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I never really thought the patient flow and staffing model I use in my practice was
all that novel, but after analyzing many other practices, it seems so. I have used
this model for over 20 years and it's worked well, so I'll describe it here. The
unique aspect of the system is that one technician begins to work with a patient
and stays with that patient throughout the entire visit. The patient is never left
alone or handed off to another person. A strong relationship develops between
the technician and patient and we are able to deliver outstanding service, while
maximizing office efficiency.
The exam sequence
Typically, after a patient checks in at the front desk, a receptionist will page for an
optometric technician over the office intercom. This page is only heard in areas
of the office that are not open to patients, but available technicians will hear it
and respond. The tech calls the patient in and introduces herself (or himself) and
explains that she will perform some tests before seeing Dr. ________. If the
appointment is for a comprehensive eye exam, the tech begins an extensive
pretest work-up, which includes retinal photography and corneal topography for
contact lens wearers. The technician and patient move into one of the exam
rooms for additional pretesting. Technicians act as scribes with every patient
encounter, so the pretester becomes the scribe when the doctor arrives.
As the technician nears the end of pretesting, she uses any office telephone to
page the doctor who is scheduled to do the eye exam. All doctors wear small
numeric pagers, set to vibrate mode, and each pager phone number is
programmed into speed dial on the telephone system. So the tech pushes one
speed dial key, waits for the pager service to answer and just hangs up. No
message is needed since we just use the pager as a signal device.
Because the doctor is silently notified that the next patient is ready, he or she can
decide how to best respond in order minimize patient wait times. There are really
many ways the doctor can be flexible and by doing so, stay on schedule. If the
previous exam is nearly over, then just complete it and move on to the waiting
patient. Otherwise, since a scribe is assisting on this exam also, it may be a
good time to have the tech instill mydriatic drops, or apply diagnostic contact
lenses, or do some special testing, or whatever may be helpful. The doctor can
come back to this patient if needed.
The doctor joins the technician and greets the patient. With all the pretest data
and images on display, the exam moves along fairly easily. During the exam and
refraction, the doctor states the findings and lens values aloud and the technician
records the data. She also makes notes of any additional information elicited
from the patient and records any advice the doctor gives. The doctor focuses on
the patient's history and complaints and on recommendations for treatment. The
technician listens to the doctor/patient consultation at the end of the exam
because she is going to carry out whatever steps are needed. As time permits
during the visit, the technician completes the record with the diagnosis and plan,
enters all fees, checks off the proper codes, and applies any insurance plans.
Written copies of lens prescriptions for the patient are completed by the
technician and recall dates are indicated. The doctor says goodbye and leaves
the technician and patient.
The technician continues to work with the patient with whatever care is needed.
If the visit is over, the tech walks the patient to the front desk. If contact lenses
are to be fitted, the tech retrieves the lenses ordered by the doctor and inserts
them. If more testing is needed, the tech either does it or reappoints for it. Any
questions that remain about insurance or other matters are answered by the
The best handoff is no handoff
In many cases, the next step after the exam is that the patient wishes to order
eyeglasses. In that case, the same technician that did the pretesting walks the
patient to the optical area and does the frame selection. The tech becomes an
optician at this point, educating the patient about lens design options, checking
the frame fit, and taking all measurements. The eyeglass order is written, fees
are written up and vision plans are applied, if any. Because the technician heard
the doctor's recommendations for lenses at chairside, no further communication
is needed and we have maximum continuity. At the completion of the eyeglass
order, the technician escorts the patient to the front desk and says goodbye. A
receptionist enters all fees for the visit into the office management system,
makes payment arrangements and prints the final receipt statement.
We have a very simple appointment system. Every exam is given a 15 minute
slot no matter what kind of visit it is and I don't try to control what kind of visits
are accepted on various days or times. In this way, we can fill any slot easily.
We schedule doctors, not technicians, and I don't worry about the lag time
required to do a pretest. All staff members and doctors work hard to be on time
for appointments and to start the day on time and quit on time.
All clinical technicians are trained in optical dispensing, but we have two full time
opticians who only work in optical and do not do any pretesting work. We have
additional staff for the business office and for the optical laboratory. This patient
flow system may seem sophisticated, but it's really quite doable.
How many technicians?
When comparing numbers of employees from one practice to another, it's
important to be aware that every office is different and how the office functions
effects staffing numbers. Having said that, I've found that I'm optimally staffed
with three technicians per working doctor. If we have two doctors working, six
techs would be ideal. There are times when I don't have the luxury of the three
to one ratio (due to call-offs, vacations, etc.), but that is my goal.