Improving Primary Care Access
Complex schedules, with many appointment types, times, and restrictions, can actually increase total delay in the system because each appointment type and time creates its own differential delay and queue. Reducing the complexity ultimately decreases system delays.
The majority of clinical practices use many appointment types and lengths in an effort to exert some control over the schedule. The belief is that limiting the number of a certain type of appointments scheduled on a daily basis, or assigning patients to different times or types of appointments, will improve access in the practice. Queuing theory, however, suggests that reducing the number of separate "lines" or "queues" for different services creates more flexibility in the system and reduces delays associated with distinct queues. Therefore, having many appointment types actually increases total delay in the system because each appointment type creates its own differential delay and queue.
Changes for Improvement
Maintain Truth in Scheduling
This means that scheduled appointment times should match the actual time that the patient is seen by the care team. Gaps between scheduled visit time and actual visit time drive significant patient dissatisfaction, are related to patients not showing up for scheduled visits, and lead to office staff time spent in explanation or apology. Measure from the start of one appointment to the start of the next appointment for 50 or 100 consecutive appointments to find out how long it takes each clinician to do their work. Create a schedule template that matches the reality of the clinician’s pace. This allows the office to work in a continuous flow mode.
Doing work as it occurs during the course of an office visit (e.g., doing documentation at the end of each visit) reduces the bottlenecks created by holding similar types of work to be done at a future time (batching). For example, some practices save all telephone calls, documentation, refills, etc., for the end of the day or session. This is referred to as batching. With continuous flow, all work is accomplished as it presents itself and completed in one continuous action. Appointment times may need to be lengthened, or pauses placed in the schedule, to accommodate continuous flow and reflect a certain truth in scheduling. Continuous flow does not mean that time is added to the day, but that it is reallocated throughout the day.
Reduce Scheduling Restrictions
In addition to reducing appointment types and times, practices can create more flexibility in their schedules by reducing other constraints such as only offering physicals on certain days of the week or times of the day. While some providers may initially fear that this change will create days with multiple back-to-back physicals, natural variation in demand means that the requests for physicals or other types of complex appointments are actually fairly evenly distributed across the appointment calendar.
Reduce Appointment Times by Using "Building Blocks" to Create Short and Long Appointment Times
First decide on the scheduling increment or building block. For example, the increment may be 15 minutes and is used for the length of a short appointment. The long appointment is usually a multiple of the short appointment, for example, 30 or 45 minutes. The scheduler simply combines two or three short appointments to make a long appointment.
Some practices standardize on a single appointment type and length so that a pace or cadence for the day can be set and maintained (e.g., a 20-minute appointment). The appointment length must be long enough to accommodate many different types of services and patient needs, and to allow providers to stay on time. For example, one patient visit may only require 10 to 15 minutes, leaving extra time for the next appointment should it take longer than the allotted 20 minutes.
Reduce Appointment Types
Practices with improved access make no distinction between urgent and routine appointments. Remember, if the goal is to do today's work today, the distinction between urgent and routine is no longer necessary. For primary care, the only distinctions between appointment types needed are:
- Provider is present vs. provider is absent
- A short appointment type for return visits
- A long appointment type for physicals and new patients
When the provider is present the patient is seen, and when the provider is absent the patient is offered the choice of an appointment the next time the provider is present or today with another care team member. All other special appointment types, such as those for disease entity or physicals by age groups, can be eliminated.
Reducing appointment types simplifies telephone appointment triage, allows more flexibility for patients, and reduces queues.