Article Date: 10/1/2009

Manage Change in Your Practice
practice management

Manage Change in Your Practice

There are a lot of great ideas out there. Here's how to bring them into your practice.

MILE BRUJIC, O.D., Bowling Green, Ohio

It's inevitable. We attend a conference, read a professional publication or meet with a colleague and learn of a great idea that will change our practice. Armed with this idea and the expectations it generates (i.e., improved patient care and a more profitable practice than before), we attempt to set the new idea in place.

Unfortunately, for all our good intentions, the idea is never implemented. Along with our office personnel, we are left with no clear answer as to why the change hadn't occurred. Often times, we can point to the fact that ideas don't work simply because they aren't properly managed in a way that involves the entire office.

At this point, we may ask, why change? If things work well the way they are and this new idea requires an additional effort from everyone in the office, is it worth changing? Was this now-abandoned idea destined to fail even if it were embraced? Or, we may even ask, are there others who've implemented the idea successfully, and if so, can we learn from them?

Why change?

Eye care is evolving quickly. It is thus a necessity for eyecare practices to evolve. This evolution requires constant change. (Certainly these changes must represent improvements to our current practice model. We don't change for the sake of change.) The question then becomes: How do we manage change so that it occurs successfully in our practices?

Understanding differences

In optometry, it may be difficult to grasp the benefits of change because our individual practice is so unique. In other words, we can discount ideas by arguing that what works so well in one practice may not work as well in our own. Yet it's remarkable to me the differences that exist in a profession in which there's a certain consistency in what we do. On a daily basis, those who operate in the trenches see patients, administer eye exams and perform certain procedures. But there are significant differences in the way we deliver this care.

Let's discuss pretesting as an example. In our office, for example, pretesting starts with one of our paraoptometrics greeting the patient and then escorting him to our pretest room. There, the paraoptometric performs multiple tests and procedures, including:

► a 40-point visual field screening;
► tonometry;
► aberrometry to identify higher-order aberrations;
► color vision testing;
► stereopsis testing;
► pupillary distance measurements;
► a measurement of the current prescription;
► undilated fundus photography

The paraoptometric then escorts the patient to the exam room, completes the patient history and measures visual acuity. Next, the paraoptometric sets the phoropter to the patient's prescription and brings the results of the pretesting up on a computer monitor in the exam room.

Some readers will examine the flow of our pretest process and feel our paraoptometrics can perform additional tests. These readers will consider our staff underutilized for pretesting procedures. Others will view our model as a goal they strive to achieve with the expectation that at some point, their office pretesting will be similar to ours. Regardless of which view you share, you may decline to implement an idea that works well in your practice.

To resolve this, you must consider the larger question: What is the right way — or the best way — to run a practice? As we've seen in the example on the previous page, the answer will certainly differ depending on the goals you've set for your practice. But in order to optimize those goals — however you've set them — you must make change occur in your practice.

Managing the challenge of change

Change can be challenging for both you and your staff. To ensure successful implementation of new ideas, my practice follows a four-step approach each time we change a process or procedure in our office. These four steps: 1) the idea, 2) the plan, 3) the plan implementation and 4) the follow-up.

The idea is the critical first component of implementing change. It's the spark that inspires you and your staff to take action. Aside from ideas coming from a meeting or journal, valuable ideas may also come from those who work in your practice. In fact, your staff is a vital source of information on what needs to change in your practice, as they are more familiar than you are with the day-to-day goings-on in your practice. Besides identifying a problem, your staff may be able to propose the solution.

Good ideas often come disguised as problems that occur in our practice. Think about the last time someone in your office brought a problem to your attention. Did you consider the problem a nuisance, or did you recognize that it represented an opportunity to change a protocol or an office procedure for the better?

Fortunately, most practices find that their list of ideas is so long that it becomes a challenge to decide which idea to work on first. I find the best way to handle this dilemma is to prioritize the ideas in terms of their level of importance. A simple way to do this is to start with a list of your ideas, and mark them as either high-, moderate- or low-priority items. This will set the stage for identifying where to put most of your initial efforts.

Once you've identified an idea that you'd like to pursue, be as specific as possible when placing the idea on paper. For example, developing a more efficient office is too broad an idea. A manager who wants to increase office efficiency can easily take on too much at one time, leading to no change and a frustrated workplace for both you and your staff. Developing office efficiency requires many small changes. You may decide to implement this idea by having your staff:

► set the phoropter;
► take visual acuities;
► perform a preliminary history before you see the patient.

By implementing each of these three ideas — one at a time — you can accomplish the larger idea of increased practice efficiency.

Keep the plan simple

Your plan of action will either make or break the proposed change. I've found the best results when I apply the KISS rule to planning: Keep It Simple Silly! By making the idea as specific as possible and the plan simple, you're more likely to implement your desired change(s).

Let's say you're interested in having your para-optometrics set the phoropter to the patient's prescription before you sees the patient. Your KISS plan would start with a staff meeting in which your paraoptometrics devote a good amount of time practicing the skill. Then, you'd have these staff members pair up and practice the skill under your supervision. For the plan to succeed, it's important to accept that while learning new skills, your staff may make mistakes. So, assure them that when they start seeing patients, it's normal to have questions. Such an attitude encourages the staff to ask questions when they're unsure about procedures — as opposed to the paraoptometrics feeling insecure about asking questions altogether. Keep in mind that their questions will allow you to refine your plan.

At this point you have set the stage to create an easy blue print for the practice to follow. Now, you're ready to put the change into effect.

Your idea becomes a reality

After your staff has practiced in pairs, you'd have them use their newly acquired skills by themselves during patient care, telling them that they are responsible for putting the correct prescription into the phoropter. On this day, all your paraoptometrics would demonstrate their skills with the patients who visit the office. When a paraoptometric forgets a part of the procedure or makes a mistake, bring it to her attention. Hold each staff member accountable.

Expect questions when the paraoptometrics begin seeing patients — it's impossible at a single staff meeting to go through all the scenarios they will need to know.2 At this phase, answer all questions, and encourage them to simply continue to “do it” so that setting the phoropter becomes a habit, and they all become comfortable and adept with their new skills and responsibilities.

Follow-up: Reinforce and correct

Follow-up should occur at several times. Provide follow-up immediately by answering questions, correcting mistakes or providing positive reinforcement for a job done correctly.

For example, consider an office visit in which a patient presents wearing a pair of two-year-old glasses. In this scenario, the patient had an exam last year, but the results of last year's refraction differ slightly from the prescription in the lenses he's currently wearing — that is, his prescription was never updated. When confronted with such a problem, the staff member asks: “Which prescription should I dial into the phoropter?”

Certainly, you can make arguments for dialing in either prescription. But the correct answer is to make a decision based on your preferences, and then provide this direction to your employee.

The inherent problem with educating one staff member in this manner is that the rest of the staff won't benefit from your advice. The time to provide this direction is at the next office meeting. Here, all staff members who now set the phoropter will assess their new responsibilities. They will identify all the unexpected events that occurred in setting the phoropter and provide the rest of the staff with the proper protocol — that is, the answers you have provided — for those particular circumstances. Translation: Everyone will now be on the same page with the new responsibility.

Final thoughts

This discussion gives you the blueprint for successfully incorporating change. Change is necessary to continue to keep your office and the care you deliver current. By understanding the process of how to change, successfully incorporating new ideas and protocols into your office will become a reality. The key is to follow a systematic approach — that is, an approach that incorporates your staff. In doing so, you will continue to evolve your practice and elevate the care you deliver. OM

Dr. Brujic is a partner in a five-location optometry practice in Northwest Ohio. He practices full scope optometry with a special interest in glaucoma, contact lenses and ocular disease management of the anterior segment. E-mail him at

Optometric Management, Issue: October 2009