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Effective and efficient scheduling can be an elusive goal. A number of scheduling solutions have been described in the literature, but there has been little evaluation of how well they work in small group practices. Larger practices have experimented with such methods as open-access scheduling with variable results. Rules-based methods of scheduling are conceptually attractive but difficult to enforce. In this article we examine office productivity from the standpoint of patient scheduling using the 4 S's method as described by Brooks and Haines and based upon the theory of constraints by Eli Goldratt.

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4S's Method

The 4S's method of evaluating office productivity uses as its benchmark the number of patients seen per hour (pph). The four components of this method are practice Space and layout, Staff, physicians Style of practice and office Systems. The overall efficiency of any practice is not determined by its resources but rather by any constraints placed on the practice in each of the four categories described.

Office Space and Layout

Office space and layout may be the most basic limitation imposed on a practice. The most obvious constraint is the number of available treatment rooms. Studies indicate that under optimal circumstances, a single physician practice with two treatment rooms can see a total of 4 to 8 patients per hour. In a practice with three treatment rooms, a doctor should be able to see between 8 to 12 patients per hour. With four treatment rooms, the single physician practice reaches a maximum of between 12 to 16 patients per hour. These numbers establish a benchmark by which physicians can measure their performance. To achieve this, the other factors outlined in the 4 S system must be evaluated and optimized.

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Staffing

Every component of the 4 S's system is important and each has its own unique constraints. Staffing is by far the most volatile. Directing time and money to address human resource issues is an ongoing process. Staff must be adequately trained and provided the tools necessary to do their jobs. Simply adding more staff to an overworked crew can cause more problems than it solves. Investment in training and useful software systems such as patient tracking programs save staff time and improve efficiency (Figure 1).

Studies indicate that the average ratio of staff to physicians is three to four staff per physician. This does not take into account staff that transcribes dictation or physician extenders who see patients or perform procedures themselves. In our practice of four podiatrists we employ only 11 full-time employees. Yet, we are able to verify all health insurance information in advance of the patients' appointments. Moreover we submit insurance claims daily and keep patient wait times to a minimum. We have been able to accomplish this by structuring our office operation to avoid duplication of work and by providing our staff with ongoing training and adequate tools.

Practice Style

The most variable of the 4S components is practice style, which depends largely on the doctor's personality. A physician who is motivated, energetic and interested in the efficiency of his/her office need make relatively few changes in his/her style. In the area of the doctor's style of practice, the foremost concern should be starting on time and avoiding non-patient-related distractions during a clinic session. Some doctors prefer to arrive at the office early to take care of paperwork and organize their desks. This is fine as long as the doctor begins seeing patients at the scheduled time, but all too often the doctor becomes distracted with personal or staff issues and begins the clinic session late. This inevitably throws off the schedule and disrupts the pace of the office for the entire day.

When the doctor is late getting started, the entire staff is put on hold and they must spend the rest of the day playing catch-up. The doctor should be focused on patient care. Every extra footstep that the doctor takes reduces efficiency. Patient tracking software is invaluable for streamlining nonverbal communication between the doctor and the staff, reducing the footsteps that the doctor takes during a clinic session. (Figure 1).

The staff should be trained to anticipate the doctor's needs. The staff should be alert to keeping the doctor on time.

Office Systems

The final component of the 4S method is office systems, which include assignment of job tasks to staff and the software needed to allow them to accomplish those tasks. There are several practice management software packages that work well. Software is only as good as the knowledge of the user, so training is essential. The wide range of software available means doctors can pick and choose only the programs that suit their particular needs. The software component that presents the greatest practice constraint is scheduling. There are very few robust and simple-to-use scheduling software packages. Patient access to the practice is also constrained by the number of available telephone lines into the practice and the number of staff available to answer them.

Scheduling

Scheduling is more than packing as many patients into the schedule as possible. A versatile scheduling software package allows the practice to attain the benchmarks described. It allows adequate patient access to medical care and meets the patients' needs during the appointment time (Figure 2).

Scheduling has evolved into a significant data-collection point. Information collected during the scheduling and patient registration process can be distributed to the billing, patient tracking, and EMR software. Newer scheduling packages are flexible enough to accommodate different scheduling methodologies. Open access scheduling allows patients to be seen on the same day of the appointment. Rules-based scheduling regulates the schedule by imposing rigid parameters for scheduling. An ideal system is a blend of these two methodologies. A rules-based approach is an attractive method of scheduling because the software forces the staff to schedule based upon predetermined parameters or rules but is only workable if the staff is allowed some flexibility. Strict rules-based scheduling is best used when the scheduling process is available to patients on-line or when the medical practice contracts scheduling out to third-party call centers. Some scheduling software packages allow patients to pre-register or make their own appointments on-line (Figure 3). This capability improves patient access to the practice and overcomes the basic constraint of the number of telephone lines into the practice and reduces staffing needs to man the phones. It also reduces patient wait time.

Generally speaking, patients who pre-register are more complete and concise in completing their medical history. Less staff time is then needed for seating and the initial interview of the patient. If the doctor reviews the information prior to entering the treatment room, several minutes of history taking is saved. A well-trained medical assistant can frequently determine what x-rays may be needed or what tray set-up may be required before the doctor ever enters the treatment room. When the scheduling software is interfaced with a patient tracking system, ongoing time motion studies are available for further fine-tuning of the office schedule. I have found these tools to be valuable time-saving modalities that have allowed our practice to meet our benchmarks of staffing levels and patients seen per hour. In summary, scheduling optimization is a function of many components in a medical practice. Utilizing the 4S's method to evaluate practice efficiency, a medical practice can set benchmarks to achieve. Evaluating and addressing the constraints in a medical practice produces an orderly improvement in practice efficiency. Scheduling has evolved into the heart of the medical practice. It is a data collection process that can effectively streamline office procedures. The two most commonly discussed scheduling methodologies are open-access scheduling and rules-based scheduling. In a majority of medical practices a hybrid of the two methods will allow for adequate patient access to the practice with an increase in the number of patients seen per hour.

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By Kirk Koepsel, D.P.M.

Dr. Kirk Koepsel MBA has been in private practice since 1985 in Houston, TX. He is the founder of EppointmentsPlus Inc., PhysicianWebPages.com and PodiatryNetwork.com. He is a member of AAPPM.

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