Delegation in Contact Lens Practice: The Finer Points
March 5, 2008
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Last week I made a case for increasing the delegation of your contact lens procedures in order to improve the profit margin of that service. In this tip, I'll provide some ideas for how to adapt your practice to make it happen. Change can be difficult and most practices have a lot of management inertia, which tends to keep things going the same way they did in the past. Let's get specific about what you need to do to take action.
Here is a review of what you need in your facility.
You must have at least two exam rooms per working doctor. Efficiency is only gained if the doctor can work with one patient while a technician works with another in the other exam room. Ideally, the doctor simply moves between the two rooms with patients ready and waiting.
Don't make the common mistake of not equipping a second exam room until demand increases. Act as you mean to go. Become efficient first and demand will increase.
A second exam room can usually be created even if the office wasn't designed for it. Be creative and look for space that is not being used for maximum benefit. You only need a room that is about 9 by 12 feet. It could be a storage room, an office or maybe a contact lens training room. If you really can't find the space for multiple exams rooms, consider looking for larger space now so you're ready when your lease comes to an end.
Contact lens training can be done in various places, from exam rooms to optical dispensing areas. Be flexible. Contact lens training is easier than ever and most patients have already worn lenses in the past and only need a review by your technician.
A separate pretest room or area is needed.
You probably have most of the equipment you need but if not, take steps now to invest in your practice. There is no better investment. Talk with your instrument dealer and attend a major eye care conference to test and compare brands.
Auto-refractor with keratometry. This is a general diagnostic instrument, but it provides major benefits in contact lens practice. Your technician will use it before you prescribe lenses and again for over-refraction with trial lenses in place.
Acuity charts. I strongly prefer the digital software type on flat screen monitors, but in any case, the technician should be measuring the acuity at far and near with diagnostic lenses; not the doctor.
Slit lamp and phoroptor in each exam room. These are for obvious doctor use but technicians can also use these instruments under the doctor's supervision in most states. Since most over-refractions are spherical, doctors who don't normally delegate refraction may find their techs can handle this task. If the final acuity is a clear 20/20 it's not likely there is any significant astigmatism, plus the doctor can tell from previous tests if astigmatism is present.
Corneal topographer. On a yearly basis, I like to have a technician obtain topography images on any patient interested in contact lenses or already wearing them. I don't generally need the data for fitting purposes, but it's the premier way for me to monitor corneal shape and integrity and I can do so at a glance.
The primary reason why most practitioners can't become more efficient in contact lens fitting is because their staff is too small. I'm pretty sure most doctors feel they can't afford to hire more staff, so they continue to do many tasks themselves, which could be delegated. When you convert the doctor's hourly pay rate compared to that of an optometric assistant, it seems like a false economy to me. The technicians in my practice work in contact lenses, general eye care, and optical dispensing. When I hire an additional employee, our whole practice gets a lift in efficiency and productivity. I've never noticed the increase in payroll cost. Here are some more key points:
Scribing. While not imperative, having technicians act as scribes greatly increases efficiency and utilization in contact lens practice. Having the tech always available eliminates paging, searching, waiting, and repeating pertinent things you said or the patient said. You can send the technician out of the room to go get something while you keep working. With the technician present, the doctor can give instructions and simply leave the room and move on to the next patient, come back in when the timing is right, and leave again when finished. The tech takes care of everything.
Trial contact lens insertion and removal. This is a hallmark task that separates the delegators from the non-delegators. It's very time consuming to retrieve trial lenses, insert them for the patient and wait for them to settle. Your tech should do that, perform additional testing, ask questions and then record everything in the record. You will be in the other exam room.
Staff free time. All practices have times when the staff is not busy with patients. Have your staff use this time to practice techniques on each other, especially contact lens insertion and removal on another person's eyes. That's how you learned to do it.
Additional training. Don't make this too big or too scary for the employee. Just have your assistant follow you and show her what to do as you go. Before long, she'll know what to do without you telling her.
Don't wait until some future time when you hope to become busier. Hire more staff now and compress the patients you already have into fewer clinical days. Use the free time created to work on practice management.
Let's not make contact lens fitting any harder than it needs to be. Don't make it more complicated then it needs to be in an attempt to impress the patient or justify your fees. Patients are more impressed if the process is simple and fast. Contrary to optometric thinking which tends to equate the value of a service with doctor time spent... patients will actually pay a higher fee if they can get done quicker and with fewer visits! That's real value to most people today!
Wipe the slate clean on your contact lens fitting paradigm. What do you really need to do to successfully fit the patient? Don't schedule another visit for a special exam if you don't really need to. Do the exam, fitting and dispensing all at the first visit. Reduce the additional visits for lens dispensing and follow-ups if possible. Of course every case is different and you should always do what you need to do to provide excellent eye health care, but don't follow a process just because you've always done it that way in the past or because you were taught that way in school.
Make changes to your appointment schedule, your exam forms, patient handouts and any other office tool or process that promotes the old approach to contact lens fitting. Design your practice to reflect the new streamlined approach.
The contact lens fitting
After I complete a comprehensive eye exam and talk to the patient for a few minutes, I pretty much know what contact lens to prescribe. The decision on the type and brand of lens is determined as I talk to the patient (more on this below). I've already examined the eye with a slit lamp. I already made note of the corneal curvature. I already know what lens power is needed. My job at this point is to confirm the fitting characteristics with the slit lamp and verify the lens power via over-refraction. It only takes a few minutes and it would be a waste of time to make the patient come back for another visit, in my opinion. We're on a roll; let's not stop now! My technician gets everything ready and I just come back into the exam room for those tests, approve the fit and leave.
I view the “talking to the patient” part before the fitting as a very important aspect of the contact lens procedure and I won't fully delegate that. There are many great options available to us in contact lens materials, designs and modalities and I want to explore the patient's wants and needs and make a recommendation. I don't like to just list all the options and ask the patient to choose; I prefer to select the best option for the specific patient and advise him. I welcome input from the patient in this process, of course. I want the patient to obtain the lenses that suit him the best. I like to sit and talk face to face with the patient after the exam is completed, but I've also gathered a great deal of information during the course of the exam. I've already asked questions, mentioned lens options and observed the reaction. The calm discussion after the exam makes the patient feel like I have all the time in the world for him, even though I spend very little actual time in the exam and fitting process.