December 08, 2017
5 min read

Five operational challenges that may be slowing you down

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Is your orthopedic clinic running as smoothly as it could? Do you find yourself getting behind or waiting around for patients to complete their paperwork? Do your clinics start on time? Do your staff members seem to be overwhelmed?

If you answered yes to any of these questions, the following five operational challenges may be the root cause of those issues.

Patient portal usage

Cheyenne Brinson

Clinics that encourage patients to complete their paperwork via a patient portal in advance of the appointment experience shorter wait times, higher patient satisfaction and higher surgeon satisfaction. The main advantage of using a patient portal is having patients complete their health history online, in advance of the appointment. When set-up properly, this frees up substantial time because the medical assistant does not have to manually enter health history because the health history is imported into the chart. For the orthopedic surgeon, it means patients are ready to be seen when they check in. No more waiting for patients to complete their paperwork.

Prescription benefit manager

Most electronic health records have the functionality to query the pharmacy network to see which prescriptions patients have filled. Instead of having patients bring all their medications with them or having the medical assistants spend a lot of time keying in the medications list, the medications are available for review. The caregiver can ask, “Mr. Jones, are you still taking coumadin?” and mark the medication as active or inactive on the list, which saves a considerable amount of time. Information about over-the-counter medications and supplements needs to be collected on the portal or manually keyed in by the medical assistants, both of which help reduce the amount of time needed before the patient is ready to see you.

Scheduling system

Good scheduling is more of an art than a science. Perhaps you have tried a scheduling system before, but it didn’t work, and the staff reverted to all “X”-minute appointment slots. However, the smoothest running clinics are the ones that control the schedule. The schedule doesn’t control them. A well-constructed schedule will improve patient flow, minimize wait times and increase patient and provider satisfaction.

The goal is to create a schedule that is efficient, offers patients good access and maintains a smooth patient flow. If a provider is scheduled to begin the day at 8 a.m., patients must be ready to be seen at 8 a.m., not 8:20 a.m. or 8:40 a.m. Once the scheduling template is crafted, the template is built into the practice management system to assist schedulers in following the scheduling guidelines with fewer errors. Think color-coded and mostly error-proof.


Here are some steps to take to maximize productivity and patient flow:

  • Study patient flow for 1 week for each provider. Identify where weaknesses in the schedule exist (ie, back-to-back complicated visits slowed down the physician or back-to-back simple visits created down time for the doctor.)
  • See if your practice management system can track patient times. If not, print the schedule and have the nurses write down the time the physician enters and leaves the room.

Based on results of the above, establish appointment types and the length of appointments by defining the most common types of appointments, such as new patient, complex (45 minutes); new patient, other (30 minutes); recheck, simple (10 minutes); recheck, complex (15 minutes), and MRI results (30 minutes). Schedule an established patient, new problem as a new patient appointment. The idea is to break down the generalized appointment reasons and the average time spent per patient.

Determine what an ideal, efficient session looks like. How many of each type of appointment should be seen per session? How are the complex appointments spaced out? (ie, new patients seen on the hour. Follow-ups are seen on the half-hour). Keep in mind if there are three or four providers in the office in a day and they all start with new patients, there will be a bottleneck at the front desk, as well as in the X-ray area.

How are patients who need a radiograph spaced out? Attempt to reduce the bottleneck in the X-ray area.

What kind of patient needs to be in each available exam room? For example, at 8 a.m., a postoperative patient who does not need a radiograph can be ready and waiting in exam room 1 while a new patient is prepped by the nurse in exam room 2.

Look at creating an X-ray schedule. Schedule patients who need an X-ray based on standing orders first with X-ray and then with the physician. Having an X-ray schedule helps reduce bottlenecks that inevitably occur.

Consider leaving prime time appointment slots, such as first thing in the morning, around lunch and at the end of the day for working, non-Medicare patients.

Surgery coordinators

The most successful orthopedic clinics have dedicated surgery coordinators who schedule surgery, verify benefits, perform preauthorizations and collect surgery deposits. Often, the surgery coordination process is fragmented. The nurse or medical assistant schedules the surgery, someone else obtains the precertification or prior authorization for surgery, someone else verifies benefits and another person collects a surgical deposit for elective cases.


Orthopedic practices can achieve greater efficiency in the clinic by consolidating the responsibility for surgery scheduling and precertification into a dedicated position, which is often that of the surgery coordinator. Typically, a surgery coordinator can handle 100 to 125 cases per month, which includes precertification and collection of patient responsibility balances in addition to precertifying and scheduling tests (MRI, CT, etc.). In best practice, surgery coordinators support the clinic rather than each supporting one surgeon.

Clinical teams

The old “secretarial” model whereby each surgeon is paired with one clinical assistant is expensive and inefficient unless there is one surgeon in the department. Cross-training among the clinical staff so they can work with all the providers serves the clinic well, especially when a nurse or medical assistant is unavailable, sick or on vacation.

To make the transition, first determine the number of clinical staff needed to support each provider. Many providers are more productive and can see more patients when they are assisted by more than one medical assistant or nurse.

One effective model is to pair a lead nurse or medical assistant with one provider each for the day and to have two to three “floaters” (depending on the number of providers in the office) who work with all providers who see patients in the office that day.

Another equally effective model is to pool all the clinical assistants available on a given day and have them equitably work with all the providers.

Having a “nurse on call” each day to handle phone calls for all providers allows calls to be answered for the most part by a live person and allows calls to be returned promptly rather than going to voicemail and then answered in between patients or at the end of the day.

The goal is to equally distribute the workload among clinical assistants and support the providers in the most efficient manner. Frequently with the secretarial model, there are workload inequities among staff based on their providers’ productivity and key man dependency with little to no cross-training to cover another surgeon when a staff member is out sick or out on vacation.

The most successful clinics provide the best patient care coupled with high-quality customer service at each point in the patient’s experience, from reception to billing. These overarching themes can be implemented with an eye toward efficiency, which will improve patient flow and experience, and ultimately, will improve staff and physician satisfaction.

Disclosure: Brinson reports she is a consultant with KarenZupko & Associates Inc., which develops and delivers CPT coding and practice management workshops presented by the American Academy of Orthopaedic Surgeons in conjunction with KarenZupko & Associates Inc.