What an Operations Audit Reveals That Your P&L Never Will
Your P&L tells you what happened. It cannot tell you why. Revenue was flat, staff costs went up, overtime crept up again. The statement records the outcome. It says nothing about the 32 minutes patients spend sitting in the waiting room after check-in, the phone line that rolls to voicemail a third of the time, or the referral that takes almost four weeks to schedule.
That is the gap an operations audit closes. MGMA's Operations Management Edition puts it plainly: the data that matters most for performance, such as wait times, staffing levels and supply use, comes out of day-to-day work and has no formal recording system. Unless you go looking for it, you will never see it.
Here is what a disciplined operations audit actually examines, how each item is measured, and what to do with what you find.
1. Access: how long it really takes to get in
The standard measure is third next available appointment (TNAA): the number of days until the third open slot for a given visit type. It is used instead of the "next" opening because one cancellation can make the next slot look deceptively close. Measure it weekly, separately for new and established patients, and by provider.
Access has been getting worse across the industry. MGMA's 2022 Better Performers report found that new-patient TNAA across all practices rose from 6.1 days in 2020 to 8.1 days in 2021, which MGMA attributed largely to staffing shortages. Better-performing primary care and multispecialty groups ran about three days shorter for new patients.
What to do with it: If TNAA is long while providers report unused time, the problem is usually the template, not the demand. Look for blocked slots nobody remembers creating, visit lengths that do not match the work, and new-patient slots that are buried weeks out.
2. The scheduling template itself
Pull every provider's template and audit it against a written standard. MGMA's model scheduling policy sets these benchmarks:
Established visits of 10 to 15 minutes
New or comprehensive visits of 15 to 30 minutes
Blocked or held slots reviewed every quarter
60 days' notice required for template changes
A share of slots opened for online self-scheduling
Also review no-show and late-arrival data by provider, day and appointment lead time. Appointments booked far in advance consistently cancel and no-show at higher rates.
3. Patient cycle time, step by step
Cycle time is the total time from arrival to departure. The audit breaks it into steps and times each one: arrival, check-in, registration, rooming, intake, provider time, checkout. It also measures the waits between steps.
Two rules make this data usable:
One start point. "Arrival" and "sign-in" are different events. Choose one definition and train everyone who collects data on it, or your numbers will not be comparable.
Separate value from waiting. Sort each minute into time that helps the patient, waits that are necessary (such as a payer that requires a phone verification), and pure waste.
MGMA's model wait-time policy sets a practical standard: under 20 minutes from check-in to the clinical area, with an improvement initiative triggered if any provider averages more than 45 minutes over a month. Most practice management and EHR systems already capture the timestamps you need to measure this. Almost no one runs the report.
One Lean case in MGMA's library found 32 minutes of waiting after check-in. The practice's first instinct was to add Wi-Fi to the waiting room. That makes the wait more comfortable. It does not make it shorter.
4. The phones
Phone performance is one of the clearest examples of a problem that never appears on a financial statement but directly drives revenue. Measure three numbers:
The percentage of inbound calls answered live
The percentage that go to voicemail
How often a returned call actually reaches the patient
In one MGMA case, 34% of inbound calls went to voicemail, and about half of the return calls hit voicemail too. Front-line staff mapped the causes, cross-trained, and moved phone coverage. Voicemail dropped to 12%.
In another, Medical Colleagues of Texas used phone-system analytics to learn that scheduling calls peaked early and late in the week. The practice staffed those windows with part-time schedulers. Its answer rate rose from about 56% to 90%, and gross revenue rose by nearly $30,000 a month as more calls became appointments.
5. Handoffs and referrals
Work rarely breaks inside a single task. It breaks between people. The audit traces items that cross desks, including referrals, prior authorizations, test results and refill requests, and measures how long each one takes from start to finish.
A small urology practice in MGMA's Lean casebook measured the average time to see a referred patient at 25.7 days. The causes were insurance verification, authorizations, data entry time and difficulty reaching patients, with the work concentrated on one person. After the practice redistributed duties, standardized referral criteria and added a tracking tool, the average fell to 4.25 days.
6. Staffing and role design
Payroll cost is a financial number. Whether that payroll is deployed well is an operational question. Track:
FTEs per wRVU, visit or procedure
Overtime compared with patient volume
Turnover and time-to-fill for open positions
Staff-to-patient ratios by function
Then compare them with MGMA DataDive benchmarks for practices of your size and specialty.
Look just as hard at who does what. When providers spend time on work that staff could handle, such as forms, inbox triage and prior authorizations, you are paying physician rates for administrative output.
7. Physical layout and supplies
Walk the floor. Lean practitioners call this a gemba walk: leaders go where the work happens and watch it, instead of reading about it in a report. A spaghetti diagram traces a staff member's actual path on the floor plan, and it quickly exposes backtracking and wasted travel.
A cardiology practice in MGMA's Operations edition found inconsistent room setups and staff hunting for supplies. It applied 5S (Sort, Set in order, Shine, Standardize, Sustain), which meant:
Fixed supply locations
Par levels based on actual use
A card-based restocking trigger
Written setup procedures
Procedure times came down.
8. Policies and SOPs
Collect every written policy, then document the unwritten rules staff actually follow. The gap between the two is usually where the risk sits. Good practice looks like this:
Every policy is dated and owned, and refers to position titles rather than names.
Every policy is reviewed at least annually.
Staff acknowledge new and revised policies in writing.
A binder on a shelf is not a management system.
A useful lens: the eight wastes
Lean groups operational waste into eight types, remembered by the acronym DOWNTIME:
Defects
Overproduction
Waiting
Not using staff abilities
Transportation
Inventory
Motion
Excess processing
Use it as a checklist while you observe. Each item on it costs money, and none of them shows up as a line on your P&L.
How to run it without disrupting the practice
Pick three measures, not thirty. For most practices, start with TNAA, check-in-to-room time and phone answer rate.
Collect two to four weeks of baseline data using consistent definitions.
Observe in person on at least one full clinic day per site.
Find the root cause with a fishbone diagram or "five whys" before choosing a fix.
Pilot one change and measure it against baseline using Plan-Do-Study-Act.
Standardize what works in a written SOP with an owner, then re-measure in 90 days.
The bottom line
Financial statements are the scoreboard. Operations is the game. Practices that only manage the scoreboard keep being surprised by it. Practices that measure access, flow, phones, handoffs and staffing see problems weeks before they reach the P&L, and fix them while they are still cheap.
If you want an outside set of eyes on how your practice actually runs, Ark Advisory Group's operational assessment measures these areas and turns the findings into a prioritized action plan with owners and deadlines. Book a discovery call or call (908) 900-4607.
Sources: MGMA, Performance and Practices of Successful Medical Groups (Better Performers data report, September 2022; 2021 data); MGMA, Advanced Strategy for Medical Practice Leaders: Operations Management Edition (2024); Owen J. Dahl, Humanizing Lean Leadership in Healthcare (MGMA, 2024); MGMA, Operating Policies and Procedures Manual for Medical Practices, 6th ed. (2025). Benchmarks are cited as published and may not reflect current conditions for your specialty or market.
