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Novel approach gets constant improvement
Wait times reduced significantly
Imagine you're a patient calling to make an appointment. You may wait an extended period of time before the call is answered. Or, someone may answer the call and then put you on hold or route you to another person who cannot help you. Either way, you're not getting that appointment as quickly as you could be, and you're likely to be dissatisfied.
The first patient access process, begun in 2004, is the first to be revamped by continuous improvement efforts at the Cleveland Clinic. The initiative has examined every way in which patients get access into the organization.
For outpatient care, "this may be as simple as helping to ensure the phone call you are making connects you with someone who can actually schedule an appointment," says Darryl E. Greene, the clinic's executive director of continuous improvement. "This is critical for an individual concerned about scheduling an appointment and getting the care they need."
First, the percentage of missed calls was measured, by comparing the number of incoming calls to the number that were actually answered. "We saw an opportunity to improve," says Greene.
For example, during a one-month monitoring of calls to a clinical division, the percentage of missed calls during an eight-hour period could be 20%, with 350 calls answered versus 450 incoming calls.
To get frontline staff involved, data on their performance were shared during a six- to eight-month period. This involved manual collection of data in each department on the number of calls that came in between 8 a.m. and 5 p.m. and how many of these were answered. "The percentage gap was shared with frontline caregivers regularly, so they could see how they were performing," says Greene.
By 2005 , there was a target of 5% missed opportunity for most clinical divisions. Since staff knew this was being measured, they were motivated to figure out what they could do to make a difference.
"Additional service-level metrics like abandonment and average speed to answer were gathered clarifying missed calls," says Greene. "The value of this transparency with data led to targets, standard protocols, defining training needs, and team efforts to perform better."
Starting in 2006, the patient's ability to actually get an appointment was evaluated. "Imagine now that a patient got through to somebody, and now wants to schedule clinic time with a physician," says Greene. "We looked at how long it took to get access measured by time to scheduled appointment. How many days wait was there? Could they get in the current week, or did they have to wait an additional third or fourth week? We found out that we had a lot of challenges behind the scenes."
This involved looking at "slots availability," the number of clinical hours available for a given physician each week to provide care. "We try to give the provider the benefit of the doubt as to the reason why their slots aren't completely filled. They might be reserving that time for other priorities doing research, for example," says Greene. "But we started measuring this, too, and gave real-time data back to physicians for a given area."
The goal was to enlist the help of providers in getting better access for their patients. "We wanted them to see how absolutely critical it is to do all we can to make sure the patient has access to a physician," says Greene. "Coming up with solid metrics, making the information very transparent, and reviewing it with the CEO regularly was incredibly helpful."
Within areas, teams looked at slot utilization, and then tried to determine the reasons why some providers had more slots filled than others. "We looked at the reasons for lack of parity, then tried to work toward parity," says Greene. "But we didn't tell them what we had to do to get slots filled. It was left up to them to work through that."
The Mellen Center in the Neurological Institute looked at how to increase appointment availability for follow-up patients with multiple sclerosis. Physicians, nurse practitioners, medical secretaries, and patient services representatives met and found unequal distribution of slots among clinicians.
There was also under-utilization of certain slot types. Solutions included converted slots, to allow nurse practitioners to see patients individually. This allowed for hundreds of additional slots.
"Slot utilization is a behind-the-scenes metric," says Greene. "What the patient experiences is the number of days the patient had to wait to be seen."
Data were shared on what percentage of new patients could get into an outpatient clinic within seven business days. "We found that 50%, based on historic data, was a good starting point," says Greene. "As the years progressed, we became more sophisticated in our processes and ability to provide transparency. What was manual in 2004 is now electronic."
Electronic dashboards display this percentage as well as gaps in performance to targets. Any provider can check the current statistics on how many days it takes to perform at a 50% level for getting access within seven days. "Some may have 25 days, and they need to ask, 'What's driving us to have this many days wait?'"
In some cases, it's not enough to just provide data, business intelligence, and to review with executive leadership. Providers may need some help with problem solving.
In this case, a multidisciplinary team comes together to review the data and analyze the issue using a collaborative problem-solving method.
"Just looking at data doesn't always give you the answers," says Greene. "If a unit is hitting eight, nine, or ten days before getting to a 50% level relative to a target of seven days, they are able to ask the team to help them look at it."
The team may includes clinicians, nurses, administrators, and coordinators who schedule and collect medical records. One solution a team in the Taussig Cancer Institute came up with was to improve the ability of staff to "triage" the caller's need for care.
"If staff are able to access medical records earlier on in the process, that can help to determine which physician they need to see sooner," says Greene. "So we ask patients to provide them earlier on. This gives us information from the patient upfront that in turn allows us to puts them with the right physician in a shorter time frame than before."
When a call is received by a clinical nurse specialist for a new patient or referring physician, basic information is obtained regarding the diagnosis and testing done to date. The patient is then triaged to the appropriate specialist.
If records are needed to triage the patient, they are faxed and appointment scheduled within one day of receipt. All new patients are scheduled within seven days of the initial phone call for the Cancer Institute, as a result of this process.
Attention is now being turned to a patient's ability to get a same-day appointment. Frontline staff are now asking new patients who call if they would like an appointment that day.
"To provide performance data, we have a metric for 'appointment when wanted,'" says Greene. "Patients are later surveyed, after they have gotten an appointment, with one question: 'How would you rate the ease of getting an appointment when you wanted one?'"
"Same-day access was a big deal in pediatrics, which paved the way. That is now a critical measure for us," says Greene. "We are seeing the value proposition and quickly starting to propagate it. It is a metric now for the Cleveland Clinic."
The goal is to create the most desirable experience for patients from the time that they call for an appointment to the end of their visit. "Creating a process for patients that is seamless and efficient is absolutely paramount," says Kelly Caine, patient access coordinator at the Cleveland Clinic's Mellen Center. "One important part of creating that ideal experience is meeting the patient's expectation of timely medical care."
Appointment availability was created in each department reserved for same-day purpose alone. "This creates a fluid process that is void of delays for both the scheduler and patient," says Caine. "Patients are often very surprised that we offer appointments within the same day that their calls are received."