Seven years ago, my husband and I moved from the coast of Virginia to a small town in North Carolina to hang out our shingle and dive into the business of medicine. We selected a growing, rural town that was close to urban areas but still deeply underserved by physicians. Within a month, both of us were averaging 17 new patients daily, and we were developing a good reputation among the residents. The practice prospered.

The next few years were busy but rewarding. We added two physicians and opened a satellite office in a neighboring community 10 miles east of town. But as our town grew, the local hospital recruited more and more physicians. Within a few years, the area was no longer underserved. Our practice was successful, but the profit margin grew narrower. Overhead expenses increased while reimbursement stagnated or even declined. We realized that our previous attitude toward patient retention (i.e., “build it and they will come”) would not keep us in business if these trends continued. It was time to refocus on two critical components for every practice: efficiency and patient satisfaction.

Straightforward strategies

When we began brainstorming strategies for improvement, we focused on long-standing and recent problems, both clinical and administrative, that were hindering the practice's success. Our practice uses monthly staff meetings to discuss patient complaints and staff concerns and to raise awareness of new or ongoing problems that affect office efficiency or patient satisfaction. We learn a great deal from our staff at these meetings. Everyone's input is encouraged, and our staff appreciate that we value their input.

The following strategies helped us jump-start our improvement process and rejuvenate our practice:

1. Capitalize on nurses' capabilities. An efficient doctor starts with an efficient nurse, preferably one who is familiar not only with the doctor but also with the doctor's patients. Because we divided our nurses and doctors into teams (with one extra nurse who floats between doctors), our nurses have come to know our patients very well. For example, a nurse who knows that Mrs. Smith usually brings a list of problems to address during each office visit can help Mrs. Smith to prioritize these issues before the physician enters the room. If necessary, the nurse can gently remind Mrs. Smith that visits must be focused on two or three issues, and others must be saved for a future appointment.

Although the nurses and doctors work in teams, we train nurses so that they can work with any doctor in a pinch. This means that all staff can function in either of our offices. This helps us maintain our efficiency and allows for a smoother transition during vacations or illnesses.

To make the most of the doctor's short time with patients, we've created protocols that enable nurses to perform certain tests before the doctor enters the exam room. The tests include fasting lipid panels for cholesterol follow-up, A1Cs for diabetes monitoring, pregnancy tests for amenorrhea, urinalysis for UTI symptoms, ECGs for chest pain, rapid strep tests for sore throat with fever, mini mental status examinations for complaints of memory loss, and Zung scale assessments for depressive symptoms. If a nurse has any doubt about whether a test is appropriate, she will wait and ask, but these protocols generally save a lot of time. When I enter the room, I often already have a significant amount of the information I need. This is much more efficient than seeing the patient, leaving the room to order tests and then returning with the results.

Additionally, nurses look over our daily schedules the evening before or first thing in the morning and make adjustments when needed to prevent us from running behind. Occasionally we get overbooked, and the nurses are able to identify in advance one or two patients we can reschedule. It is rare for us to do this, but when we do, patients are accommodating and happy to know there might be a better time when they would have a shorter wait. When appointment times can't be changed in these situations, our nurses forewarn patients to expect a delay.

2. Improve phone service. For years, we were plagued with complaints from patients about our staff not responding to phone messages. Staff maintained that they never received some messages. We solved this problem by requiring the nursing staff to keep a handwritten log of the calls they received from patients with specific medical questions. The log includes the patient's name, the date and time of the call, the patient's request and the action taken by the staff to address the request. Each entry must be checked off and initialed by the nurse.

Since we started keeping the log, patient complaints have been virtually nonexistent. The log has helped the nurses keep track of which patients have received a reply and which are still waiting to hear back from us.

Our phone log also helps our communication with local pharmacies, some of which are infamous for telling patients that our office has not responded to a refill request when, in fact, the pharmacy sent the request to the wrong practice or never received our fax. We keep copies of confirmations of the faxes we send to pharmacies and show them to patients who complain. In fact, we have been known to give patients a copy to take to the manager of their pharmacy when there is a recurrent issue.

3. Offer patient-friendly scheduling. To improve our accessibility to patients, we follow a modified wave schedule with elements of open access. We schedule chronic appointments as far out as needed, but we keep plenty of acute care appointments open for patients who want to be seen the same day they call. Our patients almost always get to see their own physician, which they appreciate.

We schedule acute care appointments intermixed with chronic care appointments and physicals at the top of the hour and schedule the rest of the hour more lightly to allow for catch-up time. The patients might have a slightly longer wait (about 20 minutes) than in a traditional schedule, but the average wait time for all patients is kept to a minimum. If I am running behind, the front office staff is instructed to update the patient of the situation every 10 minutes. We have found that people are more tolerant of delays if they know the reason for the delay and that they haven't been forgotten.

Two years ago, in another move to provide patients with more appointment options, we implemented evening hours four nights a week, with one doctor working each night until 8 p.m. These appointments are always full. Because many employers have made it difficult for employees to leave work early for routine appointments, our patients appreciate evening hours. As a trade-off for the long day, each doctor now gets one full day off each week instead of the one afternoon off we had previously. The nurse and receptionist who work during the evening shifts get to leave after lunch the next day. This arrangement has increased satisfaction all around.

Another scheduling strategy we've employed is calling all patients 48 hours in advance of their appointments to remind them of the date and time of their visit. Not only does this help them remember to come in, but it also significantly improves our missed appointment rates. We find that about 10 percent of appointments are missed. That rate is closer to 25 percent when we don't make the reminder calls.

4. Stay on top of patient information. Our electronic health record system, which we purchased in 2003, helps us manage patient data and produce current, accurate reports that help us take better care of our patients. We can generate recall letters for annual physicals and diabetes follow-up visits, and produce a list of patients taking a certain medication in the event that the medication is withdrawn from the market. These capabilities help us manage patients' health more actively.

We also keep a handwritten log of all the tests we order so that the nurses can check to make sure we receive and act on the results as appropriate. The log includes columns for the patient's name, the type of test, the date we order the test, the date the test will be performed, and the nurse's initials once the test results have been received, signed off by the physician, and reported to the patient. We also indicate whether another test needs to be scheduled in a few months, and the log prompts us to follow up with the patient at the appropriate time.

5. Implement clear payment guidelines. To minimize lost revenue, a member of our staff verifies all insurance eligibility, co-pays and deductibles online prior to patient visits. If there is any doubt as to a patient's insurance status, we ask to see the patient's insurance card at check-in. Often there has been a change the patient is unaware of or has not disclosed. We also copy photo IDs for the patient chart at initial visits, which can help derail attempted insurance fraud.

We attach a sheet to each patient's encounter form that outlines any outstanding balance so that fees can be collected prior to the visit, if appropriate. We find that when we address these issues prior to the appointment rather than afterward, we are more likely to receive payment.

If the amount due is significant, the patient is invited to discuss payment arrangements with our staff in a private office. If patients need to set up a payment schedule, we have them sign a promissory note with a specified monthly payment. The letter states that failure to make a payment will result in a referral to collections. We tackle collections on a set schedule, rather than doing it as time permits If our efforts fail, we refer the small accounts to a traditional collection agency and the larger accounts to an attorney who specializes in collections. The attorney charges a slightly higher fee, but receiving a registered letter from a lawyer grabs most people's attention.

6. Be responsive to patients' needs. We've added several other features to our practice that let patients know we value them and the opportunity to care for them. Our office employs two bilingual physicians, and we take pride in serving the Hispanic portion of our community. We've recruited and trained Spanish-speaking nurses and front office staff to make this patient population comfortable in our practice, which has helped produce a steady stream of new patients.

Additionally, we are setting up a practice Web site that will enable patients to view and download new patient information forms, get directions to the office, see photos of our physicians and learn about our after-hours appointments, refill procedures, etc. Someday soon we hope to begin receiving refill requests and other messages from patients by e-mail, which will further enhance our efficiency.

The payoff

Competitive pressures are forcing many practices to re-evaluate the way they operate. As growing numbers of patients become savvy consumers and feel less loyal to particular physicians and practices, it is incumbent upon us to provide excellent care and service to make them want to return. The tips in this article are not difficult to implement, and they can produce results that will go a long way toward greater efficiency and patient satisfaction. Our patients set the bar high; our practices should meet their expectations.