Delegation
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Try this popular ophthalmology strategy to increase efficiency while providing top-quality care.
BY NEIL B. GAILMARD, O.D., M.B.A., F.A.A.O., Munster, Ind.

One delegated task that leads to the ultimate in efficiency and that's used widely in ophthalmology, but rarely in optometry, is scribing. Though some call those who perform this task "scribes," I prefer to call them chairside technicians because they do much more than just write notes in the record. We've employed them in our office since 1986.

I've always been a big advocate of delegation in optometric practice, but now it's more important than ever. Ophthalmologists tend to think big, and despite the many differences we have with them, we can learn a lot from them.

Quality time

I first got the idea to use chairside techs when I was visiting a local M.D. and saw him providing his patients with clinical care. I marveled at how quickly he moved from one patient to the next -- yet despite his efficient manner, his patients clearly admired and respected him. They never felt that he wasn't spending enough time with them -- the expert care was obvious.

Not so obvious was the important role his ophthalmic tech played. She quietly joined the doctor in the exam room, sitting in the corner at the edge of a built-in counter, recording the test results and the doctor's recommendations in the patient's record. Witnessing the immediate benefit of this way of practice, I decided to begin using a chairside tech in my own office.

Our new office environment

We've developed and refined a system in our practice that works as well (or better) than what I observed in the M.D.'s office (see "Realizing the Full Benefit of Technicians"). We trained existing staff members to fill the role of our chairside techs. They provide complete care from pre-testing to frame measurements, without leaving the patient's side during a visit.

We continuously survey our patients to monitor their quality of care, and the staff perceives that patients don't feel rushed. In fact, I believe this system is impressive to patients, resulting in strong word-of-mouth referrals.

Patients sense that they're being well cared for in a busy, yet high-service practice. There's plenty of time for the personal, friendly touch our staff enjoys providing. We never leave patients alone, and they don't experience a long wait.

Reaping the rewards

The following are just a few of the many benefits of using chairside technicians:

• Increased efficiency. Chairside technicians are the ultimate time-saver. Just consider how much time you spend each day writing in patient charts, writing up fees, recall dates, diagnosis codes, copies of spectacle prescriptions, etc.
• Cleaner records. With my chairside tech, I don't have to write anything, and my patient records are much more detailed than they were when I took care of them myself.
• Task delegation. Another benefit is that the tech hears everything I say to the patient first-hand, then carries out the necessary tasks. These include my recommendations for frames or lenses, the type of contact lens I wish to evaluate, running additional tests that I order or a referral to another specialist.
  Chairside technicians are also helpful if I need to get another instrument, file documents or check available lens parameters. They do it for me.
• Smooth flow. I never have to search for a tech, walk a patient to another area, wait for a tech or repeat what I want to have done. I believe that this continuity is responsible for our practice experiencing a low number of patients taking their eyeglass prescriptions elsewhere.

Making the change

If you're interested in using a chairside tech in your own office, I have some advice on how to implement this new approach.

Don't take on the role of a dictator and abruptly announce the change in office procedure. This approach may make staff members apprehensive, and they may not support an idea that they didn't help invent. I recommend holding a staff meeting to discuss a problem (in this case, the growing need for increased efficiency and more patients seen per day) and listen to staff input.

Inform staff of the chairside assisting concept -- refer to this article or the professions of ophthalmology, dentistry, etc. Pledge your support for training and your desire to hire additional staff to keep the practice stress-free. Reassure staff that you'll be patient as they learn new terms. Design special exam forms that guide techs to proper recording. Then, just do it.

Modify your system as you go along. High-level delegation such as scribing does best if you already delegate well in your practice. If you don't, you may need to move toward this goal in smaller steps.

For example, in the beginning, train staff after office hours or during down time. Once they feel that they're ready, use them as chairside techs only a few times a day, then kick it into high gear and have them in the exam room with you all the time.

Scribing also works best for doctors who are comfortable with fairly quick exam times -- if not, and it takes you half an hour or longer to perform an exam, you'll waste your staff's time (plus it can become extremely boring).

Chairside manner

Exam room etiquette may seem a little strange at first, but it'll quickly become comfortable. I'm often glad to have a third person in the exam room with me. The tech has had plenty of time to talk with the patient, so when I join the picture, I prefer that the tech stay in the background unless I request her help.

The tech records some data at her discretion, such as new information revealed in the case history. I'll recite my findings out loud, but I avoid making the patient feel left out by saying something such as, "These numbers are just part of the formula we use for your lens prescription . . . I'll go over this with you later."

If part of the eye exam is normal, then I tell the patient that everything looks fine, and then I speak directly to the tech and describe the media, nerve head, cup/disc ratio and other findings.

However, if part of the exam reveals problems, I may elect to remain silent so that I can discuss the diagnosis and treatment with the patient after I've gathered more information. I can reach over and record or draw something myself, and it seems perfectly normal to the patient.

Set your worries aside

Some doctors are concerned that using chairside technicians will cause a large increase in staff payroll, but my experience has been that the increased productivity more than compensates for the cost of additional salaries. You may need to hire additional technicians, but you can do this in small steps as you go. I believe that most optometric practices are understaffed anyway.

There need not be an instant staff shortage as you begin this new system. I tell our office manager that if the office is ever in great need of a tech for some task, she always knows where to find one. She can simply knock on the exam room door, peek in and ask the tech to step out. I'll understand the office needs her and carry on alone.

The next level of efficiency

Intelligent delegation can definitely take your practice to the next level of efficiency and productivity, but one thing is for sure -- if you begin using chairside techs, you'll see some major changes occur in your practice. You'll experience less confusion when it comes to managing patients, you'll be able to delegate more to your technicians and the office will run like a well-oiled machine. Try it out in your office and see for yourself.

Dr. Gailmard is in group practice at Gailmard Eye & Laser Center in Munster, Ind. He's also OM's chief optometric editor.