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Dynamic Chiropractic – December 16, 2011, Vol. 29, Issue 26

The Checklist: Your Most Valuable Office Protocol

By Tom Necela, DC

Have you noticed that the practice of chiropractic has grown increasingly complex over time? A quick look at the work involved in getting paid for what we do proves this true. Each year, new changes, rules, regulations and "hoops" we have to jump through are added to the basic requirements of reimbursements.

Gone are the "good old days" when you submitted your claim and awaited your check. Now, chiropractors must master the art of chiropractic billing, coding, documentation and compliance to navigate these same waters of being paid.

On the "business side" of practice, this equates to a series of precisely coordinated steps that must be performed for the successful daily running of a chiropractic office. Relying on simple human memory to get those steps right 100 percent of the time seems to beg the impossible.

A Pervasive Problem

This trend was formally studied by medical writer Dr. Atul Gawande, as it is a pervasive problem afflicting all branches of health care. Specifically, Dr. Gawande's first pilot project focused on how to solve the problem of a worsening clinical outcome (a growing rate of infections at a hospital) that was increasing in direct proportion to the massive amount of information that doctors and nurses were expected to remember. To Gawande, it seemed that the complex procedural requirements were causing staff members to forget even the most basic of simple steps in the prevention of infections. Sound familiar?

checklist - Copyright – Stock Photo / Register Mark Certainly he wanted to fix the problem, but he did not have the option of going back in time to when medicine (or chiropractic) was not so difficult. Nor could he envision staff members flawlessly remembering the hundreds of steps required for surgical procedures without ever making a mistake.

One Incredibly Simple and Effective Solution

The good news is that Dr. Gawande "discovered" a humble servant here to help. This servant speaks a language that is understood by the advanced techie down to the dinosaur unable to e-mail. This servant will attend to both young and old alike, male or female.

As a result of its widespread usefulness, Dr. Gawande's servant helped the world-renowned Johns Hopkins Hospital and was able to repeat the same victory all across the state of Michigan. Dentists across the country are "employing" the same servant in their practices. Business "gurus" such as Malcolm Gladwell (author of Outliers, The Tipping Point and other bestsellers) and creative lifestyle design author/blogger Tim Ferris (bestselling writer of 4 Hour Workweek and 4 Hour Body) now praise the simple beauty and necessity of Dr. Gawande's idea. And this is how this lowly, beautiful and underutilized tool that can be used to master clinical efficiency, boost profitability, improve collections and better navigate the "insurance game" captured my attention.

The idea was so simple that it could fit on one single sheet of paper. In fact, the idea is a single sheet of paper – sort of. As described in his book, The Checklist Manifesto, Dr. Gawande's brilliant contribution was the utilization of a simple checklist. Yes, a checklist.

Immediately Dr. Gawande's idea faced criticism from all fronts. Surgeons felt a meager checklist was beneath them. Medical administrators and business "experts" thought the solution too simple. Staff complained that they didn't have enough time to fill out yet another piece of paper that wouldn't have any real effect (in their opinion) on the patient or their care. You may be similarly skeptical; but just take a look at the results.

The Achievements of a Single Piece of Paper

Skip to the end of the story and the achievements of this single piece of paper containing a checklist are nothing short of astounding. Infection rates at Johns Hopkins hospital went to virtually zero and the hospital saved millions of dollars in the process. At one time, Michigan unfortunately held the record for the worst infection rates in the country. After its hospitals employed simple checklists, Michigan was able to save over $100 million and an estimated 1,500 lives were spared. Dentists were able to reduce staff costs by 25 percent and achieve six-digit practice growth. Massive achievements, unfathomable publicity and incredible potential are all managed simultaneously by this "stupid" little piece of paper – a checklist.

How to Use This Tool in Your Practice

So, how can we apply all of this to chiropractic? Even though we may not face situations in which our patient's lives are at stake, we routinely ask our staff to remember an amazing number of details in conjunction with running our practice. Beyond the billing department, even our CAs are expected to perform flawlessly throughout the day, juggling new patients, phone calls, appointment scheduling, collections procedures, assisting with back office duties, ordering supplies, assisting with marketing endeavors – the list goes on. In short, we ask and expect a lot of our staff. And when something goes wrong, we are quick to blame their lack of attention to details.

How many times have you gone to take an X-ray, only to find there were no cervical films? Or put a patient face down on the table to discover the headrest paper was out? What about that new patient who never came back for their report of findings? (They're the one whose X-rays have been sitting in the back room for the past three months.) How about those exercises you were supposed to go over with your patient – three visits ago. Or that important call you were supposed to return?

Developing a Protocol

Problems like these affect all chiropractic practices, large or small, high- or low-volume. In fact, smaller practices tend to have more time on their hands and in theory should be able to get things done efficiently. Performing client consults in offices across the country, I have usually discovered the opposite: Smaller practices waste more time than busy docs.

How else can a chiropractor who sees a few patients a day fail to finish their notes or spend their days putting out fires wearing too many hats? It certainly adds insult to injury when a doc has a lousy day in terms of volume and has to take home paperwork, or has tasks they didn't complete. As a result, they feel they can never get any busier (and increase income) because they barely have time to do things at the level they are at! At the heart of this sad situation is a system fail.

Busy practices, on the other hand, have a tendency to allow things to slip through the cracks because, well, they are busy! Things go unnoticed, often until it is too late. New patients disappear and old ones fall away without anyone noticing. Lost revenue slips away as well. As a result, they feel they are on an endless treadmill requiring new patients for fuel. Again, a system fail.

These practices are both committing the same offense, from different angles.They are working harder – not smarter; and losing revenue and increasing stress in the process.

The Checklist to the Rescue

A checklist takes the guesswork out of the equation. A checklist can glue a chatty CA to her seat so she can concentrate on getting her work done. It can focus a scatterbrained doctor on prioritizing important tasks they may want to do in-between patients. A checklist can help avoid the embarrassment of appearing unprepared to new patients and the sting of being unaware that a patient's insurance is really not going to cover any of the services that have already been rendered.

Each office member, procedure and department (including the doctor) should have a series of checklists or protocols that allows them to know "what to do when..." Some practices employ a few routine checklists to a small degree. Great practices employ many more and would not practice without them. They give confidence and accountability to the staff and the doctor alike. They can help avoid internal squabbles of whose responsible for what, and they can foster team trust that tasks are going to be accomplished precisely and correctly each time.

Will you occasionally mess up? Of course! It's important to strive for success, not perfection. In this respect, checklists become the backbone of clinical efficiency and function as an integral tool to maximize production, minimize time wasting and promote working smarter, not harder.

Whether it is increased quality and efficiency, decreased stress, increased production or some other factor your practice lacks, chances are there is a checklist that can help you improve performance in this respect. Take a few minutes to sit and think about your practice this week and focus on what routine procedures, services or tasks keep popping up as problems. Obviously, your current methods are not providing an adequate solution to that challenge. Why not try a checklist to solve your chiropractic office protocol obstacles? If it can work to save lives, increase profits and decrease errors elsewhere in health care, it can work for you.

Which checklists do you need to reach peak performance? Since I haven't seen "under the hood" of your practice, I can't tell you. But I will offer you a free sample of three checklists my clients use. Just send me an e-mail at , noting that you read this article.

Dr. Tom Necela maintains a private practice in Washington state. He is also the founder of The Strategic Chiropractor, a consulting firm for chiropractors. Dr. Necela can be contacted with questions or comments via his Web site,


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