For employers: the practice diary

Key principles

We are often called upon to set a minimum time for an eye examination, but we know that different patients need different amounts of time. For example, a stable low myope with pre-screening will need less time than a patient with multiple ocular and general health issues along with poor mobility and no pre-screening. A patient who has a learning disability or dementia will need longer than a patient who finds it easy to understand and comply with the elements of the test.

Therefore, in answer to the question of how long we think an appointment should be, we say: as long as the patient needs. We will support any employed or locum member who feels that they are coming under too much pressure to reduce the time patients need, whether this means supporting them in first raising the matter internally with their employer, or giving them advice as to next steps beyond this, if necessary to protect patients and maintain their high professional standards.

In determining the exact time to be allocated to individual appointments, practices need to allow for not only the typical procedures involved but also the patient profile and any associated risks. As a result of COVID-19, it has become necessary to allow for any extra time required to ensure patient and staff safety, including the time to carry out appropriate cleaning. This requirement may always be with us, due to the likely endemic nature of COVID-19.

Managing the appointment diary

Scheduling every appointment for the same length of time makes it difficult to accommodate different types of patients and can lead to problems, especially if each slot is short. Short appointments can mean that patients do not get the time they need, or appointments start to overrun, or optometrists forego their breaks in order to try to see all patients on time. This poses the risk that pathology will be missed, and is stressful for staff.

One option for scheduling appointments is to divide the working day into smaller time units (eg five, 10 or 15 minutes increments).

Appointments will be any multiple of these smaller units, allowing for different appointment lengths for different categories of patient, eg for new or repeat patients, or patients with particular conditions, older patients, patients with disabilities or those attending for contact lens aftercare. Practices in England that are involved in providing CUES or other extended primary care services outside GOS will also need to add expected demand for these services into the way they manage the practice diary.

The role of unregistered staff may be key to ensuring that the right slot is given to each patient. The person who answers the phone, triages calls and manages the appointment diary should know what questions to ask in order to ascertain whether any particular patient will need extra time. Support and training for these colleagues can make a significant difference to the efficiency and safety of clinic management.

Another scheduling technique is to build in a small amount of extra time after each test to accommodate for the “inevitable unpredictable event”, such as the first patient of the day arriving 10 minutes late. In a practice with only one optometrist available to test, if a typical test is judged to take X minutes and tests are booked at, say, X + 5 minutes, then flexibility is built in. If sight tests are booked in at X minutes with no gaps or catch up time, then risk may be created. By adding a short gap or two, the risk is lessened.

Good scheduling

Good scheduling allows sufficient time and helps prevent:

• Over-running and creating delays for subsequent patients
• Rushed tests, or patients feeling rushed
• Deferring procedures to another occasion due to lack of time

Good scheduling also allows sufficient time for:

• Something out of the ordinary cropping up
• Any questions the patient may have
• Carrying out, reviewing or monitoring additional procedures
• Maintaining accurate and appropriate records
• Preparing letters for information or referral
• Any phone calls that may need to be made, for example to make a referral
• Using the wider clinical team effectively

All of these factors need to be borne in mind when developing a scheduling system.

Factors to be considered

1. What additional support is available in the practice – eg dispensing opticians, optical assistants and administrative staff
2. How the optometrist will cope when something out of the ordinary occurs
3. Whether there is time to provide and properly review results from additional procedures
4. Whether the practice has fail-safe procedures to ensure that additional procedures are carried out and the results reviewed by the testing optometrist
5. Whether the practice has systems to ensure that patients are provided with all the information they need.
6. Whether the practice has fail-safe systems to ensure that procedures can never slip through the net or fail to be reported to the testing optometrist in a way that enables them to take them into account in reaching clinical decisions
7. Whether the practice monitors and acts on non-attendance when procedures are deferred including informing the testing optometrist

The key points are that:

• Some flexibility should be built in
• Optometrists should understand and use this flexibility, and not feel pressured to rush
• All relevant patients should be followed-up so that nothing is missed

Clinician capacity

The GOC’s overarching objective is to protect the public. Its standards are designed to ensure this. Optometrists must work within their own limits and experience, and employers should recognise this. Some can safely work quickly, whilst others may take more time. All are valuable members of the team.

It is not appropriate for optometrists to be required routinely to use work breaks, training or administration time to catch up (although this may occasionally happen even in the best-run practices). Sufficient breaks are crucial to safe practice.

This is why the AOP does not support the routine use of unstaffed, so called “ghost” clinics. If an optometrist already has a fully-booked clinic and all those patients attend, it is not appropriate to ask them to see extra patients. We will support members who are asked to see high numbers of patients in a day as a result of practices such as scheduling routine unstaffed clinics, in a similar way to that described earlier in this guidance.

Options

• Build some flexibility/ catch-up time into each half day schedule
• Provide administrative support for letter-writing and referrals. It is impractical and uneconomic for the most qualified professionals in the practice to be writing or typing letters. Try using standard computer generated templates or dictation software instead
• Some patients may predictably take longer than others, eg older patients compared with younger ones, so schedule appointments to match
• Practices with several optometrists often operate a rolling clinic (next available optometrist) system, which allows some flexibility on timing. This should not of course preclude the patient exercising choice of practitioner where the patient expresses a reasonable preference