Amy Anneken, MS, Decision Support Analyst
John Bucuvalas, MD, Clinical Director of the Division of Gastroenterology, Hepatology and Nutrition
Peggy Curtin, MBA, Administrative Director of the Division of Gastroenterology, Hepatology and Nutrition
David Krier, MHA, Assistant Vice President, Access Services                     
Lori Mackey, Vice President, Children’s Hospital Research Foundation
Marlene Romer, MA, Quality Improvement Consultant

Our overall aim is to reduce the time to the third next available appointment to less than 14 calendar days by June 2006. We seek to improve our outcome measure by the following sub-aims:

1. Increasing the supply for patient visits
2. Decreasing artificial variability in scheduling
3. Decreasing demand for follow-up visits

• Third next available appointment for a new visit measured weekly
• Demand for new patient and follow-up visits measured in hours/week
• Supply as measured by physician or nurse practitioner hours available for patient care measured weekly
• Clinic cancellations measured monthly
• Number of follow-up visits for common conditions (constipation) measured quarterly

1. Increased the supply for patient visits
   • Measured the demand for new and follow-up visits to define target for supply
   • Defined target for supply as 120 percent of demand (based on queuing theory) for new and follow-up visits
   • Added 136 hours of time each month available for patient visits to reach our target
   • Made a default policy to reschedule clinics missed due to academic obligations
2. Decreased artificial variability in scheduling
   • Determined the variability in clinic scheduling template and length of clinic
   • Defined the length of a clinic as 4 hours
   • Instituted an open template schedule for the practice to reduce the restrictions and complexity of scheduling
3. Decreased demand for follow-up visits (constipation)
   • Identified constipation as most common outpatient complaint
   • Educated Primary Care Physicians (PCPs) regarding effective therapeutic management based on evidence-based guidelines
   • Developed a standard approach to treatment of constipation with polyethylene glycol medication, behavioral management based on evidence-based guidelines
   • Default care to referral back to PCPs after initial consultation

Implementing changes to ensure that there is adequate supply based on measured demand and eliminating artificial variability in scheduling have been the most significant changes in increasing access to subspecialty care at Cincinnati Children’s Hospital.  Improvement ideas have been readily shared with other subspecialty divisions at Cincinnati Children’s as part of an improvement collaborative.

• A realistic appraisal of the gap between supply and demand is critical to improve access. We did not understand the supply required until we understood the gap between supply and demand.
• You can decrease the gap between supply and demand without increasing staff. Decreasing artificial variability in scheduling and decreasing demand will reduce the gap between supply and demand.
• Reflecting the complex nature of access, small changes such as defined clinic length and open templates can have dramatic effects.
• You can increase believability when conducting improvement cycles (PDSA) by making a prediction outcome during the planning phase.
• Make certain that the intervention will impact your outcome measure. Identification of the key drivers to improving your outcome is a critical step. We wasted time at the start of efforts by focusing on changes that would not affect third next available appointment.
• Make certain that you have commitment from the institution and from your subspecialty division or section.
• Make certain that your improvement team is comprised of the right people. For us, this included a physician, a nurse, and an administrative leader from the division, an analyst, and an expert in the scheduling process.
• Recognize that change is hard and the players will adopt and accept change at different rates. It is critical for team leaders to listen to the concerns of the members of the subspecialty division.

John C. Bucuvalas, MD, Professor of Pediatrics and Medical Director of Liver Transplantation
Cincinnati Children's Hospital Medical Center
John.bucuvalas@cchmc.org  

[Storyboard presentation at IHI's National Forum, December 2005]