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Blocked clinic flow can be analogous to a beaver dam


Meaningful use and government mandates have added blocks all throughout the system that continue to add more and more time to each patient visit--and ends up damming up the clinic from ever getting their hands on the patient to do the exam.

Putting It in View


“Beaver dams are built to provide ponds a means of protection against predators (coyotes, wolves, and bears) and to provide easy access to food during winter. Dams modify the natural environment in such a way that the overall ecosystem builds upon the change. While this can be a very positive change--beaver dams can also be very disruptive. Flooding can cause extensive property damage. But on a whole, dam building can be very beneficial in restoring wetlands. While beavers can create damage, part of the problem is one of perception and time scale.”1


Having grown up in a rural community in western Massachusetts, all the children--and dogs--were very aware of beaver dams.

We kids looked at the dams as forts to conquer and sit on during the day as the beavers swam aggressively around trying to keep us away.

The dogs often looked at the dams as areas to conquer so they could capture the beavers. Unfortunately, they usually spent their days unsuccessfully stalking the beavers, and more often, being bit or chased from the water by a pair of angry buckteeth. The only reward our English setter ever achieved for hunting skills was “horse blue antiseptic,” which would be applied to the ill-timed teeth marks all over its body. And the next day--the dog would be right back there to try again in vain.

I never thought after I entered the field of ophthalmology that I would give beaver dams much thought again--but here we are analyzing the clinic flow in these terms.

In this day of electronic health records (EHRs)--where the ultimate goal of an EHR was to ensure our clinic lives went quicker and would be less bogsome-- clinic flow has never been slower.

These very systems have actually decreased production time, increased expenses, and decreased physician, staff, and ultimately patient satisfaction, due to the “dams” which have been erected.

What was once a theoretical benefit of the dam is now causing chaos all the way downstream.

Front desk, technician animosity


Front desk, technician animosity

The other day, one of my doctors came in and asked why there was such animosity between the front desk associates and technicians--in essence: “Why don’t they like each other?”

I have spent a good part of my career trying to explain this to vice presidents, administrators, and doctors--people who are neither technician nor front desk members. It never works and usually only muddies the waters more. I have learned to shrug my shoulders and live another 15 minutes by saving my breath, but it is still a valid question.

It goes back to being about beaver dams.

Meaningful use and government mandates have added blocks all throughout the system that continue to add more and more time to each patient visit--and ends up damming up the clinic from ever getting their hands on the patient to do the exam.

In most offices, the patient spends an exorbitant amount of time discussing insurance information, vision plan insurance proof, HIPAA information, billing information, and woe be it if he or she needs an interpreter or needs to have a future test scheduled.

A patient can check in for an 8:30 a.m. appointment and the technician is still waiting to receive his or her paperwork and get them going at 9 a.m.


A 'dam' scenario

Here is how it potentially goes: A patient arrives to the clinic and has forgotten his or her new insurance or vision plan card. This now creates an issue in regard to the clinic getting reimbursed. Add that the interpreter is late--on top of the 15 minutes the patient is late--and we begin to see a ripple effect downstream.

Meanwhile, the technicians are waiting in the back to get their hands on the patient.

Let’s say that patient is a visual field patient. If the patient is 15 minutes late, the process holds him or her another 15 to 20 minutes, and by the time the technician gets the patient, the next visual field patient is already 10 minutes delayed and starting to get irritated.

The last issue to deal with as a result of the system delay is the technician “standing around” and the doctor becoming angry because he or she will ultimately have six patients ready at the same time.

The whole process (the dam) causes a backup in the clinic (flooding of a pond), which, eventually, when loosened up (patient is now moving in the system), causes the farmer’s field down the stream to flood and ruin the new corn crop (patient satisfaction).


Because of these continued delays, the staff will begin to “feed off” of, and “chew” on the people they perceive are in the way of being able to do their job.

When the technicians sense the doctors are unhappy, they will go and harass the front desk to get them to turn the patient loose. The front desk employee feels caught in the middle of doing their job and holding the technician up.

And that is why front desk employees and technicians often do not like each other while at work. They are usually very good friends and have great relationships when not at work.

When the system breaks down, the effects are far reaching, and will continue to cause problems all the way down the stream. Think of it in this fashion: If an earthquake occurs on an island, a ripple will occur in the ocean where the earthquake was centered. That ripple will continue throughout the ocean so that by the time it gets hundreds of miles away, that small ripple now has the potential to become a tsunami--full of devastation.

While being behind the clinic schedule is not a potential life or death situation, try telling that to the technician who is under the gun to get patients to the doctor.


Blowing up the dam

Your clinic flow can be easily equated to a beaver dam. Evaluate the clinic as to the processes you have and where they dam up. Evaluate the effect it has downstream and work to avert those issues.

If the issues cannot be diverted, you need to evaluate the need to “blow up the beaver dam” and start anew--to prevent the problems down-stream (flow, patient satisfaction, and patient retention).

If you continue to muddle through with a dammed up system, buy a lot of “horse blue” and prepare to spend the majority of your days putting it on the beaver bites that will occur between the technicians and the front desk--as there will be many.

Lastly, remember: if you choose to blow up the beaver dam to alleviate these issues--beavers are creatures of habit.

Even after life calms down and things starts to improve at the clinic, the beaver will build another dam in the same spot. It is comfortable to them, and it is safe for them to return to. It will cause the same problems, in the same places, down the line, making it one ‘dam’ thing after another!



1. https://en.wikipedia.org/wiki/Beaver_dam

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