Once upon a time, a patient at Second Street Family Practice in Auburn, Maine, had to wait from 60 to 90 days to be seen for a routine check-up. Then, when the day of the appointment finally arrived, the patient might wait nearly 20 minutes in the waiting room, and another 20 for the exam to begin. But thanks to strong leadership, impressive teamwork, and effective tools, patients wanting care from Second Street, even routine check-ups, are now seen the same day they call. The average time patients spend flipping through magazines in the waiting room has dropped to around seven minutes; the exam room wait is down to eight. What’s more, staff say they like the new system much better, and patient surveys show that about 90 percent of patients notice and are pleased with the changes as well.

Second Street Family Practice is one of more than a dozen practice sites of Community Clinical Services, a Federally Qualified Health Center that is part of the Sisters of Charity Health System in central Maine.

Celeste Rouleau, RN, BSN, manages two of the sites: Second Street Family Practice, which includes three physicians and one physician assistant caring for between 5,000 and 6,000 patients, and the B Street Health Center in nearby Lewiston, where one physician cares for about 1,000 patients. She describes the environment before the two clinics implemented “advanced access” scheduling, which now allows most appointments to be booked for the same day. “It was hugely frustrating for everyone,” she recalls. “The physicians’ schedules were already packed when the morning started, so when a call came in from a patient wanting to be seen for an acute problem, it was a big negotiation involving several people and several steps.”

In such situations, says Rouleau, typically the front office staff would take a message and pass it to a nurse, who would call the patient back to discuss the problem and determine how urgently the patient should be seen. “If the nurse didn’t call the patient back in a timely fashion,” says Rouleau, “both the nurse and the patient would feel frustrated, and often the patient would call again.”

Rouleau, who had been reading and learning about advanced access scheduling, recognized it as the antidote for their frustrations. Developed by Mark Murray, MD, and Catherine Tantau, RN, consultants in Sacramento, California, and promoted by IHI in its office practice programs and on its website, advanced access uses queuing theory to reengineer the standard appointment scheduling system, leaving the majority of slots on any given day open for patients who call that day.

The benefits of advanced access go beyond improved scheduling, says IHI Director Marie Schall. “It improves quality and continuity,” she says. “People can get problems checked sooner rather than later, and they see the same provider virtually every time. We know that continuity contributes to better overall quality.” Schall says that, through its Breakthrough Series Collaboratives on Reducing Delays and Waiting Times and its IMPACT network, as well as its work with the Veterans Health Administration on improving access to care, IHI has worked with about 3,000 practices to introduce advanced access.

“What I love about it is that it is a whole new way of looking at efficiencies, and it is customer-service based,” says Rouleau, who was instrumental in enrolling the Second Street and B Street practices in IHI’s first-ever virtual improvement project in June 2004. Funded with the help of a $450,000 grant from the Alfred P. Sloan Foundation, the Sloan/IHI Virtual Breakthrough Series Collaborative to Improve Access to Primary Care was based on the IHI Breakthrough Series learning model, using remote-site sessions via the Internet rather than periodic face-to-face training and Learning Sessions, saving both the time and expense of travel.

“The Collaborative approach worked really well,” says Rouleau, “and it was so great that we could participate in something this big without spending thousands of dollars traveling. The listserv and the monthly conference calls were really helpful.”

Rouleau was joined in her efforts to introduce advanced access by family physician Douglas Smith, MD, who was among the first to implement advanced access with his patients at Second Street and became the effort’s physician champion. “It’s essential to have a physician champion, someone who truly believes that their practice will function at a higher level with advanced access,” says Rouleau.

Smith says there was no question in his mind that there was a better way to organize how appointments were scheduled. “Before, I felt frustrated on my patients’ behalf. I felt like I was frequently triaging in a way I didn’t like, deciding who’s really sick enough to be seen today and who can wait until next week. The patients sense that, and wonder if maybe their doctor just doesn’t care enough to see them sooner,” he says.

Rouleau and Smith began by talking to their colleagues about the benefits of advanced access, educating them and encouraging but not mandating that every practitioner give it a try. “It’s important to spend some time up front to explain your goals, why you’re suggesting it, and how it will benefit everyone,” says Smith. “They need to know it will be challenging and they will have to be flexible, but that the payoff is worth it.”

Rouleau says many physicians are initially concerned that advanced access will reduce their productivity — and their income along with it. “This can be a big barrier for physicians,” she says. “They say, ‘Our salaries are based on productivity, and you are asking us to look daily at a schedule with no patients in it.’” But productivity typically increases with advanced access because patients are seen more efficiently, which is exactly what happened in Doug Smith’s practice. “He is 20 percent more productive now, which increases his income,” says Rouleau. This, plus the improved patient flow, convinced the few holdouts to try it themselves. “When a provider notices that his colleague’s patients are getting in and out quickly, and he’s still seeing patients he should have seen an hour ago, he comes on board willingly,” says Rouleau.

But willingness to change is only half the battle. Making the transition from a traditional appointment system to advanced access requires significant initial effort. At her two clinics, Rouleau says the first step was to standardize appointment types, moving away from the complicated system of appointment categories (short follow-up, long follow-up, urgent, routine, new patient, etc.), each with associated lengths of time, and rules about in what order and how close together certain appointment types could be scheduled. “We wiped out all those barriers,” says Rouleau, “and created a single appointment type — an office visit — with two lengths: 15 and 30 minutes.”

Next came the task of working down the backlog: accommodating the appointments already booked under the “old system,” plus scheduling new appointments within a short timeframe to keep the backlog from growing. “It feels like a big mountain to climb,” says Rouleau, “and you have to work harder initially to get where you want to be.” She says they achieved their goal by adding some extra early morning appointment slots, working through some lunches, and putting in extra days. This took about four to five months, says Rouleau.

Don’t forget to tell your patients about what you’re doing, says Rouleau, and be prepared for some skepticism. “They don’t believe that they’ll really be able to get a same-day appointment when they want one,” she says. Her practices sent patients a letter, and explained advanced access to them when they called or visited. Nevertheless, some patients initially refused to leave the office without scheduling a follow-up appointment. While practices can choose to retain this option under advanced access, many patients grow to prefer the same-day scheduling option once they are used to it. But even doubters began to believe they would get same-day appointments when they began to experience it first-hand, which reminded staff how important it was to make good on their promise. “Some days were tough, when we were still working down the backlog and patients would call just like we taught them to and say, ‘Today works for me.’ We knew we had to make it work, and we did.” 

Now, all practices in Rouleau’s two clinics use advanced access scheduling, and she says it has changed more than just the way they book appointments. “It has changed the way we think about our work and ourselves. Now we remember that we are here for the patients, not to say ‘No, we can’t see you.’ We are serving our patients better, and everyone feels good about that.”

There are many reasons to feel good about advanced access, says Catherine Tantau, RN, who helped develop the concept. She cites data showing improved HEDIS scores related to advanced access, particularly because advanced access improves continuity and allows for practices to provide better prompts that alert physicians to the screening needs of the patients they are seeing. “Continuity is a pillar of advanced access,” she says. “The published literature on continuity makes the case for reduced costs, interventions, hospitalizations, ED visits, and referrals.”

IHI’s Marie Schall says that advanced access has become the standard of practice across the nation. “In the past, people would come to our programs wanting to hear about ‘the new’ advanced access approach,” she says. “Now, they come to us because they know they have to be able to offer better access in order to meet patient expectations and be able to compete in the health care market.”

For Celeste Rouleau and her colleagues at Community Clinical Services, the advantages are clear. Now, she says, the goal is to spread advanced access to all practices within the network. “We will start with the most willing, and let it sell itself from there,” she says.

05/10/2006