Lee A. Resnick, MD, FAAFP
Managing flow in the urgent care center can be daunting. Volume and acuity are variable, staff is inconsistently engaged, and our patients can create more unpredictable challenges than a “Wipeout” obstacle course. Those who master the chaos move through the day with the effortless grace of a Kung Fu master. Those who don’t resemble something closer to a “Pinball Wizard.” So, what’s the secret sauce? Can efficiency be trained, or is it hard wired? How do we ensure that quality doesn’t suffer under the weight of productivity pressures? To manage such demanding and conflicting priorities, here is a list of tips that I have found helpful in improving the efficiency and effectiveness of patient encounters…
- Determine a preliminary action plan before entering the room. Based it only on two goals: 1) differentiating stable vs. unstable illness and injury; and 2) addressing the “patient agenda” in a supportive and validating way.
- Work with support staff to ensure a patient is prepared adequately for the exam. If it is a knee, leg, foot, ankle of hip problem, then the extremity must be exposed before a provider enters the room. Patients with shoulder and upper back issues need to be in gowns. I don’t feel the need to put a patient with low back pain in a gown, because the examination can be done easily by lifting the shirt.
- Speak clearly and with appropriate volume. Annunciate and communicate in a very emphatic manner.
- Wash your hands while beginning interview, but remember to speak clearly and loudly while doing so.
- Immediately ask the patient to get up on the exam table. Doing so clearly marks the beginning of the encounter and allows for simultaneous examination where appropriate.
- Establish good eye contact and give verbal and non-verbal validation throughout the interview.
- Validate! Patients want to be made to feel that they made the right decision by coming in to be seen.
- Don’t be afraid to use humor where appropriate.
- Keep the history and physical limited to determine “stable vs unstable” or to address a patient’s agenda. Everything else is unnecessary and does nothing to build patient confidence.
- Provide the patient with expectant management based on the expected results of diagnostic testing. Be very specific so that there is no need to return to the room when results are complete.
- Handle hostility with compassion. Do not fight fire with fire, even if you feel that a patient is out of line.
- Use validation and empathy when treating a dramatic or hysterical patient, even if you believe he/she is overreacting. It may seem counterintuitive, but this will disarm a patient, foster cooperation and trust, and lead to a more efficient and effective encounter.
- Order diagnostic or interventions without hesitation and move on to the next encounter. Know ahead of time what, specifically, you are looking for (no open-ended work-ups). Diagnostics should provide you with critical information that can change your decision-making or allow you to address something in the patient agenda. Allow the nursing staff to do their job and wait for the next set of information before re-engaging.
- Do not write work notes/school notes. Task the nurse or medical assistant with this.
- Allow the nurse to download cleanup and dressing after procedures.
- Use sticky notes or forms to give orders needed for discharge. DO NOT re-enter the room to discharge unless absolutely necessary. If you have done expectant management, the patient should already know your plan based on predicted results of testing.
- Give patients the responsibility to make follow-up appointment while ensuring them that the center staff can help if they are having trouble.
This list intended to give a clinician specific tools for managing the encounter efficiently without sacrificing quality or patient satisfaction. In a typical shift seeing 30 to 50 patients, 3 minutes saved per patient can save 90 to 150 minutes per day. That’s productivity at work.