Murray points to six principles for improving access: understanding the balance between supply and demand, recalibrating the system, applying queuing theory, creating contingency plans, influencing the demand, and managing the constraints.
Understanding the Balance Between Supply and Demand
"If we can get a balance between the demand for appointments and the supply of appointments — if we can get, understand, and measure that balance — then we can eliminate waiting times," says Murray. "That involves basically doing today’s work today, rather than using the old paradigm of stratifying urgent and non-urgent work. This does not prevent us from being able to see those patients with urgencies; changing the way that we see priority allows us to do the work that needs to be done today, as well as the work that could be done today."
But hardly anyone is doing things that way. "We just don’t see it that way in health care," says Murray. Working in systems that are always behind or late, "there is a strong imperative to take care of those patients who are sick," he says. "So what we do is find mechanisms to get those patients who can’t wait in immediately. So, instead of thinking about how the whole system works dynamically, we only try to solve one part of the equation, which is, ‘how do I take care of those patients with so-called urgent care needs?’" What results is a fairly even flow of work, but three months late.
One way to change that is to consider how external demand and internal demand contribute to the whole picture. Primary care physicians don’t have much control over external demand, says Murray — when patients decide they are sick or need to be seen. Internal demand, however, is far more controllable; it is created by doctors who bring patients back for repeat visits or checkups. "You use the internal demand to load-level," he says. "You bring patients back at times during the day when demand is predictably lower — early mornings or late in the week."
The second way is to measure the supply and "recognize that it’s the supply variation that causes the waiting times," Murray says. The number of doctors working any particular day should fit the demand as well as possible — "making sure we have enough supply each day, each half-day, each hour, each minute," he says.
Recalibrating the System
"Once we understand the balance between demand and supply and we understand the system’s dynamics, the second step is to recalibrate our system," says Murray. That means getting rid of the backlog — like "draining a lake or emptying a warehouse." There’s nothing magical about clearing out the warehouse; practices need to figure out how much work is coming in each day, and "do more stuff for a period of time to catch up."
Applying Queuing Theory
Health care providers must apply queuing theory to appointment scheduling. "If we can reduce the number of queues or lines, we can actually reduce the time it takes in total wait time inside the system," says Murray.
Compare a grocery store and a bank, he says. At a grocery store, you pick a particular line. There are multiple lines, each with a specific clerk, and each with a short or long wait time. At a bank, however, one line feeds any one of a number of universal tellers. There’s less waiting time at a bank, says Murray, and the reason is that you’re "load-leveling."
In health care, practices tend to have several different appointment types — some for Pap smears, some for physical exams, and some for procedures. Where the increased waiting times occur is when there’s an open slot for a physical exam, but no one is using it. "That’s where we end up creating variation," says Murray, and that means longer waits. Reducing the number of appointment types — which frees appointment clerks and receptionists from trying to figure out what patients want or putting them into a particular pigeonhole — is probably one of the more dramatic ways to reduce demand." It’s not always possible to do it completely — variables such as needing a particular room for a sigmoidoscopy or accommodating a patient’s choice of clinician can make it difficult — but most of the time it can be done.
Creating Contingency Plans
This is where systems can accommodate the variations inherent in health care delivery. "There’s demand variation and there’s supply variation, and the contingency plans deal with or address, ‘how do we manage those predicted variations in a predetermined manner?’ We’re prepared to deal with the variation rather than react to it."
Practices should ask, "What are we going to do when there’s variation in supply or variation in demand?" says Murray. Despite what many doctors think, seasonal demand involving the flu, for example, is the result of not only some increase in demand, but is just as likely due to a decrease in supply, he notes. The January and February flu season follows the holiday season, during which many doctors take vacations. That means they’re catching up on work from the holiday as well as handling increased demand; both must be taken into account when creating a contingency plan.
Influencing the Demand
"In primary care, the best way that we can influence demand is to cement that doctor- or clinician-patient relationship and to make sure that patients get to see their own providers every time and that providers get their patients every time," says Murray.
When patients see their own providers, there are less visits and there is less time with each visit, explains Murray. "That relationship results in not only reduced visits, but better clinical outcomes and lower system costs," he says. "So continuity is really the key." Specialists already have continuity, Murray notes. "On the other hand, when we look at the specialists in terms of the constraints in the system [see below], what we often see is specialists are asked to do work that actually could be done by somebody else in the system. The development of service agreements between primary care and specialty care is a strong way to reduce the demand for specialty care." Such service agreements define which work is done by each of the entities, and defines the packaging in which the work is sent from one to the other, says Murray. "In addition, the service agreement helps clarify the referral process, both for those patients that are known and those patients that are unknown," he says.
Managing the Constraints
The constraints in a system are the rate-limiting step, Murray explains, and they ought to be the providers. In a private practice, things can only move as fast as the doctor-patient relationship. The trick here is to take the unnecessary work from the constraints, or elevate the care team so that work can be properly allocated to them, he says: "This frees up the providers to do the work they are unique and essential for." That means taking away any work that can be done by someone else.
All of these approaches, he says, will result in doctors being able to "do the work sooner – not quicker, but sooner."