IMPROVING PATIENT
ACCESS TO CARE
Open Access
“If we keep doing what we are
doing, we will keep getting what we
got”
Yogi Berra
“Every system is perfectly designed
to get the results it gets”
Paul B. Batalden MD
Co-founder Institute for Health care Improvement
Founding Director Center for Healthcare Improvement
and Leadership – The Dartmouth Institute
Open Access
Why should you care?
Is Baldwin Family Health Care
Ready for Open Access
Scheduling?
Reasons for Change
• Increased patient satisfaction
• Increased provider and staff satisfaction
• Improved continuity of care.
• Reduced rate of no shows
• Reduced demand for after hours care and use of urgent
care (reduced costs)
• Reduced visits per patient
• When patients can see their “own” provider, demand drops by 5%
• Reduction in telephone time for Triage staff as less time is
needed when patients are scheduled to be seen today.
• Nearly eliminates need for patient reminder calls.
Access Models
1) Traditional
2) First Generation Open Access
Carve Out
3) Second Generation Open Access
Advanced Access
Traditional Scheduling
• Reservoir is full with routine visits at the beginning of
each day
• Urgent cases are accommodated by double booking,
overtime or running behind.
• Most Common System in offices
• Average waiting time for medical appointment in the US is 3 weeks.
• Accommodates demand with a restrictive and complex
categorization system
• New vs. Established Pt.
• 10, 15, or 30 minute appointment
• Wellness vs. acute problem
• Per Murray and Tantau – “Do last month’s work today.”
Carve Out / 1st Gen. Open Access
• System utilized by BFHC / GLFC
• Hold a quantity of urgent care appointments for same day scheduling.
• Quantity is based on predicted demand
• Accommodates for some (much) of the urgent need.
• Increases complexity of scheduling
• Designating “Urgent Care” or “Same Day” provider decreases
continuity of care.
• Drives dates for scheduled / routine appointments further into the
future.
• Staff may be forced to “steal” from spots held for same day visits in
order to get in patients who need to be seen.
• Per Murray and Tantau – “Do some of today’s work today.”
Open Access
• Removes all distinction between urgent and routine visits.
• Patients are placed on the schedule as they call for
appointments.
• Need More Here
• Per Murray and Tantau – “Do today’s work today.”
Panel Size
• About 2,500 patients
• 0.7 to 0.8 percent of a providers patients will call for an
appointment each day.
• Share data on BFHC panel sizes
Causes for Failure
• Not assigning Primary Care Providers
• Continue to run under “Carve Out” system believing it is
open access.
• Routinely running overtime for visits and overbooking
providers
• Not maintaining continuity of care.
• Diverting care to urgent care or same day clinic
Standard Pattern of Demand
• Increases very quickly in morning
• Flattens at about 10 AM
• Drops over lunch
• Drops more from 2pm til end of day
• Demand for appointments after 4PM is about 4% of
volume.
• Late night demand often created when provider cannot fit patients
into day appointments and only open time is evenings.
Transition
How to get from “here” to “there”…
Principles
1) Understand, measure and achieve a balance between supply and
demand;
2) Recalibrate the system (or reduce the backlog);
3) Reduce the number of queues by reducing the variety of
appointment types or lengths (queuing theory);
4) Create contingency plans for times of heightened demand or
lessened capacity;
5) Influence the demand (e.g., by matching patients with their own
physicians, making the most of current visits and rethinking returnvisit intervals);
6) Manage the constraints or bottlenecks (e.g., remove from the
physicians any work that can be done by someone else).
Open Access Tips
• Offer all patients an appointment on the day they call regardless of
the reason for the visit.
• If they do not want to be seen the day of the call, schedule an
appointment of their choosing. Do not have them call back on the day
they want to be seen.
• Allow providers to pre-schedule patients when clinically necessary
(good backlog). Normally 20 to 30 patients per 1000.
• All appointments will be on standard length of time.
• Reduce types of appointments (the fewer, the better)
• Appointment length should match provider practice style.
• Panel size must be manageable
• Protect provider schedules from colleague overflow
• Develop plan for extreme demand or provider absence
• Reduce demand for unnecessary visits.
• Reduce future demand by maximizing today’s visit
High Demand Times
• Double book with patients PCP
• After several double bookings, offer an appointment with a
different provider
• Agree to “stay late”
• Offer appointment with designated “same day” provider
and advise patient that there will be a wait.
How to Reduce Backlog
Reduce Workload
• Increase intervals for return appointments
• Utilize alternatives to face to face office visits
• Phone calls
• E-mail
• Group Visits
• Maximize activities at each visit
• Transfer duties to support staff to allow provider to see
more patients in same amount of time
• Reduce provider interruptions
• Support staff (RN?) manage sub-populations
How to Reduce Backlog
Increase Availability
• Add Appointments
• Use Administrative Time
• Defer Time Off
Match Capacity to Demand
• Modify schedules to have more providers working when
demand is the highest
Key Points
• Reinforce the relationship between the patient and their
PCP. This needs to be a key priority.
• Ensure accuracy of records as to who the patient
identifies as the PCP
• Start every appointment on time.
• Agree what “on time” means.
• Make sure systems are in place to allow provider to see patient at
the time scheduled.
Phone Scripts
• Receptionist: “Which provider do you see?”
• Patient: “I have seen Dr. Doe but it doesn’t really matter.”
• Receptionist: “It is really better for you to see the same one as
frequently as possible so that they get to know you better and can
take better care of you. Dr. Doe is not in today, but I can schedule
you tomorrow with her when she returns”.
• Patient: “I would rather come in today.”
• Receptionist: “That’s fine, you can see one of the other providers
today and next time we will try and get you in with Dr. Doe.”
Phone Scripts
• Patient: “I would like to make an appointment with Dr.
Doe.”
• Receptionist: “When would you like to come it?”
• Patient: “Tomorrow sometime”
• Receptionist: “Dr. Doe is not in tomorrow. She could see
you today at 3:00 today or she will be back on Thrusday
and I could schedule you then.”
• (Patient gets to choose)
Phone Scripts
• Patient: “I would like to make an appointment for next
month with Dr. Doe for my physical”
• Receptionist: “We really try not to schedule out so far,
since plans change and it can be hard to keep an
appointments that is scheduled so far in advance. Would
you kike to come in sooner, or would you like to call back
within a few days of when you would like to be seen? We
will have appointments available then”
• (If patient is insistent and the schedule is open, go ahead
and schedule, but make a not for someone to confirm
appointment the day before.)
Phone Contacts
• It is the patients choice, accommodate them whenever
possible.
• Always confirm PCP and schedule with that provider
whenever possible.
• If a patient wants a future appointment, do not ask them to
call back on the day they want to be seen, this just
increases phone traffic.
• Try not to schedule out any further than 2 weeks since the
no show rate rises dramatically after that time.
• When pre-scheduling appointments, guide patients
toward known low demand days or times.
• When scheduling for another day, try to encourage the
early morning appointments.
Measures
• Percent of Same Day Work
• No Show Rate
• Patient Satisfaction
• Panel Size
Next Steps
• Provider Buy In
• Key Staff Buy In
• The people who do the work need to transform the work
• Site Specific Plan and milestones
• Staff Education and Training
• Patient Education