'Truth-in-scheduling' solves access problems

QI team wipes out frustrating 'ferris wheel ride'

Getting an appointment at a primary care clinic at Dean Medical Center in Madison, WI, was once somewhat like riding a Ferris wheel - without the squeals of delight.

When patients called in to see a doctor about a pressing problem that was not an emergency, they would move from one stop to another, says Sheryl Thies, vice president for marketing. "You ride along a little bit, talk to someone else, maybe someone lets you off, maybe not," she says. "If you were lucky, when you finished you had an appointment."

The problem: Too many scheduling rules. A group of five or six nurses fielded about 1,200 calls a day, many of them from patients who needed an OK before the receptionist could add them to a doctor's schedule.

With a full-blown quality improvement project, now in its second phase, the Dean clinic tore down barriers to access and ultimately improved scheduling for everyone, including doctors.

The nurses' daily calls dropped to 600, referrals to an urgent care center dropped by 25%, and the patient count actually grew slightly as the scheduling became more efficient. "The efficiency we gained was unbelievable," says Thies. "We didn't ask physicians for more time out of their day. We just made better use of the time that was available."

To solve the clinic's access problems, a quality improvement team analyzed all the complicating factors. But the solution could be summed up in a simple catch-phrase: truth in scheduling. "You have to build the schedules truthfully and [do] what's reasonable," says Thies.

The doctor's schedules had a myriad of "special holds," rules about which type of patient visits could occur during various times. Even for routine scheduling, receptionists had to decide where the patient fit among 19 protocols.

"There were complex little rules that were never really written down," says Thies. "The receptionist learned this over time. There was a crisis and [the doctors] said, 'Never again do this to me, to my schedule.' These rules just built up."

As a result, the schedulers had little to offer patients when they requested an appointment. "There were no appointments within six to eight weeks that our receptionists could schedule," says Linda Vind, RN, a regional supervisor for Dean Health Systems. "If you had a sore throat, you called and left a message for a nurse."

When the phone lines opened at 8 a.m., patients seeking an appointment were instructed to call back at 9 a.m. to speak to the doctor's nurse. With everyone calling at the same time, the phones became overloaded and callers hung up after spending too much time on hold. "We had some people saying our phone system stinks; buy a new phone system," says Thies. "A bigger switch wouldn't have made a difference. We just needed to begin to figure this out."

QI team cuts rules, barriers

With physician input, the QI team of receptionists and nurses broke down the schedule and rebuilt it from scratch. They reduced the number of scheduling protocols (such as new patient visit or full physical exam) from 19 to six. They acknowledged the different practice patterns of physicians and took those into consideration - while eliminating special holds.

"If the physicians needed more dictation time as the day progressed, they built that in," Thies says. "Or if physicians had a busy hospital practice, they built that in. So the physicians could feel they had a realistic schedule to start with so they didn't feel that they couldn't do it unless they were Superman [or Wonderwoman]."

Meanwhile, receptionists could add patients to the schedule of a doctor who had a cancellation - without checking with that doctor or the doctor's nurse. "It was all this asking permission which generated more work," Thies says.

Some doctors had worried that the program to streamline access would cause new problems. But in the end, even some physicians who weren't affected by the new system asked if they, too, could join.

Meanwhile, the clinic educated patients about what to do if they needed to change or cancel an appointment. "We thought if we could find out if people weren't coming, we could use the appointment slots," says Vind.

The instructions, with a phone number, are printed in bold on the appointment cards. Many physicians sent their patients letters explaining how to contact doctors and nurses during an emergency; what days the physician see patients in the office; and how to make, change, or cancel appointments.

The clinic also calls patients seven to 10 days before their appointment as a reminder.

Patients who want to see a physician in the internal medicine department for a pressing problem can now get in within the same or next day. But the clinic is still working on improving access for physical exams or other lengthy office visits.

The clinic's success also inspired a broader quality improvement project for Dean, which has 40 sites and 400 physicians in southern Wisconsin. Family practice, orthopaedics, and neurology are involved, and others will be added.

"We have just as many [access] problems in specialty areas as we do in primary areas," says Thies.

However, improving scheduling and reducing backlogs will likely require a different approach. For example, in specialty areas, the QI team will consider the expectations of the referring physicians as well as of the patients, she says. The project began with focus groups of referring physicians who are part of the Dean system.

"Once you begin to see what's causing some of these apparent problems, only then can you make the changes to resolve the issue," Thies says. "Otherwise you're applying Band-Aids. We applied band-aids for so many years. That's why the schedules were such a mess."