Gearing back up

Co-editor Jane Shuman discusses re-evaluating operations and practice after quarantine.

While practice revenues may have been drastically reduced or even halted, we now face the task of re-evaluating operations and procedures, both during the COVID-19 pandemic and after the crisis has passed.

First and foremost is the health and safety of staff and patients. Although difficult to predict, it is likely contagion precautions will continue for months. Even with a return to pre-virus schedules, we still may be wearing masks, washing our hands and disinfecting equipment more frequently. At least for a while, social distancing may require us to separate waiting room seats by six feet, either by removing chairs or taping signs on those chairs not to be used.

Organizations such as the New York Optometric Association ( ) have published a list of the surfaces that should be wiped between each patient visit. The list includes virtually every surface touched by the patient, technician, doctor and scribe, from doorknob to phoropter.

Increased time and reduced schedules

These precautions will increase the time between patients, and require practices to control the number of patients in the office. One option might be to ask patients to stay in their cars until the technician is ready for them. (Some practices continued to check the IOPs of concerned glaucoma patients in the parking lot.) When possible, ask companions to remain in their cars. To comply with these precautions, offices will likely reduce the patient schedule (fewer visits per hour) while extending evening and weekend hours, which will need to be staffed.

To optimize a reduced schedule, triage patients in advance. Here, doctors or lead clinical personnel review the records of patients who were scheduled during closed weeks to determine when they should visit. Patients with visually compromising conditions such as glaucoma, dry macular degeneration and corneal pathology should take priority. When reviewing records, consider the patient’s medical history, especially of patients who may be immunocompromised. When calling to reschedule visits, the technician can update the medication lists and histories (medical, family and social), saving considerable time during the office visit.

Regarding postponed cataract surgeries, some patients may fear contracting the virus and prefer to wait, leaving space for others. Of those eager to have surgery, consider scheduling patients who opted for presbyopic or toric correction among the first surgical blocks. Doing so will boost the cash flow before the insurance payments arrive.

Speak with the surgical facility about extending the 30-day window for pre-op evaluations. (This may be subject to carrier rules.) If your practice has the primary care physician perform these exams, discuss the possibility of your surgeon or anesthesiologist updating their clearance.

Evaluate work-up protocols

To improve efficiency, evaluate work-up protocols. For example, there may be no need to refract every year if the patient’s vision has not changed more than a line and they have no intention of purchasing new glasses. Complete the CC/HPI, ocular medications, work up and dilation, and then finish the elements of the comprehensive history. Dilating first will reduce the amount of time the patient has to wait before seeing the doctor.

In order to reduce the number of contact points, the doctor may choose to defer some diagnostic tests until the following visit. Also, consider leaving patients in the work-up room where the doctor will do the exam. Rooms that are not fully-equipped for work-ups can be used for post-op visits and quick follow-ups if a portable slit lamp is available.

Tips for using your time effectively

A final word: use your time effectively. If there is not enough work to keep you busy, ask a coworker to train you on a new skill. Cross train so you can jump into another area if necessary. Work towards your certification or next level up. Most of all, remain positive—COVID-19 has affected everyone. A positive attitude may comfort an anxious or sad coworker or patient for just a moment or two. OP

The table that follows presents an office re-opening checklist for ophthalmology practices.


The following checklist, from BSM Consulting, provides a list of work items required for office re-opening. The complete checklist, including implementation notes, is available with the online version of this article. To begin: 1) Review the list and customize as necessary. 2) Assign responsible party(ies) to each activity, and a timeline for completion. 3) Update the work plan regularly to note activity that has occurred and circulate to all members of the work team.

TIMEFRAME: Authorized individual(s) to determine with owners the appropriate timeframe to re-open.
FULL OR PARTIAL: While offices are shuttered or partially closed, consider if all locations should re-open.
PERMANENT CLOSURE: If an office will remain permanently closed, consult the BSM Closing an Office Location Checklist to cease operations.
STAFFING RESOURCES: If the office will re-open, determine how to best align providers and staff to that location such that the practice is stronger once business as usual resumes.
PRIORITY SERVICES: If partially re-opening, identify types of services that can be addressed via telemedicine/remote care vs. services that may require an in office visit.
PATIENT OUTREACH: Determine patients waiting for scheduled treatments (i.e. cataract surgery, routine eye care, or elective surgeries that were postponed) and reach out to patients.
PROVIDER SCHEDULES: Develop initial schedules, consider ramp up schedule and timeline to increase services.
PATIENT RECALL: Develop re-visit exams for all surgical patients. Re-activate patients by using previous surgery schedules and cancellation lists.
PRIORITY SUPPLIES: Obtain PPE required to see patients according to best practices advised by specialty societies, AAO, CDC, etc.
SECURE STORAGE: Secure all supplies, particularly PPE and cleaning supplies, to manage inventory and preclude pilfering.
FRONT OFFICE SAFETY: Consider installation of glass barrier between patient and check in staff.
INVENTORY CONTROL: Designate staff member responsible for ordering PPE and monitoring inventory.
PPE PROTOCOLS: Publish and review protocols for employees’ use of PPE.
DISINFECTANTS: Establish protocol for staff to disinfect surface areas, exam chairs, and all equipment between patients, restroom, and check-in area. Please see CDC list of approved cleaning agents and issue written and verbal instructions for staff.
COVID-19 SCREENING: Develop system to screen patients before they enter the clinic by calling and asking questions about COVID-19 symptoms and taking patient temperatures before proceeding with an exam.
EMPLOYEE SCREENING: Establish protocol for employees to monitor body temperature or symptoms. Employees are to self-report if their temperatures are > 100.0 F or become symptomatic for COVID-19 (cough, shortness of breath, or sore throat).
QUARANTINE: Work with HR Attorney and practice physicians to develop protocol for employees to self-quarantine if they are not wearing PPE but are exposed to a patient who has a temperature > 100.0 F or COVID-19 symptoms.
NOTIFICATION: Notify landlord and paid parking structures of office re-opening or modified office hours.
PHONES: When “shelter in place” orders are lifted and non-clinical staff can return to the office, re-route phone systems back to the office.
IT VENDOR: Work with IT services on necessary tasks to ensure network security.
BUILDING SECURITY: Update security access to the network and building.
VENDOR SUPPORT: Restart any suspended vendors necessary to facilitate patient care (laundry, fire extinguisher checks, housekeeping, medical waste disposal, etc.).
BUILDING SUPPORT: Review modified work schedule for cleaning services, landscape care, and building maintenance. Increase or modify only essential services.
OFFICE SIGNAGE: Place a sign on all office doors with updated clinic hours and patient instructions to enter the building.
EQUIPMENT: Restore any equipment that might have been moved for security purposes.
PRODUCT STORAGE: Review and make necessary revisions to storage for patient medications, drug samples, or optical inventory.
CLINIC SCHEDULES: Evaluate patient schedules, including recent cancellations. Identify which patients should be scheduled first for a return visit.
IMMEDIATE SERVICE: Schedule clients such that they do not wait in the practice lobby. Patients should arrive and be taken straight back to an exam or treatment room.
PATIENT INTAKE: Streamline patient intake process by having the technician or scribe gather information before the patient arrives in the office. Consider using video software to create personal connection while completing intake remotely. Enter information into the patient’s chart note for the provider.
PATIENT ARRIVAL: Provide concierge service such that patients can text a designated staff member when they arrive in the parking lot.
VOICEMAIL: Change voicemail messages to include new work hours and how patients may schedule video or in-office exams.
VIDEO CONSULTS: Provide video options for refractive surgery or other cosmetic services through telehealth. Touch base with surgery patients regarding scheduling.
RE-OPENING ASC: Continue to monitor AAO/OOSS/CDC/HHS and surgical society guidelines regarding “elective” procedures. Stay in communication with the local Ambulatory Surgery Centers (ASC) or Hospital Outpatient Departments (HOPD) for guidance on when surgeries may resume.
ROTATING WORK SCHEDULES: If the practice has more than one provider, consider dividing the physicians and staff into work teams/pods. Allow one work team to have access to a designated office or area of the clinic.
CASH FLOW: Continue monitoring cash flow using the BSM Consulting 13-week cash flow forecast tool. Authorized individuals should meet weekly with practice owners to discuss cash available, upcoming accounts payable, staffing needs and payroll, and any other financial needs.
PPP LOAN PROGRAM: If the practice is drawing on a line of credit or receiving loan assistance through the Paycheck Protection Plan (PPP), develop a long-term plan regarding how to use the monies (payroll, rent, utilities, etc.) and develop a budget for use and monitoring of these funds.
CMS ACCELERATED PAYMENT PROGRAM: If the practice sees medical patients and accepts Medicare, the CMS Accelerated Payments option is also available.
2019 TAXES: Work with practice accountant to prepare 2019 tax returns as necessary.
GENERAL INSURANCE: Notify general liability and malpractice insurance carrier that practice is re-opening.
PETTY CASH: If petty cash funds were taken offsite, return to each office location that is reopening. Ensure that a system is in place to monitor these funds.
CREDIT CARDS: Retrieve any copies of the company credit card that may have been issued on an emergency/temporary basis.
SUPPLY INVOICES: Continue to review all spending / purchasing. Only restock items needed as practice resumes business.
RENT: If your landlord provided an abatement of lease payments due to loss of revenue, contact landlord to arrange payments/resume rental agreement.
MEMBERSHIPS: Re-activate practice memberships once the business is back at full capacity.
WEEKLY COMMUNICATION: Continue offering weekly communications to all staff, informing them of schedule updates, who is returning to the practice and why, as well as any safety instructions that need to be reviewed.
STAFF RECALLS: Recall staff as needed to manage patient flow. Determine appropriate staffing level to assure patient safety. Mirror staffing needs to the volume of patients coming to the office.
PAYROLL: Communicate payroll changes/plans with payroll company if outsourced.
TELEWORK: Continue to have administrative staff (billing, clerical, phones, etc.) work remotely as possible.
PTO: Review all PTO balances for employees.
RECRUITMENT: If the practice needs to replace staff who do not return, create emails, job postings, and competitive offers to attract new recruits.
WORKERS’ COMPENSATION: As staffing needs/adjustments are made, contact workers’ compensation provider to assess any changes needed to update policy.
FINAL RULES: Continue to monitor FFCRA and CARES Act legislation that may pertain to your practice regarding emergency employee provisions, mandatory sick leave, and extended FMLA.
REQUIRED POSTER: Download and post the Department of Labor’s required FFCRA informational poster in an employee common area. Ensure that employees who are working from home receive a copy of the poster. Add the poster to the practice’s employee intranet or online shared drive, if available.
BANKING: When returning to the office, confirm/designate authorized individual(s) to open the mail and deposit paper checks, sort bills, explanation of benefits (EOBs), etc.
3RD-PARTY BILLING: If practice outsources billing, contact 3rd-party billing company to alert them the practice is resuming patient exams. Verify that the billing company is also open and has the necessary staff to support the practice.
ACCOUNTS RECEIVABLE: Review progress made by the practice’s accounts receivable (AR) collection task force. If the practice is still trying to collect on outstanding AR, develop a plan to follow-up on claims
ONGOING SERVICES: Develop a plan on next steps to recover any monies owed to the practice, including telemedicine exams and consults.
COMPUTER SOFTWARE: If EHR/PM software vendors negotiated a suspension of unneeded computer licenses during closure, contact vendor to re-instate number of licenses/workstations required for physicians to see patients.
INVENTORY: Conduct a hand count inventory on all injectables, surgical supplies, optical supplies, and cosmetic products. Compare results to inventory conducted at the time of the office’s closure. Manage any discrepancies found in reports.
COMPLIANCE PLAN: Once able with ample staff, resume normal compliance activities according to your Compliance Plan and internal policy commitments. Create a Compliance Plan memo to document the plan.
PROVIDER TRAINING: Ensure providers are confident with new technologies and telehealth offerings. Schedule training as needed.
STAFF TRAINING: Provide staff team with training relative to telehealth best practices to ensure consistency and continuity.
ONGOING SERVICES: If continuing to offer telehealth services, create on-call/consult hours to rotate providers.
POTENTIAL REVENUE: Add potential revenue of ongoing telehealth services and exams to practice’s 13-week financial forecast.
COMMUNICATION: Include providers in discussions about re-opening policies and coordinate clinic schedules.
TELEHEALTH ANALYSIS: Schedule meeting with providers who have offered telehealth options to patients (video consultations). Ask staff and providers to give feedback about these options. Identify what worked and what didn’t work and make adjustments to keep telemedicine options for patients.
TASK FORCE MEETINGS: Continue daily meetings with key leaders to discuss any news that may affect the whole group/company (suggest video meetings through Zoom or Google Hangouts).
SHARED DRIVES: Maintain the shared digital folder where this document and any other documents (vendor communications/loan applications, etc.) can be stored and updated live (OneDrive/Dropbox).
RE-OPENING PLAN: Communicate operational plan/reinstatement of hours/modified work schedule to all providers and staff with clarity including available hours, scheduling procedures, and the need for clearance by the Medical Director as appropriate.
STAFF DEBRIEF: Meet with staff and key leaders to debrief on communication during
STAFF SCRIPTING: Script key messaging for staff to communicate to patients on phone and in person.
REFERRING PROVIDERS: Notify primary provider referral sources of practice’s current hours/offerings to patients.
PRACTICE WEBSITE: Update website message regarding practice re-opening and availability of services.
SOCIAL MEDIA: Consider posting blogs and updates on the website and social media sites, informing patients of practice news. Include a marketing campaign on topics related to COVID-19 and how the practice has weathered the crisis.
PERSONAL TOUCH: Ask patients if they would be willing to share personal stories about your office and their treatments.
Source: BSM Consulting