By Chad Fleming, OD, FAAO
June 29, 2016
First and foremost, the OD must provide patient care, the driver of practice revenue. Free up valuable doctor time and improve office processes by handing off tasks that staff can be taught to handle.
SET UP SYSTEM. Create a system in which practice owners review the work delegated to ensure completion of tasks and quality control.
TRAIN STAFF. Have staff first observe a task, then do the task, and then, once mastered, teach others.
INCREASE PATIENTS SEEN. Increase the number of patients seen by as much as the equivalent of adding one additional office day.
There is only so much practice owners can do themselves, and there are many tasks that others in the office, or outsource partners, can do more expertly and efficiently. In my practice, valuable doctor time is preserved, and processes are kept efficient and smooth, with a well-honed system of delegation.
The OD’s main task is patient care, which drives revenue generation. From a business point of view, ODs needs to maximize revenue-generation, and lessen non-revenue-producing tasks that sap their time.
How Much Is Your Time Worth?
According to Management & Business Academy Key Metrics, the average optometrist is generating revenue of $337 an hour based on 1.1 exams an hour at $306 revenues generated per exam.
Delegating additional tasks to your support staff, so you can add just one extra exam per hour, can more than double the hourly revenues you generate from conducting exams.
Calculate Time Savings & ROI of Delegation
Delegation affords myself and my partner the time to research large purchases more, and spend more time negotiating ophthalmic lens prices and equipment prices. We have found that many times this has led to purchases with thousands of dollars to spare when normally we would have just purchased at the given pricing. This most importantly does not raise revenues as much as it lowers our heart rates, and makes us better spouses and parents.
Too many times we as owner/doctors spend hours after seeing patients working on all those things that could be delegated. We do it in the name of running a good business and keeping the business thriving only to find out decades later that we highly regret the relationships we left behind.
Our practice historically nets much higher than the published averages, and I believe that it is because of our diligence in reviewing the processes and systems, and working only on those things that the owner/doctor can do and letting a well trained staff do the rest. This does not, however, mean hands off. On the contrary, it means all hands on deck reviewing purchases and constantly working to improve the efficiency and cost of our systems. Delegating has allowed me to eat with my family around the table at the end of the day. It has allowed for weekends to focus on family and faith.
I see patients 3.5 days of the week, and do systems review and business management one day of the week, with a goal to be done Friday sometime between 2 pm and 11 pm, depending on the week. Ironically, since cutting back to 3.5 days per week, my gross production has stayed the same, or increased. With four patients an hour the production goes up by 10-15 percent. There are many doctors that produce more than I do, so I don’t aim to make that the benchmark. The benchmark is what you are content with, and what your life priorities are. The amount you delegate should line up with those goals.
By delegating documentation into the EHR to a scribe, I have increased the number of patients that I see in a week by almost one full day. So, the number of patients at 4.5 days can be seen in 3.5 days. The example I used above by cutting my schedule to 3.5 days/week of patient care without sacrificing production was comparing apples to apples as that was three patients an hour in before and after 3.5 days. The four patients increases production by 10-15 percent overall. For those owners, it also increases staffing overhead as additional pre-testing staff must be added, so it is does not go straight to the bottom line as that can be mis-perceived.
Editor’s note: In Dr. Fleming’s numbers, he is factoring in insurance reimbursement changes and the evolving dynamics of more medical visits and decreasing vision benefit reimbursements.
Identify Tasks for Delegation
“Delegate what others can do so you can work on only what you can do,” I’ve heard it said.
You can delegate without losing control when you have systems in place for the practice owners to periodically review completed tasks. We use a “trust but verify” approach to managing the cost of goods sold and general overhead. The other owner and I divide the office into seven executive branches, of which we are the “VPs,” and review purchases and expenses through those areas of the office.
It allows for us to be aware of all monies going out for expenses without the daily details of having to actually do them. Since we both worked originally under a system of management where owners did a lot more of the above tasks, it has given us the knowledge of how to purchase products and run systems efficiently so that we can teach them to our optical and clinical managers. I would strongly advise anyone looking to delegate more to first do it themselves for a period of time and be successful doing it, then use that knowledge to train others.
For example, when ordering contact lenses as the doctor, you learn what mistakes a vendor will make, and how they will accidentally send four to a patient, but charge you for eight. We now have systems in place where our optical manager reconciles mail-to-patient charges with actual boxes received by a patient. This all occurred due to a very detail-oriented doctor who compared invoices with orders and discovered these mistakes.
Here are the tasks that ODsin our practice delegate:
PRE-TESTING: Visual acuities, tonometry, auto-refractor, color testing, stereo testing, blood pressure, patient eye and health history and review of systems, pupils, visual fields both automated and arcuate confrontational, dilating drop insertion, Optomap, OCT, topography, fundus photography, pulse, height, weight.
EXAM ROOM. Documentation in EHR, trial contact lens scripts, coding.I give my scribe the levels of medical decision making, then she communicates to me what the EHR recommends, and then I accept or adjust accordingly.
OPTICAL. Everything that goes into the selection and ordering and purchase of eyewear, including sunwear and sports and safety eyewear.
HUMAN RESOURCES. Job applications, interview process, scheduling staff, 90-day reviews, discipline warnings (initial stages of discipline), time off, sick leave.
ORDERING PRODUCTS. Ophthalmic lenses (cut and un-cuts), frames, contact lenses including cross-cyl calculations and building of RGP or SynergEyes lens, office supplies.
OFFICE UPKEEP. Facilities maintenance and cleaning.
ACCOUNTING/PAYROLL. Reviewed by owner, but processed and managed by CPA firm.
TECHNOLOGY. Web site and social media development and management.
I am considering delegating the refraction. As an established OD with a full schedule of established patients, most refractions take 2-5 minutes. If I started delegating refractions I would expect to add a patient per hour to my schedule. I’m very content with the current model and resulting production, so I’m not overly anxious to increase that. At this point, I see four patients per hour and enjoy the amount of time it affords me to educate and answer questions. There is a breaking point between number of patients run through the office and clinical enjoyment. At this point, we do not need any additional change within the systems of our office. My scribe and I have a very good flow to the schedule and we look to take what we have done, and possibly bring scribing to all the doctors. Myself and the other owner are the only ones with scribes at this point.
Identify What NOT to Delegate
A task is inappropriate for delegation when only the owner/doctor can do it, such as clinical tasks like slit lamp exam, interpretation and reports of testing, physician test ordering and E/M level determination. The other non-clinical task that needs to be done by owners is final hiring or firing, I would even say the disciplinary warnings prior to firing should be handled by the practice owners, along with compensation packages and changes for all staff, discussions with associate doctors regarding compensation and employment, high level accounting review, $200+ financial purchasing decisions outside of contact lens ordering, frame and ophthalmic lens ordering, large equipment purchases, rental agreements with building owner, strategic marketing plans and any decisions with a high risk for litigation.
Choose Whom to Delegate To
Different individuals obviously have different skill sets. At this point, many of the tasks get assigned to the optical manager, or clinical manager, and then delegated from there. The other owner and I make recommendations on who we think might be a good person to carry out the task, but for the most part, the managers make delegation decisions. We also delegate according to earned trust. Earned trust is something that gets talked about and developed over the course of the employer-employee relationship.
Train Staff to Do Delegated Tasks
Surgeons have a saying that goes something like: “see one, do one, teach one.” If a doctor has been doing the task, such as documentation into the EHR during the clinical exam, the doctor would have another employee observe them doing that inputting first, then transfer the task, and then have them teach others. The doctor would see patients with the staff member following and asking questions as they observed for a week, then the doctor would allow the newly trained scribe to do all of the history intake and testing through the final refraction. The doctor would then proceed with a slit lamp exam and binocular indirect evaluation.
The newly trained scribe would enter all aspects to the end of the refraction and then the doctor would enter all data after the refraction, including assessment, plan and recall information. They would work like this until the scribe became competent in the initial part and then the doctor would continue to turn more and more over of the documentation into the EHR. This works to train the new scribe at the pace that allows for learning, questions and keeps the chart clean of significant errors from learning. Today, my scribe enters everything and I review the chart at the end of my morning and then at the end of my afternoon. Proper training, and not becoming impatient with the learning curve of new delegation, is key to long-term accuracy, efficiency and overall better care for the patient and job satisfaction for the doctor.
Learn When to De-Delegate
We tried to delegate banking of contact lenses to the vendor, but stopped it. When you bank contact lenses the practice receives a price break to help increase margins, however, since we had one of the owners combing through the banking invoices and tracking every single order and return only to find out that the contact lens group we purchased lenses through was making small, but costly, banking errors, we decided to take back delegating tracking back to us so that a staff member could do it instead of the owner.
Most everything we have delegated has come with a staff learning curve, but we have continued with the delegation. Since the owners trust, but verify, purchases and testing, we have been able to continue to delegate without taking any of it back.