No. While this may take unnecessary work away from the specialist, it is still using scarce specialty clinic resources to do the work that others could do. An alternative is to insert the pre-consult screening either at the primary care clinic (e.g., referral criteria are used to check a patient's appropriateness for referral) or to build it into the process in some other way (e.g., automatic review of referral criteria).

In most cases, the provider is the key person who determines the flow in the clinic (the rate-limiting step). If the provider is waiting for patients, charts or equipment, the clinic is severely limiting its ability to move patients through the system. You don't want to eliminate the provider as a constraint, but make sure that everything else flows around his or her work. If there are other constraints such as rooms, equipment, or other staff members, these constraints should be eliminated so that the provider's work flows more smoothly.

Think about the smallest replicable unit and the means to link them as part of a coordinated and cohesive whole. All too often teams are working around unfortunate physical design. Some teams have improved communication and efficiencies in a challenged environment with the use of walkie-talkies, room flag systems, and other technologies. Care teams that find ways to improve communication and coordination of their work uncover significant capacity. The improved coordination, communication, and efficiency of a microsystem is inversely related to the degree to which the team intermingles with other care teams. Ideal physical design takes microsystem functioning into account. If the microsystem has its own physical space, there is no need for elaborate systems to communicate the work in progress.

Put the equipment in a specific exam room, but use the room for all appointments rather than designating it for use only with particular appointment types.

Consider finding alternative space for provider offices or standardize everything in the room except the providers' personal things. This allows others to use the office space, while still accommodating the provider's need for his or her personal space.

No, the clinic can balance having clearly defined responsibilities for staff while at the same time preparing for contingencies. For example, while a staff member may have primary responsibility for ensuring that the patients' charts are available and all tests are complete prior to the appointment, he or she can also be prepared to help out the receptionist or the person escorting patients to the exam rooms if delays are developing in those areas.

Staffing models (i.e., the mix of different levels of staff) are determined by the needs of the population served by the clinic and the clinic's decision about how to meet those needs. The key consideration is how the clinic will care for its patients, given its present and/or future level of resources. A clinic with a richer mix of staff in addition to physicians (e.g., physician assistants, nurse practitioners, nurses, technicians, medical assistants, etc.) can handle a larger panel of patients and will divide responsibilities among staff differently from a clinic with a smaller complement of staff.

Standardize the leave of absence policy for all team members. Make the policy available online so that physicians can access and review it as needed.

The rationale for huddles (or short meetings of the care team) is to create the needed capacity to do today’s work today, and to deliver the appropriate care by the appropriate level of provider. The provider, nurse, and receptionist should be involved in huddle meetings. However, the receptionist must have good daily communication with the phone nurse or anyone else who can alter the provider schedule. Huddles can be scheduled in the morning or late in day depending on the team's needs. Many teams huddle in the morning since it lets them close the day, if needed, and the rest of the day’s work can be moved quickly to other providers. This eliminates the need for locating people to check on add-ons. Huddles should occur daily because this helps reception get a good feeling for the practice and how to anticipate daily needs.

One method to consider is using walkie-talkies or beepers to facilitate communication and coordination among staff.

No, it is not avisable to have huddles without the physicians.  However, huddles can be held at any time of the day depending on what works best for a particular clinic. Try scheduling huddles at lunch or at the end of the day in order to plan for the next day. Clinics that do conduct huddles without the physicians have a dedicated person assigned to brief the physicians on the plan for the day. This is not the ideal situation, but it may work if the physicians are open to incorporating the plans of the team into their clinic day.

A system in which each appointment type has its own clinic creates many opportunities for separate queues (and delays) for patients. One solution is to combine a number of separate clinics within one specialty area into one general clinic (e.g., urology). Then the urology clinic can set up its scheduling system with only two different types of appointments: (1) consults, routines, and return; and (2) procedures.

You might, but the risk of creating special times for physicals is that patients will be restricted when they can see their provider. If all the designated appointment slots for physicals are taken up today, this forces a patient requesting a physical into the future and adds to the backlog. A better approach is to set aside a particular length of appointment for physicals (say 30 minutes), rather than designating a physical as a particular appointment type.

Having multiple appointment types doesn't really help to control demand; it only appears to do so. To say "I'll only do physicals on Tuesday or Thursday afternoons" does not control the demand for physicals; it just puts that demand off and creates a delay for the patient. The delay happens because if the patient doesn't fit the criteria that you've established for a particular clinic slot that might be open today, then the clerk will put that patient into the next available designated slot (which may not be for several weeks). When appointments are completely open to all types of care, the demand for specific types of appointments (such as physicals) typcially becomes evenly distributed and the concern that a provider will have five physicals in a row is probably unfounded.

The best approach is to ask the question, "Who else can help you do the work?" There are routine tasks associated with physicals that other members of the care team can do, such as the preventive measures checklist, medication checks, health promotion education, etc. Make sure that every member of the care team is using his or her maximum level of training and expertise. (See Optimize the Care Team for additional ideas on this issue.)

Work with primary care to develop a process for assigning all patients to a primary care provider. Direct booking from your office to the primary care clinic is the most efficient method, but at least have some agreement about how a patient without a primary care provider can be assigned to one.

One solution is to develop internal partnerships within primary care. These are agreements among the primary care physicians and mid-level providers, specifying which physicians and mid-level providers will be responsible for certain procedures or conditions (e.g., Dr. Z agrees to handle all dermatological lesions, while Dr. H handles all acute back pain complaints).

Try developing a partnership with the primary care physicians. The development of guidelines and protocols for referrals cannot be done in a unilateral way. Find out the questions and concerns of the primary care physicians regarding referrals. They want to make sure that specialists will see their patients in a timely way, that they'll be informed about the patient's progress, and that the patient will return to them when and if it is appropriate.

Maximizing what you do for patients at each visit (such as giving immunizations at the current visit instead of waiting for the patient to come back) is only an option, not a mandate. If you look for ways to maximize the patient visit, you will benefit because you are reducing future demand.

The decision about when to bring a particular patient back for a visit is a clinical one, made at the discretion of the physician. You can use technology to keep track of patients, for example, by using clinical guidelines to generate suggested return visit rates for particular groups of patients. A computer program can also generate a schedule for telephone contact with patients in lieu of the return visit.

There is no one right answer. It will differ by individual patient and individual provider. One thing that is clear is that there is a lot of variation in current interval lengths. Any time there is variation, there is an opportunity to make improvements.

Change your clinic start times to when the physicians will be available, or consider having a nurse or other provider see the patient at the 8:30 AM start time to take care of some of the parts of the clinic visit that do not require the physician's presence (e.g., preventive vaccinations, diet and/or smoking education, etc.).

Agree on a system for assigning new patients so that each physician is given the same number of new patients each week or month.

No, practice style should not be factored into panel size; this is a deep and never-ending pit. It requires a judgment about what is an acceptable pattern of practice and what is not (e.g., my "style" requires 45-minute visits for everything, or my "style" requires that I re-do all my patients' vital signs, etc.). If we adjust for style, some physicians will in effect subsidize others and there is no limit on style choice.

There is no right panel size. A rough calculation of target panel size is the total number of patients divided by the number of physicians or full time equivalent (FTEs). This number can then be adjusted to take into account factors such as age and sex of the population of patients, specific diseases, scope of the clinic practice (i.e., what the physicians do), and the presence of support staff, clinical pathways, or other types of support. However, the adjusted panel size for each physician, added together, must equal the total number of patients in the population being cared for by the clinic as a whole.

For these physicians, their time in the clinic is the constraint. For them, the principle is "Do all this week's work this week." In other words, if patients want to see their own provider, then they should be offered an appointment with the provider on the day the provider is in clinic (or with another provider if they choose). This may require greater coordination with support services (lab, x-ray, etc.) to make sure that all the patient's needs can be taken care of on the day the provider is in clinic.

This may be the case for some patients, but this has to be weighed against the overall negative impact of the delay. Some patients may get better on their own, but there are others whose physical conditions may worsen. You also have to consider the cost of maintaining a waiting list, such as assigning staff the responsibility of answering phone calls from patients who call and want to try and come in sooner, have questions, or are concerned about their condition. Typically, patient satisfaction suffers as a result of waiting lists.

No-shows or fail-to-keep (FTK) appointments are usually related to how long the delays for appointments are in the system (i.e., the longer the delay, the more no-shows). It is better to invest your resources in managing the clinic based on the principle of "truth in scheduling." This way, you know exactly how many patients are seen each day and can better match provider availability with patient appointments. Additional difficulties with relying on overbooking appointments include: (1) patients pay for any miscalculation (i.e., they are forced to wait if two patients have been given the same appointment time); and (2) as access improves, the no-show rate will decrease making it more difficult to accurately predict the no-show rate.

It's expensive in a number of different ways. First, no-show or fail-to-keep appointments waste resources. The longer the waiting time, the higher the fail-to-keep rate. Second, a system with waits relies on someone to triage patient requests for care. Triaging for the purpose of assigning patients to categories (i.e., who is sick enough to be seen and who can wait) uses resources that can be used to meet today's demand today. Third, rework is wasteful. People waiting don't wait quietly. They call us up or they go to the Urgent Care Clinic or try and see some other provider, or to get a referral to a specialist by going around primary care. The longer the wait time in primary care and the longer the wait time in specialty care, the more rework and excessive referring that occurs.

One way to tell is to look at your true demand and supply data. If you align these data on the same graph, they should basically follow the same patterns over time. Another way is to look at your waiting time data. If the waiting times are flat (i.e., there is a three-month wait for an appointment for a year or longer) it means that there is a reservoir of demand. Demand goes into this reservoir and supply comes out every day, so supply and demand are in equilibrium but we're three months too late.

It is better to create a system based on "truth in scheduling," in which your schedule accurately reflects your capacity (available appointment slots on any given day). Occasionally, you may need to use double booking as a way to handle unexpected surges in demand, but it is not recommended as a strategy for regularly gaining capacity.