As technology evolves, while competition increases and financial pressures multiply, holding on to patients (and staff) while maximizing efficiency and outcomes has become a challenge. To help, we asked a number of ophthalmologists and practice management experts to share some of the strategies they use to keep their practices thriving.

Making the Most of Waiting

Every practice has a waiting area. Our contributors offer the following suggestions for using it to maximum advantage:

Provide portable DVD players. Mark Packer, MD, FACS, clinical assistant professor of ophthalmology at Oregon Health & Science University, says his practice used to let patients sit in an exam lane with educational materials showing on a TV, but notes that this took up valuable space and left much of the burden of patient education on the surgeon. Today, his practice has put its informed consent video and all educational information on a DVD; patients are provided with a copy of the DVD, along with a portable DVD player and headphones, in the waiting area. Each patient can view whatever is relevant to his or her needs. "It's kind of amusing to walk out there and see all these people watching their portable DVD players," notes Dr. Packer. "But it makes patients' perceived waiting time decrease, and it also gets them the information they need in a pretty effective way."

Let patients listen using infrared headphones. Lisa B. Arbisser, MD, adjunct associate professor of ophthalmology at the University of Utah, and Amir I. Arbisser, MD, founder of Eye Surgeons Associates, P.C., with branches in Iowa and Illinois, have a television in each office's dilating area, showing an informed consent and educational video. What makes their setup unique is that patients are provided with infrared headphones, enabling them to listen and watch the DVD without disturbing other patients or doctors—and with the volume as high or low as their hearing requires.

Provide books instead of magazines. John Pinto, president of J. Pinto & Associates, an ophthalmic practice management consulting firm, observes that when it comes to reading material for the waiting area, magazines are costly in the long run and tend to favor negative reporting ("if it bleeds, it leads"). "Instead of letting patients be reminded about terrorists and soaring drug prices, buy discounted coffee-table books," he suggests. "Most book store chains carry a nice selection for $10 or less. Because they're large and bulky, they're less likely to be stolen, and they don't go out of date. When they start to look worn, donate them to a local library or nursing home."

Patients at Drs. Fine, Hoffman & Packer LLC, in Eugene, Ore., can watch a DVD of educational material and informed consent information on portable DVD players (with headphones) while waiting to be seen. Each patient can view whatever is relevant to his or her needs. Watching the DVD also shortens patients' perceived waiting time.
Mark Packer, MD, FACS

Don't show standard television fare. Mr. Pinto says the same principle applies to a television in the waiting area: Negative material is commonplace, and not a good precursor to your exam. "If you aren't using the television for education," he says, "play prerecorded documentaries or classic movies."

Provide diagnosis-specific materials written by your doctor(s). Eric Donnenfeld, MD, co-chairman of cornea and external disease at Manhattan Eye Ear and Throat Hospital and associate professor of ophthalmology at New York University Medical Center, provides patients in his waiting area with published articles specific to their problem, written by the practice's physicians. "These materials range from peer-reviewed medical journal articles to Review of Ophthalmology articles, to informational instruction sheets," he says. "We have customized materials on 30 or 40 different diagnoses. Letting patients read these articles while waiting educates them before the exam and gets them involved in the decision-making process. It also saves me time explaining basic information about their diagnosis."

Provide patient testimonials. Dr. Donnenfeld says his practice has created scrapbooks for each doctor, including notes and mementos sent in by happy patients. Each day, the doctors who are in the office seeing patients have their book placed in the waiting area. He notes that patients enjoy perusing the books, and it reaffirms the patient's confidence in the doctor and the practice.

Improving Patient Encounters

Making a good impression, communicating clearly and simplifying practical steps help make patient encounters go smoothly. Try these strategies:

Have all staff members interacting with a patient introduce themselves. Penny A. Asbell, MD, professor of ophthalmology and director of the cornea and refractive surgery service at Mount Sinai School of Medicine, says that having staff members state their position and the reason for interacting with the patient makes a great impression and ensures that the patient understands exactly what's happening. (For example, "Hi, I'm Susan. I'm the technician today, and I'm working with Dr. Smith, who asked me to get your eye pressure before she sees you in a few minutes to review the information.")

Consider adding bilingual staff to your practice. Mr. Pinto notes that many of your patients may lack English skills. "If appropriate, consider hiring one or more bilingual staff members," he suggests. "Even better, learn to examine your patients in a second language. It's much easier to do this in the field of ophthalmology than in internal medicine."

Write the name of people accompanying the patient in the chart. Drs. Lisa and Amir Arbisser note that writing the name (and if possible the phone number) of individuals accompanying a patient can be useful when you need to verify counseling—especially when dealing with elderly or very young patients.

Apologize immediately for long waits. Dr. Asbell suggests having the patient's check-in time written on the chart and noting it as soon as you pick up the chart. If the patient has waited a long time, apologize right away. "Acknowledging the long wait tends to defuse patient frustration and/or anger," she says. "If you wait until the patient says something, it may come in the form of an angry letter. Writing an apology takes a lot more time and effort." She adds that if you notice a long wait occurring when you're still not available, have a tech apologize to the patient so the patient will know he hasn't been forgotten.

Use templates and patient delivery for referrals and consults. John S. Jarstad, MD, medical director of Evergreen Eye Centers in Federal Way, Wash., says that he uses a template form to convey this kind of information, especially for diabetic or hypertensive patients who usually see their primary physician monthly; then, the patient hand-carries the form to the doctor.

"Most of the busiest practices in our area have now switched to using a form," he says. "We just write in the findings and check off the appropriate boxes. This essentially condenses the report to 'This is what we found and this is what we're going to do about it.' In fact, a number of local referring primary-care doctors have asked me not to send letters because they never have time to read them." He adds that sending the form with the patient also saves mailing costs.

Note the next visit's tests in the chart. Dr. Asbell says that when a patient will be returning, she clearly lists what will need to be done in her final note. "This way," she says, "when the patient returns, the staff doesn't need to come back and ask me what I'd like done, unless something new has occurred."

Pre- and Post-Visit

Our contributors offered these tips for managing non-face-to-face aspects of patient visits:

Charge a fee for no-shows. Bruce Koffler, MD, director of the Kentucky Center for Vision in Lexington, Ky., says that not long ago, last-minute cancellations and no-shows were becoming a serious problem in his practice. "Some days 20 percent of our schedule would fail to show up," he notes.

Once they decided to address the problem, the first step was to get more serious about calling patients a day or two before the appointment to eliminate the common excuse of forgetting. Having done all they could in that respect, Dr. Koffler decided to take the next step, despite mixed feelings: charging the patient a fee for not showing up.

"We now charge $35 for a no-show," he explains. "This doesn't cover our costs, but we wanted the fee to have some financial bite without being a hardship." Dr. Koffler notes that the practice doesn't always impose the charge. "Some patients just forget once," he says. "Other patients miss habitually. Those are the ones you really want to charge."

At first he says it wasn't clear whether this would be a practical idea, but it has worked well. "We have now sent out many of these bills—and gotten paid," he says. "Initially we were worried about patient reaction, but now patients are more concerned about showing up. Some patients have felt that the fee was well-deserved. In fact, it may give the practice more value in our patients' eyes. And we've cut our no-show, late cancellation rate by about half."

Dr. Koffler says that this policy can only work if patients know about it ahead of time. "New patients are told when they make the appointment that if they don't show up, or if they cancel at the last minute, there's a $35 fee," he says. "We ask existing patients to sign a notice that's included in the chart. Once in a while a patient is offended because he thinks he had to wait too long to be seen, but very few patients have complained."

Dr. Koffler adds that to incorporate this strategy, a practice needs to focus on reducing waiting time—to eliminate that potential objection—and that charging a fee for no-shows might be less successful in a new practice just starting out.

Simplify the process of making post-surgery follow-up calls. Drs. Lisa and Amir Arbisser suggest having your surgery center sync its patient information database with a handheld PDA such as a Palm Pilot, so that the phone numbers of your patients who have had surgery each day automatically show up in the PDA. With the push of a few buttons you can call them to follow up during your trip home.

Send a follow-up thank-you letter. Mr. Pinto notes that a few smart practices send follow-up letters to their patients after the first visit (or even after every visit) thanking them for coming in. "This makes a great impression on patients," he says. He recommends that the letter include a customized paragraph abstracting the visit: "As we discussed, you have early signs of cataract formation in your eye. I don't believe this is appreciably impacting your vision, but together, in the months and years ahead, let's monitor these cataract changes. I can assure you that when the time comes, we will be able to treat your cataracts using the latest methods."

Be persistent with recall efforts. "All practices have periods of time when things are slow and you wonder why you're not filling your schedule," observes Dr. Koffler. "Originally, we'd send one postcard to remind patients to return. If that didn't get a response, nothing else was done. Now we have two recalls, a month apart. If the patient doesn't respond to the second postcard, we try to contact the patient by telephone, or by letter as a last resort."

Dr. Koffler says this strategy has eliminated the cyclical highs and lows in scheduling that he used to see. He adds that it also keeps the lines of communication open with patients, allows a little patient education, and keeps front office staff busy during slow periods.

Managing Your Staff

Nothing is more important to a practice than finding and keeping good staff—and making the most of their skills and knowledge. A few helpful strategies:

Make sure new employees understand the maximum you expect from them. Mounir Bashour, MD, CM, PhD, a partner in LasikMD, an ophthalmologist-owned chain of LASIK eye centers in Canada, observes that employees are far more likely to become disgruntled and make demands—or quit—if their initial expectations of the job are less than what the reality later becomes.

"One of the most important things you can do is make sure your employees see their job at its maximum on their first day, if possible, and definitely by the end of their first week," he says. "It's human nature that when workload increases or responsibilities are added in a job environment, employees start to complain and want to quit. But if you have them working very hard at the beginning, there won't be any complaints—certainly not if their workload gets a little bit lighter."

To control job perception at the outset, Dr. Bashour advises stipulating everything that will be or may become the employee's responsibility in the initial contract. "That way, they won't come to you later and say, 'I never used to do that—that's not part of my job.'

"This policy has definitely reduced the amount of quitting and dissatisfaction at our centers." he says. "It prevents grumbling and late surprises. It's made a big difference."

Track which tech is managing which patient.  Dr. Jarstad says his practice keeps a master list of all scheduled patients for the day posted at the tech station. Each technician is assigned a different color of highlighting pen. As a tech takes a patient back for testing, the tech highlights that patient's name on the list with his highlighter, so everyone can tell at a glance who is managing which patients.

At the end of the day, the list goes to the office administrator, who keeps a running total of how many workups each tech is managing. This makes it clear if a tech would be better suited for a different clinic job. Dr. Jarstad estimates that this simple strategy has saved his clinic more than $200,000 a year in improved efficiency.

Keep every member of the staff educated about the details of what you do—and why you do it. Dr. Donnenfeld says it's very helpful and reassuring to the patient when it's clear that every member of the staff understands everything that's happening, and everyone conveys the same information.

To make sure the staff is this knowledgeable, Dr. Donnenfeld spends time with his staff explaining what he looks for in each test in each type of patient, and why. "For example," he says, "I'll put a sample of different topography scans on a computer screen and go over them with the staff, including our optometrist. I point out the abnormalities and the things I'm looking for, and tell them that if they see something abnormal to please bring it to my attention. In addition, I discuss each case with the techs, the optometrist and my fellow, so there's education going on all the time.

"The result is that our staff is really sharp and well-informed," he says. "Obviously our technicians are not making health-care decisions, but they know why I think something is important and they do a better job of explaining to the patient why a certain test is being done. This also makes the staff feel that they're contributing to patient care, so they like their jobs more and do them better."