Pathways for better care: When patients and providers move in sync

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The challenges and pressures of clinical practice have physicians looking for ways to increase their office’s efficiency, an attempt to meet the sweet spot that balances the results obtained with the effort expended. Han et al describe reevaluating and designing office flow so that the patient and physician are ready for each other simultaneously, improving the experience for everyone: patient, staff, and physician.¹ Much of their book, Make Your Clinics Flow With Synchrony: A Practical and Innovative Guide for Physicians, Managers, and Staff, can be encapsulated in reducing wasted effort.

A systematic review of patient care steps will reveal areas that can be streamlined, simplified, or eliminated. Timing each step of patient encounters over several days (arrival at check-in, completion of check-in, technician calling the patient back, completion of screening, time to optical coherence tomography (OCT), time during OCT, physician arrival time and completion time, checkout, etc) will reveal bottlenecks, opportunities for improvement, and a baseline against which to measure progress. Chen et al at the University of California, Davis highlighted their experience measuring and improving workflows, particularly around imaging.² Switching to decentralized OCT imaging significantly reduced testing time for patients.

Lessons from clinic renovations

In recent years, we worked with our respective teams to renovate our glaucoma clinic areas—Myers at Wills Eye Hospital and Friedman at Massachusetts Eye and Ear. During the planning process, we consulted with each other and incorporated many of the same concepts.

During the COVID-19 pandemic, the glaucoma department at Wills Eye Hospital had switched to having one technician remain with a patient, leading them to an individual visual field (VF) or OCT room for a test on the way to the exam room and keeping them in a single room for their screening, physician exam, and checkout. This reduced the number of potentially infectious exposures between staff and patients and resulted in fewer room cleanings compared with using multiple rooms for each patient. Reduced patient movement to and from the waiting room and the implementation of escorting resulted in better flow and required less time and effort than the prior workflow. This heavily influenced the redesign, placing individual OCT and VF machines near each cluster of exam rooms rather than in a centralized location. Ultimately, this has reduced patient wait times, waiting room space requirements, and staff and patient frustration.

Decentralized testing: Advantages and considerations

The decentralized testing model may not be appropriate for every practice setting as it requires adequate rooms, testing equipment, technicians, and staff cross-training, and this approach may be less practical in high-volume settings. Each physician should take the time to understand each employee’s work, as often employees work very hard in antiquated workflows that are no longer relevant or necessary. Examples include billing staff keeping unnecessary paper copies of records, imaging technicians routinely capturing views that the physicians seldom use, and document scanners located far from surgical coordinator workstations. Efficient clinicians need to develop efficient teams and efficient practices to realize the opportunities described in Han et al’s book.

Optimizing exam room layout

Renovations at the Massachusetts Eye and Ear Glaucoma Department focused on optimizing the exam room layout for efficiency and improved patient-physician interactions. The process began with the removal of all unnecessary equipment from the room and an evaluation to determine what was essential. The shift to internet telephony, with a web-based service now used primarily for interpretation, eliminated the need for a physical phone. To increase patient comfort, overhead lighting was replaced with upward diffuse lighting, significantly reducing glare for patients with glaucoma.

Repositioning the slit lamp to the patient’s right streamlined the process of getting into the chair and enhanced patient-physician interaction, creating a more comfortable and efficient exam experience. (Photo courtesy of Jonathan S. Myers, MD, and David S. Friedman, MD, PhD, MPH)

A significant change that simplified the patient getting into the exam chair and improved patient-doctor interaction was to move the slit lamp to the patient’s right (Figure). This allowed computer screens to be placed at the end of the table near the patient’s left ear so team members could look at the patient directly while charting. Putting 2 large screens in this location allows image management software to always be open and visible, reducing the time needed to load the images. A third screen, positioned to the patient’s left and facing them, mirrors the testing screen, allowing for a clearer and more interactive discussion of findings during the exam. Standardizing the layout of the various programs on the screens between rooms and providers also helps to simplify the work environment for all users.

Optimizing room layout can save time by keeping essential supplies within easy reach and consistently placed across all rooms. Prepacking betadine, 5-FU, and syringes and needles in the refrigerator streamlines procedures, while maintaining adequate sterilized forceps and scissors ensures readiness. Standardizing the tasks for technicians enhances efficiency. Eliminating the patient tracking sheet has reduced unnecessary staff movement throughout the office.

Aligning visits with capacity

A final and important change to the workflow involved more thoughtful templating of patient visits. Each office only has so many tests it can complete in an hour, and scheduling testing ensures this threshold is not exceeded. There are times throughout the day when staffing is reduced; reducing patient volumes during lunch hour and at the start and end of the day reduces wait times.

Scheduling the day with the number of practitioners who will be working in mind avoids unnecessary bottlenecks. For example, Massachusetts Eye and Ear staggers the start of the day with each physician starting and ending at a different time because not all staff are present at the start and end of the day. One must ensure that these templates are followed, as the improvements they provide are lost if clinicians or staff override the templates and overbook resources. Continued success demands discipline and buy-in from everyone on the team.

Improving efficiency requires a focused leadership, a persistent drive to always do better, and a committed team. Instead of keeping educational materials and consent forms in exam rooms and hallways, which requires staff to routinely check supplies in each location and often leads to dog-eared copies being provided to patients, on-demand printing is more efficient. PDFs of consent forms and educational material within the electronic medical record or on each workstation desktop make on-demand printing by the same printers used for eyeglass and medication prescriptions a simple process that frees staff to focus on other issues.

Harnessing software for VF and imaging analysis

Software to allow easier viewing and analysis of OCTs and VFs may reduce clinician time and effort to achieve similar results to reviewing individual tests. For example, platforms such as Zeiss FORUM (Carl Zeiss Meditec AG) make viewing a series of VFs and OCTs much easier and show trends and highlight areas of change. EyeSuite software (Haag-Streit) allows the storage and viewing of imaging and fields, with trend analysis of VFs. A prior study showed that 8 glaucoma specialists having little experience with these software platforms graded 40 sets of Advanced Glaucoma Intervention Study VF series with similar results when aided by software, but in 30% to 50% less time.³

The beauty of a more efficient practice is that everyone benefits. It is worth the time and effort to improve your professional home.

Jonathan S. Myers, MD

E: JMyers@willseye.org

Myers is chief of the Glaucoma Service at Wills Eye Hospital in Philadelphia, Pennsylvania.

David S. Friedman, MD, PhD, MPH

E: Friedman@MEEI.Harvard.edu

Friedman is director of the Glaucoma Service at Massachusetts Eye and Ear and the Edith Ives Cogan Professor of Ophthalmology at Harvard Medical School in Boston.

The authors did not indicate any financial interests relevant to the subject matter.

References

1. Han DP, Suneja A. Make Your Clinics Flow With Synchrony: A Practical and Innovative Guide for Physicians, Managers, and Staff. Quality Press; 2016.

2. Chen D, Xu C, Jones DR, Moussa K, Lim M. Enhancing patient flow: impact of clinic resource redesign on wait times for glaucoma and retina services in an academic practice. Paper presented at: American Glaucoma Society Annual Meeting 2025; February 26-March 2, 2025; Washington, DC.

3. Lin AP, Katz LJ, Spaeth GL, et al. Agreement of visual field interpretation among glaucoma specialists and comprehensive ophthalmologists: comparison of time and methods. Br J Ophthalmol. 2011;95(6):828-831. doi:10.1136/bjo.2010.186569