Open access ends delays for appointments, delights patients
Open access ends delays for appointments, delights patients
Medical groups discover efficiencies in same-day care
Imagine all the doctors walking into your office each day with a wide-open schedule. Patients call and get appointments the same day, whether they need a physical exam or an acute care visit.
This revolutionary concept of "open access" is taking hold among some practices that have managed to eliminate backlogs and remove barriers to patients who want appointments. The result: ecstatic patients, happier doctors, and a competitive edge in the marketplace. One practice even reported a boost in patient satisfaction with access of 14 percentage points within a year.
"In every other industry, in every other walk of life, we’ve eliminated delays," says Mark Murray, MD, MPA, co-chair of the Boston-based Institute for Healthcare Improvement (IHI) collaborative on "Improving Efficiency and Access to Care."
"In health care, we institutionalize delay," says Murray, who also is clinical director for Sacramento (CA) Appointment and Advice Services of the Permanente Medical Group. "You call and get put on hold. You come in, and you get stuck in the waiting room. If you can eliminate the wait in other industries, you can eliminate the wait in health care.
"There’s no reason we can’t do all of today’s workload today," he says. "The only reason we can’t is because we’re doing last month’s work today."
Others came to the same conclusion after reducing appointment types and holds and creating new efficiencies. At Sauk Trails Health Center, a part of Group Health Cooperative of Madison, WI, patients typically waited a month or two for a physical exam. Now, they can schedule one the same day they call.
When the system changed, they responded with disbelief — then with delight, says J. Fred Brodsky, MD, Group Health primary care site chief. "It really was doable. The reason it seems impossible is you’re walking into clinic every day with 20 people on your schedule. If you make the commitment to ride the wave every day, it’s possible."
What are the steps toward open access? Physician leaders in practices that developed open access offer this advice:
1. Begin with adequate support, especially among top leadership.
Expect skepticism when you suggest open access, but look for allies. You’ll need colleagues who are willing to join you in the effort. And you’ll need the clear and strong support from practice leadership.
For example, access team members at HealthSystem Minnesota in Minneapolis meet with senior vice presidents monthly to report on their progress and receive help breaking down barriers to the changes they needed. But such help isn’t always immediate.
Murray recalls first broaching the idea of same-day scheduling when he was assistant chief of adult medicine at the Permanente Medical Group in Roseville, CA. "People thought we were crazy," he recalls. "[But then] we met other people who were just as crazy as we were."
Murray won over doctors who were frustrated with schedules that simply didn’t work. Long waits for appointments breed patient dissatisfaction, and overbooked schedules put unnecessary pressures on physicians and staff. Meanwhile, when patients can’t get in to see their own doctors for acute problems, they end up with a partner or at an urgent care clinic. In fact, physicians may be seeing each other’s patients because of scheduling nightmares.
At Peekskill (NY) Area Health Center, medical director Paul Kaye, MD, received eight patient complaints about access in the three months before the center began the IHI quality improvement project. There have been no access complaints since the center implemented a version of open access.
You can’t do it alone
But the center’s initial experience was also telling. Duane Stoner, PA, began by reserving half of his schedule for same-day appointments for his own patients. Soon, doctors who couldn’t accommodate their patients’ demands started sending them to Stoner, since he always had open spots. His plans to remain available for his own patients fell apart.
The lesson: He couldn’t do it alone. "We weren’t able to sustain [the open access] because we didn’t have everyone focused on the same goal," Stoner says. "It is a team effort." The health center then launched efforts to improve efficiency and patient "cycle time," or time in the office, as a prelude to opening up access.
2. Evaluate your current practice.
How big is your backlog? What is your daily demand for appointments?
You can determine your backlog by looking at the schedule as far out as it goes and counting the number of patients who are on it, says Murray, who works with medical groups to help them implement open-access systems.
Or you can use a chart such as one developed by HealthSystem Minnesota to tabulate the third available appointment and the average number of appointments seen per week to determine the backlog of individual physicians.
(For a sample chart to determine backlog, see insert. For a sample chart of excess demand, see p. 14.)
IHI recommends tracking access with the third available appointment, since cancellations or no-shows may skew results if the "next available" were used as a measure.
HealthSystem Minnesota is implementing open access with 196 provider teams, led by Linda Peitzman, MD, an associate medical director. The backlog sheet is a first step — even before the site has altered appointment types or any other processes. It gives physicians a sense of how much work it will take to catch up with the demand, says Laura Frazier, access specialist.
Some backlog is expected. For example, pregnant women will have future prenatal exams, children will have well-child visits, and some patients must follow up with a return visit. You will never have a backlog of zero.
"The key is getting rid of unacceptable backlog," says Murray, who began his open-access efforts with a backlog of about three months.
You’ll also want to reassure doctors that they could see all of the current demand if they had little backlog. "You measure true demand," he says. "You add up all the patients who call you today for an appointment at any time, plus those that walk in, plus the number that went to urgent care because you couldn’t see them."
Murray contends that unless a physician’s panel size — or total number of patients — is out of line, the daily demand will not exceed 20 patients.
"The myth out there is that demand is insatiable," says Murray. "Backlog is finite. The demand is determined by the illness burden and the panel size."
Of course, there are times of the year when the demand for appointments rises along with the spread of infectious diseases. But even then, Brodsky says, the variability isn’t as great as he expected, rising only as high as 24 patients in a day.
Brodsky says he manages those high demand times by maintaining good clinic flow, using physician assistants or nurse practitioners, or, as a last resort, referring patients to an urgent care clinic.
3. Reduce appointment types.
Sometimes the problem isn’t a lack of appointments. It’s a lack of the right kind of appointment. "For any kind of access improvements, appointment types have to be simplified," says Murray. "Appointment types are just barriers."
The department of community pediatric and adolescent medicine of the Mayo Clinic in Rochester, MN, had about 60 appointment types, including camp physicals, well-child visits, general exams of various lengths, and acute care.
"Everyone thought we needed to make sure we had these appointments and save them for different patient needs," says Jill Swanson, MD, assistant professor of pediatrics in the Mayo Graduate School and section head of community pediatric and adolescent medicine for Mayo Clinic. "It really worked against us instead of for us."
After joining the IHI collaborative, the pediatric section created two appointment types: same day and next day (which could include any future, return visit). Appointments are scheduled in blocks of 15 minutes. An "N+" indicates a next day visit that requires two blocks of 15 minutes. (For a before-and-after example of appointment scheduling, see box, p. 15.)
Sauk Trails Health Center, which has 4.7 physicians and 2.7 physician assistants, reduced 10 appointment types to four: physicals, procedures, obstetrical, and everything else. "We were laboring under a system of scheduling templates and lockout codes," says Brodsky.
No more excuses
The receptionists had become experts at making excuses to patients, he says. Now, they are paired with a particular physician so they can learn that physician’s preferences. Every day, either at the beginning or end, the receptionist confers with a physician and nurse to discuss scheduling issues.
4. Eliminate your backlog.
To get rid of your backlog, physicians and their staff have to work harder in the short term. They add hours, perhaps in the evening or weekends, or agree to see more patients in a day. (For changes in backlog, see chart, at left.)
Practices also have to function more efficiently, getting the most out of each patient visit, say Murray and Brodsky. For example, if a patient who comes in with a sinus infection has a physical scheduled a couple of weeks later, Brodsky will go ahead with the physical at the time of the acute visit. He then opens the other slot.
"You need staff that are sensitized to those issues," says Murray. If a patient calls at 11 a.m. asking for an appointment to inspect and remove a cyst, then is scheduled at 11:30, the staff has a half-hour to get ready.
Instead of scheduling a return visit for the procedure, the physician removes the cyst during the initial visit. If a nurse performs the suture removal, then a process that could have taken three physician visits now requires only one, he says.
At Sauk Trails Health Center, physicians are treating cystitis, or uncomplicated urinary tract infections, by phone without an office visit. Physicians also try to anticipate the scheduling impact of vacations and peak times, such as flu season.
After determining that the average patient spent 16 minutes with a provider, the appointments were changed from 20 or 40 minute intervals to 15 or 30 minute intervals. That alone added seven time slots per day per provider.
5. Gradually add access.
As you work down your backlog, time slots begin to open on the daily schedule. "Gradually, you start seeing more of your daily demand," says Brodsky. "If you start accommodating daily demand, eventually you do reach the end of your backlog."
Working down backlog should be part of an overall access plan and process improvements, advises Frazier. For example, HealthSystem Minnesota developed a minimum staffing policy to prevent sudden backups.
"You can’t just work down the backlog and expect it to fix your access problem," she says. The health system’s goal is to see all patients within two weeks and to meet all acute care needs within the same day. About half of the teams have met that goal.
Some practices choose to take an intermediate step toward open access by blocking out a portion of the schedule that is reserved for same-day appointments.
In fact, it may be unrealistic for some practices to anticipate a fully open access system. For example, in the dental department of Peekskill Area Health Center, dentists generate about half of the backlog by asking patients to come for return visits. But a policy of retaining half of the appointments for same-day use still has transformed the access. Previously, patients waited two months or more for an appointment.
"It’s been a godsend for allaying patient complaints about not being able to get appointments," says dental director Clifford Hames, DDS.
At Kaiser, Murray saw patient satisfaction with access rise by 14 percentage points after implementing open access. That improvement took about a year, as patients slowly realized that the easy access to appointments was no fluke.
Brodsky recalls the stunned comments of patients. "It’s amazing how many people actually laughed when told they could come in at any time for an appointment," he says.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.