
• History

Train staff to anticipate needs

Teach your clinical assistant to anticipate needs for each patient. For example, if a 50-year-old is presenting for her well-woman exam, your assistant should anticipate completing the administrative portions of the mammogram requisition form in advance of the exam.

The power of a simple introduction

Although it might seem the intuitive thing to do, make sure your clinical assistant introduces herself to the patient, provides an overview of her role, and briefly describes the course of the encounter. Thus informed, the patient will be less anxious about the few minutes she may spend waiting for you after your clinical assistant leaves the room.

7. Ask the patient about other concerns—first

Your first step with a patient should be introducing yourself (if she is new) or greeting her warmly (if she is an established patient). A handshake often is appropriate, or a gentle touch of the shoulder.

You might also consider including a place in your charts to record personal notes about the patient, such as a hobby or pet. Exhibit care and concern for your patients, and they will be relaxed and ready to begin the encounter.

To start the exam efficiently, and avoid having the patient withhold important questions until the end of the visit, direct the conversation as follows: “Ms. Jones, I see that you’re here because of painful cramps. Is there anything else that you would like for us to address today?”

If the patient raises an issue that can’t be managed in the time allotted for the visit, tell her the issue is so important you’ll need to schedule another visit in order to address it adequately.

Using the patient’s chief complaint and any other issues that have been raised as a starting point, commence the exam. Make eye contact with the patient whenever possible and keep her informed about your actions during the physical exam.

8. Do the documentation immediately

When the exam is completed, document the encounter. Consider dictating in front of your patient. This strategy can be advantageous because the patient will hear your advice repeated and will be able to provide any clarification needed. You can also document that the note was “dictated in the presence of the patient” this notation is a good way to reduce medicolegal risk. Finally, completing the record before you move on to the next patient means you won’t end up spending extra time at the end of the day recalling that encounter along with all the others.

9. Multitask between patients

Ask your clinical assistant to bring you any outstanding messages and test results so you can review them between patients. Processing work on a real-time basis means less work will be waiting for you at the end of the day. It will save staff time from constantly sorting and re-prioritizing an ever-higher number of messages and tasks accumulating as the day wears on.

The problem with batching

If you batch work until the end of the day, your staff is forced to constantly reorganize the workflow throughout the day, as well as manage all incoming communication from patients. If patients could be counted on to call only once and patiently wait for your response, batching would be more palatable. But when their messages remain unaddressed until the end of the day, chances are that some number of anxious patients will call back.

Batching these communications also increases the odds that your staff’s return calls will be missed. If it seems that your staff is in the phone room most of the day instead of helping you in the clinic, batched communications may be the culprit.

Performing tasks as time permits helps you avoid confronting a big stack of work at the end of the day. This stack is often left to the next day, which means that your team begins every day working in the past. They will try to handle at least some of those messages in the morning hours, which makes it very likely that today’s clinic will fall behind schedule before it even starts.

Avoid batching work by conscientiously reviewing the day’s work as it develops. Tell staff members what they can do to help manage the work, such as completing the administrative portions of Family and Medical Leave Act forms before passing them along to you. Order inked stamps that bear the information you find yourself writing repeatedly. Consider taking a speed-reading course to help you review documents efficiently and effectively.

10. Count your steps

Put a pedometer on your belt during your next clinic, and you’ll be amazed to discover how much walking you do. Although the exercise is wonderful, unnecessary steps reduce your efficiency.

Pay attention to where you walk in the exam room and why. If you have to walk to reach the trash can, put it where you can dispose of garbage without walking. If you have to walk to reach equipment, place those tools nearby. If you have to walk to your office to dictate, invest in a portable machine or a shelf in the hallway that can be used as a workstation.

Watch your steps; saving even 3 or 4 steps per patient will, over the course of the day, improve your efficiency.

Why efficiency matters

The operations of an ObGyn practice are undoubtedly complex; don’t let this complexity overwhelm your efforts to improve efficiency. Even small improvements can quickly add up to a major savings of time.

Efficiency means you can spend more time with each patient, see more patients, or just get home and enjoy some personal time.

The author reports no financial relationships relevant to this article.

Suggested Reading

Delio S. The Efficient Physician: 7 Guiding Principles for a Tech-Savvy Practice. Englewood, Colo: Medical Group Management Association; 2004.

Fitzsimmons JA, Fitzsimmons MJ. Service Management: Operations, Strategy, and Information Technology. New York: McGraw-Hill; 1998.

Goldratt EM, Cox J. The Goal. Great Barrington, Mass: North River Press; 1985.

Heskett JL, Sasser WE Jr, Schlesinger LA. The Service Profit Chain. New York: Free Press; 1997.

Maister DH. The psychology of waiting lines. In: Czepiel JA, Solomon MR, Suprenant CF, eds. The Service Encounter: Managing Employee-Customer Interaction in Service Businesses. Lanham, Md: Lexington Books; 1985. www.davidmaister.com.

Mozena JP, Black SC, Emerick CE. Stop Managing Costs. Milwaukee: American Society for Quality; 1999.

Nolan TW. Reducing Delays and Waiting Times Throughout the Healthcare System. Cambridge, Mass: Institute for Healthcare Improvement; 1996.

Womack JP, Jones DT. Lean Thinking. New York: Simon & Schuster; 1996.

Woodcock EW. Mastering Patient Flow: More Ideas to Increase Efficiency and Earnings. 2nd ed. Englewood, Colo: Medical Group Management Association; 2004.

Zaslove MO. The Successful Physician: A Productivity Handbook for Practitioners. New York: Aspen Publishers; April 1998.

As reimbursement plummets and expenses rise, the options to improve your practice’s profits may seem more limited than ever—either you see more patients or spend less time with the ones you have. There is another option, which is often overlooked: Reduce the constraints on your time by improving your efficiency.

This article outlines 10 practical steps you can take to streamline your practice.

1. Manage the psychology of waiting

The link between patient wait times and practice efficiency may not be immediately apparent, but it does exist. When a patient feels you have kept her waiting unnecessarily, she may conclude that you have no respect for her or her time.

This perception can lead to situations in which you must spend time fielding complaints and making apologies and explanations in the exam room. Although such “service recovery” may consume only a minute of your time, it takes precious minutes away from your efficiency.

Keep patients informed about extended waits

Instruct your staff to inform patients of longer-than-usual waiting times when they first arrive at the office for their appointment. Maister and colleagues found that patients perceive waiting to be longer than it actually is when they are uninformed, uncomfortable, and unoccupied.

Update patients about delays every 15 minutes. Consider asking a member of your clinical team to address the issue if the wait exceeds 30 minutes. Explain lengthy delays, and give patients the choice of waiting or rescheduling. This attention to communication makes patients feel you value their time, too.

Waiting room comforts, personal touches, entertainment

Pay attention to comfort issues such as chairs, room temperature, and back-ground music. Review pre- and post-exam dressing protocols, and make sure to stock extra-large gowns for patients who may need them.

Make your waiting room a delight

Some creative but tasteful ideas to brighten the reception area include hanging artwork from your personal collection or from local artists, many of whom are happy to display their work in exchange for the exposure (place their business cards discreetly next to the work). Other ideas:

• Baby pictures of you and your staff
• Pictures of you at your hobby or with your family
• Interesting memorabilia
• Jigsaw or crossword puzzles, word searches, and other lap games (you can create your own using Web sites such as www.teach-nology.com)
• Personal computers with Internet access
• Free long-distance on available phones (restricted to domestic calls only)
• A diverse magazine collection for patients and their partners
• Pagers to allow patients to walk to nearby shops if delays are lengthy
• Notepads and envelopes for patients to write a letter or 2 (consider offering to stamp and mail completed letters)
• Brochures about services you offer

In short, comfort and entertain your patients, and you can turn the potentially negative situation of waiting into a delight.

2. Review charts in advance

A failure to review charts prior to seeing patients can limit your efficiency, add to your frustration, and give patients the impression that your practice is disorganized.

Tell your staff that chart preparation is a high priority. Require that all charts be previewed 1 or 2 days before patients are seen. Let staff know you expect them to include in the chart the results of tests you ordered at the last exam, communications from physicians to whom you referred the patient, and relevant operative reports.

Don’t overlook billing issues

In addition to the clinical review, an administrative review of a chart in advance of the visit can ensure that your efficiency and good care will be remunerated.

Assign a biller to review your charts for insurance verification and benefits eligibility. He or she also can note any accounts with outstanding balances, and evaluate and resolve any outstanding referral or authorization problems.

Check samples and supplies

As a corollary to chart preparation, assign a staff member to ensure that the pharmaceutical sample closet has adequate supplies for the following day, and review equipment and supplies to see what needs to be ordered.

Red-sticker the low inventory items. To make it easier for staff to spot low inventory, provide small red adhesive flags for them to stick on shelves (or remaining stock) when supplies run low. Appoint a staff member to make the rounds of exam rooms and closets to identify the flags, restock, and order any necessary supplies. Items should not be allowed to run out.

3. Ready the room

A well-prepared exam room means you can care for patients without unnecessary delays. Rooms should be cleaned between—not in front of—patients, and staff should ensure that supplies and equipment are readily available.

A quick and easy tip for equipment preparation is to draw an outline of the equipment in the base of the drawer, or hang a hook on the wall for each piece. That makes it easy to see at a glance whether something is missing—and you’ll always know where to look for the equipment.

If physicians change rooms (eg, at lunch), make sure that the staff knows to restock personalized items such as notepads and prescription pads.

4. Create a start-of-the-day checklist

Provide a written description of what you expect your staff to have accomplished by the start of the clinic. The list may instruct them to:

• Ensure cleanliness of the clinic
• Turn on computers, including those in exam rooms
• Contact the hospital for overnight admissions and cross-match with your schedule
• Review all schedules to anticipate problems
• Evaluate inventory of supplies and equipment in the clinic and each exam room
• Gather and organize incoming results from email and fax machines
• Ready equipment

5. Huddle with your staff

Commit 5 minutes every morning to huddle with your staff, using your schedule as the agenda. At a minimum, ask your clinical assistant and scheduler to be present.

This huddle is not a meeting. It’s about setting the game plan for the day. Consider the analogy of a football team: The quarterback huddles with his teammates before every play. The team members have practiced the play and are prepared to execute it, but the opposing team creates some dynamics they need to plan for. Your day is similar: You and your team are prepared, but every patient poses a challenge to the routine plan. Predict and prepare for that challenge and you’re more apt to be efficient at managing it. Start huddles a few minutes before the clinic begins.

The huddle is your opportunity to anticipate problems—and solve them before they happen. Don’t let the day control you; predict problems and manage them proactively.

Let’s consider a couple of examples that are a daily occurrence in ObGyn offices, yet wreak havoc in practice efficiency:

The situation: Too few slots for acute needs

Several patients call at 8:15 AM with acute needs that must be handled today in the office. The scheduler has to guess where to direct them. You delivered Mrs. Smith’s baby at 2 AM this morning, yet she is still on your partner’s schedule for 9:30 AM today.

The game plan: The huddle reveals that Mrs. Smith won’t be presenting for her 40-week antepartum visit; 2 patients with acute needs can be scheduled during her now-open slot.

The situation: 3 patients with depression are scheduled for the same slot

Three patients, all in their 50s and all with a history of depression, were scheduled for annual well-woman visits at 10 AM. At 10:05, you’re looking for someone to blame for the scheduling mistake that will cost you—and the rest of your patients—dearly that day.

The game plan: Holding the huddle in advance of the clinic reveals that 3 patients were mistakenly scheduled at the same hour. Decisions are made about where and how to accommodate the patients elsewhere in the schedule. A decision is made to contact 1 or 2 of the patients immediately and ask them to reschedule.

6. Establish intake protocols

An efficient ObGyn knows that, when he or she walks into an exam room, the patient is ready to be seen. Intake protocols tend to vary with the style of practice, but it is wise to set minimum expectations for the following intake activities based on the patient’s chief complaint:

• Documentation of chief complaint and symptoms
• Position of patient; for example, seated or on the exam table
• Dress of patient
• Vital signs
• Date of last menstrual period
• Urine sample
• Standing orders for laboratory or other tests
• Current medications and refills needed
• History

Train staff to anticipate needs

Teach your clinical assistant to anticipate needs for each patient. For example, if a 50-year-old is presenting for her well-woman exam, your assistant should anticipate completing the administrative portions of the mammogram requisition form in advance of the exam.

The power of a simple introduction

Although it might seem the intuitive thing to do, make sure your clinical assistant introduces herself to the patient, provides an overview of her role, and briefly describes the course of the encounter. Thus informed, the patient will be less anxious about the few minutes she may spend waiting for you after your clinical assistant leaves the room.

7. Ask the patient about other concerns—first

Your first step with a patient should be introducing yourself (if she is new) or greeting her warmly (if she is an established patient). A handshake often is appropriate, or a gentle touch of the shoulder.

You might also consider including a place in your charts to record personal notes about the patient, such as a hobby or pet. Exhibit care and concern for your patients, and they will be relaxed and ready to begin the encounter.

To start the exam efficiently, and avoid having the patient withhold important questions until the end of the visit, direct the conversation as follows: “Ms. Jones, I see that you’re here because of painful cramps. Is there anything else that you would like for us to address today?”

If the patient raises an issue that can’t be managed in the time allotted for the visit, tell her the issue is so important you’ll need to schedule another visit in order to address it adequately.

Using the patient’s chief complaint and any other issues that have been raised as a starting point, commence the exam. Make eye contact with the patient whenever possible and keep her informed about your actions during the physical exam.

8. Do the documentation immediately

When the exam is completed, document the encounter. Consider dictating in front of your patient. This strategy can be advantageous because the patient will hear your advice repeated and will be able to provide any clarification needed. You can also document that the note was “dictated in the presence of the patient” this notation is a good way to reduce medicolegal risk. Finally, completing the record before you move on to the next patient means you won’t end up spending extra time at the end of the day recalling that encounter along with all the others.

9. Multitask between patients

Ask your clinical assistant to bring you any outstanding messages and test results so you can review them between patients. Processing work on a real-time basis means less work will be waiting for you at the end of the day. It will save staff time from constantly sorting and re-prioritizing an ever-higher number of messages and tasks accumulating as the day wears on.

The problem with batching

If you batch work until the end of the day, your staff is forced to constantly reorganize the workflow throughout the day, as well as manage all incoming communication from patients. If patients could be counted on to call only once and patiently wait for your response, batching would be more palatable. But when their messages remain unaddressed until the end of the day, chances are that some number of anxious patients will call back.

Batching these communications also increases the odds that your staff’s return calls will be missed. If it seems that your staff is in the phone room most of the day instead of helping you in the clinic, batched communications may be the culprit.

Performing tasks as time permits helps you avoid confronting a big stack of work at the end of the day. This stack is often left to the next day, which means that your team begins every day working in the past. They will try to handle at least some of those messages in the morning hours, which makes it very likely that today’s clinic will fall behind schedule before it even starts.

Avoid batching work by conscientiously reviewing the day’s work as it develops. Tell staff members what they can do to help manage the work, such as completing the administrative portions of Family and Medical Leave Act forms before passing them along to you. Order inked stamps that bear the information you find yourself writing repeatedly. Consider taking a speed-reading course to help you review documents efficiently and effectively.

10. Count your steps

Put a pedometer on your belt during your next clinic, and you’ll be amazed to discover how much walking you do. Although the exercise is wonderful, unnecessary steps reduce your efficiency.

Pay attention to where you walk in the exam room and why. If you have to walk to reach the trash can, put it where you can dispose of garbage without walking. If you have to walk to reach equipment, place those tools nearby. If you have to walk to your office to dictate, invest in a portable machine or a shelf in the hallway that can be used as a workstation.

Watch your steps; saving even 3 or 4 steps per patient will, over the course of the day, improve your efficiency.

Why efficiency matters

The operations of an ObGyn practice are undoubtedly complex; don’t let this complexity overwhelm your efforts to improve efficiency. Even small improvements can quickly add up to a major savings of time.

Efficiency means you can spend more time with each patient, see more patients, or just get home and enjoy some personal time.

The author reports no financial relationships relevant to this article.

Suggested Reading

Delio S. The Efficient Physician: 7 Guiding Principles for a Tech-Savvy Practice. Englewood, Colo: Medical Group Management Association; 2004.

Fitzsimmons JA, Fitzsimmons MJ. Service Management: Operations, Strategy, and Information Technology. New York: McGraw-Hill; 1998.

Goldratt EM, Cox J. The Goal. Great Barrington, Mass: North River Press; 1985.

Heskett JL, Sasser WE Jr, Schlesinger LA. The Service Profit Chain. New York: Free Press; 1997.

Maister DH. The psychology of waiting lines. In: Czepiel JA, Solomon MR, Suprenant CF, eds. The Service Encounter: Managing Employee-Customer Interaction in Service Businesses. Lanham, Md: Lexington Books; 1985. www.davidmaister.com.

Mozena JP, Black SC, Emerick CE. Stop Managing Costs. Milwaukee: American Society for Quality; 1999.

Nolan TW. Reducing Delays and Waiting Times Throughout the Healthcare System. Cambridge, Mass: Institute for Healthcare Improvement; 1996.

Womack JP, Jones DT. Lean Thinking. New York: Simon & Schuster; 1996.

Woodcock EW. Mastering Patient Flow: More Ideas to Increase Efficiency and Earnings. 2nd ed. Englewood, Colo: Medical Group Management Association; 2004.

Zaslove MO. The Successful Physician: A Productivity Handbook for Practitioners. New York: Aspen Publishers; April 1998.

As reimbursement plummets and expenses rise, the options to improve your practice’s profits may seem more limited than ever—either you see more patients or spend less time with the ones you have. There is another option, which is often overlooked: Reduce the constraints on your time by improving your efficiency.

This article outlines 10 practical steps you can take to streamline your practice.

1. Manage the psychology of waiting

The link between patient wait times and practice efficiency may not be immediately apparent, but it does exist. When a patient feels you have kept her waiting unnecessarily, she may conclude that you have no respect for her or her time.

This perception can lead to situations in which you must spend time fielding complaints and making apologies and explanations in the exam room. Although such “service recovery” may consume only a minute of your time, it takes precious minutes away from your efficiency.

Keep patients informed about extended waits

Instruct your staff to inform patients of longer-than-usual waiting times when they first arrive at the office for their appointment. Maister and colleagues found that patients perceive waiting to be longer than it actually is when they are uninformed, uncomfortable, and unoccupied.

Update patients about delays every 15 minutes. Consider asking a member of your clinical team to address the issue if the wait exceeds 30 minutes. Explain lengthy delays, and give patients the choice of waiting or rescheduling. This attention to communication makes patients feel you value their time, too.

Waiting room comforts, personal touches, entertainment

Pay attention to comfort issues such as chairs, room temperature, and back-ground music. Review pre- and post-exam dressing protocols, and make sure to stock extra-large gowns for patients who may need them.

Make your waiting room a delight

Some creative but tasteful ideas to brighten the reception area include hanging artwork from your personal collection or from local artists, many of whom are happy to display their work in exchange for the exposure (place their business cards discreetly next to the work). Other ideas:

• Baby pictures of you and your staff
• Pictures of you at your hobby or with your family
• Interesting memorabilia
• Jigsaw or crossword puzzles, word searches, and other lap games (you can create your own using Web sites such as www.teach-nology.com)
• Personal computers with Internet access
• Free long-distance on available phones (restricted to domestic calls only)
• A diverse magazine collection for patients and their partners
• Pagers to allow patients to walk to nearby shops if delays are lengthy
• Notepads and envelopes for patients to write a letter or 2 (consider offering to stamp and mail completed letters)
• Brochures about services you offer

In short, comfort and entertain your patients, and you can turn the potentially negative situation of waiting into a delight.

2. Review charts in advance

A failure to review charts prior to seeing patients can limit your efficiency, add to your frustration, and give patients the impression that your practice is disorganized.

Tell your staff that chart preparation is a high priority. Require that all charts be previewed 1 or 2 days before patients are seen. Let staff know you expect them to include in the chart the results of tests you ordered at the last exam, communications from physicians to whom you referred the patient, and relevant operative reports.

Don’t overlook billing issues

In addition to the clinical review, an administrative review of a chart in advance of the visit can ensure that your efficiency and good care will be remunerated.

Assign a biller to review your charts for insurance verification and benefits eligibility. He or she also can note any accounts with outstanding balances, and evaluate and resolve any outstanding referral or authorization problems.

Check samples and supplies

As a corollary to chart preparation, assign a staff member to ensure that the pharmaceutical sample closet has adequate supplies for the following day, and review equipment and supplies to see what needs to be ordered.

Red-sticker the low inventory items. To make it easier for staff to spot low inventory, provide small red adhesive flags for them to stick on shelves (or remaining stock) when supplies run low. Appoint a staff member to make the rounds of exam rooms and closets to identify the flags, restock, and order any necessary supplies. Items should not be allowed to run out.

3. Ready the room

A well-prepared exam room means you can care for patients without unnecessary delays. Rooms should be cleaned between—not in front of—patients, and staff should ensure that supplies and equipment are readily available.

A quick and easy tip for equipment preparation is to draw an outline of the equipment in the base of the drawer, or hang a hook on the wall for each piece. That makes it easy to see at a glance whether something is missing—and you’ll always know where to look for the equipment.

If physicians change rooms (eg, at lunch), make sure that the staff knows to restock personalized items such as notepads and prescription pads.

4. Create a start-of-the-day checklist

Provide a written description of what you expect your staff to have accomplished by the start of the clinic. The list may instruct them to:

• Ensure cleanliness of the clinic
• Turn on computers, including those in exam rooms
• Contact the hospital for overnight admissions and cross-match with your schedule
• Review all schedules to anticipate problems
• Evaluate inventory of supplies and equipment in the clinic and each exam room
• Gather and organize incoming results from email and fax machines
• Ready equipment

5. Huddle with your staff

Commit 5 minutes every morning to huddle with your staff, using your schedule as the agenda. At a minimum, ask your clinical assistant and scheduler to be present.

This huddle is not a meeting. It’s about setting the game plan for the day. Consider the analogy of a football team: The quarterback huddles with his teammates before every play. The team members have practiced the play and are prepared to execute it, but the opposing team creates some dynamics they need to plan for. Your day is similar: You and your team are prepared, but every patient poses a challenge to the routine plan. Predict and prepare for that challenge and you’re more apt to be efficient at managing it. Start huddles a few minutes before the clinic begins.

The huddle is your opportunity to anticipate problems—and solve them before they happen. Don’t let the day control you; predict problems and manage them proactively.

Let’s consider a couple of examples that are a daily occurrence in ObGyn offices, yet wreak havoc in practice efficiency:

The situation: Too few slots for acute needs

Several patients call at 8:15 AM with acute needs that must be handled today in the office. The scheduler has to guess where to direct them. You delivered Mrs. Smith’s baby at 2 AM this morning, yet she is still on your partner’s schedule for 9:30 AM today.

The game plan: The huddle reveals that Mrs. Smith won’t be presenting for her 40-week antepartum visit; 2 patients with acute needs can be scheduled during her now-open slot.

The situation: 3 patients with depression are scheduled for the same slot

Three patients, all in their 50s and all with a history of depression, were scheduled for annual well-woman visits at 10 AM. At 10:05, you’re looking for someone to blame for the scheduling mistake that will cost you—and the rest of your patients—dearly that day.

The game plan: Holding the huddle in advance of the clinic reveals that 3 patients were mistakenly scheduled at the same hour. Decisions are made about where and how to accommodate the patients elsewhere in the schedule. A decision is made to contact 1 or 2 of the patients immediately and ask them to reschedule.

6. Establish intake protocols

An efficient ObGyn knows that, when he or she walks into an exam room, the patient is ready to be seen. Intake protocols tend to vary with the style of practice, but it is wise to set minimum expectations for the following intake activities based on the patient’s chief complaint:

• Documentation of chief complaint and symptoms
• Position of patient; for example, seated or on the exam table
• Dress of patient
• Vital signs
• Date of last menstrual period
• Urine sample
• Standing orders for laboratory or other tests
• Current medications and refills needed
• History

Train staff to anticipate needs

Teach your clinical assistant to anticipate needs for each patient. For example, if a 50-year-old is presenting for her well-woman exam, your assistant should anticipate completing the administrative portions of the mammogram requisition form in advance of the exam.

The power of a simple introduction

Although it might seem the intuitive thing to do, make sure your clinical assistant introduces herself to the patient, provides an overview of her role, and briefly describes the course of the encounter. Thus informed, the patient will be less anxious about the few minutes she may spend waiting for you after your clinical assistant leaves the room.

7. Ask the patient about other concerns—first

Your first step with a patient should be introducing yourself (if she is new) or greeting her warmly (if she is an established patient). A handshake often is appropriate, or a gentle touch of the shoulder.

You might also consider including a place in your charts to record personal notes about the patient, such as a hobby or pet. Exhibit care and concern for your patients, and they will be relaxed and ready to begin the encounter.

To start the exam efficiently, and avoid having the patient withhold important questions until the end of the visit, direct the conversation as follows: “Ms. Jones, I see that you’re here because of painful cramps. Is there anything else that you would like for us to address today?”

If the patient raises an issue that can’t be managed in the time allotted for the visit, tell her the issue is so important you’ll need to schedule another visit in order to address it adequately.

Using the patient’s chief complaint and any other issues that have been raised as a starting point, commence the exam. Make eye contact with the patient whenever possible and keep her informed about your actions during the physical exam.

8. Do the documentation immediately

When the exam is completed, document the encounter. Consider dictating in front of your patient. This strategy can be advantageous because the patient will hear your advice repeated and will be able to provide any clarification needed. You can also document that the note was “dictated in the presence of the patient” this notation is a good way to reduce medicolegal risk. Finally, completing the record before you move on to the next patient means you won’t end up spending extra time at the end of the day recalling that encounter along with all the others.

9. Multitask between patients

Ask your clinical assistant to bring you any outstanding messages and test results so you can review them between patients. Processing work on a real-time basis means less work will be waiting for you at the end of the day. It will save staff time from constantly sorting and re-prioritizing an ever-higher number of messages and tasks accumulating as the day wears on.

The problem with batching

If you batch work until the end of the day, your staff is forced to constantly reorganize the workflow throughout the day, as well as manage all incoming communication from patients. If patients could be counted on to call only once and patiently wait for your response, batching would be more palatable. But when their messages remain unaddressed until the end of the day, chances are that some number of anxious patients will call back.

Batching these communications also increases the odds that your staff’s return calls will be missed. If it seems that your staff is in the phone room most of the day instead of helping you in the clinic, batched communications may be the culprit.

Performing tasks as time permits helps you avoid confronting a big stack of work at the end of the day. This stack is often left to the next day, which means that your team begins every day working in the past. They will try to handle at least some of those messages in the morning hours, which makes it very likely that today’s clinic will fall behind schedule before it even starts.

Avoid batching work by conscientiously reviewing the day’s work as it develops. Tell staff members what they can do to help manage the work, such as completing the administrative portions of Family and Medical Leave Act forms before passing them along to you. Order inked stamps that bear the information you find yourself writing repeatedly. Consider taking a speed-reading course to help you review documents efficiently and effectively.

10. Count your steps

Put a pedometer on your belt during your next clinic, and you’ll be amazed to discover how much walking you do. Although the exercise is wonderful, unnecessary steps reduce your efficiency.

Pay attention to where you walk in the exam room and why. If you have to walk to reach the trash can, put it where you can dispose of garbage without walking. If you have to walk to reach equipment, place those tools nearby. If you have to walk to your office to dictate, invest in a portable machine or a shelf in the hallway that can be used as a workstation.

Watch your steps; saving even 3 or 4 steps per patient will, over the course of the day, improve your efficiency.

Why efficiency matters

The operations of an ObGyn practice are undoubtedly complex; don’t let this complexity overwhelm your efforts to improve efficiency. Even small improvements can quickly add up to a major savings of time.

Efficiency means you can spend more time with each patient, see more patients, or just get home and enjoy some personal time.

The author reports no financial relationships relevant to this article.

Suggested Reading

Delio S. The Efficient Physician: 7 Guiding Principles for a Tech-Savvy Practice. Englewood, Colo: Medical Group Management Association; 2004.

Fitzsimmons JA, Fitzsimmons MJ. Service Management: Operations, Strategy, and Information Technology. New York: McGraw-Hill; 1998.

Goldratt EM, Cox J. The Goal. Great Barrington, Mass: North River Press; 1985.

Heskett JL, Sasser WE Jr, Schlesinger LA. The Service Profit Chain. New York: Free Press; 1997.

Maister DH. The psychology of waiting lines. In: Czepiel JA, Solomon MR, Suprenant CF, eds. The Service Encounter: Managing Employee-Customer Interaction in Service Businesses. Lanham, Md: Lexington Books; 1985. www.davidmaister.com.

Mozena JP, Black SC, Emerick CE. Stop Managing Costs. Milwaukee: American Society for Quality; 1999.

Nolan TW. Reducing Delays and Waiting Times Throughout the Healthcare System. Cambridge, Mass: Institute for Healthcare Improvement; 1996.

Womack JP, Jones DT. Lean Thinking. New York: Simon & Schuster; 1996.

Woodcock EW. Mastering Patient Flow: More Ideas to Increase Efficiency and Earnings. 2nd ed. Englewood, Colo: Medical Group Management Association; 2004.

Zaslove MO. The Successful Physician: A Productivity Handbook for Practitioners. New York: Aspen Publishers; April 1998.