Wave 6 Quality Improvement Charter:
Advanced Access, Efficiency and Chronic Disease Management in Primary
Care
“Advanced access has dramatically improved my patients’ ability to see me at the starting point of their
health problem. Only having to wait one day has decreased their stress, as well as the stress of me
and my staff”
~Dr. Paul Cano, Physician, Smithville Family Health Team
“[This HQO] initiative has revolutionized the way we do business.”
~Susan Ouellet, Administrator, Greenstone Family Health Team
“Diving deep into understanding your practice provides great opportunities for improvement. I used the
5 P's and specifically one of the 5 P's (patients) to make dramatic shifts in how I care for patients with
complex health needs -- and in doing so have seen a 50% reduction in 3NA.”
~Dr. Jamie Read, Physician, Sherbourne Family Health Team
What are we trying to accomplish?
According to Health Quality Ontario’s 2012 Quality Monitor, “only half of sicker adults could see a
doctor or nurse the same or next day when they were unwell, compared to 79% in the United
Kingdom.”1 Patient delays in seeing their primary provider results in “patient dissatisfaction,
contributes to staff dissatisfaction, and may lead to worsening clinical outcomes.” 2 Delays are also
expensive:
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There is a cost in maintaining the wait list and triaging patient requests for appointments;
The no-show or fail-to-show rate increases the longer the patient has to wait for their
appointment;
There is a risk that patients waiting for an appointment will arrive to their office visit with a
more costly clinical condition;3 and
Patients use the emergency department to access medical care that they could have received
from their primary care provider (Canadian Triage Acuity Level (CTAS) 4 or 5). “Almost one in
two Ontarians felt they could have been treated by their primary care provider if care had been
available the last time they went to the hospital or Emergency Department.” 4
Findings in the 2012 Quality Monitor demonstrate some positive signs of improvement when it comes
to chronic disease management (CDM) related to complications and the use of recommended
medications. There remain many opportunities for improvement to ensure people routinely receive all
of the evidence-based best practices in CDM.5
2
The Project AIM:
Improvement in access to primary care and efficiency in the delivery of primary care will be
realized within six months during participation in the Learning Community Wave 6 Advanced
Access, Efficiency and Chronic Disease Management in Primary Care. Using practice
assessment tools, primary care teams will identify chronic disease management improvement
opportunities during the final three months of Wave 6.
The online Advanced Access and Efficiency for Primary Care Road Map will guide you through the
improvement process. Teams will apply changes to their practice to improve office efficiency and
better match their supply of appointments with patient demand for appointments to achieve advanced
access. The core principle of advanced access is that patients calling to schedule a physician visit are
offered an appointment with their primary care provider on the same day or a day of the patient’s
choosing.6
After working to improve access and efficiency, you will be guided through an assessment of your
management of patients with chronic disease in order to identify where improvements can make a
difference to the quality of care you are able to provide. The online Chronic Disease Management
Road Map will guide you through the assessment, diagnosis and quality improvement plan
development.
How will we know that a change is an improvement?
The following four measures will be tracked to monitor whether the changes are resulting in
improvements. The tracking will occur throughout the nine months during which practices participate in
Wave 6 Advanced Access , Efficiency and Chronic Disease Management in Primary Care (March
2013 to December 2013), and continue for another three months (January 2014 to the end of March
2014) to demonstrate sustainability of improvement efforts made during the Wave.
Access and Efficiency:
1. Third next available appointment – Patients will wait less than one day for the third next
available routine appointment. This sentinel measure is used to measure the number of days
a patient has to wait to get a routine appointment. “The third appointment is featured because
the first and second available appointments may reflect openings created by patients
cancelling appointments and thus does not accurately measure true accessibility.” 7
2. Continuity of care – 85% of patients from a multi-provider practice will see their own provider
at each visit instead of another provider of the same discipline within the clinic.
3. Cycle time – Patient office visit duration will be <60 minutes in length from patient arrival to
departure.
4. Red zone time – Patients will spend >50% of the office visit in face to face contact with the
care team (e.g., family physician, nurse practitioner, registered nurse).
Teams are encouraged to use their data to guide their change efforts. In the early stages of the
initiative, completing the panel size equation, tracking daily appointment demand and supply and
activity rates will assist the practice team to inform their change decisions. Third next available
appointment and future open capacity are helpful measures to monitor on an ongoing basis to
sustain the improvements and identify when and where additional changes may be needed.
Wave 6 Charter
Health Quality Ontario
3
Chronic Disease Management:
Teams will be assessing and identifying improvement opportunities for chronic disease management.
At the end of the three months (September 2013 to December 2013) focusing on chronic disease
management, assessment and diagnosis, teams will be able to:
Identify their patient population with chronic diseases; and
Identify two areas for improvement for their practice.
Patient Experience:
Teams will also be encouraged to guide their change efforts with information about the patient
experience. Capturing, understanding, and utilizing the patient experience with access to care, care
delivery and the management of chronic disease can create incredible opportunity for the team to gain
insights, as well as identify opportunities for improvement, and ultimately engage patients in co-design
to improve the patient and care team experience. 8 Teams participating in Wave 6 Advanced Access,
Efficiency and Chronic Disease Management in Primary Care will be able to track an optional
measure(s) to capture the patient experience.
What changes can we make that will lead to improvement?
Change concepts are general approaches that have been found to be useful in making an
improvement. There are a number of change concepts reported in the literature and experienced by
teams that will lead to improvement. From these change concepts, practices will develop more specific
ideas for change that they want to test. These specific change ideas may include processes and tools
that are new, or that have been tested and implemented with demonstrated effectiveness in other
environments.9
A list of change concepts a team can further develop and test are listed in the document Advanced
Access and Efficiency for Primary Care Workbook.
1
Health Quality Ontario (2012). Quality Monitor. Toronto: Ontario, p.4.
Murray, M. (2000). Modernising the NHS – Patient Care: Access. BMJ, Vol. 320, p.1594.
3
Ibid., p.1594.
4 Health Quality Ontario (2011). Quality Monitor. Toronto: Ontario, p.80.
5 Health Quality Ontario (2012). Quality Monitor. Toronto: Ontario, p.10.
6 Murray, M., & Berwick, D. (2003). Advanced Access: Reducing Waiting and Delays in Primary Care. JAMA, Volume 289(8), p.1035.
7 Ibid., p.1038.
8 Baxter, H., Mugglestone, M., & Maher, L. (2009). The EBD Approach – Experience Based Design Concepts and Case Studies. NHS Institute
for Innovation and Improvement. New Audience Ltd: West Midlands, UK.
9 Langley, G.J., Moen, R.D., Nolan, K.M., Nolan, T.W., Norman, C.L., Provost, L.P. (2009). The Improvement Guide. 2nd Ed. Jossey-Bass: San
Francisco, California, USA.
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Wave 6 Charter
Health Quality Ontario