Advanced Access/Office Efficiency
for Specialists
www.pspbc.ca
What are we trying to accomplish?
 Decrease the wait of patients for an appointment with a
specialist
 Decrease the time patients spend at an appointment with a
specialist
 Increase the use of a care delivery mechanism that is efficient,
effective, and improves capacity (Group Medical Visit)
 Improve the provider and staff experience
 Improve the patient experience and outcomes
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“Every system is perfectly designed to get the
results it gets.”
 Systems work more efficiently, more effectively, and at a lower
cost when they work with no delay
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What’s the current state in
your “system”?
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What if….
You could offer your patients an appointment
with the specialist of their choice at a time that was
convenient for them?
What would it take?
© Tantau & Associates
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Traditional model
100% booked
 Saturated schedules into the future
 No flexibility
 Triage & rework using expensive resources
(MD and RN)
 Multiple appointment types
 Urgents and routines juggled
 Capacity: overbook and over there
 Continuity: delayed
“Do last month’s work today.”
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Advanced Access Model
65% open
 Referred patients are offered an appointment
with any provider within five days
 Backlog eliminated (good vs. bad)
 Continuity is improved/maintained
 Capacity for new patients is increased
 Optimal ratio of new:return is maintained
 Increased patient, physician and
staff satisfaction
35% booked
 Change how to do follow up
“Do today’s work today.”
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Benefits of Improved Access
 In Specialty, care is better, physicians, staff and patients are
happier, costs are lower, and income is increased when the right
people receive the right care and with minimal delay
 Decreased no-shows (decreased waste)
 Improved outcomes (more timely)
 Increased patient and referring GP satisfaction
 Increased provider and staff satisfaction
 Decreased cost/visit
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Key Concepts for Access Improvement
 Balance demand and supply daily
› Shape the demand for new and return
› Reduce or plan for supply variation
 Reduce backlog
 Reduce scheduling complexity
 Optimize the care team
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Measure of Access (delay): 3rd Next Available
Appointment
 Choose appointment type
 Select day & time (e.g. Mondays at 11:00)
 Count days a patient waits
 Repeat weekly and chart
 Gold standard for 3rd next for specialist: 5 days
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Ideal Access Aim
 Office Based Medical Specialty:
› To offer an appointment within 5 days of the date of referral.
 Surgical Specialty:
› To offer a surgical date within 5 days of agreeing that a
surgical intervention is recommended.
©Tantau & Associates
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Supply and demand
Demand (referrals plus
caseload)
Caseload: creates real work
reservoir
Waiting: creates re-work
waiting
Supply
(physician available to do the work)
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Supply
 Number of appointment slots available to patients in a given day
 Needs to balance the demand for appointments
 Constant tension between new and return visits that must be
taken into account
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Demand (requests for services/time)
 New:
› Referral from GP office
› Referral from ER
› Telephone calls
› Specialist to Specialist referral
› Returns (Follow-up)
 Physician-initiated (internally generated)
› Requests patient come in for a follow-up visit (which is
booked today)
…/
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Balancing Supply and Demand
 Measure supply and demand
 Match demand with supply
› Build in adjustments for predictable blips (long weekends,
etc.)
› Reduce appointment types
(increases flexibility, patient focused)
› Consider group visits to increase supply
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Measuring Supply




Choose a typical week in the future
Count every available appointment slot
Count pre-defined double-booking slots as two
Does not include time booked for admin, teaching,
rounds, etc.
 Result = available slots per week to meet patient demand
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Measuring Demand
 Record every request for an appointment whether or not an
appointment is booked
 Track “new” vs. “return” demand
 Count appointment requests from all sources (all referrals for a
consult)
 Count the demand on the day request comes in
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Determine Practice Caseload
 Paper records – count active charts
 EMR
 Billing software
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Backlog
 Delay in your system which represents scheduled, but currently
unmet clinical service
 Two types:
› Good backlog = appropriate follow-up/planned future
appointments
› Bad backlog = today’s work pushed into the future e.g.,
patient needs to be seen today but cannot be accommodated
 To calculate backlog:
› Count total booked appointments until 3rd next; Subtract
“good” backlog. Balance = true backlog
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Clearing Backlog
 Ideas:
› Add ½ hour a day or a few hours a week
› Increase hours on busiest days
› Move some appointments from the future to any open slots in
today or tomorrow’s schedule
› Offload work (e.g., shared practices)
› Increase supply – locum, RN, etc.
…/
Continue to try to do today’s work today
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Clearing Backlog
 Ideas
› Review future schedule to determine appropriateness of
appointments
 Reduce frequency for follow-up visits?
› Adjust schedule to match trends
› Block some :10 minute ‘do not book’ slots
› Reduce appointment types
 short for regular visits/ long for physicals, etc.
Continue to try to do today’s work today
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Clearing Backlog – Long Term
Ideas
 Make better utilization of MOA, RN, LPN and other team
members’ skills to:
– take BP, weight etc.
– discuss medications with patient
– review lab results
– take patient histories
• Consider group visits
Continue to try to do today’s work today
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Reducing Scheduling Complexity
 How many types of appointments do you have?
 Does your day follow your schedule of appointments as
anticipated? Do you start and end appointments and your day on
time?
 Reduce the number of appointment types you use
 Ensure truth in scheduling, i.e. schedule according to clinical
need rather than template or habit
 Use “Freeze-Unfreeze” for “time out of office” such as vacation
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Freeze / Unfreeze
 A “Practice Re-entry Survival Plan”
 Before holidays, all appointment slots for the physician’s first
week back are frozen
 During the last week of the physician’s vacation, the MOA will
gradually unfreeze part of the first week back from vacation
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Benefits of Improved Office Efficiency




Appointments start and end on time
Work days start and end on time
The office visit is optimized; patient-provider time is protected
Rework and duplication of work is decreased, thereby increasing
capacity
› Rooms
› Staff
› Provider
 Satisfaction of patient, staff and provider are increased
 Costs/visit are decreased
 Income is increased
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Key Concepts for Improving Efficiency
 Work is streamlined and standardized where possible
 The care team’s roles are optimized
 Needs are predicted and anticipated
Source: IHI.org
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Measure of Office Efficiency – Cycle Time
 This is a measure of the time an appointment takes for the
patient
 The measure includes time between “check-in” and “check-out”
 Includes all segments of an appointment, including providerpatient interaction
 In Specialty, this may include more than one provider in the
course of a visit
 Can be captured with the assistance of the patient
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Get to Know Your Work
 1. Complete assessment of common practice processes
Each staff member has opportunity to evaluate what works well
and what doesn’t
› Evaluate the current state of these processes
 2. Complete a clinic walk-through
 3. Map your processes
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Know your processes – activity
 Each practice team member fills out the “Know your Processes:
Specialty” form
You have ___ minutes for this activity
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Steps for Improvement
 Each of the processes identified for improvement should be
mapped in its current state
 Once you have mapped the current state of a process, identify
some possible small tests of change that could improve the
process
 Use the Plan, Do, Study, Act (PDSA) cycle to try small tests of
change
 Measure baseline and outcomes
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Process Mapping
 What is a “process”?
› A series of connected steps or actions with an identifiable
start and end point
› Leads to a specific outcome
 Why map a process?
› It illustrates “how things work in our clinic or program”
› Includes several perspectives
› Starting point for improvement
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Process Mapping
 Oval - the start and end of the process
 Box - the tasks or activities of the process
 Diamond - a question is asked; a decision
is required
 Arrow - the direction or flow of the process
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Process mapping – activity
 Instructions
 In your groups, create a process map to illustrate one of the
processes identified in “Know Your Processes”
 Start point: ……………
 End point: ……………
You have ___ minutes for this activity
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Analyze the process





Where are the hand-offs?
Is it clear who does what?
Where are the delays?
Is there duplication or rework?
Are there identifiable areas where a small change could make
an improvement?
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Clinic Walk-through
 Have a staff member pose as a patient and walk-through a clinic
process
 Tell the staff about the walk-through and ask them to act
normally
 Start the process with the pre-process step and continue the
process through to completion
 Document the starting time of each step in the process, what
works well, what does not work well, what thoughts you have for
improvement, what feelings you experienced during the process
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Cycle Time - Patient flow through the clinic
Patient enters clinic
Registration
Pre-Red
Zone
Clinic Room
Provider-Patient Interaction
Completion of
procedures/orders
Cycle time
Red Zone
Post-Red
Zone
Checkout
Non-appointment time =
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Improved Cycle Time - Patient flow through
the clinic
Patient enters clinic
Registration
Clinic Room
Provider-Patient Interaction
Completion of
procedures/orders
Checkout
Non-appointment time =
Pre-Red
Zone
Cycle time
Red Zone
Post-Red
Zone
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Optimize the Practice Care Team
 Who does what?
 Who could do what?
 Who should do what?
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Structured Huddle
 What it is
 Brief morning meeting to
› review schedule
› deal with issues left over from previous day
› anticipate needs for current day
› give ‘heads up’ for anything special to be aware of
› Brief – no more than 5-10 minutes
 Why use it
 Being proactive
› helps ensure smoother patient flow
› may help divert potential problems
› improves communication between team members
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http://adventuresinimprovingaccess.blogspot.com
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Practice team activity – Planning for your small test
of change
 What are we trying to accomplish? (Aim)
 How do we know a change is an improvement? (Measures)
 What changes can we make that will result in an improvement?
 Draft your small test of change with your practice team (e.g.
each physician and MOA)
 Share your plan with the group (report-out)
You have … minutes for this activity
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Closing
 Next visit to be held ________
 Don’t forget to send in your information for CMEs and
remuneration for your time
 Good luck with your changes!
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