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Open Access Scheduling Prevents Delays in Care
By Lisette Hilton
Lisette Hilton is a writer for Physicians Practice
Source: Humana's
YourPractice Newsletter
Janis Dillard, chief operating officer at Family Health Center of Battle
Creek, had spent a year learning about open access, a patient scheduling
model that emphasizes seeing patients on the days they call for appointments.
But, she had yet to begin implementing it at the practice. "It's
a very scary thing, and it seems overwhelming," she said from her
practice located in Battle Creek, Mich.
Then, one of the physicians approached her at the end of a long, hard
day and told her, "I can't do this anymore. We're double-booked;
we're triple-booked. This is not good care." That evening, when
the physician resigned, Dillard knew she had to do something drastic.
"We had tried every other type of scheduling and couldn't make
anything work," Dillard said. "I can say without any hesitation
that it is totally different now since implementing open access in January
2000."
Likewise, medicine had become a "job" for John Giannone,
M.D., medical director of the Family Care Center in Deposit, N.Y., and
an associate professor of clinical medicine at Upstate Medical College
in Syracuse.
"I was swamped," Giannone said.
He couldn't stand hearing patients say that they tried to see him,
but could not because he was booked. "There's such disappointment
in their voices. They have a doctor, but he doesn't take care of them.
I want to be someone's doctor," he said.
Now, after almost a year on open access, Giannone is becoming that
doctor. He sees patients when they want to see him. And significantly,
his patient satisfaction ratings have increased nearly 50 percent.
Patients are not the only ones who are happier with Giannone's practice.
After working hard (and failing a few times) to cut his schedule backlog
so that he could free it for open access scheduling, Giannone actually
works fewer hours than he did before implementing the model. He has
cut two hours a week out of his office schedule and eliminated evening
and Saturday hours. Revenues at the practice have increased by 44 percent
in the past year, and volume has increased by 22 percent.
Changing perceptions
Mark Murray, M.D., was in a busy group family practice with an average
55-day wait for nonurgent patients. "Patients with urgent needs
could get in, but they couldn't get in to see their own doctors. And,
there was no place to put a returning patient who couldn't wait 55 days.
The system was frozen in the future," he said.
Murray started studying the scheduling processes of successful companies,
including Toyota and Starbucks, and realized that medicine was doing
it all wrong. About seven years ago, he started to develop a new model,
which is now called open or advanced access. And today, he works full
time consulting with practices and health systems worldwide about how
to implement it.
"Basically, [it's a] do-all-of-today's-work-today model. The emphasis
is on the word 'all,' " he said. "What happens is that all
the urgent and nonurgent work is done today. Tomorrow is flexible because
you don't have to hold or freeze appointments or carve out any space."
The new model worked like a miracle in his practice, Murray recalled.
"We got done on time; there was a lot less work. The nurse who
worked with us actually became free to help take care of patients because
she didn't have to do triaging anymore. The amount of time that the
receptionist took on the phone to make a decision was cut in half so
it freed up people at the front desk. [They] were able to do more patient
care services because they didn’t have to spend so much time on
the phone arguing about appointments with patients," he said.
According to Murray, convincing his partners and staff to make the
change wasn't easy. He had to teach them to think differently —
to shift from the triage mentality that doctors and nurses are taught,
to seeing all patients, regardless of need, on the day they call.
Implementing open access
True to Murray's experience, a practice has to change its way of thinking
in order to begin the process of open access. "In [other scheduling]
models, what we're doing is in order to protect today; we're pushing
nonurgent demand out to the future. In the 'do-today's-work-today' model,
the world and the mindset change: in order to protect tomorrow, we’re
pulling all the work into today," Murray said. "You have to
pull the work instead of push it."
According to Murray, applying open access is a step-by-step process.
And each step is important for successful implementation.
Step One
Measure supply and demand — and find balance.
No model is going to work if demand is greater than the supply, so you
must start by balancing the two. "People say I can't do it because
my demand is bigger than my supply," said Murray. "Well, actually,
what you're saying is that you can't do anything. Even in a saturated
model, every day will put you further behind if you’re out of balance."
Murray defined the saturated model as "the schedule that fills
up today [with earlier] nonurgent demand, and we take urgent and pile
it on top."
Step Two
Get the backlog out of the way.
Backlog reduction is not itself access improvement, but it is a necessary
stage to get there. Treat backlog reduction as a controlled burn —
look at the backlog and then look at how much additional work the staff
can take on. If your time to the next available appointment is now four
weeks, it will likely take that long to eliminate your backlog. Beware
that it takes a fraction of that time to allow backlog to creep back
into place.
Step Three
Eliminate appointment types.
Medical practices are notorious for breaking down appointments into
types in an effort to control demand. "If you're going to do today's
work today and calls are coming in, you don't need appointment types.
All you need is an appointment," Murray said. "If you want
to reduce the waiting time, which is what the access issue is all about,
you have to reduce the [different appointment types] to the minimum
number."
You may wonder how you can treat all appointments the same when a physical
takes longer than treating a patient for an earache. Murray's response
is that visits often change dynamically as they are progressing, particularly
if patients have more than one problem to discuss. "It's the best
system to have the same appointment length and adjust on the back end
rather than trying to control it on the front end," he said.
Step Four
Develop contingency plans.
Contingency plans allow the staff to adjust when a doctor calls in sick
or comes back from vacation, or something else happens to throw off
the schedule.
Step Five
Reduce demand.
The best demand reduction strategy is to get doctors to see their own
patients. "In my experience — working with multiple practices
around the world — if doctors would just see their own patients,
the demand would go down by about 15 percent," said Murray.
Step Six
Optimize the care team.
Make the best use of the physician's time by eliminating tasks from
his schedule that the physician should not be doing, like appointment
triaging that the nurses could be doing. Murray suggests elevating everyone
on the team to the highest limits of their interest, expertise and licensure.
Step Seven
Review office efficiency.
Optimize efficient office flow in areas such as patient care, billing,
appointments, etc.
Murray added that strong leadership, physician involvement and engagement
of the entire team are also key to successful implementation of open
access.
Beyond fear to success
Gordon Moore, M.D., a family practitioner in Rochester, N.Y., became
so distraught about being crushed with the burden of the work and making
slim — sometimes negative margins — that he left his group
practice and struck out on his own. To Moore, "on his own"
means being the only person in his practice — he answers the phone,
does the billing and uses the open access model to schedule patients.
According to Moore, the fear of backlog reduction is overblown. "A
lot of the fears around open access are unfounded. People wonder: 'Am
I going to be overwhelmed by demand? All of a sudden my books are going
to be clean, and I'm not going to have revenue.' Well those things are
not the case because patients will love you for it, and you will be
rewarded," Moore said.
Still, those who are successfully running their practices using the
model agree it is no easy task to start or maintain, and like every
scheduling model, it takes constant work and commitment. "One of
our biggest challenges is keeping the schedule open," Dillard said.
Dillard added that despite the work involved, open access has been
the best thing that ever happened to the practice, which has almost
20 practitioners. Due to the change in scheduling, the no-show rate
has dropped from 21 percent to 14 percent; while 47 percent of the practice's
patients surveyed used to report that they did not see the doctor of
their choice for their appointments, only 6.5 percent have the same
complaint today. The wait in the office has even diminished, and, while
Dillard said that there continues to be room for improvement, about
60 to 70 percent of patients are seen within 15 minutes of their scheduled
appointment time.
Read More About It
Visit our Web site, www.PhysiciansPractice.com to read more. Type "Open
Access Scheduling" into the search engine on the home page. You'll
find a number of related resources, including Q&As answered by our
practice management experts. Some highlights:
Open access and advanced access scheduling basics
Measuring demand for open access
Making open access work with part-time physicians
Also, learn what others are saying about the topic by joining the Institute
of Healthcare Improvement’s "Idealized Design of Clinical
Office Practices" list serve at www.ihi.org.
Visit the American Academy of Family Practice Web site to read other
related articles at www.aafp.org.
