Adding accountability to the practice vocabulary

Accountability comes in many shapes and sizes in a medical clinic. One group of ophthalmic technicians learned a valuable lession in prioritizing to the patient, relates Dianna Graves.


Putting It In View By Dianna E. Graves, COMT, BS Ed

Before I begin, I must apologize to the caretakers of the Liberty Bell for any potential new damage that may have happened when I went ballistic on a recent business trip to Philadelphia.

I worried all evening that I would see on the 10 p.m. local television news that there had been aftershock damage that had occurred to the bell and a second crack had suddenly occurred!

Having a conniption

On Friday afternoon, I literally had a “conniption fit” while sitting in my hotel room. I always wondered what a conniption fit was and now I know. It’s defined as a sudden, violent emotional, outburst generally triggered by shocking news or an unexpected turn of events.

What could have caused this rapid explosion of emotion while on my trip? 

While I was out of the office, the largest clinic in our system had hit an iceberg, full speed ahead, and was taking on water!


The doctors were angry, two patients had left, and the technicians were either in tears or were threatening to move to another country to start an early retirement counting coconuts dropping on the beach in a given day.

When the lead of the clinic called me to tell me this was occurring, I tried to get her to give me a report of what was occurring. 

You may be thinking that we should have stepped back and gridded out where we were failing and how these actions had occurred, but in the middle of the crisis, you have to stop the bleeding so the patient doesn’t die. And we were hemorrhaging to death.

What really angered me was that the problems we were having were man-made, or I should say, woman-made. We did this to ourselves and, that day, it all came to a head.

For more than a month, I had been popping into clinics throughout the system to see how the flow was. Doctors had told me that the technician flow was off, and while there weren’t any patients in the pile to be worked up, there weren’t any patients in their chairs being seen by them either! And then at 10:45 a.m., there were seven patients glaring at them from the waiting room because they had been there two hours!


I call it “the putters.”

I noticed that everyone was reviewing a patient, everyone was working on a problem for the patient, everyone was checking on a patient, or calling in a prescription for a patient.

Everyone was running. But NO ONE was actually working UP a patient. 

The technicians who had a patient were spending 45 minutes with each patient-ensuring that they received the quality eye exam they sought. Tons of patients in the system, none in the doctor’s chair.

I was angry at a lot of different areas, but after calming down a fraction, I realized that I needed to start at the top and look at myself before I spoke to them. And I remembered a discussion no less than a month earlier, where one of my strongest technicians admitted to me that she could see 13 or 14 patients in a shift, but since others were only seeing seven or eight, she would see that number, too. She has since moved on!

But, her attitude regarding her “fair share” was lingering, and needed to be called out to all and stopped immediately.


Taking action

I told my second-in-command lead that she was to send an e-mail to the technicians, from me, that the following policy was to go into place immediately until I returned Monday morning:

  • 1 As we still print off a copy of that day’s patient list, when technicians took a patient to be seen, they were to INITIAL the patient’s name on the doctor’s list. 

  • 2 At the end of every day, these lists were to be sent to me.

  • 3 I will evaluate them, and if you are not keeping up, I will be calling to ask why you saw three patients in one morning when everyone else saw nine or 10.

  • Then I called a mandatory all-technician meeting for that Wednesday evening.

When I returned to the office Monday, I began to have technicians call me, or stop into my office, telling me this was the best thing that had happened in a long time. You would think, and in some cases, rightfully so, that this was just high-level schmoozing. But the people talking with me were the hard workers, the worker bees of the clinics. The leads of each of our eight clinics were commenting that the clinics were flowing very well. And the doctors were actually smiling.

By Wednesday, two of the doctors who were having the highest concerns actually sat down and told me that this was exactly what they were talking about and that things had turned around drastically.

“What did you do?” 

My only comment was: “I lost my mind.”


Wednesday night, for the meeting, I didn’t even order supper as I usually do. 

We had Dilly Bars and M&Ms in a cup!

All 48 of the technicians were sitting in their chairs, and I pulled a chair up at the head of the group and sat down (with some M&Ms for comfort).

I was more upset Wednesday night than I had been Friday night! I began:

“Ladies, we did this to ourselves. You had a great thing going . . . puttering along, seeing some patients here and there, and getting to be with your friends and then getting paid for the effort. But, no one was SEEING any patients,” I said. 

“I have had a few of the other managers ask me if I felt it was embarrassing to the technicians to have sign their initials on the check-in sheets. My response was: ‘Why should it be embarrassing? If I am doing my job and seeing patients. I wouldn’t care if you printed it in the newspaper daily!’ ”


“We did something that we never want to do again. We made it so that the doctors felt they needed to chime in on the schedule and tell us how to work. We KNOW how to work. We just chose not to.”

No discussion. No comments. Meeting over in 40 minutes.

Where do we go from here?

We wait and watch for the people that play the system to figure out how to get around this. Some have tried, but with me reviewing the sheets, they are asked immediately for an explanation of why they were so slow.

I have had one doctor tell me (jokingly of course) that I need to tell the technicians to STOP doing this in his clinics because they are being so efficient he has no time to go online and read his journals! I’ll take that as a “roundabout” compliment.

But, the word “accountability” is in my head now, and I make sure to keep it in theirs. 

The staff needs to be reminded continually that it is their job to see the patient, and get the patient to the doctor. All the other things-prescriptions, phone messages, questions-are important too. But, first, see the patient. Do the other things when you have a lull in the action. There is time to do it later.


Accountability comes in many shapes and sizes. 

For the technicians, they did this to themselves and are now walking the walk. And from all accounts and conversations, they are happy with the way things are going.

For the doctors, patients are being worked up and presented to them in a timely fashion. So they can’t read their journals during the day. Oh well, they can read them at night like the rest of us!

And for me, I am forever vigilant for the people who find a way around the system. They are working on that now, making tunnels and figuring out how to pull it off. 

I will be waiting at the end of the tunnel wearing a brightly lit miner’s hat, gaining speed and heading them off!

I have since learned there was no further cracking to the Liberty Bell-and can relax on that front as well. 

And so another day ends. 

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