Practice Efficiency for Cochlear Implants

Understanding efficiency, quality, and productivity is critical to the viability of cochlear implant programs. As well it is necessary to work with your administrators to assure you align in terms of which metrics your program will use to measure efficiency, quality, and productivity. We hope the ideas shared in this article will provide clinicians insights into ways efficiency could be improved.www.shutterstock.com. Cochlear implants, schedule optimization, non-billable services, CI program.SCHEDULE OPTIMIZATION One of the most powerful ways to improve clinic efficiency is to optimize scheduling. How does your clinic determine patient scheduling? Are you seeing existing patients too often? Do you find yourself utilizing CI evaluation slots for patients who are not truly CI candidates? Is your no-show rate too high? Below, we offer scheduling suggestions for your clinic to consider: Screen incoming audiograms prior to scheduling CI evaluations to assure patients are audiometrically appropriate. Incorporate telehealth pre-CI evaluation counseling to educate potential candidates properly. If patients call to cancel an appointment, attempt to move up other patients. Charge a no-show fee for patients who miss their regularly scheduled appointment. Reduce the number of appointments for a newly implanted patient to no more than four in the first year (activation, 1 month, 3 months, 1 year). Consider remote options for established patients. Annual visits can be pushed to every two years or “as needed.” Charge a fee for transfer patients to cover the clinician’s time reviewing outside records and programming files. UTILIZATION OF AN ADMINISTRATIVE ASSISTANT, GRADUATE STUDENT, OR AUDIOLOGY ASSISTANT Minimizing the amount of time audiologists spend performing non-billable services can be paramount to the viability of a CI program. This can be achieved through the utilization of other team members. The job responsibilities of an administrative assistant or audiology assistant can be vast. For an administrative assistant or CI coordinator, non-billable tasks such as answering calls and emails in a timely fashion are critical to the patient’s accessibility to the clinic. The assistant/coordinator can also maintain a master calendar to improve surgical and clinical scheduling so students and audiology assistants can be utilized optimally to help with clinic flow. The assistant can also maintain a list of all patients who have been evaluated but did not yet qualify for a CI so they can be scheduled for a re-evaluation visit in the future. An audiology assistant can be responsible for many non-billable tasks. Examples are: Maintain clinic stock and inventory. Provide LMNs for patients needing upgrades. Review backpack and relevant apps with recipient backpack. Maintain master list of loaner processors and compatible hearing aids for bimodal users. Provide and obtain outgoing records for other team members and patients. Triage phone calls and emails. Provide troubleshooting. Order replacement equipment. Import OR data into the software so impedance and ECAP telemetry is available at activation. Assist with scheduling imaging appointment and medical consultations. Order external and internal equipment. Upload programming files for replacement processors. Maintain equipment logs for patients. Serve as second tester for pediatric or difficult-to-test patients. The use of a graduate student has also been instrumental in improving clinic efficiency. Third- and fourth-year graduate students can help with many non-billable tasks, while at the same time gaining critical experience with recipients. They can help newly activated patients become familiar with their equipment, download and demonstrate appropriate apps, and discuss potential rehabilitation tools. The graduate student can also help with troubleshooting and can participate in candidacy testing and reprogramming of cochlear implants. STREAMLINING REPORTING AND STANDARDIZING PROTOCOLS Report writing can be laborious for CI clinicians. However, reports should be streamlined for efficiency. Most CI programs use electronic medical records (EMR) for documentation. It can be time consuming on the front end for clinics to set up their report templates, but it is worth the effort on the back end when report writing time is drastically reduced. Smartphrases, templates, and drop-down menus are terrific tools available to assist clinicians in documentation efficiency. In our clinics, we start the report when the patient enters the room, and we fill out the report template as the appointment unfolds. Forms and questionnaires can be given to the audiology assistant, student, or staff member to scan into the patient’s EMR, so the CI audiologist does not spend time assuming non-billable responsibilities. If your forms and questionnaires are digital, then screenshots can easily be entered into the patient’s report. Additionally, protocols can be standardized to improve efficiency and consistency of outcomes. Protocols should be clearly described so each team member is performing the same tests, at the same presentation level, using the same signal-to-noise ratios when evaluating implant candidates. Protocols can also be created for post-operative testing and may describe the various test intervals as well as speech perception materials, presentation levels, test conditions and completion of appropriate surveys and quality-of-life measures. Consider using step-by-step protocols for each of the following: pediatric and adult CI evaluations single-sided deafness CI evaluations sequential bilateral CI evaluations post-operative programming intervals transfer patient evaluation second opinion evaluation hard and soft failures bimodal fittings billing codes. EFFICIENCY WITHOUT COMPROMISING QUALITY OF CARE In the late 1990s, the CI program at the Rocky Mountain Ear Center (RMEC) worked in tandem with the Colorado Neurological Institute (CNI), a non-profit organization housed on the same campus as RMEC. CNI provided support to each of the programs under their auspice, including research support. CNI was also interested in patient satisfaction outcomes. The audiology assistant at RMEC prepared satisfaction surveys, which were given to patients at regular intervals. The surveys were completed anonymously, and the survey results were published annually. The satisfaction survey consisted of 6 questions, and the patient was asked to rate each question on a scale of 1 to 5, with 5 reflecting the most favorable response. The 6 survey questions were: What is your overall satisfaction with the services you received? Is this the outcome you hoped for? Does your outcome match your expectation? How easy was it to get scheduled and how available were the staff to answer questions? How would you compare the care you received to previous care received elsewhere? Would you recommend this center to others seeking care? The 2004 survey results did not differ significantly from those obtained 15 years later, despite making substantial changes to scheduling and protocols to improve clinic efficiency. In 2004, appointment slots were longer and significantly fewer patients were seen each day. The lowest average score obtained in 2004 for one of the survey questions was 4.5 out of 5 while the highest score obtained was 5 out of 5 on a different question. Fifteen years later in 2019, the lowest score obtained for the same question was 4.2 out of 5 and the highest score obtained was 5. When analyzing the impact streamlined changes had on patients’ speech perception, it was apparent that the decision to streamline had not negatively impacted quality of care. Five years ago, when patients averaged 6-7 visits from activation to one year post activation, the average CNC word score at six months was 62%. In the last two years, the number of visits has been reduced to 3-4 per year and the average CNC word score has increased to 69%. CONCLUSION In summary, we passionately believe in the positive effects of improving clinical efficiency, productivity, and quality. While each of the suggestions listed in this article may not be available or applicable to all clinics, we hope you can use at least a few of our tips to improve your overall efficiency and accessibility for CI services. Ultimately, CI centers want to grow and provide CI technology to as many patients who need it. However, this cannot happen without thoughtful improvements to clinical service delivery models. We charge each of you to reassess your program’s clinical efficiency and productivity at least annually and remember to work closely with your organization’s administrators to align clinical goals.