It’s in the systems

To deliver a patient-centered experience, Retina Associates of Cleveland developed systems that focus on effectiveness and efficiency.

Alaina Piscioneri, ophthalmic technician, reviews data with Jerome P. Schartman, MD.

Practices face an onslaught of non-patient care issues, such as CMS requirements, but Retina Associates of Cleveland ( ) has not let these issues compromise their commitment to “friendly, patient-centered retinal care.” The proof: a four-star Yelp rating and slew of patient testimonials. So, how does this Northeast Ohio practice with 10 MDs, 131 support staff, nine offices and 13 satellite practices in Northeast Ohio keep this commitment? The answer: effective and efficient team management. (See also “Excellence in research,” p. 12.)

“I think that to run a successful practice, it’s all about taking care of the patient while being respectful of his or her time,” says David G. Miller, MD, Retina Associates of Cleveland’s president and managing partner. “And, to take good care of a patient, you must have certain systems in place that focus on effectiveness and efficiency.”

Here’s a look at how the practice maintains this effectiveness while staying efficient.

1. Efficient business practices

The staff says it recognizes that the business side can infringe upon the patient care side, so they keep a close watch to ensure that doesn’t happen. “I maintain knowledge of the federal programs and reporting guideline requirements, so we continue to receive reimbursements and don’t have to take away from patient care to focus on penalties and such,” says Warren Laurita, MBA, COO. “I communicate this knowledge to the managers and make sure that they then share that information with their staffs.”

Wendy Lord, lead clinical supervisor, says she does her part by making sure the practice’s EHR is efficient by working with the vendor and the practice’s IT manager, John Nagy. As an example of EHR efficiency, staff must fill out all required information in the current window before they can proceed to the next window. This eliminates the risk of entering incomplete records — fixing such records can take time away from patients.

2. Consistent meetings

Dr. Miller says the practice holds three regularly scheduled staff meetings: a managers’ meeting (every two weeks), a board meeting (once a month), and an in-service meeting (once a quarter). At these meetings, staff stay on top of any issues that could potentially threaten the practice’s high level of patient care.

“All occur after hours, so they don’t disrupt patient care. And, if any situations occur in between meetings, email and company voicemail are used to disseminate ‘quick fixes’ in the interim,” Dr. Miller says.

For example, Ms. Lord says that, at the managers’ meeting, they discuss issues such as the need for additional staff on certain days to maintain optimum patient flow, something beneficial for the practice and patients.

Madison Moore, ophthalmic technician intern (left), and Wendy Lord, clinical supervisor, discuss patient education.

John DuBois, CRA, acquires images with the fundus camera.

3. Decentralized decision making

Retina Associates of Cleveland favors a “more decentralized, democratic management style” in all its operations, as the practice’s upper management has found this style lends itself to better patient care, Dr. Miller says.

“We get as many minds around a decision as possible, because we recognize that the employees often have excellent ideas,” he says. “For example, we asked all the practice’s managers and technicians to look at the blueprints for a new office we’re getting ready to build. We didn’t do this with other practice locations, and some things, such as sink locations, ended up hindering efficiency.”

With the staff’s input on the blueprints, Dr. Miller says he made 10 to 12 changes that will increase the new office’s efficiency and therefore, the ability to spend needed time with patients.

Retina Associates of Cleveland overview

Founded: 1974

Practice specialties: “Medical and surgical treatment of AMD, diabetic retinopathy and retinal detachment, among other diseases of the macula, retina and vitreous” ( ).

Practice research: Pharmacologic and surgical interventions associated with retinal disease.

Claim to fame: “Friendly, patient-centered retinal care, going above and beyond to make a difference every day and treat each patient with exceptional, personalized care” ( ). Also, top enroller in the country for Macugen (Bausch + Lomb), Proxima (Genentech), and MacTel CNTF implant clinical trials.

Locations: 22 (including 13 satellite offices)

MDs: 10

Allied health staff: 131 (not all full time): 23 receptionists, 72 technicians, 13 billing personnel, 6 clinical trial staff, 4 physician assistants, 2 IT, and 11 administration

Equipment used includes:

Accutome B-Scan Pro

Allscripts Practice Management System

Haag-Streit AT 900 Tonometer

Heidelberg Spectralis Ultra-Widefield Angiography

Marco G4 Ultra Slit Lamp

Medtronic Tono-Pen XL

Nextech MDIntelleSys

Reichert Technologies LongLife


Zeiss Cirrus HD-OCT 4000

Zeiss FF4 Fundus Camera

Zeiss SL 115 Classic slit lamp

4. Uniform processes

Mr. Laurita says that establishing uniform processes (often birthed from the staff meetings) has enabled the practice to deliver “friendly, patient-centered retinal care.”

Examples include the following:

  • Front desk manual. The practice’s receptionists have binders that contain specific directions and scripts for dealing with both new and follow-up patients, including how to greet them and help them fill out paperwork, if needed, Ms. Lord says.
  • Patient work-up manual. Given to the techs, this manual includes specific directions for acquiring patient medical history, medication history, changes in vision information, dilation, IOP checks, VAs, required EHR elements, and more, Ms. Lord says.
  • “Follower” manual. “The ‘follower,’ or scribe, manual provides instructions on how to follow through with the EHR system relative to the diagnoses and what related patient education to provide,” Ms. Lord says. This includes reiterating the doctor’s directions and furnishing related hand-outs, such as those detailing what to do prior to surgery.
  • Coding spreadsheets. Vicki Gunter, Retina Associates of Cleveland’s billing manager, says that coding matrix spreadsheets in every exam room contain the diagnoses, correct codes for injections, and drugs that the health insurance companies cover. The front desks have spreadsheets that identify which carriers require prior authorizations. “The spreadsheets have worked to not only decrease coding errors but also to eliminate the doctors from calling the billing department during an exam and asking, ‘Can I…’” she says.

An exceptional patient experience begins at the front desk. Shown (from left): Stacy Richard, Lisa Barko and Erika Marconi, receptionists, with John Nagy, IT manager.

5. Staff training

The practice trains staff in these previously mentioned uniform processes — another factor the staff credits with their ability to keep their commitment to patient care.

When training technicians, for example, Ms. Lord says she and clinical supervisor, Bill Garven, provide a retinal disease handout for personnel and patient education, as well as the aforementioned work-up manual. Also, a seasoned technician follows the new hire until that seasoned staff member and the clinical supervisors feel the new hire can do the patient work-up efficiently and correctly — while also treating patients with kindness.

“Sometimes patients are slow or eager to chat, which can make getting the pertinent information in a timely manner a challenge,” she says, adding that techs must remain considerate to patients while acquiring the needed information. To do so, Ms. Lord uses this script as an example: “I’m so sorry to hear your knees are bothering you. Let me get the information on your eyes, and I’ll show you the section on the chart where you can include information about your knees or any other part of your body.”

Ms. Gunter says that the practice’s practice management software system contains knowledge-based instruction, such as webinars, that facilitates training and enables staff to work effectively and efficiently.

“As part of the training program, a core group of staff will view a webinar on a new process or procedure, take notes, and then teach the information to the staff members in their respective offices,” she says.

Excellence in research

Retina Associates of Cleveland’s commitment to an efficient and effective delivery of best-in-class patient care extends to the practice’s three-office research division. The practice’s approach to research includes:

Equal patient opportunities. “All practice locations have an app developed by the research staff that includes study information, including inclusion and exclusion criteria, so all the practice’s pertinent patients have the opportunity to try a drug or surgical intervention,” says Diane Weiss, RN, head of this department.

Efficient personnel scheduling. Ms. Weiss developed a “study schedule” spreadsheet, which is posted on the practice’s shared drive, so the clinical supervisors know well in advance when a tech is needed. The supervisors can then adjust schedules accordingly.

Ensuring patient comfort. “Most of the research coordinators are nurses, physician assistants or techs with roughly 30 years of experience, so they are very educated in retina, enabling them to deliver a massive amount of education to allay any fears,” Ms. Weiss explains. “They discuss the specific trial with patients, provide consent forms with the instruction to patients to circle anything that they don’t understand and let patients know I’ll be calling them to answer any questions. Typically, I spend about 30 to 40 minutes on the phone with these patients because I want to make sure they understand what’s involved and are comfortable with it.”

6. In-house IT support

In-house IT management also plays a role in providing patient care.

“My assistant and I make sure all the practice’s technology — email, voicemail, EHR, diagnostic devices — is readily accessible and running efficiently,” Mr. Nagy says. “Specifically, we’ve become knowledgeable in the technology the practice uses, so we can fix it fast or, if need be, recommend and install something to facilitate patient care.”

An example: Recently, the PC end of one of the practice’s retina cameras had a malfunctioning on/off switch, Mr. Nagy says. He says he immediately rigged a temporary fix, got in touch with the vendor, acquired the specifications on the device, ordered and installed a new switch, and the PC was good to go.

“We were able to handle this situation without the tech having to sacrifice any time — which would have delayed the patient — except for maybe a slight lag in turning the PC on that first time,” he says.

7. Reallocated office space

Physical changes to office space have enabled Retina Associates of Cleveland to improve patient flow and, thus, decrease patient wait times, says Mr. Laurita. “For example, to accommodate the flow of a growing number of patients who require intravitreal injections, the practice converted some of its office space and nonclinical space into clinical space used primarily for injections.”

The practice recently eliminated its paper charts and, thus, the need for file rooms. They converted those rooms into additional exam rooms to “eliminate patient backlogs and reduce patient wait times.”

Staff training provides a foundation for the practice’s commitment to patient care. Pictured from left: Warren Laurita, MBA, COO; Mark O’Conner, MBA, internal accountant; John Nagy, IT manager; Vicki Gunter, CMM, CPM, business office manager; Diane Weiss, RN, clinical trial manager; Wendy Lord, clinical supervisor.

High volume equals better care

“In having a high-volume practice, the advantage to the patient is that, in medicine, the physicians who tend to be very good are the ones who see a lot of patients,” Dr. Miller says. “And I think the same is true of support staff. Most of Retina Associates of Cleveland’s staff members have been with the practice for decades. By doing what we do hundreds of times over in a consistent, systematic fashion, we’re also able to give every patient the individualized attention and expertise they deserve.” OP