This article has been a struggle to write over the past few months for a few reasons but at some point I have to just push the publish button and move on. As a disclaimer, the opinions expressed in this article are solely my own and do not necessarily reflect those of my employer. Furthermore, my articles are meant to be reflective for myself and others to generate discussion and lead to positive change. If we can't analyze what we're doing and always strive to improve, how can we be our best?
Whether in private practice or a hospital setting, nobody wants to be throwing money away on ancillary testing devices and staff salaries so we usually try to make sure we use our resources to their fullest. With the cost of equipment such as perimeters to perform visual field testing or Ocular Coherence Tomographers for nerve fibre layer scans in the $25-125K range, and technicians to perform the tests drawing salaries of $20-$40 per hour, you can understand why those making the purchasing and hiring decisions would not want to see any idle time. But, does maximizing utilization of resources lead to an improved patient experience in glaucoma care? You need an abundance of resources to have smooth patient flow which leads to a positive patient experience and improved staff morale.
If your practice management plan to optimize patient care is centred around scheduling a scarce resource, then you are doomed to failure. No matter what you try in the way of scheduling tweaks, you will still be left with patients facing bottlenecks. The goal should be to exceed basic patient expectations rather than often falling short and this requires excess resources and other value added services. In other words, if you consistently have patients waiting for their visual field or nerve fibre layer scan, you need to buy another visual field machine or two and hire extra technicians to run them. The cost is relatively small, patient delays will be greatly reduced making everyone's experience a happier one and down the road, the remuneration for the tests will offset the initial cost of the machines and technician time to run them. There may indeed by big blocks of time during some days when some equipment is sitting idle but it is there for those times when you need them.
Unpredictability of humans taking care of other humans
We are only human and we are taking care of fellow human beings. Given the reality of human error, at times we will defy the predictions of computer models, and a perfectly scheduled day in the clinic will be derailed. How are we best able to accommodate for the unpredictability of humans? The ONLY way is by having excess resources, even if this goes against the wishes of administrators who might fail to understand the real world, just thinking of initial outlay costs, and losing sight of the big picture. Just-in-time scheduling of a scarce resource can't work in the real world as unexpected delays are the norm. Of course adequate data collection, examining patient flow for several months, will reveal how much fluctuation there can be in wait times for a resource such as a visual field test. You have to have adequate resources to always accommodate the worst case scenario, not the average or ideal case scenario. In other words, the best solution is often to have excess resources if you find that one visual field machine or one nerve fibre layer scanner is creating big delays in your patient workflow.
Can't I just factor in the human variability in my scheduling?
If the average visual field takes 20 minutes to perform including setting up the machine and saving the data and you just have one perimeter and one visual field technician, what would your visual field schedule look like? Would you schedule one patient every 20 minutes? Most people would figure out, even without doing a time trial, that just intuitively this won't work. Patients can be a bit late either by arriving late to your office or because they already started their initial work up with a technician and there were new issues to report, making the initial encounter take longer than planned. You might therefore either intuitively or after looking at a time trial of patient flow, see that the AVERAGE amount of time needed is 30 minutes between tests. You can add in a couple of standard deviations from the mean to be more assured of capturing all your patients but then you'll quickly realize that it's not terribly efficient to schedule a test that only lasts about 15 minutes every 45 minutes - this is 33% utilization of the instrument with it fully booked. This won't work at all if you need to see your patients on the same day and most of them need visual field testing. Add in more doctors in need of visual fields for their patients, a technician or two calling in sick, and the whole day is a mess for everyone. This was all preventable but you didn't think it was worth having an extra one or two visual field perimeters because your one machine wasn't being used 100% of the time everyday. Guess again...you need an abundance of resources to have smooth patient flow.
Doubling up the resources
What would things look like with having that extra visual field machine? For starters, calmness for your practice as you no longer need panic if one patient is running a bit late as the next patient will be able to get their test on the other machine. Remember, if someone is running late, this means that every single patient to follow ends up running late if tests are booked back to back. Aside from calming down you, your staff and your patients, it also means that you can be running two visual fields at a time and the first patient that is ready, gets to move to the next step in your office flow...keeping the eye doctor busy. Remember, the doctor is probably the highest paid member of the team so any time he or she is spending shopping on-line or just twiddling their thumbs is costing the whole organization and is the biggest financial loss for your group.
The bottom line is that extra resources, even if they are sitting idle at times, pays back in spades. It helps prevent bottlenecks in patient flow so that patients and staff don't get frustrated on a daily basis and because it keeps everyone busy which is preventing money from going down the drain. Not only is it improving the quality of patient care but it is paying for itself. Don't waste your time micro-managing in search of 100% utilization of your testing equipment. You are not throwing money away by having excess capacity.