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Dr. Darrell White's Personal Blog

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How To Handle Emergency Visits In The Doctor’s Office?

We have an interesting problem a Skyvision Centers, one that we have all anticipated with a combination of longing and fear. We are about to become too busy to see emergency visits.

Let me back up a little bit and explain why the entire Skyvision crew is experiencing agita over this before it becomes some version of reality. Skyvision is that rare entity that continues to try to be exactly what it professes to be. In our case, while not unique, Skyvision is a rare example of true patient-centered medicine. You can read about our story here http://skyvisioncenters.com/blog/?p=108. I’ve also been very frank about how I feel about the mega-trends in medicine, trends that is seems will be magnified and accelerated in the coming “Healthcare Reform”. http://skyvisioncenters.com/blog/?p=145. None of these current fads or trends are terribly helpful blueprints for the solution to our new “problem” at Skyvision.

The ultimate consumer service industry is healthcare. Oddly enough, I wrote something about that: “The Ultimate Consumer Service Business” http://skyvisioncenters.com/blog/?p=56 (I’m clearly not above self-promotion here!). Everyone at Skyvision Centers is  on board with that concept. We’ve all quaffed the same Kool-Aid as it were. That’s how we have come to the conclusion that we are about to run out of time to see patients with an emergency, at least in the patient- centered way in which we have done so in our first 5 years. For you see, we have allowed our patients to define what it is that constitutes an emergency FOR THEM; we have not imposed any internal definition of “emergency” on our patients, and we have responded to every single patient-defined emergency with the same response: “come right in.” We have also evaluated and responded to every “oh by the way” additional problem that our patients brought up in the exam room but forgot to mention on the phone when they scheduled an appointment.

So how do we know that it’s a problem now, or about to become a problem really soon? Well, we still measure and evaluate all kinds of metrics that relate to the customer experience in the office. Some of those metrics are really kind of objective, like time and volume and such, and they lend themselves pretty easily to trend analysis. We know, for instance, that our average patient volume is dramatically up, especially over the last 6 months. We also know that the average time that a patient spends in the office for our core service has increased by 6 minutes over the last year, and that one of the internal intervals–how long it takes to be brought into the exam after your paperwork is ready–has increased by 4 minutes. We know that the average number of emergency visits (ER’s) is now 6/day, and that the range is 0-12; there is no meaningful pattern to the ER’s, no actionable mode.

We have been able to handle our ER load in the past because of our dedication to the concept of “process”, our adherence to clinical protocols and flow protocols, aspects of Skyvision Centers that were learned and adopted from the Toyota manufacturing processes. Our internal benchmarks for patient experience were established when we had so few patients and so much time to see them that I found myself telling childhood stories to entertain my patients, lest they feel they were getting the bum’s rush. We find that we have now bumped against the outer limit of “acceptable” by our own standards, standards which place us in the top 1% of patient experience, and must now make capital investments in order to remain there.

It is the ER load that has forced our hand, for it is the ER visits that have pushed us into the “discomfort zone” of longer patient waits and longer patient “transit times”. Without ER visits we would still be have “running times” like 2008 or 2007, even though our schedule volumes are dramatically higher, and we would perhaps be able to make smaller capital and staff investments more slowly. Adding more equipment and more staff is scary, especially in this economy and with all of the uncertainty surrounding Healthcare right now. Skyvision Centers is a business after all, and no one has received a raise in our first five years (indeed, I am still working for what amounts to an 80% pay CUT). Simply throwing more staff and more exam space at the problem isn’t so effective if it bankrupts the business. Kinda tough to provide a wonderful patient experience if the doors are padlocked.

So the question is now how do we handle ER visits? I know of a number of practices, probably the majority in our region, that simply give the ER patient the next available open appointment, whenever that may be, even if it is days or weeks ahead. Should we do that? Still others send patients to a local Emergency Room; it’s an emergency after all. One of our local institutions, widely lauded by DC gobbersnoppers including our President as the bellweather example of all that we should aspire to in healthcare, directs all patient-defined same-day ER visits to the World Class Hospital Emergency Room; even if you are an established patient with an established doctor-patient relationship their triage in the Emergency Room directs you to a doctor-in-training for your ER care. Should we simply “turf” our ER visits like World Class Hospital?

Thus far we have allowed our patients to define an emergency as anything they, the patient, feels is an emergency, and we have seen them right away that same day. Should we take back control of the definition of emergency and perform telephone triage? My staff and I certainly know the difference between emergency, urgency and inconvenience. We can define and ascertain what constitutes severe and what constitutes minor. Should we perform triage and schedule ER visits in open slots on subsequent office days according to long-established standards of severity and then availability? Tough call. A foreign body sensation is a “next couple of days” triage, but have you ever felt like you had something in your eye? It’s maddening. Imagine waiting a couple of days to be seen.

Should we openly state to all of our patients that we will continue to see ER visits as we have always done? Severity defined by the patient and “come on in” our response? In tandem with this will our scheduled patients agree to the implied contract that any increased wait they experience is an “investment” in their own future ER care? That they are agreeing to wait a little longer for their scheduled visit because of the “there, but for the Grace of God” phenomenon, that they, too, will go to the front of the line should an emergency befall them?

We’re all patients; I fear that that we  will all experience this in the near and not so near future, especially if the DC gobbersnoppers get their way with “Healthcare Reform”. We at Skyvision Centers are quite frankly way better at providing an enjoyable patient experience to go along with best in class medical outcomes already, and I fear that we are going to find the going even more lonely as we agonize over issues like this. I don’t see a whole lot of folks on the “service” side or the finance side of this equation spending too very much time thinking about the effect of emergencies in the medical office and how they affect our experiences as a patient, the person receiving the service.So what do you think? You’re a patient. From the patient’s point of view what would YOU have us do?

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18 Responses to “How To Handle Emergency Visits In The Doctor’s Office?”

  1. January 14th, 2010 at 1:13 pm

    jakers says:

    Price, Service, Quality

    Pick two. You have selected Service and Quality as the focus. Price is left as the variable. I would raise the price. Your census will drop and your net revenue should increase with out a major capital expenditure.
    I’m all about re-investing but at some point the stake holders need to be compensated for their worth. Providing a superior service/product for sub-standard compensation cannot be sustained long term.
    Will the capital investment to handle the additional load provide you greater compensation at some point in the future? It doesn’t sound like it will. If you write it up as business proposal and submitted it to investors would you get raised eyebrows?
    It just doesn’t sound like a winner from what I know at this point.

  2. January 14th, 2010 at 6:35 pm

    darrellwhite says:

    Jakers, your analysis and recommendation are both massively spot on except for one very important variable: medical care is not a market-based service. I live in a price-controlled environment with more in common with a utility than any service sector business. Your evaluation and suggestion is perfect for any other service, be it a restaurant or hotel, or the services of a plumber or electrician. Even the exterminator has more pricing control than 99.9% of physicians.

    You see, we are not allowed to price independently for levels of service for any patient who has “health insurance”. I must charge every patient in any given insurance contract the same, whether I see them after a 90 day wait or see them 90 seconds after they place the call. I can only collect the contracted amount whether I have 20 years of experience or am just out of training. The fact that my outcomes are in the top 0.1% matters not a whit–I get paid the same as the guy who is right on the 50th percentile meridian. Service and quality are the only variables that are open for business, and each of those only to improve the top line by increasing volume. Profit is strictly a function of cost control and efficiency.

    Funny, isn’t it, that even a really bright guy like you isn’t aware of how not-free-market medicine is in America right now, eh? Knowing what I just shared put your thinking cap back on! Thanks for your thougts.


  3. January 14th, 2010 at 7:36 pm

    jakers says:

    Hmmm. Some how I was under the misguided notion that most of the services offered/procedures performed were elective.

    They are not so that certainly changes the dynamic.

    The same remove the market from performance has been applied to education and the outcome isn’t anything to be desired. Unless the desired outcome is slack jawed automatons that do as they are told.

    Emergency visits are the problem. You can invest/risk to increase capacity with no increased return in the near term. You can funnel patients to a standard level service provider(Sky vision is superior). Your staff can call an audible at the line of scrimmage and risk offending patients who believe they have an emergency but might not.

    Will the insurance regs allow you to ‘offer’ a front of the line fee. For the small sum of $500 we can see you and your emergency today, Right now. Or you can choose to wait 8 hours in the ER. Or maybe it isn’t such an emergency now and you would prefer to follow SOP.
    Customers are wonderfully brilliant at self selection when given the option.

  4. January 15th, 2010 at 10:49 am

    dwayne.. says:

    DOC..Any process improvements to reduce the average patient visit time? Regain some of that 6 min increase? What do you attribute that increase to? More paperwork? More HIPAA madness? More chatter because you know people from repeat visits? What’s the tech landscape? Once the process is refined, can any further refinements be done with tech?

  5. January 16th, 2010 at 9:53 am

    darrellwhite says:

    Dwayne, avg. transit time has increased to what we consider our maximal allowable for scheduled patients, given our awareness/concern for our patients’ experience in the office, without adding any ER’s at all. We will address the transit time issue for scheduled patients by adding support staff and “internal real estate” (more exam space), since physician capacity has not been reached. The issue of time in the office for scheduled patients is one that we anticipated and one where our response/solution was worked out 5 years ago. Our challenge is to figure out the best/fairest way to accommodate non-scheduled emergencies that are not really emergencies from a medical triage standpoint, but which FEEL like an emergency from the patient standpoint. Fair in that we want to take care of the emergency patients (they deserve it) without inconveniencing our scheduled patients (they DON’T deserve an additional wait).

    Hope that helps.

  6. January 16th, 2010 at 4:21 pm

    Buck Buckner says:


    Great article and followon comments. My daughter is a PA doing surgery with a plastic surgeon on cancer patients. I am going to show her this site. They do perform accident reconstructions, but may not have the ER frequency requirements you do; but scheduling and time control are certainly critical. Her job was an outgrowth of his expansion (hiring a PA vice another surgeon.) She turned out to be highly skilled (my prejudice notwithstanding) and not nearly as high a cost factor, so he did well; but as you said….times they are a changing. As a patient I would understand your being the “revenue generator” and backing out of the “personal relationship” mode, as hard as that would be for a personable guy like you. Hire and train that skill, which I am sure you already do, and keep the “business” end moving. I don’t see how you can do otherwise given the lack of market forces you and Jakers discussed.

  7. January 16th, 2010 at 5:53 pm

    darrellwhite says:

    As I mention to Jamie, Buck, my concern is not yet the time capacity of the docs. Once upon a time, when pay for services was better and costs were lower, a practice could simply run “fat” as far as both space and staff was concerned. Now, well, that’s a pretty direct path to going out of business. The big institutions, “World Class Hospital” and the like, simply elevate their collective noses just a bit and sniff “aren’t you fortunate that we are here so that you can wait.” Unfortunately, that particular flavor seems to be the flavor of the moment, and we can all expect to be force fed more of that if folks like us can’t stay in the game. Premium service and premium outcomes are not rewarded with a premium.

  8. January 16th, 2010 at 4:36 pm

    Jamie Ginsberg says:

    Darrell. This is a great problem to have! I am convinced starting health care reform will reduce your ER visitors. Why? Because most people have such crappy insurance they use ER visits so their insurance will cover their issue. Politics aside, how do you balance?

    As a customer I can not stand waiting. I have made it a practice to answer my phone when it rings, call back people I miss asap, respond to emails immediately. Because when we have a problem and call someone for help, we need and want a solution. At the very least we want to know the issue is being taken care of. Doctors are generally the worst in this area. Get to your appointment 5 minutes late and get reprimanded, wait an hour to see the doctor and that is ok.

    Really, our eyes are incredibly important to us. As a patient it is important to know you are putting in the time and thought necessary to evaluate my eyes and identify issues. At the same time, if I don’t have a critical problem…I WANT the person who does have an emergency to be seen first, even if that means rescheduling me.

    Judging by your thoughts and statistics, I think you are on the right course…

  9. January 16th, 2010 at 5:49 pm

    darrellwhite says:

    Thanks Jamie. Thus far our scheduled patients have been understanding on those 10-12 ER visit days when we just can’t keep up, and I have been personally very open with those in the lobby waiting as to why we are struggling to keep up on those days. I also personally address the waiting issue with anyone who is openly unhappy or hostile; I do not leave that conversation to staff. My concern is the trend. My gut says to just keep seeing ER visits on-demand, “come right in”, and hope that our planned increase in staff/internal real estate will be enough. At least until we bump up against the time capacity of our three docs.

  10. January 17th, 2010 at 3:06 pm

    Buck Buckner says:


    Not sure if it works for specialists like you but how about a mix of “normal” patients and boutique/concierge/retainer patients who pay the annual “fee” to have immediate access and an education program to explain the difference to patients and the reality as to why? BTW I am with Jamie on his wait scenario and how frustrated I get. I’d rather reschedule and not have to wait than get in right away and wait–something about instant gratification, I guess.

  11. January 17th, 2010 at 4:29 pm

    darrellwhite says:

    Buck, the concierge service/system doesn’t work very well in my particular specialty. I think it would work well for certain specialties, say endocrinology/diabetes, but not so well in vision. I am a huge fan of the boutique/concierge system, by the way. I think we will see “trickle-down” effects from this high-touch, high value-added type of care that will filter throughout healthcare. That is, if these practices aren’t made illegal by the DC gobbersnoppers.

  12. January 18th, 2010 at 1:15 pm

    darrellwhite says:

    Brandon Bowen January 17 at 10:48pm

    Good evening. As I sit here and recover from Pony’s challenge of five rounds of Fight Gone Bad, I wonder if you’ve found any possible solutions to your scheduling dilemma. The reason I mention it is that I was a family practice clinic manager for about four years when I was on active duty, and we had similar scheduling issues.

    Because our primary job was to care for the active duty population and their families, our providers’ schedules were consistently full with routine and follow-up appointments. Each provider was allowed four AM same day or “urgent” appointments and four same day appointments right after lunch. Most of these appointments were utilized for “sick call” for the active duty folks, which were mainly to determine whether or not they should be at work for the day.

    The appointment lines opened at 0645 and by 0700, our schedules were filled, which resulted in a significant number of off-base referrals for care that could have otherwise been provided in-house, especially during cold and flu season. Our administration didn’t like this at all. We had one on-call provider for each week, but that really wasn’t effective because having a true on-call provider meant that the person on-call would spend the week with an open schedule, which was unpredictable at best.

    We tried many different approaches from increasing appointment times and working people in to leaving half of the day completely open for a couple of providers, but the solution that seemed to work best was manipulating the types of appointments for one provider on a given day, with the understanding that he or she would be responsible for overflow. The appointments scheduled for that provider would be routine or follow-up appointments, which meant the appointments were generally finished well before the allotted time was up. Basically, each provider had one day per week where he or she did nothing but routine/follow-up appointments all day and worked in unscheduled patients in between appointments.

    This allowed us to work in unscheduled patients with that provider without sacrificing the number of available appointments, and it seemed to satisfy the greatest number of people.

    I hope my description wasn’t too confusing. Without knowing how your appointment templates are set up with regard to number and type, I don’t really know if this would be a viable option for you. I just thought I would share what worked for us.

    By the way, thanks for the newbie posts on the main page. I’ve been doing CrossFit since June of last year, and your posts have been really helpful.

    Have a great evening.


  13. January 18th, 2010 at 2:08 pm

    Neal Van Duyn says:

    If you recall, I became a patient because of an emergency, but I was referred to you from another doctor because I had burned my cornea and you were trying to save my eye – which you did. I think you need to respond to the emergencies as best you can and perhaps have your attendants do some form of triage over the phone. One thing that is affecting your patient time in the office is that we have to fill out the same paperwork each time we come in. That is a waste of my time, your paper, your employees and your files. We all live in times of uncertainty and have to do more with less. Suck it up like the rest of us. I also remember the last recession. We were on a convention at Disney World and they were investing in infrastructure like crazy while the rest of the world bemoaned their fate. When the recession ended, Disney was ready for business and has done fine since. I’d like to see you invest even more in your future. I don’t think Health Care is really going to change all that much. As far as your 80% pay cut is concerned, that’s a conversation we should have in the parking lot next time we see each other. Hope this helps.

  14. January 18th, 2010 at 3:14 pm

    darrellwhite says:


    Great comment! We addressed the paperwork issue since your last visit. We sought and obtained a new interpretation of medicare/insurance/HIPPA regulations which allows us to use prior information absent any changes.

    We have invested in new equipment. We are in the process of expanding staff. Next step is increasing internal exam space, a step we anticipate prior to our Spring “surge”. “Come right in” seems to be winning the contest right now, so it seems that some version of gentle phone triage in combination with structural changes is our next step.


  15. January 18th, 2010 at 9:11 pm

    Barry Cooper says:

    I liked Brandon’s reply. My suggestion was going to be substantially (or exactly) the same thing: to make one doctor a de facto “floater” per day by intentionally underscheduling them a bit. You keep careful metrics, and of course averages do not prevent acute overflows (or underutilization), but no matter how you approach it, some dynamic improvising will be needed to most accurately match what you offer to what your patients perceive to be needed and appropriate.

    I don’t know the climate, but given that ER’s charge extra, perhaps you could charge a mild premium–say 10%–for immediate, unscheduled service, which will offset periods when your floater is surfing the internet.

    Obviously, you have a fixed amount of time per day. Efficient scheduling, coupled with a robust practice, will ensure the schedule is booked morning to night daily. Gaps need to appear, lest the whole tightly-bound system come unraveled on a regular basis. A doctor with gaps in his schedule would meet that need. So, potentially, would extended office hours after your normal close time, which would be the honor and priviledge of each of you on a rotating basis. That doesn’t sound like a fit for the image and reality you are trying to provide, though.

    Actually, one last, totally random thought: you could do house-calls after you are done. You may not be able to FIX the problem, but the patient would LOVE this, and of course you could work them in the next day. Again, this would be faciliated by leaving a few gaps in the schedule.

    You keep your schedule full by doing a great job. You get a mild upcharge, hopefully, by being superior. The only way to continue being superior is to sacrifice absolute efficiency–solid, paid visits, one after the other, all day every day–in favor of relative efficiency, which is providing the best possible experience for THEM, not for you.

    I’m likely rambling, but I figured I’d pipe in my two cents.

  16. January 19th, 2010 at 12:59 pm

    darrellwhite says:


    Some really good thoughts in there. Here is the unfortunate difference between Brandon’s experience and mine: we have too few providers to leave open slots that stay open. Remember the part of the post about how hard it is to provide a great experience to your patients when you are bankrupted and closed? We run there right now. Once we expand both flow (increased staff) and space (more exam rooms) we will be able to enact some version of what you and Brandon suggest. Equally unfortunate is the fact that there is no premium fee associated with premium service, only an incentive (hopefully) for those receiving that care to refer more business to us vs. lower service level providers.

    Thanks for your thoughts.

  17. January 20th, 2010 at 8:49 am

    darrellwhite says:

    From my college friend Guy:

    I don’t think that you should go with the underutilized doctor on a rotating basis, but maybe do something along slightly similar lines. If I remember correctly you said that you were averaging six emergency visits a day. Why not block out three slots for emergency visits each day (late morning, early afternoon, end of day, or whatever your records indicate are the most frequent times)? I think that with some form of the triage described, the average number of visits may come down from six a bit. If three slots are open, then regularly scheduled patients’ waiting times would not be as impacted as they are now, and at those times when there are six or even twelve emergency visits in a day, the three slots will take some of the edge off and your explanations to your patients, and their understanding that you will provide them with the same service, will go a long way. In the event that there is not an emergency visit in a certain slot then paperwork, rest, or moving patients in the waiting room up in the queue.

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