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Up Front | Sep 2009

Enhancing the Patient Experience

Patient-friendly organization can improve both the ophthalmic practice and the operating theater.

Like all doctors, I began my medical training with idealism regarding my role of helping people as a physician and with ample empathy to go with it. But I soon discovered that these noble attributes alone are not enough to organize and run a medical practice.

During my training as an eye surgeon, I had the opportunity to work in a large number of settings. I worked at a university, in two private practices in Belgium, in two hospitals in the United Kingdom, and in a short locum tenens position in four other UK hospitals. By observing others in these varied settings, I learned a number of practical realities: (1) organization is important, (2) organization can be accomplished in many different ways, and (3) organization does not have to be costly to be better.

Patients accept your method of organization even if it differs from other practices in your area or around your country.

I like to think that I attract staff (and patients) who like my way of working. Good organization allows you to work the way you like and attracts people who suit you, rather than the other way around.

In organizing my practice and my patients' operating theater experience, I emphasize two things: patient friendliness (because I care about patients) and efficiency (because I do not like to waste time).

IN THE PRACTICE
Patient friendliness in the ophthalmic practice starts with investment in sufficient parking space near the entrance. It includes making sure the practice is accessible to wheelchair patients (with no stairs or steps at the entrance, large corridors, and a handicapped-accessible toilet). We even keep a wheelchair in the practice. The staff also aims to answer the telephone as quickly as possible; four ringtones is the goal.

Once the patient arrives, a receptionist completes the computerized patient record, including name, address, birth date, phone number, and general practitioner. The same staff person also performs noncontact tonometry, autorefractometry-keratometry, and measures the patient's existing glasses with a lensmeter (Figure 1).

A spacious waiting environment with acoustic ceiling and ventilation puts patients immediately at ease. In the waiting room, daylight is abundant and no medical posters disrupt the peaceful atmosphere (Figure 2). A corner with a small tent and spongy building blocks keeps children occupied as safely and quietly as possible.

A qualified optician first takes the patient into the examination area, asks briefly for the main complaint, and measures visual acuity at distance and near. Refraction is performed only if necessary.

With these tasks already performed, I can concentrate on performing the exam, making a diagnosis, and explaining the treatment. Because everything else has been taken care of, all my attention is on the patient and on building the patient-doctor relationship.

After I have seen the patient, the secretary deals with follow-up or treatment appointments and payment arrangements. She also gives the patient his prescription for eye drops and glasses, which I have ordered printed from my own computer terminal.

To be able to work like this, I need two to three outpatient examination rooms with a slit lamp in each (Figure 3). Another room is reserved to supervise orthoptic patients and for other purposes such as preoperative exams for cataract and refractive surgery (in our practice, mainly LASIK or phakic IOLs) or optical coherence tomography. Fluorescein angiography, visual field exams, and argon and Nd:YAG laser treatments are performed in other rooms.

On a yearly basis, the greatest cost in a medical practice is for personnel. Therefore, I have invested in space and equipment to make sure the staff can do their work. There is enough space that three secretaries can keep busy when three ophthalmologists are at work simultaneously, and there is enough examination gear to keep the opticians at work and of course the physicians, whose time is the most precious.

Patient friendliness combined with good organization are keys to success. My method of organization allows me to see two additional patients each hour. This shortens the waiting list and helps to pay the additional costs for personnel and equipment. Seeing more patients also helps to fill the surgical lists, which contributes to financing the entire practice.

It is obvious that happy, friendly secretaries and opticians add to the positive experience of the patient. My advice is to take this part of your practice to heart, just as you do your patients' medical concerns.

Another element that improves the doctor-patient relationship is our self-made patient-education brochures explaining common pathologies such as cataract, glaucoma, strabismus, and amblyopia, and common refractive surgical procedures such as LASIK. These take a lot of time to create, but patients react positively to them.

IN THE OPERATING THEATER
In the operating theater, patients experience stress, which may positively or negatively enhance their impressions of the experience. Therefore extra care should be taken to create a positive experience for the patient. Although I perform cataract surgery in a hospital, I want the patient to experience the operation as though he were going to the dentist. My patients do not undress; however, they do wear a gown and have an intravenous drip inserted. While the preoperative drops are administered, the patient sits in a large room with his family and watches television.

I insist on doing patient transport myself. As the waiting room is nearby, this is the best way for me to fill the time while the nurses change over the phaco equipment and instruments between cases. Patients feel more at ease after having seen me before surgery. A short walk and the personal time to ask the patient if he is afraid works miracles. On the table the patient is more relaxed, and this in turn not only shortens the operation but also makes it easier for me and safer for them. It is, however, often an architectural challenge to create this arrangement with respect to operating room rules.

Topical anesthesia, topped with a bit of intracameral lidocaine, helps us honor the promise of painless surgery. Of course asking for a knife or declaring that it is blunt during surgery has to be avoided, even by the nurses. Because patients see nothing under the theater drape, the sensitivity of their ears multiplies, and little details can cause unexpected amounts of stress.

The surgery itself, as we all know, usually does not take long. Music plays; sometimes nurses chat during surgery, and sometimes I explain what I am doing. For nervous patients, however, I like to ask them where they spent their best holiday ever. Distraction works better for me than shouting at the patient to comply.

When I bring the patient back to the daycare unit, I personally give the instructions for the drops (the first time). Bringing back a relaxed, smiling patient works like a charm to reassure the remaining patients in the waiting room.

Because patients get only minimal sedation (if only from the cyclopentolate drops), they can return home immediately after surgery. The total amount of time spent in hospital is around 2 hours—often less.

Taking the surgery out of the hospital entirely is of course even better. In Belgium, unfortunately, this involves considerable additional cost for the patient and a loss of insurance coverage. It is to be hoped that this situation will change in time.

From a patient-experience point of view, there is no denying that there is no better surgery than topical cataract surgery.

With the organization described here in my practice and the operating theater, I feel relaxed and am able to be more friendly with patients, which is of course more important than anything else in this article. I wish you good luck building some of these ideas, which I learned from others, into your own practices.

Bruno J.H.G. Smeets, MD, is an ophthalmic surgeon at the Oogcentrum Hasselt in Hasselt, Belgium. Dr. Smeets states that he has no financial interest in any product mentioned in this article. He may be reached at tel: +32 11 23 33 91; fax: +32 11 23 34 10; e-mail: bruno.smeets@telenet.be.

Sep 2009